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St Andrew's Healthcare - Adolescents Service Inadequate

We are carrying out a review of quality at St Andrew's Healthcare - Adolescents Service. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Inadequate

Updated 6 June 2019

We rated St Andrew’s Healthcare Adolescents service as inadequate because:

  • Staff did not always treat patients with kindness, dignity compassion and respect. Eleven of the 15 seclusion rooms did not include furnishings such as a bed, pillow, mattress or blanket. We reviewed 13 episodes of seclusion where staff had not provided the patient with a mattress or chair. Observation records for nine episodes of seclusion detailed 28 entries describing the patient sitting or lying on the floor. Staff, on one occasion, did not respect a patient’s privacy and dignity when changing the patient’s clothing and did not ensure that female staff assisted with this for female patients. It was the inspection team’s view that this practice was uncaring, undignified and disrespectful.
  • Managers had not ensured that they consistently identified or addressed safety concerns quickly enough. There were sharp edges on door frames in seclusion rooms and extra care suites, blind spots in seclusion rooms and pieces of exposed sharp metal in extra care suites. Staff did not always follow safety procedures in relation to cutlery checks and food hygiene. Staff did not always check emergency equipment and medicines. Staff did not always record, accurately, the events that took place during incidents. There was discrepancies between incident reports, staff recollection and the images captured on CCTV.
  • Staff did not follow best practice when using seclusion and long term segregation. We have raised this issue with the provider on 12 separate occasions following previous inspections of their locations. Medical, nursing and multidisciplinary reviews had not taken place as required by the Mental Health Act Code of Practice. Staff had not always completed seclusion care plans for patients, had not involved advocacy, or informed the local authority when required. Staff secluded three patients for longer than necessary.
  • Staff applied blanket restrictions without justification. All wards had imposed set snack times for patients. Other restrictions included access to drinks and takeaways, patients not allowed to wear shoes on Meadow. Staff on Willow ward locked the patient’s en suite rooms which meant patients had to request staff to unlock them for access. and staff locking en suites on Willow. Managers told us that patients themselves had requested set snack times and to not have shoes on wards. Staff provided minutes of community meetings, however only records for two wards indicated patient agreement.
  • Managers had not always ensured that there were the required numbers of staff on all shifts. Managers had not filled 13% of shifts between 1 and 31 March 2019. Managers had used bank and agency staff to cover 47% of shifts. Staff shortages sometimes resulted in staff cancelling escorted leave, appointments or ward activities. Staff on Fern, Maple and Willow wards told us that the high use of bank and agency staff impacted on patient care as risk events increased due to inconsistencies in patient care.
  • The leadership, governance and culture did not always support the delivery of high quality, person-centred care in relation to the comfort of patients in seclusion and the application of blanket restrictions. The arrangements for governance did not always operate effectively. Governance arrangements had not always identified that staff practices were sometimes in breach of the Mental Health Act Code of Practice. The provider had not addressed issues with restrictive practices and the environment previously raised by the CQC. Provider audits had failed to address the issues with restrictive practices. Managers did not always deal with risk issues appropriately or in a timely way. Although the provider had carried out work to rectify hazards, it was incomplete. The provider did not have a system to check that the maintenance team had completed required works satisfactorily.

However:

  • Managers had completed up to date ligature audits and risk assessments identifying all potential ligature points. Managers had displayed ligature ‘heat maps’ in each ward office highlighting high risk areas on the wards. Ligature cutters were located throughout the ward areas in secure boxes.
  • Staff had completed a risk assessment for each patient, which they updated regularly and after any incident. Staff identified and responded to changing risks to, or posed by, patients. Staff had completed comprehensive mental health assessments and developed care plans to meet identified needs.
  • Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and delivered in line with, guidance from the National Institute of Health and Care Excellence. Interventions included a full therapy programme and the use of recognised rating scales to assess and record severity and outcomes. The teams included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff had the experience, qualifications and the right skills and knowledge to meet the needs of the patient group. Teams held regular and effective multidisciplinary meetings. Managers ensured that staff received the necessary specialist training for their roles.
  • Staff and patients had access to an extensive range of rooms and equipment to support treatment and care. All patients and carers spoken with reported that the environment and facilities were very good. Patients had access to the provider’s college for educational activities. Each patient had an individualised timetable to meet their needs. There was a specially designed classroom for patients with autistic spectrum disorders. Patients had opportunities for work experience and access to the provider’s on-site light industry workshop. Staff ensured that patients had access to appropriate spiritual support. The service had a multi-faith area and access to support for different religions.
  • Leaders were visible in the service and approachable for patients and staff. Staff spoken with told us that the chief executive officer and operational and clinical leads for the service were visible on the wards. Staff told us that they felt respected, supported and valued. Staff said the management culture had changed for the better. A trauma nurse and occupational health service supported staff’s physical and emotional health needs. The provider had invested in a programme of support to promote staff well-being.
Inspection areas

Safe

Inadequate

Updated 6 June 2019

We rated safe as inadequate because:

  • Managers had not ensured that they consistently identified or addressed safety concerns quickly enough. We found sharp door frames in nine seclusion rooms and five extra care suites. A Mental Health Act reviewer had raised this issue with the provider on seven separate occasions. We found blind spots in ten seclusion rooms and an exposed piece of sharp metal in two extra care suites. There was damage to the paint work in five seclusion rooms. Staff did not always record, accurately, the events that took place during incidents. There were discrepancies between incident reports, staff recollection and the images captured on CCTV.
  • Staff did not follow best practice when using seclusion. We reviewed 21 episodes of seclusion. Medical reviews had not taken place within the first hour of seclusion in six episodes. Nursing reviews had not been carried out by two nurses in all instances. Continuing medical reviews had not always taken place every four hours. Multidisciplinary team reviews had not taken place for three episodes. Records were incomplete in 11 episodes of seclusion. Staff had not developed care plans for the patient’s episode of seclusion in nine records and seclusion care plans were incomplete in a further six records. Staff had nursed a patient in conditions of seclusion, intermittently, for five days and had not implemented seclusion processes. Staff secluded three patients for longer than necessary.
  • Staff did not follow best practice when using long-term segregation. We reviewed four episodes of long-term segregation. An approved clinician (who may or not be a doctor) had not formally reviewed the patient’s situation at least once in any 24-hour period. Multidisciplinary team reviews had not always taken place as required. We could find no evidence of the multidisciplinary reviews including involvement of an independent mental health advocate. We were unable to establish, from the care records, whether staff had made the local safeguarding team aware of any patient in long-term segregation.
  • Staff applied blanket restrictions without justification. All wards had imposed set snack times for patients. Other restrictions included access to drinks and takeaways. Meadow and Willow ward had restricted patients from wearing their shoes on the ward. On Willow ward staff kept patients’ en suites locked and only opened on request. Staff did not record the reason for applying blanket restrictions in risk assessments. Managers told us that patients requested set snack times and to not have shoes on certain wards and that staff recorded this in community meeting minutes. Staff provided minutes of community meetings, however only records for Meadow and Bracken wards indicated patient agreement.
  • Staff did not always complete safety checks appropriately. Four wards did not follow the cutlery checking process. Staff had not completed cutlery checking in/out forms correctly, therefore it was unclear how many items of cutlery there should be, and if any items were missing. There were unlabelled food items in fridges on Willow and Brook wards. Staff did not check emergency and medical equipment on Marsh and Acorn wards, as required by the providers policy which states staff are to carry out checks weekly. Since December, staff on Marsh ward had only carried out two checks. On Acorn ward, staff had only completed eight checks over the 14 weeks prior to the inspection. On Marsh ward we found five out of date drug testing kits and on Acorn ward staff had not tested the fridge temperature on five days in February and March 2019. Staff had stored aftershave in the medicines cupboard on Acorn.
  • Managers had not always ensured established staffing levels on all shifts. Managers had not filled 13% of shifts between 1 and 31 March 2019. Managers had used bank and agency staff to cover 47% of shifts, although some bank shifts were additional hours by permanent staff. Staff shortages sometimes resulted in staff cancelling escorted leave, appointments or ward activities. We reviewed the record of a patient on Fern ward, who had a medical appointment cancelled as there were no regular staff to provide support. We reviewed the records for one patient on Maple ward whose planned leave was cancelled on nine occasions between 9 January 2019 and 17 March 2019 due to staff shortages. Staff on Fern, Maple, Acorn and Brook wards told us that staff shortages impacted on patients accessing escorted leave and activities. Staff on Fern, Maple and Willow wards told us that the high use of bank and agency staff impacted on patient care as risk events increased due to inconsistencies in patient care.
  • The provider had not fitted or supplied call alarms in patient bedrooms. Staff had not completed risk assessments detailing how patients would summon help.

However:

  • Managers had completed up to date ligature audits and risk assessments identifying all potential ligature points. Managers had displayed ligature ‘heat maps’ in each ward office highlighting high risk areas on the wards. Ligature cutters were located throughout the ward areas in secure boxes.
  • Staff had completed a risk assessment for each patient and updated them regularly and after any incident. Staff identified and responded to changing risks to, or posed by, patients. We observed staff responding quickly and effectively to a patient presenting with risk behaviours during our visit.

Effective

Good

Updated 6 June 2019

We rated effective as good because:

  • Staff had completed comprehensive mental health assessments for patients and developed care plans to meet the identified needs. These included ‘Positive Behaviour Support’ plans for the majority of the patients of the wards. We reviewed 58 ‘Positive Behaviour Support’ plans, all were holistic, personalised and recovery orientated. Staff had updated care plans when necessary.
  • Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and delivered in line with, guidance from the National Institute of Health and Care Excellence. Interventions included a full therapy programme and the use of recognised rating scales to assess and record severity and outcomes.
  • The teams included or had access to the full range of specialists required to meet the needs of patients on the ward. As well as doctors and nurses, teams included or could access occupational therapists, technical instructors, physiotherapists, clinical psychologists, social workers, pharmacists, speech and language therapists and dieticians. Staff had the right experience, qualifications, skills and knowledge to meet the needs of the patient group. Teams held regular and effective multidisciplinary meetings as evidenced in the ward round meeting we observed.
  • Managers ensured that staff received the necessary specialist training for their roles. Staff told us that they had accessed courses in personality disorders, RAID (reinforce appropriate, implode disruptive) approach, dialectical behavioural therapy, autism and sensory integration and coaching.
  • We reviewed 25 sets of Mental Health Act detention papers. These related to the patients’ current period of detention including, where applicable, section 19 (authority for transfer from one hospital to another under different managers) and section 20 (renewal of authority for detention). The detention papers were complete and appeared to be in order.
  • Staff we spoke with demonstrated knowledge of the Mental Capacity Act, Gillick competency and Fraser guidelines. The Gillick competency and Fraser guidelines help people who work with children to balance the need to listen to children’s wishes with the responsibility to keep them safe. Staff explained that once a patient was 16, the Mental Capacity Act would apply and they were required to gain patient’s consent to share information with parents.

However:

  • Staff did not always explain to patients their rights under the Mental Health Act. We reviewed the care records of 25 patients detained under the Mental Health Act. In seven records it was not evident that staff had provided patients with information about their rights at the point of the patient’s admission or detention.

Caring

Inadequate

Updated 6 June 2019

We rated caring as inadequate because:

  • Staff did not always treat patients with kindness, dignity and respect when in seclusion. Except for Brook ward, none of the seclusion rooms included furnishings such as a bed, pillow, mattress or blanket. We reviewed 13 episodes of seclusion where staff had not provided patients with a mattress or chair. Observation records for nine episodes of seclusion detailed 28 entries describing the patient sitting or lying on the floor. It was the inspection teams view that this practice was uncaring, undignified and disrespectful.

  • Staff, on one occasion, did not ensure female staff supported a female patient when the need arose for the patient to change into rip proof clothing. This did not protect the patient’s privacy and dignity.
  • Staff did not always engage with and support carers. Five out of 12 carers spoken with expressed that communication from staff on Maple ward was poor. There were significant delays in addressing concerns raised by families about the treatment of their loved ones.

However:

  • Patients told us that most staff treated them well and behaved appropriately, although some agency staff were not as kind as regular staff. We observed staff being polite and caring towards patients. Patients told us that staff supported them to understand and manage their care, treatment or condition.
  • Patients told us that they were invited to their own multidisciplinary review meetings, involved in their care plans and staff gave them a copy of their care plan. We observed a multidisciplinary meeting which confirmed this.
  • Seven carers reported positive experiences with the service, telling us that staff were kind, brilliant, amazing, and the hospital was the best their child had been in. The service provided accommodation on site and money towards travel costs for families who had long distances to travel to visit their child.

Responsive

Good

Updated 6 June 2019

We rated responsive as good because:

  • Staff and patients had access to an extensive range of rooms and equipment to support treatment and care. This included activity rooms, games rooms and courtyards on each ward. Within the secure perimeter of the building there were family visiting rooms, numerous sports facilities, an animal courtyard, a tranquillity garden, a horticultural garden, sensory rooms, music, art and craft rooms, a hairdresser, a café, social areas, therapy kitchens, a multi-faith area. There were enough treatment rooms and conference rooms for tribunals and care and treatment reviews. All patients and carers spoken with reported that the environment and facilities were very good.
  • Patients had access to the provider’s college for educational activities. Each patient had an individualised timetable to meet their needs. There was a specially designed classroom for patients with autistic spectrum disorders. Patients had opportunities for voluntary work experience at a local charity shop, this included upcycling furniture and selling it. Other patients operated the mobile toiletry trolley and worked in a pop up coffee shop. Patients were also able to access the provider’s on site light industry workshop.
  • Staff ensured that patients had access to appropriate spiritual support. The service had a multi faith area and access to chaplaincy support, which included access to leaders from different religions including Christianity, Islam and Wicca.

Well-led

Inadequate

Updated 6 June 2019

We rated well-led as inadequate because:

  • Governance arrangements did not always operate effectively. For example, governance systems had not always identified that staff practices were sometimes in breach of the Mental Health Act Code of Practice. The provider had not addressed issues raised by the CQC on 12 previous occasions, across different locations, in relation to restrictive practices or action points previously issued by the CQC Mental Health Act reviewer, and while staff undertook a range of audits across the service, these audits had failed to address the issues with restrictive practices.
  • The leadership, governance and culture did not always support the delivery of high quality, person centred-care. Staff practices were not always caring in relation to patient’s in seclusion and when using restrictive interventions. Staff applied blanket restrictions without justification. Managers at all levels told us that staff recorded the impact of blanket restrictions in patients’ records. There was no evidence of this in the records we reviewed.
  • Managers did not always deal with risk issues appropriately or in a timely way. Although the provider had carried out work to rectify hazards, it was incomplete. We asked senior managers who checked and signed off work carried out on the wards and they advised that ward managers were responsible for this. The provider did not have a system to check that the maintenance team had completed required works satisfactorily.
  • The provider had not always reported notifiable incidents to CQC. There had been two incidents involving the police that staff had not reported to CQC.

However:

  • Leaders were visible in the service and approachable for patients and staff. Staff we spoke with told us that the operational leads and clinical leads for the service were visible on the wards. Staff also told us that the new chief executive officer visited regularly and had been particularly supportive to staff on one ward who had been dealing with a difficult situation.
  • All staff spoken with told us they felt respected, supported and valued. The provider had a relatively new leadership team in place developing and changing the culture. Staff said the management culture had changed for the better and there was no longer a blame culture. Overall, staff felt proud and positive about working for the provider and their team despite the high levels of media coverage and scrutiny from external organisations in recent months.
  • A confidential trauma nurse and the occupational health service supported staff with any physical and emotional health needs. The provider had invested in a programme of support to promote staff wellbeing. This included the provider training staff being in mental health first aid (to support colleagues), staff wellbeing events, massage and Zumba classes.
  • The provider recognised staff success within the service through staff awards. The provider issued values based awards on a monthly and quarterly basis, which then culminated in an organisation wide annual awards ceremony for the overall winners. Bracken ward had won team of the year in 2018.
  • Staff had opportunities to participate in research, this included staff on Meadow ward working with a university researching genetic approaches to the treatment of psychosis, and staff working with a student from another university researching the positive impact of physical activity in adolescents with mental health problems. Innovations were taking place in the service. These included the introduction of behavioural family therapy and the physiotherapist using virtual reality equipment to support patients with dyspraxia.
Checks on specific services

Child and adolescent mental health wards

Inadequate

Updated 6 June 2019

Services for people with acquired brain injury

Good

Updated 16 September 2016

  • Rose ward is a medium secure male ward.

  • Tallis, Tavener, Althorp, Berkeley Close (1st floor) are male locked wards.

  • Berkeley Close (ground floor) is a female locked ward.

  • Berkeley Lodge, 37 and 38 Berkeley Close and 19 The Avenue are locked units

  • Walton is for male patients with Huntingdon’s disease.

  • Harper – specialist ward for male and female patients with Huntingdon’s disease.

Wards for people with a learning disability or autism

Good

Updated 16 September 2016

  • Hawkins is medium secure ward for men with learning disabilities (LD).

  • Sitwell is a medium secure ward for women with LD.

  • Naseby is a low secure ward for men with LD.

  • Spencer North is a low secure ward for women with LD.

  • Mackaness is a male medium secure ward for people with ASD.

  • Harlestone is a male low secure ward for people with

    ASD.

Forensic inpatient or secure wards

Requires improvement

Updated 16 September 2016

  • Seacole Ward is a medium secure ward for women.

  • Stowe Ward is a medium secure ward for women.

  • Sunley ward is a medium secure ward for women.

  • Elgar ward is a low secure ward for women.

  • Spencer South is a low secure ward for women.

  • Sinclair ward is a low secure ward for women.

  • Robinson ward is a medium secure ward for men.

  • Fairbairn is a medium secure ward for men with hearing difficulties.

  • Prichard ward is a medium secure ward for men.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 16 September 2016

  • Thornton ward is a locked rehabilitation unit for women.

  • Ferguson ward is a locked rehabilitation unit for men.

  • Spring Hill House is a locked facility rehabilitation unit for Women offering 23 beds.

Wards for older people with mental health problems

Good

Updated 16 September 2016

  • O’Connell ward is a locked ward for male older adults.

  • Compton is a locked ward for male and female older adult patients.

  • Foster is a locked ward for male older adults.

  • Cranford is a medium secure ward for male older adult patients.

Acute wards for adults of working age and psychiatric intensive care units

Requires improvement

Updated 16 September 2016

  • Sherwood ward is the psychiatric intensive care unit.