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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 26 February 2020

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

  • Patients were at risk of continuing harm. The service did not always manage patient safety incidents well. Managers had not investigated incidents thoroughly, or in a timely manner. Staff did not always use approved restraint techniques, which resulted in staff dragging patients along the floor or physically injuring patients during restraint. Senior staff told us they observed CCTV footage of these incidents and were concerned that other staff present had not acted to intervene. Staff did not always keep patients safe from harm whilst on enhanced observations. The provider reported 212 incidents of patients’ self harming whilst on enhanced observations between 1 September 2019 and 30 November 2019. Staff did not always make sure they shared clear information about patients and any changes in their care. Staff did not always complete required safety checks in line with the providers policy and procedures.
  • Staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk of harm to themselves or others. We found staff on enhanced observations for the same patient for between three to ten hours. We found staff completed observations continually throughout a shift for up to three different patients. Staff completing extended periods of enhanced observations may be less likely to maintain the levels of concentration required to maintain patient safety. We found examples of staff not completing observation records.
  • Staff did not always treat patients with kindness, dignity and respect on four wards. Staff referred to a patient who identified as male as her/she, this upset the patient and continued after the patient complained. We found staff recorded an incident of bullying behaviour between patients as “a bit of fun”. We found examples of a punitive culture on some wards. Staff criticised and sanctioned patients, without justification, for talking to other patients and cooking different meals to those planned.
  • The leadership, governance and culture did not always support the delivery of safe, high quality, person centred-care. Leaders did not always understand the issues, priorities and challenges the service faced. The provider’s governance processes had not addressed staff failures to follow the provider’s procedures. There was no evidence that the provider undertook regular and effective audits of these issues. We were not assured that the provider acted to keep patients safe from harm. The provider did not oversee patient risks effectively. We found that evidence to support serious incident investigations was not preserved. There was a lack of leadership during serious incidents. Investigations into serious incidents were not completed in a timely manner.
  • We were concerned about the culture within the organisation in relation to the perception of the regulator and the message leaders relayed to staff and patients. Comments made in board papers downplayed the significant concerns raised in the last Adolescents inspection. A senior leader requested wording in a safeguarding report was changed from ‘dragged’ to ‘moved along’ in relation to use of non-approved restraint techniques.
  • Use of restraint and seclusion had significantly increased since the last inspection. The provider reported 2,266 incidents of restraint from 01 February 2019 to 31 July 2019. This was an increase of 29% since the last inspection. Use of prone restraint increased by 44% since the last inspection. Use of seclusion increased by 79% since the last inspection.
  • The service did not have enough nursing and support staff to keep patients safe. We reviewed four incidents where staff shortages impacted on patient safety. Between 01 May 2019 and 31 July 2019 managers were unable to fill 17% of shifts, bank staff filled 50% of shifts and agency staff 35% of shifts.
  • Staff did not always identify and meet patients’ needs. Staff had not completed physical health assessments on admission for three patients reviewed and two patients had no care plan. Staff had not taken action to meet the physical healthcare needs of three patients.
  • Although staff compliance with the Mental Health Act Code of Practice in relation to seclusion and long term segregation had improved, we found 21 examples where practice did not meet the code in 22 records reviewed, for example, staff not recording their role in review records and care plans lacking detail.

However:

  • The provider made improvements since the last inspection. They introduced a new leadership team, ensured safe environments and made significant changes to blanket restrictions. The service had been working with external partners, including NHS trusts with outstanding ratings to help the service improve.
  • Staff and patients had access to an extensive range of rooms and equipment to support treatment and care. Patients had access to the provider’s school for educational activities. Each patient had an individualised timetable to meet their needs. Staff ensured that patients had access to appropriate spiritual support. Staff supported patients to access a range of leave activities, including football matches and horse riding.
  • Staff completed comprehensive mental health assessments for patients. Staff provided a range of care and treatment interventions suitable for the patient group. The teams included or had access to the full range of specialists required to meet the needs of patients on the ward.
  • Senior leaders were visible in the service and approachable for patients and staff. Staff spoken with told us that the operational lead and clinical leads for the service were visible on the wards. Staff told us that the chief executive officer visited regularly and had been particularly supportive following the last inspection.
  • Staff involved patients in decisions about the service. The provider introduced a new recruitment process, which involved patients as equal partners in deciding on staff to recruit.
Inspection areas

Safe

Inadequate

Updated 26 February 2020

We rated safe as inadequate because:

  • Patients were at risk of continuing harm. The service did not always manage patient safety incidents well. Managers had not investigated incidents thoroughly, or in a timely manner, and did not always involve patients, families or staff in their investigations. We reviewed 13 incidents and found eight delayed investigations, including for safeguarding incidents, and one investigation of poor quality.
  • Staff did not always use approved restraint techniques. We found nine examples of staff using non approved restraint techniques, which resulted in staff dragging patients along the floor or physically injuring patients during restraint incidents. Five of these incidents occurred on Meadow ward. Senior staff told us they observed CCTV footage and were concerned that other staff present had not acted to intervene.
  • Staff did not always act to prevent or reduce risks to patients and staff. Staff did not always keep patients safe from harm whilst on enhanced observations. The provider reported 212 incidents of patients’ self harming whilst on enhanced observations between 1 September 2019 and 30 November 2019. The ward with the highest number of incidents was Fern with 79.
  • Staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk harm to themselves or others. We found issues on five of the eight wards visited. We found staff on enhanced observations for the same patient for between three to ten hours. We found staff completed observations continually throughout a shift for up to three different patients. This is not in accordance with the providers policy and does not adhere to guidelines by the National Institute for Health and Care Excellence (NG10). Staff completing extended periods of enhanced observations are less likely to maintain the levels of concentration required to maintain patient safety. We found examples of staff not completing observation records on Fern, Brook, Marsh and Meadow wards.
  • Use of restraint and seclusion significantly increased since the last inspection. The provider reported 2,266 incidents of restraint from 01 February 2019 to 31 July 2019. This was an increase of 29% since the last inspection. Use of prone restraint increased by 44% since the last inspection. Use of seclusion increased by 79% since the last inspection.
  • The service did not have enough nursing and support staff to keep patients safe. We reviewed four incidents where staff shortages impacted on patient safety. Between 01 May 2019 and 31 July 2019 managers were unable to fill 17% of shifts, bank staff filled 50% of shifts and agency staff 35% of shifts.
  • Staff did not always complete safety checks in line with the providers policy and procedures. We found gaps in the checklists on Maple, Willow, Fern and Marsh wards.
  • Although staff compliance with the Mental Health Act code of practice in relation to seclusion and long term segregation had improved, we found 21 examples of poor practice in 22 records reviewed, for example, staff not recording their role in review records and care plans lacking detail.

However:

  • Managers ensured safe environments and addressed issues with sharp door frames and blind spots following the last inspection.
  • Managers made significant changes to blanket restrictions, removing snack restrictions and introducing positive and safe champions and restrictive practice logs across the wards.
  • Staff completed detailed risk assessments for patients, which they regularly reviewed.

Effective

Requires improvement

Updated 26 February 2020

We rated effective as requires improvement because:

  • Staff did not always make sure they shared clear information about patients and any changes in their care. Staff did not always complete handovers in line with the provider’s policy and procedures. We found examples of staff not handing over important risk information and lack of, or poor record keeping of handovers.
  • Staff did not always identify and meet patients’ physical health needs. Staff on Fern ward had not completed physical health assessments on admission for three of the four patients reviewed. Staff on Maple ward had not completed the required physical health monitoring for one patient and missed three nasogastric feeds for another patient. Nasogastric feeds consist of delivering liquid nutrients through a tube passing through the nose and into the stomach.
  • Staff recorded for one patient on Brook ward

    , that the patient lacked capacity and that a best interest meeting was required, however there was no capacity assessment to support this decision.

  • On Acorn and Brook wards staff had not completed a care plan for one patient on each ward.

However:

  • Staff completed comprehensive mental health assessments for patients and developed care plans to meet identified needs. These included ‘Positive Behaviour Support’ plans for all patients and, SPELL (Structure, Positive approach, Empathy, Low arousal, Links) plans and trauma informed care plans for some patients. Staff created holistic, personalised and recovery orientated plans. Staff 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 meetings we observed.

Caring

Inadequate

Updated 26 February 2020

We rated caring as inadequate because:

  • Staff did not always treat patients with kindness, dignity and respect on four wards. Some staff referred to a patient who identified as male as her/she, this upset the patient and continued after the patient complained.
  • Staff did not always take bullying incidents between patients seriously. We found staff recorded in handover an incident of bullying behaviour between patients as “a bit of fun”.
  • We found examples of a punitive culture on some wards. Staff criticised and sanctioned patients, without justification, for talking to other patients and cooking different meals to those planned. Staff told one patient they had to be risk free for 72 hours before they could visit the on-site hair salon, when their plan advised risk free behaviour for 24 hours.

However:

  • Staff involved patients in decisions about the service. The provider introduced a new recruitment process, which involved patients as equal partners in deciding on staff to recruit.

Responsive

Good

Updated 26 February 2020

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 and a multifaith area. There were enough treatment rooms and conference rooms for tribunals and care and treatment reviews.
  • Patients had access to the provider’s school 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. Patients were also able to access the provider’s on site light industry workshop. Staff supported patients to access a range of leave activities, including football matches and horse riding.
  • Staff ensured that patients had access to appropriate spiritual support. The service had a multifaith area and access to chaplaincy support, which included access to leaders from different religions including Christianity, Islam and Wicca.

Well-led

Inadequate

Updated 26 February 2020

We rated well-led as inadequate because:

  • The leadership, governance and culture did not always support the delivery of high quality, person centred-care. The providers governance processes had not addressed staff failures to follow the provider’s procedures on enhanced observations, handovers and safety checks. There was no evidence that the provider undertook regular and effective audits of these issues. We were not assured that the provider acted to ensure staff were not using unapproved restraint techniques, resulting in patients being dragged or injured.
  • Leaders did not always understand the issues, priorities and challenges the service faced. We were concerned about the culture within the organisation in relation to the perception of the regulator and the message leaders relayed to staff and patients. We reviewed comments in board meeting minutes that downplayed the significant concerns raised in the last Adolescents inspection, which resulted in a rating of inadequate and the service being placed in special measures. We were informed that a senior leader requested the local authority changed wording in a safeguarding report, relating to an incident of a patient being dragged during restraint, from ‘dragged’ to ‘moved along.’ This did not accurately reflect the severity of the incident reported or provide assurance that leaders took this incident seriously.
  • The provider did not oversee patient risks effectively. We found that evidence to support serious incident investigations was not preserved as a matter of course, for example CCTV footage. We were unable to identify any robust senior leadership during an ‘organisational disturbance’ incident and CCTV footage showed a lack of clear direction for staff to follow to resolve the incident to keep patients and staff safe from harm.
  • Leaders had not ensured managers completed investigations into serious incidents in a timely manner. We reviewed 13 incidents and managers had not completed eight investigations in a reasonable timeframe.

However:

  • Senior leaders were visible in the service and approachable for patients and staff. Staff spoken with told us that the operational lead and clinical leads for the service were visible on the wards. Staff told us that the chief executive officer visited regularly and had been particularly supportive following the last inspection.
  • Staff reported that the provider promoted equality and diversity in its day to day work and in providing opportunities for career progression. The provider ran several patient and staff events including their first Trans-inclusion Healthcare conference, St Andrews Pride, Mental Health Awareness Week, Black History Month and International Women’s Day. The provider was an NHS Diversity & Inclusion Partner and facilitated workshops for 150 inclusion allies and partnered with an external agency to run trans awareness workshops.
  • The service had been working with external partners, including NHS trusts with outstanding ratings to help the service improve.
Checks on specific services

Child and adolescent mental health wards

Inadequate

Updated 26 February 2020

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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.