• Mental Health
  • Independent mental health service

Archived: St Johns House

Overall: Inadequate read more about inspection ratings

Lion Road, Palgrave, Diss, Norfolk, IP22 1BA (01379) 649900

Provided and run by:
Partnerships in Care Limited

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Background to this inspection

Updated 17 September 2021

St Johns House is an independent hospital, part of the Priory Group, that provides care and treatment for patients with a primary diagnosis of a learning disability and associated mental health problems. This includes autistic spectrum disorders, personality disorders and enduring mental illnesses.

The hospital was registered to carry out the following regulated activities:

  • Treatment of disease, disorder or injury
  • Assessment or medical treatment for persons detained under the 1983 Act
  • Diagnostic and screening procedures

The hospital had 49 beds across four wards.

At the time of inspection 29 adults were admitted all of whom were detained under the Mental Health Act with some being subject to Ministry of Justice restrictions.

St Johns House had four wards which were:

  • Redgrave ward which was a 16-bed medium secure female ward. There were 11 patients on this ward.
  • Walsham ward which was a 16-bed medium secure male ward. There were 10 patients on this ward.
  • Bure ward which was a 11-bed low secure female ward. There were four patients on this ward.
  • Waveney ward which was a six-bed low secure female ward. There were four patients on this ward.

The service does not currently have a registered manager and the previous registered manager of the service had been absent from the hospital since July 2020, with temporary managers covering this role since this time.

Following a risk based focused inspection in December 2020, the hospital was placed in special measures and rated as inadequate overall and within the domains of Safe and Well-led. Following the December 2020 inspection, we imposed urgent conditions on the provider’s registration at this location including preventing the provider from admitting further patients to the hospital.

During an inspection in April 2021 we rated the hospital again as inadequate overall and within the domains of Safe, Effective, Caring and Well-led. Responsive was rated as Requires Improvement. The hospital remained in special measures.

Following this inspection in July 2021, based on the impact and seriousness of our findings, we issued the provider with an urgent Notice of Decision imposing further conditions on the providers registration.

The purpose of this inspection was to review key areas of risk that we identified during previous inspections, relating to patient safety. We did not re-rate the location during this inspection. As we looked at specific key lines of enquiry during this inspection, we have reported in the following domain:

  • Safe

What people who use the service say

We spoke with two patients during this inspection. One patient raised concerns that there were not enough staff during the night. The other patient who we spoke with said they did not feel safe in their bedroom as they frequently experienced seizures and their alarm to call for staff assistance was located near their door rather than beside their bed. They were concerned that they could not call staff for help. We raised this with the service and the following day staff moved the patient’s assistance alarm to beside the bed.

Overall inspection


Updated 17 September 2021

This service was placed in special measures in December 2020. Insufficient improvements have been made. The rating from this inspection remained Inadequate and the service has remained in special measures due to the lack of sufficient improvement. The conditions we placed on the hospital’s registration in December 2020 remain in place following this inspection.

St Johns House provides care and treatment for patients with a primary diagnosis of a learning disability and associated mental health problems.

We rated St Johns House inadequate because:

  • Staff were placing patients at risk of harm by not completing patient observations safely or in line with patient care plans or national guidance. Staff were completing continuous patient observations for up to 10 hours at a time, despite the providers policy stating this should only occur for a maximum of two hours continuously. We found in two out of three checks we undertook, staff were asleep whilst they were meant to be undertaking patient observations. For one patient who had three staff observing them, all three staff were seen to be asleep at the same time. We checked written observation records for the same period, and we found that the staff who were asleep had written observation entries correlating with the times that they were asleep.
  • The service did not always have enough nursing and support staff to keep patients safe. Despite an initial improvement in staffing levels since the December 2020 inspection, staffing levels remained inconsistent and during May 2020 there were significant staffing challenges resulting in the manager adjusting patient clinical observation levels to meet staff availability. The service had high rates of agency staff and staffing levels for each day were unpredictable. Nurses were often replaced with healthcare workers. Ward managers and activities staff had to regularly cover gaps in staffing levels.
  • Managers had not ensured that agency staff had the right skills or experience to meet the needs of patients in their care. Agency staff lacked mandatory training and not all agency staff were provided with an induction. Managers did not support staff through regular, constructive clinical supervision of their work. Supervision figures ranged from four per cent in January to 19% in March 2021 despite the provider’s policy stating this should occur monthly.
  • Patients did not have regular access to individual time with named staff as this was affected by low staff numbers on the ward. Staff told us that by taking a patient on leave for an activity, this left staffing too low on the ward. Psychological or therapeutic sessions and patient activities were sparse, and we found that some patients were only offered one or no activities per week. We saw one patient who was waiting four months for a follow up appointment following an initial psychological assessment. We saw a lack of speech and language assessments and staff told us they felt under-resourced and that they did not have time to update care plans in relation to such needs. Managers informed us of gaps in therapy posts over a four-year period.
  • Patient risk assessments were not always reviewed after every incident and where reviewed we found that risk assessments were not an accurate reflection of patient risk. Documentation between patient risk assessments and care plan was inconsistent. When risk assessments had been updated following incidents, staff had not specified how they could prevent or reduce the likelihood of the incident occurring again. Staff did not always act to prevent or reduce risks to patients and did not always respond to any changes in risks to, or posed by, patients. We saw two incidents involving patient self-harm where staff did not intervene in a timely manner, with one incident resulting in injury to the patient’s head. Risks to patient’s physical health were also not always acted upon, for example, when patients’ physical observations were beyond their normal range, this had not always been escalated or monitored.
  • Managers did not investigate all serious incidents and those that were investigated, did not identify appropriate learning or follow duty of candour processes. Where learning had been identified, this had not been shared with staff in a timely way. Recommendations from reviews were not always implemented and there was no oversight or monitoring to check if they had been. We found that not all lower graded incidents had a management review within two to seven days of reporting in line with the providers policy. When managers did review lower graded incidents, this was often very brief and included no evidence of how they assessed if the incident was managed in line with the patients care plan.
  • When a patient was placed in seclusion or long-term segregation (LTS), staff did not always keep clear records that followed the Mental Health Act Code of Practice. Documentation was not always clear as to where a patient was secluded, and we observed that staff were not always recording a patient’s seclusion in a timely manner. Patient care plans did not indicate risks within the areas of seclusion or LTS or how they would be managed. Patient positive behavioural support (PBS) plans did not always reflect that the patient was in LTS, medical reviews were not always completed and over half of the daily LTS records were not recording food and fluid intake.
  • Staff developed care plans for each patient, however these did not always meet their mental health, individual or physical needs. Care plans were complicated, overly detailed, appeared to have been copied and pasted across patients and did not describe all patient’s physical health conditions or detail a plan of how to safely manage all patient needs. Communication and religious needs were also not clearly documented and there was a lack of planned care for asthma, incontinence and for the side effects of specific medications and dietary needs.
  • Staff did not always manage patients in line with their care plans. Staff roles and responsibilities were not clear for supporting patient’s physical health needs and information on such needs was not shared effectively between physical health staff and ward staff. Staff did not escalate signs of clinical deterioration in patient health, such as a high pulse, or compete further physical monitoring in response. It was not clear who had oversight of these processes or a plan of action to resolve them. Positive behaviour support (PBS) plans were not regularly reviewed and ward-based activities often failed to link directly to the goals and care needs on individual plans. PBS plans also lacked clear information for staff to provide appropriate care and support to patients.
  • Patients were offered a copy of their care plan however some patients who we spoke with reported they did not have up to date copies of their care plans, with one patient’s copy dated from 2019. Despite patients and carers having opportunities to feedback about the service through community meetings and surveys, it was not clear how patient and carer feedback was being used to drive quality improvement at the hospital.
  • Multidisciplinary team (MDT) meetings did not always ensure all patient risk factors and care needs were discussed or appropriate action was taken. For example, staff did not review a patient’s epilepsy care plan during their MDT meeting despite this being a current prominent risk and patient observation levels were not always reviewed during MDT meetings, nor was patients understanding of their observation levels checked.
  • Staff did not always assess and record patient’s capacity. We checked 14 patient records, and nine records did not have any evidence of a capacity assessment. For patients in seclusion we also found that two patients did not have an updated capacity and consent assessment form when a new medication was added.
  • Patients privacy and dignity was not always managed appropriately. Staff told us that there were often too few female staff on duty to care for female patients, meaning male staff provided personal care whilst on female patient observations on occasion. Patients told us that while most staff were kind and caring some staff would speak in a different language in front of them which made them feel uncomfortable and frustrated and that night staff were not fully aware of their risks or actions required to manage their risks. Generally, patient incidents had been managed sensitively however staff did not always direct other patients away from the incident when they had the opportunity to do so, resulting in other patients watching a patient being restrained. Patients were often secluded in side rooms along the corridor of the ward which were not suitable due to the environment and the ability for other patients to observe into the room.
  • Prior to our previous inspection the hospital’s admission criteria had not been clear which meant that it had admitted patients with acute complex and challenging conditions. Since, the clinical team had completed a review of all patient’s suitability against the hospitals admission criteria and identified many patients where an alternative provision was required to ensure their needs were being met. Despite the providers strong efforts to re-locate patients who required an alternative provision, many patients had not been able to move on from St Johns House therefore acuity at the hospital remained very high. Despite hospital plans to discharge and transfer patients where appropriate, patient documentation including clinical notes and care plans were not kept up to date with this information and we were not assured that these plans were fully communicated to patients. The average length of stay for patients at the hospital was 2.7 years, however patient stays ranged from 5 months to 9 years 7 months.
  • Since July 2020, there had been no registered manager. A total of four temporary managers had covered this role since that time which has resulted in a lack of clear leadership of the service as each manager has needed to develop their knowledge of the service. In addition, due to the hospitals vacant position of medical director, we were not assured that there was suitable oversight of aspects of mental and physical health. We found a lack of oversight for physical health monitoring and it was not clear how medical governance processes were being monitored.
  • Our findings demonstrated that governance processes were not yet operating effectively. Managers had developed new ways of working and processes to improve the service, but these were not yet fully embedded or effective. Managers had not yet fully embedded quality assurance processes, such as regular audits of the service, to assess, monitor and improve the quality and safety of the hospital. The service did not complete physical health audits and had not completed other scheduled audits.
  • The provider did have a risk management process and improvement plan in place to assess and monitor risk and we noted that the providers improvement plan included most concerns found at this inspection, however sufficient action had not been undertaken to address these issues and risk at the hospital was not always managed well, as patients continued to be exposed to harm due to low staffing levels and poor practice as outlined in this report.
  • Not all staff knew and understood the provider’s vision and values and staff felt that communication of key decisions between managers and staff could be improved. Many staff felt stressed and reported concerns about under staffing which impacted staff morale and staff did not feel that managers addressed racist abuse towards staff from patients. There was no equality and diversity lead at the service.


  • Ward areas were clean and well maintained and staff adherence to infection prevention control (IPC) measures had improved since our last inspection.
  • Clinic rooms were clean and fully equipped with emergency drugs that staff checked regularly, and audits picked up on any missing items.
  • Permanent staff employed by Priory Group had completed and kept up to date with their mandatory training.
  • The hospital conducted an external review of restraint incidents to identify if physical restraint was necessary, proportionate and that provider approved techniques were used. The review was conducted by a specialist nurse who was a lead in restraint techniques. The review shared areas for improvement with staff to improve their management of such situations.
  • For patients in long term segregation, daily access to activities and access to fresh air had improved since the last inspection.
  • Staff worked with other agencies to report safeguarding alerts and took part in safeguarding meetings with the local authority.
  • We did not find the quality concerns with care plans and patient documentation on Bure ward as care plans were specific and person-centred.
  • In most interactions we observed, staff treated patients with compassion and kindness. Patients were supported with daily living tasks.
  • Staff helped patients to stay in contact with families and carers. Staff facilitated visits from patients’ children and supported patients to attend family events.
  • Staff made sure patients could access information on treatment, local services, their rights and how to complain.
  • Staff spoke highly of the operational manager who had been overseeing St Johns House since January 2021, as they felt she was committed to improving the hospital and was visible on wards.
  • Staff felt supported with COVID-19 related matters such as access to testing, vaccination and personal protective equipment.
  • Staff reported positive team working with one another and we observed effective team coordination in relation to a restraint incident on the ward.