This service was placed in special measures in December 2020 and remained in special measures following a further inspection in April 2021.
As this was a focused inspection, we did not re-rate the location. Therefore, the previous rating of inadequate remains unchanged. Insufficient improvements had been made and the service remains in special measures.
Following this inspection, 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 conditions we placed on the hospital’s registration in December 2020 also remain in place.
This inspection was an unannounced, focused inspection to review key areas of risk relating to patient safety, incident management and safe staffing. We looked at specific key lines of enquiry during this inspection therefore we reported in the following domain:
We found the following areas of concern:
- The service did not have enough nursing and support staff to keep patients safe. Staffing levels were below the number needed to maintain patient observations.
- The provider had not ensured that patient observations were completed in line with patient care plans or the providers patient observation policy. We reviewed CCTV footage and found staff were asleep whilst completing patient observations. We found this concern during our previous two inspections of this service.
- We found staff were completing patient observations for up to six hours continuously, despite the provider’s policy stating this should not be for longer than two hours. Managers told us of an incident in which intermittent patient observations were not completed for up to six hours for at least three patients with no explanation as to why this occurred. Staff were not always seeking permission from an on-call doctor to reduce a patient’s observation levels which was against the provider’s policy.
- Male staff were often placed on intimate female patient observations due to the shortage of female staff. On one occasion, this resulted in a delayed response from observing male staff to respond to a patient suspected of self-harming.
- The service had high rates of agency staff and during the night we found that some wards were operating solely on agency staff.
- Agency staff did not all have adequate training or experience. This included mandatory training such as safeguarding for adults and children, breakaway techniques, first aid, basic life support and the Mental Health Act.
- Patients in long term segregation did not have access to constant fluids in the segregation area.
- The service did not always manage patient safety incidents well or respond to changes in patient risk. Staff did not always respond appropriately to patients who were self-harming, on one occasion this resulted in injury to a patient. During a separate incident, staff did not immediately transfer the patient to the Accident and Emergency centre when required.
- Managers had not acted to prevent patient safety incidents from reoccurring. We raised concerns relating to various patient safety incidents during this inspection which we also found at our previous inspections of the service. This demonstrated a lack of improvement and not learning from when things went wrong.
- Staff did not follow the provider’s policy when using restrictive interventions with patients. Staff using soft handcuffs on patients did not seek appropriate approval, were not appropriately trained and had not ensured a care plan was in place for the safe use of handcuffs.
- Staff did not report incidents clearly in the patient’s clinical notes and failed to accurately report rationales for key decisions to protect patients from harm.
- Managers did not fully investigate incidents and learning from incidents was not always completed or shared with staff. When it was, learning points lacked context or were repetitive, making this ineffective at implementing changes.
- The hospital was not reporting all abuse or safeguarding allegations to the local safeguarding authority.
- Patients continued to be exposed to harm in key risk areas such as staffing levels and staff not completing patient observations appropriately. Managers told us that since our last inspection in April 2021, night-time checks were in place to ensure staff were not asleep and daily CCTV reviews were taking place to check that staff were awake. However, managers told us they had not identified any staff asleep, despite the findings of this inspection. This demonstrates that the provider’s governance processes were not operating effectively, and that performance and risk had not been addressed or improved.
- Permanent staff employed by the provider had completed and kept up to date with their mandatory training.
- Managers provided an explanation to patients when things went wrong in three out of 17 incidents which we reviewed. This was an improvement since our last inspection.