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  • We have suspended the ratings on this page while we investigate concerns about this service.

Reports


Inspection carried out on 15 December 2020, 16 December 2020

During an inspection looking at part of the service

This inspection was an unannounced, focused inspection in response to concerns regarding patient safety, incident management, safe staffing and the use of restraint.

We looked at specific key lines of enquiry during this inspection therefore we have reported in the following domains:

  • Safe
  • Well led

We are placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

As this was a focused inspection, we did not inspect the domains of Effective, Caring and Responsive. Due to the concerns we found relating to the quality of care in other key questions, we have suspended the provider’s current ratings within these domains. This suspension will remain in place until CQC is able to review this key question.

We rated St Johns House Hospital as inadequate because:

  • The ward environments were not always safe. Ligature points were found in areas used for seclusion and ligature audits had outstanding actions which required completing to keep patients safe.
  • Staff were not following infection prevention and control (IPC) measures to keep the hospital clean and to help prevent any infectious diseases from spreading.
  • Staff on Walsham ward did not have access to working resuscitation equipment and the emergency bag checklist did not match the contents of the emergency bag.
  • The service did not have enough nursing and support staff to keep patients safe and staffing was not structured in line with patient acuity and clinical need. Staffing levels were consistently 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 found staffing allocations for observations were not completed and we reviewed CCTV footage where staff were asleep whilst completing patient observations.
  • The provider had not ensured that all staff had completed or were up-to-date with their mandatory training. Only 56% of staff had completed their physical intervention training and only 62% of staff for their basic life support training.
  • Staff did not always manage risks to patients and themselves well. Patients did not have adequate nursing assessments, associated care plans, risk assessments and positive behaviour support plans in place to enable staff to safely manage patients. Staff did not always act to prevent or reduce risks or respond to changes in patient risks.
  • Staff did not make every attempt to avoid using restraint. Levels of physical restraint were high, and between 1 November 2020 and 22 December 2020 there were 204 instances of physical intervention. We observed CCTV footage of seven patient incidents where we found that staff restrained patients using inappropriate techniques that were not ‘provider approved’ techniques taught to staff or proportionate to the risk.
  • Restraint incidents frequently took place in sight of other patients and staff, as staff did not attempt to direct other patients away from the scene. Staff did not always support patients to stand up following restraint.
  • The hospital had high numbers of incidents, some of which resulted in injuries to both patients and staff. The provider reported 273 incidents between 16 November and 13 December 2020, 158 of which were related to violence and aggression.
  • Levels of seclusion were high, and patients were regularly secluded in side rooms as the seclusion room was regularly in use. Seclusion rooms and areas used for seclusion and long-term segregation were not fit for purpose and compromised patient dignity and safety. Patients in long-term segregation did not always have access to fresh air or activities. Patients did not always have lounge and en-suite facilities. Patients who were segregated on general corridors could be observed by other patients as staff kept the door open to complete observations.
  • Staff did not keep clear records or follow the Mental Health Act Code of Practice when a patient was placed in seclusion or long-term segregation as records were incomplete and unclear. Nurses did not always complete meaningful seclusion reviews and reviews were not always completed when they should be.
  • The service did not always manage patient safety incidents well. Staff did not report incidents clearly or as a true reflection of what occurred. Staff did not highlight the severity of the incident or transparently report the actions of staff during the incident. Managers did not fully investigate incidents and learning from incidents was not always completed or shared with staff. Staff did not always complete post incident checks with patients including checking for injuries or completing body maps.
  • The hospital was not reporting all abuse or safeguarding allegations to CQC or the local safeguarding authority. Staff did not always demonstrate the values of the provider and incidents which we reviewed highlighted that staff did not always treat patients respectfully. There were four ongoing investigations, relating to the use of restraint from staff, in which staff were suspended from either working at the hospital or working directly with patients.
  • Staff highlighted concerns with the culture at the hospital and felt stressed due to low staffing levels, patient aggression and wanted improved training and communication at the hospital.
  • Our findings demonstrated that the providers governance processes were not operating effectively, and that performance and risk was not always managed well. For example, we found that incident reviews did not highlight key learning which could help to prevent incidents from occurring again. Risk at the hospital was not always managed well, as patients were exposed to harm due to low staffing levels and inappropriate use of restraint.
  • The providers clinical governance meetings did not address key service risks as actions were not set to address all risks and concerns raised. The provider did not have an overarching quality assurance process of issues that had been identified.

However:

  • Staff were able to give examples of abuse and managers held monthly safeguarding meetings.

Inspection carried out on 03 - 04 July 2018

During a routine inspection

We rated St Johns House as good because

  • The provider had established the staffing levels required to meet the needs of the patients. Ward managers had the autonomy to increase staffing levels if required. Staff training was 94% complaint. Staff received regular supervision and annual appraisal in line with the company policy. The provider had completed a ligature assessment and took steps to reduce the risk as required. All wards complied with the Department of Health guidance on same sex accommodation. Medical cover was available day and night.
  • We reviewed 16 care and treatments records and found evidence that patients received a comprehensive risk and physical health assessment on admission. Patients were involved in developing their care plans and were outcome focused. The hospital offered a range of psychological interventions recommended in the National Institute for Health and Care Excellence guidelines. For example, offence specific interventions such as fire setting intervention programme for mental disordered offenders, motivational work and emotional regulation interventions such as cognitive behavioural therapy and anger management therapy.
  • Patients knew the complaints process and had access to an independent mental health advocate if requested. Staff were aware of the provider’s whistle blowing policy and knew their responsibilities in relation to safeguarding. Staff spoken with told us they felt confident raising concerns to senior managers without being victimised.

  • Ward managers and senior managers had oversight of the hospital. Ward performance was monitored by completing regular audits and the outcomes were recorded on key performance indicator dashboards. This meant that managers could monitor performance over a period of time to ensure continuous improvement.

Inspection carried out on 06-07 February 2017

During a routine inspection

We rated St John’s House as good because:

  • The provider had ensured the few ligature points (ligature points are where something can be tied in order to self-harm) across the site were recorded on the environmental risk register. The provider mitigated the risk posed by ligature points by locking off or highly supervising areas where ligature points remained.

  • The wards complied with Department of Health guidance on same sex accommodation. All wards were single sex environments. Outside space was accessible from each ward. Each ward had a fully equipped and spacious clinic room that was fit for purpose. The environment was visibly clean and comfortably furnished. There was a range of rooms for activities, quiet lounges, and communal areas.

  • Medical cover was available both day and night. Doctors attended the ward within an hour when patients were secluded.

  • The provider had clear referral and assessment processes. Assessments were comprehensive and included both current and historical information.

  • A full review of physical intervention training was being carried out, with the aim of introducing new techniques where staff would be taught to safely disengage from patients who unexpectedly descended in to a prone position.

  • Staff worked well as part of a multi-disciplinary team. Each ward had a designated full time activity co-ordinator. Speech and language therapists and assistants were available.

  • Care records showed that physical health examinations were completed on admission. The provider employed a full time physical healthcare nurse to offer advice and support to staff in between the weekly GP visits to the hospital. Patients’ physical health was regularly monitored, recorded and actions taken where necessary.

  • Staff involved patients in all aspects of their care. Patients attended individual care reviews and created their own activity plans with staff. Patients held information about their care and treatment.

  • Staff morale was consistently high across the range of staff roles.

However:

  • There was higher than expected use of restraint, including prone restraint. There were 1263 instances of restraint from April 2016 to September 2016. These restraints were in the main among the same group of patients, for instance on Redgrave ward there had been 531 restraints between 17 patients. The provider classed and recorded restraint as any form of hands on contact. This was supported by a breakdown seen of restraint records between April and September 2016 where 82 ‘come along’ techniques were identified. Standing restraint was recorded at 152 and seated episodes at 281. There had been 168 prone restraint episodes.

  • The frequency of supervision varied between staff. Some staff told us they had supervision six weekly, some said three monthly and others monthly.

  • Some staff were unable to explain how issues of capacity might affect this patient group.

  • Positive behaviour support plans lacked individual detail.

Inspection carried out on 13-14 January 2016

During a routine inspection

Overall we rated St John’s House as inadequate because:

  • There were high incidences of restraint including prone and rapid tranquillisation. On Redgrave ward on four occasions there was no monitoring of rapid tranquillisation. Restraint was not effectively monitored and action taken. The provider had a plan in place to reduce restrictive intervention since 2014 but this had not been effective.

  • Some of the wards did not provide a safe and clean environment. Bure had ligature risks that staff had not assessed. Although Walsham and Redgrave wards were clean and well maintained, both Bure and Waveney were dirty.

  • Staff did not always monitor the physical health of patients adequately. Staff on Waveney ward did not monitor the physical health of one patient with diabetes regularly. Staff on Redgrave did not change the level of observation or make any other health intervention after one patient had swallowed an item.

  • Not all of the staff were up to date with mandatory training some training levels were below 75%. Staff did not receive the appropriate mandatory training necessary for their role. However, an experienced member of staff was present on the ward at all times. The ward manager was able to adjust staffing levels to take account of the patient mix. Staff knew how to recognise and report incidents.
  • The seclusion suites did not meet the requirements of the Mental Health Act code of practice. Patients in seclusion on Bure and Waveney could not see natural daylight because ward staff did not know how to operate the electronic blinds. The seclusion suite on Waveney room door had a window that was cloudy and unclean. The Bure ward seclusion room was dirty. The seclusion wet room window area was dirty with mould around the window frames.
  • Although the staff had strategies to manage challenging behaviours, one patient on Redgrave ward needed a mechanical restraint plan and did not have one. Patient care records varied in content and detail. Although staff recorded patients life histories particularly those with long and complex histories of care.
  • There were blanket restrictions related to access to outside space after 7:15pm. Staff told us this was due to staffing levels.

  • One patient needed medicines for a rash and was in discomfort. The medicines were not in stock and staff did not seek to obtain emergency medicines.

  • On Bure ward clinic room sharps bins in use were not dated and recorded once in use. There was no signage present regarding the presence of oxygen cylinders on the wards.

However:

  • Throughout the inspection we saw patients were treated with kindness, dignity, respect and compassion whilst they received care and treatment. Patients knew where and how to access advocacy services. Staff appeared interested and engaged in providing good quality care to patients. Patients were involved in care planning. There was effective input from the GP with regular visits and chiropody care. Medicines management were generally satisfactory on wards. The records showed that patients were getting their medicines when they needed them.
  • Patients had access to a full range of rooms and equipment to support care and treatment including a multifaith room. There was a choice of food to meet the specific dietary requirements of religious and ethnic groups. There was a weekly timetable of community and on-site occupational activities. Staff liaised with outside agencies and groups to ensure patients received an effective discharge.
  • Complaints received had been investigated and acted upon quickly, and there were good systems in place to share learning from complaints throughout the hospital. However, there was insufficient accessible information around patients care and treatments.
  • There were regular and effective multidisciplinary meetings and working relationships with teams outside the organisation such as social services. Staff had received an annual appraisal of their work performance and regular managerial supervision. Staff told us there was good team work and staff morale. Staff knew the senior management team. The lead psychologist was involved in research and development of offence related treatment programmes specific to learning disability. Regular security briefings alerts were circulated to wards with lessons learnt and recommended actions.

Inspection carried out on 24 November 2014

During an inspection looking at part of the service

We found;-

  • An audit of ligature points had been carried out . There were potential ligature points in bathroom and bedroom observed on Walsham and Waveney wards relating to taps and doors. The provider had rated these as low risk. Patients assessed as at risk of self harm or suicide had specific care plans to address this risk.   

  • The Patients' Council and three other patients reported feeling unsafe because of the number of incidents, patient on patient physical assaults and sexual harassment. The patients’ council did not consider that the issues it raised were responded to by the hospital.   
  • Staff at St. John's House used physical restraint to control the behaviour of patients on 684 occasions in the six months leading up to the inspection visit. On 290 of these 684 occasions the patient was restrained in the prone (face-down) position. 56% of the prone restraints related to one patient. Staff told us that prone restraint was used as part of planned packages of care. An audit report dated 10 April 2015 showed that number of restraints were reducing each month during 2014.
  • Department of Health guidance published in April 2014 is that planned or intentional prone restraint should not be used. The guidance also calls for providers to implement restrictive intervention reduction programmes. The managers of St. John's house had established such a programme.
  • 98% ward staff had been trained in using positive behavioural support (PBS) to minimise and manage challenging behaviour. However, care plans did not consistently include the functional assessments of behaviour that underpin PBS. Also, staff did not use proactive strategies to reduce the likelihood of disturbed behaviour such as anticipating and meeting patients’ needs.
  • The dignity of patients was affected by the lack of seclusion furniture in two seclusion rooms.   
  • There was a lack of regard to the Mental Health Act Code of Practice in failing to record discussions relating to second opinion appointed doctors’ reviews, and the prescribing of medication in relation to statutory treatment certificates. 
  • Performance information was collected and reported from “ward to board" which had been recently introduced. This information was not fully embedded in ward areas as staff were not able to say how the data informed decision making to drive improvement and inform ward objectives.
  • Staff were trained in risk management and emergency care. Staff felt safe on the wards. Staff knew how to report incidents and safeguarding issues.
  • National Institute for Health and Care Excellence (NICE) guidance was followed in relation to medication. Clinical audits were being undertaken, that showed positive results. The hospital had published research into interventions it was used such as mindfulness and positive behaviour support.

  • The majority of patients said that they could talk to staff and were listened to. They received one to one sessions and felt supported by the clinical team.
  • There was a care pathway that patients followed and co-ordinated discharges were organised.
  • Most staff felt supported by senior managers. Healthcare support workers were and exception. This group of staff did not feel listened to. There was good team working, and staff received managerial supervision.

Inspection carried out on 8 July 2013

During a routine inspection

During our inspection we spoke in detail with six people who used the service. They told us how the service involved them in decisions about their day to day lives and about their care and treatment.

They told us that there were regular 'in house meetings' held on their ward. One person said that this gave them, "The chance to talk up." However, they added that,� Meetings don�t always make a difference." Another person told us, �We always speak up at in-service meetings." They also told us they had used the advocacy service and said, "They're good." Another person we spoke with told us the advocate came to their review meetings and said, "They speak up for me." This showed that people had the chance to discuss concerns with an independent advocate who would speak up on their behalf where appropriate.

People we spoke with told us about activities that they were able to take part in. these were vocational as well as leisure activities. Three people told how much they enjoyed horticultural sessions.

We looked at how the service responded to incidents and at the safeguarding procedures in use. This showed that measures were in place to ensure people were safe and that any incidents were quickly responded to and dealt with.

We looked at care, staff recruitment, maintenance and training records. These were well maintained and ensured that information was accurate and fit for purpose.

Inspection carried out on 6 August 2012

During a routine inspection

During our visit we spoke with eight of the 31 people who were receiving treatment at the time. They told us they were well treated and supported with their day to day living. One person told us that staff "Go out of their way to help us" and another person said "Staff support me as much as they can."

We were told by five people who used the service that they had care plans although one person told us that some of the other people who used the service "Did not always follow them (the care plans.)"

We were told about recreational activities which included art, gardening and sailing and also about numeracy and literacy sessions. We were told by one person that their chosen activities were "Sometimes cancelled" and that "No one tells me why."

We were also told that plans for the future had been discussed with most of the people we spoke with. One person told us that they knew what they had to do first. They said that they had to "Do all my psychology work first" and added that it was "Hard work but helpful."

Most of the people we spoke with told us they knew what to do if they were being abused or witnessed abuse, but only one person said that they "Felt safe."

Inspection carried out on 20, 21 December 2011

During a themed inspection looking at Learning Disability Services

At the time of the review there were 31 people receiving treatment at St Johns. Two people were on trial leave, and seven beds were not being used due to refurbishment of one of the units. We spoke with nine people during our visit to get their views on the service and the treatment they received.

The people we spoke with told us about their past and events that led to their admission to St Johns House. One person told us that �they knew they needed help because of what had happened to them� (in the past) another that they had �improved since I came here�

Two people knew that they had a care plan and Health Action Plan, but were not sure where it was, another told us they were �involved in the care plan, it was about helping them�

People we spoke with told us of things they do during the day which included rambling, gardening, arts and crafts, swimming, bowling, football and exercise. One person told about the educational activities they did which they enjoyed. This included literacy and computer work.

We also spoke with the relatives of four people being treated at St Johns. None of the relatives had any involvement with the care planning of their family member, although one acknowledged that their parent had been more involved, and one told us they had respect for the staff team and felt �no other place could care for their relative.�

Inspection carried out on 31 August 2011

During an inspection in response to concerns

During our visit on 31 August 2011 we spoke with a number of people about their views and experiences of Bure ward.

People told us that they were involved in planning and reviewing their care. We were told that people had opportunities to ask questions about their treatment and one person told us, "People listen here, we get lots of support from staff."

We were told that there was a good balance of activities, including educational sessions, arts and crafts, cooking and games. Most people also had escorted leave and made use of community facilities.

Two of the people we spoke with were complimentary about the staff.

One told us that if things were difficult staff helped them. Another said, "I have communications with the staff and I would tell them if I wasn't happy." People named specific staff whom they felt comfortable speaking to about their concerns.

Inspection carried out on 9 June 2011

During an inspection in response to concerns

People using the service told us that they received the support they needed from the staff. Two people said they liked the staff and got along well with them. People had opportunities to participate in therapeutic and recreational activities, which they said they enjoyed. People had different views about whether the sessions were voluntary and some people told us there were consequences if they did not attend. We asked the manager to look into this and ensure that everyone was clear about what was expected of them.

Inspection carried out on 8 February 2011

During an inspection in response to concerns

We were able to ask people about their views and experiences relating to all of the outcomes we looked at. We spoke at some length with five people from two of the wards.

People gave us examples of how they were able to make decisions and consent to their care and treatment, unless this was part of their treatment under the Mental Health Act. One person told us that they had asked staff for information about the medicines they took, which helped them to give informed consent. Another person said that staff tried to encourage her to accept help but no-one tried to force her if she said no.

Four of the people with whom we spoke had been subject to restraint at some time during their stay at St Johns House. They held the view that restraint was used too quickly by staff. However, two people then went on to give us examples of how staff had tried to help to calm them by talking and it was only when this did not work they needed to resort to restraint. Two of the people with whom we spoke raised concerns for their safety because the staff call system was not working properly.

Four of the people with whom we spoke said they thought the cleanliness of St Johns could be better. Two people told us that the hot water on one of the wards was not working properly. We later found out from the manager that this issue had been resolved. Another person we spoke with said they thought the cleaning products in use could be better, but this was their personal opinion.

People were not really clear about what training staff had or whether staff always understood their needs. One person told us, "Sometimes when I get upset I feel they don�t understand but when I talk to them they do."

We asked three people about how complaints were dealt with. It was their perception that nothing was done about complaints. We looked into this and found that this was not the case.

Reports under our old system of regulation (including those from before CQC was created)


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.