• 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

All Inspections

19 July 2021, 20 July 2021

During an inspection looking at part of the service

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:

  • Safe

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.

20 - 30 April 2021

During a routine inspection

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.

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.


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

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.

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.


  • 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.

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.


  • 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.

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.

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.

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."

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.'

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.

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.

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.

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.