Emerald Place Clinic was first registered with CQC in March 2024. It provides general adolescent inpatient care and treatment for young people aged 13 to 18 years. Elysium Healthcare and the local NHS Trust worked together to develop Emerald Place Clinic as a new, purpose-built 12 bedded unit providing solely NHS funded care for young people, primarily from the local area or relocating back to their home locality with a diagnosis of mental illness across a wide range of disorders and complex needs.
We undertook this assessment following a series of serious incidents which commenced not long after the service opened and had continued to happen. These included young people accessing the roof, a young person falling from an external windowsill and several assaults on staff. This led to a pause to admissions, although the unit reopened to admissions once the acuity had been de-escalated. However, following the reopening, a number of concerns about the quality of care were raised with Surrey Provider Collaborative. NHSE placed the unit on Level 3 Intensive Quality Oversight. Following a site visit on 5 September 2024 by NHSE and the Provider Collaborative the Intensive Quality Oversight level was reduced to 2 and a Response and Recovery Plan initiated. On receipt of the report from the visit we made the decision to conduct an assessment covering all the quality statements across the five key questions; is the service safe, effective, caring, responsive to young peoples need and well led.
At the time of the site visit there were 4 young people receiving care and treatment at the unit.
We found:
Although Emerald Place Clinic had been purpose built, there were a number of significant environmental safety issues that had not been picked up at the handover of the building. Due diligence checks did not appear to have been robust. This was a breach of Regulation 15, Premises and equipment.
In addition, there had been a lack of substantive, strong leadership at the service since it opened. Systems to ensure the safety of both young people and staff had not been effective, which had placed both young people and staff at risk. This was a breach of Regulation 12, Safe Care and Treatment. The new hospital director and ward manager had both only been in post less than two weeks at the time of our visit.
The regional service director and hospital director told us that they welcomed the oversight and support from NHSE and the provider collaborative and the weekly meetings were having an impact on improving the quality. They outlined that the nature of the partnership between Emerald Place Clinic and the local NHS Trust had shifted from initial inception of the unit during the commissioning phase. Initially the local NHS Trust was going to appoint multidisciplinary team staff and hold the registration. However, this responsibility had now passed to Elysium, the provider for the service.
Leaders acknowledged this new relationship with the local NHS Trust would benefit from further development particularly in relation to strengthening relationships and partnership working with community services.
Alongside the external environmental safety concerns, we had concerns about whether the ward layout and space could safely and effectively accommodate 12 young people. The décor in the ward was white and clinical, there was a lack of communal space, no dedicated activity space or quiet space; it did not meet the needs of neurodivergent young people or interests and choices of young people. This was a breach of Regulation 9 Person Centred Care.
The service was subject to NHSE Level 2 Intensive Quality Oversight and although improvements had started to be made there was still much to do to ensure the environment and care was safe and met the needs of young people. As part of the plan to bring about improvements NHSE and the Provider Collaborative were looking to transfer or discharge all the young people. Neither young people, or staff felt this would be in their best interest.
Until the external environmental work had been completed, restrictions were placed on young people’s access to fresh air and physical exercise in the garden area. Staff placed blanket restrictions on all young people, meaning that all young people required three staff to escort them into the garden and only one young person could go in the garden at one time. This was not in line with assessed risk or care plans. This was a breach of Regulation 9 Person Centred Care
Young people didn’t always have their needs met. Young females requested that only female staff provide their care, especially when they were on enhanced observations and required personal care but at night there were more male staff than female staff. Young people were often restrained in their bedrooms which they didn’t like as this was their safe space. There were no advance statements/directives documented in peoples’ care plans to support young people in their decisions that if restraint was necessary, where possible, it would be carried out where they could be protected by the use of CCTV and reflect the views of young people in relation to their choice in relation to gender of staff involved their restraint. This was a breach of Regulation 12, Safe Care and Treatment
The service was situated a considerable distance from local towns with no access to public transport. Whilst the service had access to a minibus, they did not always have enough drivers available to facilitate young people accessing activities that would be appropriate and of interest to them. In addition, staff found it difficult, and expensive, to get to and from work due to the location of the service and lack of public transport. The Elysium Healthcare service next door had a minibus that was used to pick staff up and drop them off at nearby rail/bus services. This facility wasn’t available to staff at Emerald Place Clinic. This was a breach of Regulation 9 Person Centred Care
Leaders had put some governance systems and processes were in place, but these were not operating as effectively as they should.. There was now a recognition that more work was needed to ensure systems and processes were robust, could provide information to monitor the service, make improvements and provide assurance to senior leaders and partner organisations. This was a breach of Regulation 17 Good Governance.
However,
NHSE and the Provider Collaborative informed us that, following a site visit on 5 September 2024, it no longer had significant concerns about the safety of young people at the service The service was now being supported by senior leaders from Elysium Healthcare. Hospital leaders and more staff had been recruited and were receiving training. Young people’s risks were thoroughly assessed and were being managed. There were plans in place to minimise the environmental risks until the work could be caried out to remove them. Leaders at the service welcomed the support and oversight provided and partners involved in the quality oversight process recognised the positive approach and effort made by the service to improve and develop the service.
Leaders had developed a programme of work to address environment safety issues was due to start imminently and be completed by the end of October 2024. The hospital director had plans to develop a sensory room and was working with staff and young people to consider how the internal environment could be improved to provide a more therapeutic space that reflected the needs and wishes of young people.
The hospital director had a clear vision for what they wanted to achieve at the service and was developing and implementing systems and processes focussed on supporting staff wellbeing and ensuring everyone promoted a culture of safe, good quality, person centred care and treatment. All staff spoken with were positive about the new leadership team and said they had made a significant impact and positive change in a short space of time.
The hospital director had implemented a programme of training and checking staff competencies and staff were more aware of how to provide safe care. Staff had started to receive regular 1:1 supervision and monthly reflective practice sessions were held. There was enough staff on each shift on the ward to keep young people safe and generally meet the needs, including their level of enhanced observations. Good practice was recognised and celebrated.
Staff completed comprehensive risk assessments, positive behaviour support plans and care plans and reviewed them regularly. Young people were involved in planning their activities, attended the onsite school and were supported to produced good work. Staff completed physical healthcare monitoring as needed and managed medicines were safely. Young people were encouraged to be as independent as possible, make informed decisions and take control and responsibility for their choices. They were encouraged to think about their discharge and life outside hospital and encouraged to engage with staff from the Hope Unit (a local service that provided support for young people with mental health problems both in hospital and in the community).
Staff delivered care in line with national guidelines and had a good knowledge of their roles and responsibilities under the Metal Health Act and Gillick Competency Guidelines.