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Edith Shaw Hospital Inadequate

The provider of this service changed - see old profile

We are carrying out a review of quality at Edith Shaw Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Inadequate

Updated 27 April 2021

Edith Shaw Hospital is part of the John Munroe Group and is an independent mental health hospital that provides care, treatment and rehabilitation for up to 14 females, aged 18 or over, with long-term mental health needs. John Munroe Hospital is also part of the John Munroe Group and is located nearby in Rudyard, both hospitals share the same registered manager.

We undertook this unannounced focused inspection based on concerning information received about poor infection prevention and control practice (IPC) and the impact on patient and staff safety. We received several whistleblowing concerns and were informed in December 2020 that the provider had experienced a significant outbreak of COVID-19. In addition, we received death notifications which were all listed as COVID-19-related deaths. In response, a multi-agency improvement plan was implemented at the end of December 2020 to support the provider and gain assurance that actions were in place to mitigate risks to patients and staff. This involved the Care Quality Commission, Public Health England, NHS Staffordshire and Stoke-on-Trent Clinical Commissioning Groups and Health and Safety Executive.

We did not look at all key lines of enquiry during this inspection. However, the information we gathered and the significance of the concerns and clear impact on patients provided enough information to make a judgement about the quality of care and to re-rate the provider.

Following the inspection, we served the provider with a letter of intent under Section 31 of the Health and Social Care Act 2008, to warn them of possible urgent enforcement action. We told the provider that we were considering whether to use our powers to urgently impose conditions on their registration. The effect of using Section 31 powers is serious and immediate. The provider was told to submit an action plan within four days that described how it was addressing the IPC concerns. Their response provided enough assurance that they had acted to address immediate concerns and so we did not take forward urgent enforcement action.

Our rating of this location went down. We rated it as inadequate because:

  • The provider did not ensure all wards were clean, well maintained and fit for purpose. Audits and checks were not enough to provide assurance staff were following good practice to prevent the spread of infection between healthcare workers and patients.
  • Safeguarding alerts were not always made as required and the service did not always work well with other agencies.
  • The service did not always manage patient safety incidents well. Staff told us they were not always supported to report all incidents appropriately and felt managers did not investigate all incidents. Lessons learned were not always shared effectively with the whole team. When things went wrong, the provider did not always apologise and give patients and their family honest information and suitable support.
  • Staff did not always have easy access to clinical information, and it was not easy for them to maintain high quality clinical records, whether paper-based or electronic. Teams did not always have access to the information they needed to provide safe and effective care and used that information to good effect. Not all staff had access to the electronic systems which meant they were heavily reliant on the paper records being up to date. Not all staff knew where to find risk assessments or care plans.
  • Risk assessments were not always personalised, completed to a good quality or appropriate. We saw examples of risk increasing after control measures were put in place. Risk scoring was inconsistent; the outcome of the risk assessments was classed as being higher than that indicated by the scoring.
  • Staff told us that managers were not always visible, and some were not approachable. Staff gave examples of feeling unsupported and demoralised. Staff suggestions for improvement in patient care were not always acted on. In addition, there were examples of staff being dismissed from their role by managers when raising concerns. Staff told us they felt a blame culture had developed that meant they were reluctant to speak with managers.
  • The provider did not always operate effective governance processes throughout the service and with partner organisations. Managers were unable to provide assurance about the safety of the service. Infection prevention and control audits were not always completed, and it was unclear if actions arising from audits had been completed. Investigations including root cause analysis were not always completed to a good standard, there was a lack of consistency and learning from investigations was not always included.
  • Teams did not always have access to the information they needed to provide safe and effective care or use that information to good effect. Not all staff had access to the electronic systems which meant they were heavily reliant on the paper records being up to date. Not all staff knew where to find risk assessments or care plans.

However:

  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • The provider was working with the multi-agency review team to address concerns raised in relation to IPC. However, it was too soon to gain assurance that those changes were fully imbedded and sustained.
  • At the time of inspection, there was one hospital manager responsible for both John Munroe Hospital and Edith Shaw Hospital. After the inspection, the provider shared plans to reorganise their management structure to ensure each ward had their own manager.
  • There had been an improvement in the quality of investigation report templates and reporting into patient complaints. Patients knew how to complain or raise concerns.

As this service has been rated inadequate it will be placed 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.

Inspection areas

Safe

Inadequate

Updated 27 April 2021

Effective

Good

Updated 27 April 2021

Caring

Good

Updated 27 April 2021

Responsive

Good

Updated 27 April 2021

Well-led

Inadequate

Updated 27 April 2021

Checks on specific services

Long stay or rehabilitation mental health wards for working age adults

Inadequate

Updated 27 April 2021

We rated this service as inadequate for safe and well-led. We did not inspect the effective, caring or responsive domains, as such their rating of good remains. . Our concerns related to the lack of good governance arrangements, poor infection prevention and control practices, a lack of therapeutic input to support rehabilitation and a culture whereby staff were not supported to speak up.