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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 carried out on 13 January 2021

During an inspection looking at part of the service

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.


  • 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 carried out on 31st July 2018

During a routine inspection

We rated Edith Shaw Hospital as Good overall because:

  • During this inspection, we found that the service had addressed the issues that had caused us to rate Safe as requires improvement following the November 2016 inspection. The hospital was now meeting Regulation 18 HSCA (RA) Regulations 2014 Staffing.
  • At this inspection, we found that the provider had ensured that all staff received mandatory training and all staff knew how to report safeguarding incidents appropriately. All staff had received regular supervision and appraisal, and were competent in their roles and responsibilities.
  • We found that staff used restraint as a last resort and had positive behavioural plans in place for all their patients. This meant that following assessment staff helped patients to develop strategies to recognise triggers of behaviours that challenge to find ways to manage it better.
  • Risk assessments at Edith Shaw Hospital positively involved patients and built on their strengths. All risk assessments contained agreed plans to reduce identified risks and both medical and nursing staff were involved in developing them. This involvement ensured the inclusion of different clinical perspectives in the risk reduction plans for patients. Staff also made holistic assessments that included both physical and psychological factors.
  • Edith Shaw Hospital was a clean and safe environment and the provider had invested in a continuing refurbishment program that included redecoration, new furniture and flooring. 
  • The hospital continued to have good working relationships with the local GP, practice nurse and pharmacist. These relationships were important to support the safe care and treatment of Edith Shaw Hospital patients.
  • Care planning for patients at Edith Shaw Hospital included comprehensive and personalised plans for patients. Staff were caring towards patients, treated them with dignity and respect, and demonstrated a high level of understanding of individual patients needs and wishes.
  • Staff encouraged patients’ involvement in activities and ensured patient consultation on the type and frequency of activity they would like to join. The hospitals activity program had improved since our last inspection in 2016.


  • We observed that a nurse was interrupted several times by other members of staff when administering drugs to patients.
  • Edith Shaw hospital staff learned lessons at a local level with support from clinical colleagues. However, learning from incidents decided on at governance meetings and to be shared from the sister hospital was sometimes not formally communicated to Edith Shaw Hospital staff.
  • No patient satisfaction survey had been conducted in several years.
  • There were of lapses in effective communication within Edith Shaw Hospital’s governance systems. In one case senior managers did not effectively communicate the learning from a drug administration error.
  • There was limited occupational therapy (OT) input to patients.

Inspection carried out on 9 November 2016

During a routine inspection

We rated Edith Shaw Hospital people as good overall because:

  • During this most recent inspection, we found that the service had addressed the issues that had caused us to rate effective and well led as requires improvement following the December 2015 inspection. The hospital was now meeting Regulation 17 HSCA (RA) Regulations 2014 Good governance.
  • The provider had robust recruitment processes in place for directors. All board members human resources files had completed fit and proper person declaration forms, professional references, and disclosure and barring service (DBS) checks.
  • The provider had updated all Mental Health Act (MHA) Code of Practice policies and procedures in line with the revised Code of Practice dated April 2015.
  • During this most recent inspection, we also found that daily checks on staffing levels ensured the safe staffing of the hospital. These arrangements included contingency plans to manage unplanned staff sickness and absence.
  • Patients had a comprehensive physical and mental health assessment on admission to the hospital and a full multidisciplinary team was responsible for their care. Staff attended regular review meetings to formulate positive behaviour support plans and ensure that care plans focused on patients’ physical and mental health.
  • The hospital had good working relationships with the local GP and practice nurse and had access to an experienced therapies team and occupational therapy service.
  • Staff were caring towards patients and treated them with dignity and respect. Patients could attend their care review meetings, were encouraged to be involved with their care plans, and agreed their discharge and follow-up care in consultation with their family and carers.
  • Patients’ bedrooms were personalised and had adjacent bathroom suites for individual use. Patients also displayed pictures, in their rooms, that they had painted during activity sessions.
  • Processes were in place to monitor and learn from incidents. Staff also received regular supervision and were of the right grade and experience.


  • Staff compliance with mandatory training was low. Training rates were low for safeguarding, food safety, and Mental Health Act, Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Staff did not always report all safeguarding incidents appropriately.
  • Hospital staff were restricted in their observation of patients due to the layout of the building.
  • The patients’ quiet room was frequently unavailable to patients because of its dual use as a multidisciplinary team meeting room.
  • Staff were not consulted on the review of the John Munroe Group’s vision and values statement.

Inspection carried out on 07 and 08 December 2015

During a routine inspection

We rated Edith Shaw as requires improvement because:

  • The unit did not fully meet the rehabilitation needs of patients due to the lack of a full onsite multidisciplinary team to deliver a recovery focus service. Staff and patients reported there was insufficient occupational therapy (OT) support to meet the needs of the patients. OT staff numbers and input as well as the lack of recovery focus in care plans also indicated this.

  • The units planned establishment of nursing staff on a shift was two qualified staff to meet the needs of the patient group. We heard from staff and saw in rotas that only one qualified staff member was on shift routinely between Thursday and Sunday due to current vacancies.

  • Staff under-reported incidents that were potential safeguarding concerns to external agencies.

  • Care records did not consistently show patients’ views on and involvement in their care.

  • The staff recruitment processes were not consistent applied to staff at a senior level. Employment files for board members did not contain evidence how they were selected, references or disclosure and barring service checks.

  • The portable wooden steps used to help patients onto the unit’s minibus were not sufficiently sturdy to steady and support patients safely.

  • The unit had blind spots in the bedroom corridors. Staff reduced the potential danger from these by taking into account individual patient risk factors when allocating bedrooms, and using staff observations.
  • The provider generally managed the application of the Mental Health Act well. However, we found errors in completion of forms relating to the MHA and the unit had not updated its Mental Health Act policy in line with the changes in Mental Health Act code of practice. Both of which have been addressed since inspection.
  • There were gaps in some of the medicines charts even though the provider had tried to address the issue. Documentation on the medicine charts was unclear if the doctor had reviewed some PRN medication (‘as required’) within a two week period.


  • The unit was safe, clean, well maintained and allowed patients a degree of autonomy. The hospital had identified ligature points in the ligature risk assessment and put measures in place to reduce the danger from these. Ligature points are places to which patients intent on self-harm might tie something to attempt to strangle them. All staff followed infection control procedures. The unit was well adapted for disabled access. All patients personalised their rooms and held their own bedroom keys.

  • Electronic and paper records systems were well co-ordinated and easy to access. Staff carried out appropriate checks on medicines storage and emergency equipment to ensure high standards of safety.

  • Patients received good physical healthcare support from staff, the local GP and a practice nurse who visited the unit weekly. There were effective arrangements for out-of-hours medical cover and staff confirmed they could have medical support day and night. Staff we talked to spoke positively about the unit describing a good team working ethos, and said that management were supportive.

  • Patients received meals that met their health needs and personal preferences and had access to drinks and snacks throughout the day.

  • Staff used the least restrictive options to manage challenging behaviour including de-escalation (calming down) techniques. Staff rarely used physical restraint or rapid tranquillisation. Staff told us they received training in physical restraint and knew how to report incidents and safeguarding concerns, and received debriefs following all adverse events.

  • Staff received induction, training, supervision and appraisals. They also had access to regular team meetings. There was good interaction between staff, patients and relatives; patients felt listened to and relatives felt involved.