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John Munroe Hospital - Rudyard Inadequate

The provider of this service changed - see old profile

We are carrying out a review of quality at John Munroe Hospital - Rudyard. We will publish a report when our review is complete. Find out more about our inspection reports.


Inspection carried out on 12 January 2021

During an inspection looking at part of the service

John Munroe Hospital is part of the John Munroe Group and is an independent mental health hospital that provides care, treatment and rehabilitation for up to 57 adults, aged 18 or over, with long-term mental health needs. Edith Shaw Hospital is also part of the John Munroe Group and is located nearby in Leek, 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 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, 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.

Due to the serious nature of the concerns, we immediately suspended John Munroe Hospital rating. The concerns related to infection prevention and control (IPC) measures and processes, including a lack of management oversight. 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.

We inspected two core service; working age adults in long stay rehabilitation mental health wards and wards for older people with mental health problems. The hospital mainly provides care to working age adults in long stay rehabilitation mental health wards, so although we inspected both services, we have reported on both core services in a single report.

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

  • The provider did not provide assurance all wards were safe, 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.
  • Staff did not always follow good practice in medicines management. Single use equipment was washed and reused. Oral medicines were not dated on opening and medicines were not being administered immediately after being dispensed.
  • Safeguarding alerts were not always made as required and the service did not always work well with other agencies. This had not improved since the most recent inspection in September 2020.
  • 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, we found the provider’s systems for duty of candour were not always effective and patients were not adequately supported when they raised concerns.
  • 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.
  • 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.
  • Care plans were not always goal-specific and lacked detail. The care plans and notes did not always refer to the patients’ diagnoses or risk assessments, nor was it always evident there was a multi-disciplinary team approach. There was limited reference to patient discharge in care plans and/or care notes. Care plans lacked detail in several places, especially around treatment plans for medication; and we found plans were not always consistently reviewed in the light of change.
  • Staff from different disciplines did not always work together as a team to benefit patients. They did not always support each other to make sure patients had no gaps in their care. The ward teams did not have access to the full range of specialists required to meet the needs of patients on the wards. The entire psychology team has recently resigned and as such patients did not have access to psychological therapy or care. There were examples of therapeutic advice being overridden by clinical nurse managers which then impacted on the quality of care being given to the patients. Following the inspection, the provider told us a psychologist had been successfully recruited.
  • The service did not always adequately support patients to raise complaints. Nor did they share learned lessons with the whole staff team and the wider service. We saw examples of investigations where the patient’s Independent Mental Health Advocate (IMHA) had not been invited to support the patient. Following the inspection, the Independent Mental Health Advocacy team told us communication with the service had improved.
  • Staff did not always support patients to have a healthier lifestyle by encouraging them to be active. Patients did not have access to a range of social, cultural and leisure activities as well as education and vocational resource in the wider community.
  • Some wards did not meet the needs of all patients who used the service including those with a protected characteristic. Rudyard ward had not had a dementia friendly assessment despite being the predominant ward for care of older people with mental health problems. Staff did not always help patients with communication and advocacy support.
  • 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 3 and 15 September 2020

During an inspection looking at part of the service

We completed this focused inspection based on concerning information received about the alleged abuse of patients and the impact on staff safety. We specifically focused on our safe and well led domains.

We did not rate this inspection.

We identified the following areas of concern:

  • Staff did not make a safeguarding alert when they recognised possible abuse. Staff said they were not always supported to report all incidents appropriately and felt that leaders did not investigate all incidents. The provider did not follow their own policy in raising concerns and investigating them. Lessons learned were not always shared effectively with the whole team. Not all risk assessments were up to date.
  • 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.
  • Not all staff felt respected, supported, and valued. They did not always feel able to raise concerns without fear of retribution. Leaders were not always visible or approachable. Our findings from the other key questions demonstrated that governance processes did not always operate effectively at ward level.


  • The provider used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s physical health. Staff managed risks to patients and themselves well and had training on how to recognise and report abuse.
  • Leaders had the skills, knowledge, and experience to perform their roles, had a good understanding of the services they managed.

Inspection carried out on 14th November 2019

During a routine inspection

Our rating of this location for people requiring long term rehabilitation and care for their dementia improved. We rated it as good because:

  • The hospital provided safe care. The ward environments were safe and clean and fit for purpose. For example Rudyard ward had been adapted to meet the specific needs of patients with dementia . The wards had enough nurses and doctors to provide care and treatment for patients with dementia and for patients requiring long term rehabilitation. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff provided a range of treatments suitable to the needs of the patients on both the long-term rehabilitation and on Rudyard, the dementia ward. The hospital followed national guidance on best practice for all patients. Staff working on the long-term rehabilitation ensured that the orientation and quality of therapies helped patients in their recovery and rehabilitation. The focus for patients with dementia was to support the development of skills in decision making and help patients plan wherever possible. Staff working on Rudyard had received specialist training in the management of patients with dementia and all patients had access to independent advocacy services. Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The hospital worked to a recognised model of mental health rehabilitation and dementia care. It was well led and the governance processes ensured that ward procedures ran smoothly. The registered manager, in post since the summer of 2018, had been instrumental in making significant improvements at the hospital. All staff recognised that these improvements, made with the full support of the hospital board, were essential to sustain and build upon.


  • The inspection team reviewed twelve care records across the long-term rehabilitation and dementia wards. Seven of these records showed that staff had not included personalised details and treatment goals for patients. These plans were therefore not holistic or recovery orientated.Clinical support workers, who provided most of daily the care for patients, did not have access to the daily electronic patient record and could not personally write their records directly on the system. This meant that detailed information from staff who had frequent contact with patients was not fully available for developing individual rehabilitation plans for patients. However verbal reports, given at handover, from clinical support workers were uploaded onto the electronic record by registered nurses.

  • We found that hospital wards lacked a comprehensive range of accessible information on mental health problems, treatments, physical health problems and smoking cessation. All wards advertised independent advocacy services and all wards, except Kipling, had information on how to make a complaint.

Inspection carried out on 7th December 2018

During a routine inspection

The provider had implemented a full program of staff training and awareness to address all the issues raised in the warning notice issued on 28th June 2018 in relation to medicines management and learning lessons from incidents. This included enhanced pharmacy support and liaison, a continuing review of policies and the employment of a health consultant to ensure the implementation of the action plan they had developed.

  • The provider had ensured there was managerial oversight of the clinical monitoring and safety of patient’s medicines.

  • The provider had ensured that all nursing staff had completed the competency assessment to administer and manage medicines.

  • The provider had ensured that all staff were aware of the incident reporting policy and criteria for reporting incidents.

  • The provider had ensured oversight of the reporting of incidents to identify themes and trends in their medicine management and that there was a process for learning lessons from these themes.

Inspection carried out on 18-19 June 2018

During an inspection looking at part of the service

  • This inspection was a focussed unannounced inspection in response to medicines safety concerns raised by a whistle-blower to the Care Quality Commission. During the inspection we found issues around the management of medicines across all wards.
  • The provider’s safe and secure handling of medicines policy was not being followed by staff. We found there were systematic failures in the management of medicines that included:
  • Medicine stocks not ordered in a timely manner that resulted in patients not receiving medicine as prescribed. Of the 53 patients in the hospital, 23 patients were affected by medication being out of stock on 207 occasions in the three months before our inspection.
  • Medicines that had been opened or removed from the fridge did not have the patient name or new expiry date recorded on the packaging. This meant that staff could not be confident in the continued effectiveness of the medicine
  • Procedures for the safe disposal of medicines were not followed, which is required for audit purposes and the protection of staff.
  • Staff nurses had not received annual training on medicines competency in line with local policy.
  • The actions from internal medicines audits and external pharmacy audits were not implemented to address non-compliance.
  • There was a lack of equipment to monitor the physical observations of patients where an abnormal reaction may have been suspected.
  • Staff did not routinely report the absence of medicines as incidents on the provider’s system and were unclear of the incident reporting criteria. Staff told us they raised incidents verbally with managers, who did not report them on the incident reporting system. This meant that the senior leadership team did not have oversight of emerging trends and themes for medicines incidents.
  • Staff raised safeguarding concerns with the deputy hospital manager or registered manager, who spoke with the local safeguarding board. However, we found this was not a consistent process and not all safeguarding concerns had been raised to the safeguarding board in a timely manner.

However, we found:

  • All the wards monitored and recorded the room and fridge temperatures, and records of these checks were completed daily by staff.
  • Resuscitation equipment and emergency drugs were available in the clinic rooms and staff regularly checked the contents.

  • The multidisciplinary team discussed patients and put risk management plans in place, which staff followed to keep patients safe from harm.
  • Staff were able to describe how they identified safeguarding issues and how they received yearly safeguarding training.

Inspection carried out on 13th-15th February 2018

During a routine inspection

We rated John Munroe hospital as requires improvement because:

  • We saw that provider had made improvements since our last inspection. The provider had resolved some of the issues that we had identified or had started to make improvements but there was further work to complete. However, there were still improvements that the provider needed to make in other areas.

  • We saw there was still a blanket restriction in place. On Kipling ward patients did not have free access to a toilet without asking staff permission. This general restriction was not justified although it may have been in the interests of a few patients on the ward.
  • The hospital did not always follow best practice in relation to gender separation requirements; there was not a female only area on Rudyard ward.
  • Staff did not have consistent access to supervision and appraisals. There had been an improvement in appraisal completion, but supervision and appraisal completion were still an issue on Rudyard; approximately 10% of staff had received regular supervision in the year prior to our inspection and 45% of staff had an appraisal.
  • The ligature risk policy was out of date and an environmental ligature risk assessment for Kipling ward was out of date. Staff did not always update ligature risk assessments where individual patient’s risk was recorded and were not assessing risks in line with policy.
  • We did not find evidence that learning from incidents; patient feedback or complaints took place at team meetings. Team meetings took place regularly on only three of the five wards. The hospital had introduced a lessons learnt bulletin in December 2017 to share learning more regularly but most staff were not familiar with this.
  • Most staff did not understand what duty of candour was and could not describe why it was important.
  • All patients had a care plan but these did not always demonstrate a recovery focus or personalisation. Active involvement in care planning was not always evident; it was not always clear whether patients had received a copy of their care plan.
  • The provider did not maintain comprehensive records of the activities offered to and taken up by patients. Individual therapists maintained records but there was no overall summary of the provider offering support to engage patients in activities that aimed to assist them to gain skills for their rehabilitation.
  • Staff did not know the values of the organisation. Staff described a ‘disconnect’ between the most senior management on the board and the hospital staff. There had been a low level of feedback from the staff survey.


  • There were effective processes in place to ensure staff implemented the Mental Health Act properly. The Mental Health Act manager supported the wards and ensured that mental health act processes were regularly audited and that staff were supported in relation to the act.

  • Staff had a good understanding of safeguarding, staff had completed training and there were effective processes in place for safeguarding. Overall, mandatory training figures had improved since our last inspection. Staff compliance was at 92%. There were effective processes to monitor and implement training.
  • Staff said they felt comfortable to raise concerns and knew how to whistle-blow and said they would do if needed. The provider had a ‘freedom to speak up guardian’ who staff could raise concerns with directly. Staff were positive about the support they received from managers throughout the hospital including the hospital manager.
  • Staff demonstrated that they knew and understood patients’ needs, preferences and risks. Staff ensured risk assessments were up to date, thorough and reviewed regularly. Clinical items and areas were clean, the integrity of mattresses was audited and staff completed checks of emergency equipment.
  • Staff managed patients’ often chronic and complex physical health problems well. The service had a GP who saw patients regularly. Staff promoted healthy lifestyles and supported patients to make healthy choices
  • Staff treated patients kindly and respectfully. We saw staff had a good rapport and were kind and sensitive to patients’ needs. Carers and family members were positive about the care of their loved ones, they felt appropriately involved with care and were happy with the way staff communicated with them about patients. Overall patients and carers were satisfied that patients’ belongings were safe.


Inspection carried out on 7-10 and 22 November 2016

During a routine inspection

We rated John Munroe Hospital – Rudyard as requires improvement because:

  • There were some gaps in checks of emergency resuscitation equipment in High Ash bungalow, there were no records confirming checks of portable equipment on Kipling ward, and clinical equipment such as the medicines cutter on Kipling/Rudyard wards was not clean.
  • Staff delayed replacement of a patient’s mattress that was not fit for use and posed an infection control risk.
  • Staff found it difficult to access the nurse shared between High Ash and Larches because of a lack of adequate means of communication.
  • There were a number of blanket restrictions on Horton, Kipling and Rudyard wards. Patients could not make their own drinks or snacks or keep food in their rooms or elsewhere, and staff did not allow relatives on Horton, Kipling and Rudyard wards or in the patients’ bedrooms.
  • The ward environments of Horton, Kipling and Rudyard wards were sparsely furnished and had poor décor.
  • The design, layout and facilities on Rudyard ward did not promote the safety, comfort and wellbeing of patients living with dementia. The ward had no handrails, orientation aids, signage or other furnishings to support people living with organic conditions.
  • There was a lack of meaningful and recovery-orientated activities on the three main wards. On Rudyard ward, staff engagement and communication with patients with cognitive impairment was limited.
  • Staff were not up-to-date with their mandatory training, and there were gaps for specialist training such as dementia-focused care.
  • Three relatives we spoke with raised concerns about poor communication with the hospital generally, including a lack of updates and difficulties getting through when they phoned.
  • Patients on Horton, Kipling and Rudyard wards did not have access to kitchen facilities. Patients complained about the quality and choice of food available to the three wards (Horton, Kipling and Rudyard). There were no menus displayed.
  • On the three wards, patients’ belongings were not looked after well and went missing.


  • The provider had installed a new alarm system that would allow all staff access to mobile alarms and swipe cards to enter or leave the wards.
  • The hospital had access to a wide range of disciplines that provided clinical input to the wards and patients. This included a skilled and experienced therapies team and occupational therapy service.
  • All staff received supervision regularly.
  • Staff personnel files contained appropriate up-to-date documentation, and fit and proper person declaration forms were in order.
  • The provider had implemented a monitoring system that ensured there were sufficient staff on each ward that could carry out physical interventions safely.
  • The hospital had a strong focus on patients’ physical healthcare needs, and patients had regular and timely access to physical healthcare support.
  • All wards had regular, effective and well-coordinated multidisciplinary team meetings and handovers.
  • The provider had good incident reporting systems and processes that included a central database, daily ward reports and good links with the local authority safeguarding team.
  • The hospital had a risk register that set out risks to the business and service delivery, and described the contingency plans.
  • The provider had improved its governance systems and processes for monitoring all aspects of care. Managers and staff had access to information that helped them assess service delivery and identify areas for improvement.

Inspection carried out on 9, 26 and 31 August 2016

During an inspection looking at part of the service

We found:

  • Staff had limited access to swipe cards and keys, reducing their freedom of movement and their ability to respond to alarms and patient need. Although we could not find evidence that this had led to an increase in assaults the potential risk was evident and a concern to staff.

  • Personal alarms were not in regular use and were limited in supply. A nurse call system allowed staff to call for an emergency response in all rooms and corridors provided an alternative. However, staff responses could be limited by the inability of staff to move freely between rooms.
  • Some agency staff did not have training in the use of physical restraint and could not support permanent staff in managing aggression. This meant possible delays in responding to incidents as the staff team would need to wait until enough suitably trained staff were present before being able to safely restrain the patient.
  • There was a lack of governance around the monitoring of staff on shift each day, their skill profile and distribution around the hospital. Each ward maintained an individual register but there was no central register for the hospital managers to refer to.

  • The cleanliness and the management of bedding was a concern and we found no system in place to support its regular review and renewal when worn or soiled.


  • There were reliable systems in place to support the physical health needs of patients including access to a GP, community nursing team and specialist care. There was no evidence that staff had neglected the physical well-being of patients.

  • Staff operated a transparent system of recording all transactions made on a patients behalf and made an effort to maximise the financial independence of patients. There was no evidence to support the claim that staff financially exploited patients.

  • Inductions for agency staff and new bank staff were robust, and included an introduction to the patient’s risk profiles and individual needs.

  • The majority of staff were very positive about the responsiveness of management and the quality of support they received when incidents took place.

Inspection carried out on 11th January 2016

During an inspection looking at part of the service

We found:

  • There was no reliable system or policy for regularly checking emergency equipment. This was a requirement following the last inspection.

  • Supervision levels for the majority of staff were below the local standard. Annual appraisal of staff performance and development needs levels were inconsistent, being lowest for the basic grade support workers. This left staff unsupported and management without a reliable way of assessing how well staff did their job.

  • Clinical staff did not all know about the results of a check on ligature risks, in the clinical and public areas of the hospital. Ligatures are places to which patients intent on self-harm might tie something to strangle themselves. This made it more difficult for staff to manage risks created by the building when planning care for patients.


  • The hospital had increased the amount of emergency equipment. Each of the three wards and two cottages had immediate access to resuscitation equipment.

  • The service had an up-to-date, full and detailed ligature risk assessment. Following this, managers had developed and carried out an action plan to reduce ligature points across the hospital.

  • Permanent staff vacancies had gone down significantly since our last inspection and a full-time rota co-ordinator had reduced the use of agency staff. A robust system was in place to block book familiar bank staff to cover staff holidays, and long-term sick and study leave.

  • Information on safeguarding people from abuse was on display throughout the hospital. Staff were aware of the forms of abuse they might come across working with vulnerable adults. They also knew how to report their concerns.

  • There was evidence of a developing programme of activities for patients from Monday to Friday, and active monitoring of how many patients took part. Opportunities for weekend activities were limited and dependent on clinical staff rather than dedicated activity workers.