All inspections: The Langford Centre - Care Quality Commission

The Langford Centre is an independent mental health hospital providing care and treatment to working-age adults with severe mental illness or a learning disability. The service provides one low secure forensic ward, two high-dependency mental health rehabilitation wards and three acute mental health wards for adults of working age.

The Care Quality Commission (CQC) conducted an unannounced inspection of The Langford Centre on the 1 and 2 March 2023. The inspection was carried out to check if the improvements required following the inspection in May 2022 and detailed in an action plan submitted by the provider in October 2022 had been made.

One of the acute mental health wards for adults of working age (Arlington ward) had recently opened in September 2022 and this was the first time we had inspected this ward.

Due to the concerns we identified during this inspection, the CQC used its urgent powers under section 31 of the Health and Social Care Act 2008 and issued the provider a Letter of Intent. The letter instructed the provider to provide assurance of its immediate action to improve the assessment and management of ligature risks. Subsequently, the provider supplied evidence of revised ligature audits which were an accurate reflection of ligature risks on the wards and the mitigation actions for these risks. The provider also acted promptly by removing or reducing identified ligature risks which had not previously been identified, supplied staff with appropriate ligature cutting equipment in line with their policy and rolled out additional ligature awareness training for all staff.

Our rating for The Langford Centre stayed the same. We rated it as requires improvement because:

Each of the three core services were rated as requires improvement overall. Potential ligature anchor points still existed across the wards which had not been identified on the providers’ ligature risk assessment document, despite the provider implementing a programme of works to minimise the presence of potential ligature risks after the last inspection in May 2022. A ligature anchor point is anything that could be used to attach a cord or other material for the purpose of hanging or strangulation.
Equipment for managing ligature risk, such as wire cutters, were not available for staff to use in line with the provider’s policy. Staff did not know how many ligature cutters should be available on the wards and ligature cutters which were present were not always in working order.
We issued a Letter of Intent because the governance was not robust enough to ensure that ligature risks were assessed and managed well. The governance processes around how ligature risks were systematically reviewed, and actions carried out were not evident or documented effectively, and this had not been identified by the provider. Although immediate improvements were made in relation to the assessment and management of ligature risks, these improvements needed to be sustained and embedded.
Staff did not always follow systems and processes to safely administer, record and store medicines and did not routinely check medical equipment.
Whilst the provider had recruited additional occupational therapy assistants, there was only one qualified occupational therapist working across the hospital. This meant that there was limited occupational therapy support, particularly on the high-dependency rehabilitation wards where patients needed to be supported for discharge to community settings after long stays in hospital.
Although the provider had plans to review the service model for the two high-dependency rehabilitation wards, this service did not adhere to the current model. Whilst there had been some improvement, the length of stay for patients on the rehabilitation wards was over two years, which was much longer than the anticipated maximum stay of one year for this type of service, as outlined in the CQC’s brief guide for high-dependency unit specification.
There were limited activities of daily living during weekends and evenings which were basic and nurse led.
The quality and detail of patient care plans was inconsistent across wards. Patient care plans on Seaford and Balmoral wards did not always capture patient views or goals. Positive Behaviour Support (PBS) plans on Pevensey ward were not always tailored to patient’s needs and not updated regularly.
Record keeping was inconsistent across wards. Staff recorded patient clinical information on both paper and electronic records, which posed a risk that all the information they needed to deliver safe care and treatment would not be accessible or up to date. Some staff reported that there was a lot of duplication and that documents were often disorganised and difficult to find.
Patients’ privacy and dignity was not maintained. On Arlington ward, staff searched patients returning from leave in an area which could be observed by others. On Seaford and Fairlight wards, staff did not routinely close the nursing office door which meant confidential discussions including patient identifying information could be overheard.
A hospital wide systematic process for sharing lessons learned from incidents and complaints was inconsistent and not embedded.

However:

Staff treated patients with compassion and kindness and understood the individual needs of patients. All patients we spoke with were positive about their experience using the service. Staff felt there was an inclusive culture and found their managers approachable.
The provider had made progress with international nurse recruitment which had improved staffing levels and reduced the use of agency staff. Leaders ensured shifts had appropriate staff skill mix to ensure temporary staff had the right skills and experience to safely meet the needs of patients. Staff received support from ward managers and had access to clinical supervision and appraisals.
Staff carried out comprehensive risk assessments for all patients. They understood their responsibilities in relation to safeguarding and knew how to identify issues of potential abuse and how to escalate these.
The provider was taking proactive steps to enable patients to access Independent Mental Health Advocacy (IMHA) services on admission and routinely throughout their admission by referral, despite ongoing challenges regarding the IMHA service provision.
Staff understood their roles in relation to the Mental Capacity Act 2005 and the Mental Health Act 1983 (MHA) and the application of the MHA was monitored closely by MHA administrators

The Langford Centre is an independent mental health hospital providing care and treatment to working-age adults with severe mental illness. The service provides one low secure forensic ward, two high-dependency mental health rehabilitation wards and two acute mental health wards for adults of working age. The two acute mental health wards for adults of working age had recently opened during 2021 and this was the first time we had inspected these wards.

On 15 May 2022, a few days after the inspection, a patient sadly died after fixing a ligature to the sash-style window in their bedroom on Cooden ward, an acute mental health ward.

Due to the concerns we identified during this inspection, we used our powers under section 31 of the Health and Social Care Act to take immediate enforcement action and placed a number of conditions on the provider’s registration. This meant that the provider could not admit patients to Fairlight or Cooden wards, the two acute mental health wards for adults of working age, without seeking written permission from the CQC. The CQC also required the provider to make improvements to how ligature risks were identified and managed on Cooden and Fairlight wards, and to how individual patient risks were assessed on Fairlight ward.

The urgent conditions were subsequently lifted and the provider was able to admit patients to Fairlight and Cooden wards from 9 June 2022. This was because the provider had taken prompt action to make improvements to keep patients safe. The provider worked in collaboration with the local mental health NHS trust to make some immediate improvements to the service.

Our rating for The Langford Centre went down. We rated it as requires improvement because:

Each of the three core services were rated as requires improvement overall. Although immediate improvements were made in relation to the assessment and management of ligature risks and assessment of individual patient risk on the acute wards for adults of working age, these improvements needed to be sustained and embedded. We also identified a range of other areas for improvement during the inspection.
The leadership and governance of the service needed to be improved. We received some reports of a poor leadership culture with some staff feeling that they had not been involved in discussions about recent service changes and unable to speak up due to fear of retribution. The provider needed to recruit to the ward manager posts on Seaford and Balmoral wards.
Most of the issues we identified during the inspection were not known to the provider because they had not been identified by their own internal governance assurance processes. Staff recorded patient clinical information on both paper and electronic records, which posed a risk that all the information they needed to deliver safe care and treatment would not be accessed.
The service was not safely staffed. This was because the provider relied heavily on temporary staff to cover vacancies, who were less familiar with patients’ needs and the way the service operated. Leaders did not properly assess staff skill mix to ensure temporary staff had the right skills and experience to safely meet the needs of patients. The provider had started to make some progress with international nurse recruitment, but vacancies still needed to be filled.
Potential ligature anchor points existed across the wards. Although the provider had a programme of works planned to minimise the presence of potential ligature risks, these works were not yet complete. A ligature anchor point is anything that could be used to attach a cord or other material for the purpose of hanging or strangulation. We took urgent enforcement action because ligature risks had not been appropriately assessed and managed. The provider acted promptly to improve their approach to assessing and managing ligature risks, but this improved approach needed to be sustained and embedded.
Initial patient risk assessments were not sufficient on the acute mental health wards for adults of working age. Initial risk screens were completed by the doctor on duty during admission but were not routinely accessible to staff. Risk assessments were not always developed in collaboration with the range of multidisciplinary team members, and some patients did not have an initial risk assessment in place for up to 11 days, meaning that staff were not suitably equipped to safely manage individual patient risks, such as suicide and self-harm. We took urgent enforcement action because the provider’s approach to individual patient risk assessment was unsafe. The provider acted promptly to improve their approach to assessing patient risk, but this improved approach needed to be sustained and embedded.
We identified a range of other safety concerns. On the acute mental health wards for adults of working age, staff completed patient observations at set times, rather than intermittently. This meant that it was possible that patients could predict when staff would next check that they were safe. Staff had not been trained to safely search patients for prohibited items, posing a risk that items that could cause harm could be brought onto the wards. Staff did not ensure that the physical health of one patient on Seaford ward who had received rapid tranquilisation was robustly monitored to minimise the side effects of the medication which put them at significant risk of physical health deterioration. Clinical waste on Balmoral ward was not safely managed, which posed a risk of injury and infection.
Patients did not receive the appropriate support to develop their daily living skills and one occupational therapist was working across the entire hospital. This was not enough occupational therapy cover to meet the needs of patients, particularly on the high-dependency rehabilitation and low secure forensic wards, where patients needed to be supported for discharge to community settings after long stays in hospital.
Although the provider operated two high-dependency rehabilitation wards, this service did not adhere to this model because the multi-disciplinary team cover, including consultant psychiatry and occupational therapy, was not enough to meet the needs of patients. Patients had stayed at the service for up to ten years, while patients requiring support from a high-dependency rehabilitation service should stay for up to one year.
The provider did not ensure patients could easily access an independent mental health advocate (IMHA) and IMHAs were not routinely able to access the wards to meet with and introduce themselves to patients.
We identified that many patients across the hospital did not have access to their care plan. On Fairlight ward, patients had not been involved in decisions about their care and treatment.
Patients’ privacy and dignity was not maintained on the acute mental health wards for adults of working age because bedroom doors either had peep-holes that anybody in the corridor could use to observe patients in their bedrooms, or viewing panels that were left in the open position by staff.

However;

Permanent staff received support from ward managers, including those who were covering two wards because of ward manager vacancies. They had access to clinical supervision and appraisals.
Patients were generally positive about their experience using the service and the provider was working to improve the quality of meals in collaboration with patients.
Staff understood their roles in relation to the Mental Capacity Act 2005 and the Mental Health Act 1983 (MHA) and the application of the MHA was monitored closely by MHA administrators.
Staff understood their responsibilities in relation to safeguarding and knew how to identify issues of potential abuse and how to escalate these.
Staff managed medicines well and know how to report incidents.

On 20 October 2020 we undertook an unannounced comprehensive inspection of Camber ward at The Langford centre. This was following information received from a member of the public, which raised concerns about the safety of patients and quality of care on the ward.

We had not previously rated Camber ward at the Langford centre under our comprehensive methodology. This was a new additional core service that had opened since our last inspection. Camber ward is a ward for up to 12 men who have had a diagnosis of a learning disability or autism. At the time of the inspection there were six patients on the ward.

Our rating of Camber ward at The Langford Centre is good. We rated it as good because:

The service provided safe care. The ward environments were safe and clean. The wards had enough care staff, nurses and doctors. Staff assessed and managed risk well, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans, which enabled them to work with patients who displayed behaviour that staff found challenging.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients with a learning disability or autism and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
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 staff received training, supervision and appraisal. Ward staff worked well together as a multidisciplinary team, and with those outside the ward who would have a role in providing aftercare.
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.
Discharge plans were in place to ensure patients would have a smooth discharge or transfer, and appropriate support in place when moving on.
The service was well-led, and the governance processes ensured that ward procedures ran smoothly.

However:

As required (PRN) medicines protocols lacked detail meaning there was not clear guidance for staff as to when to administer medicines.
We found the window protectors were damaged meaning there was not a clear view of outside for patients.
Incident forms could have been more detailed. Some lacked specific detail regarding timescales of actions taken following an incident.
We found staff did not consistently wear masks in clinical areas. This posed a risk to patients and staff of passing on infection during the current pandemic. Staff told us this was sometimes necessary as distressed patients needed to see facial expressions to reduce stress. The provider had not advised staff to use other forms of protection in these situations.

We rated The Langford Centre as good because:

Mandatory training completion for the wards was high.
Staff completed and routinely reviewed comprehensive assessments of patients’ risks, physical and mental health.
Patients had access to psychology and a range of occupational activities including personal training sessions, weekly health walks, gym sessions, swimming, roller skating, volunteering at a local animal sanctuary, furniture restoration, and gardening.
All staff received regular supervision.

Patients told us they felt safe and cared for in the hospital.

Carers and family members were involved in patient care wherever patients authorised for this.

Staff, including the psychology and occupational departments, worked with patients from point of admission to rehabilitate and support them towards a positive move on from the hospital as part of their recovery.

In 2017 the hospital took part in a Nottingham University-led pilot to review the hospital’s policy and practice regarding the political participation of residents. The pilot was held in conjunction with local snap elections at that time. The study involved observing how patients were supported to vote using policy, discussion around political views and choices, and social worker and speech and language therapist (SALT) support.

However:

On Cooden Lodge and Seaford Suite we found that a range of equipment was out of date. The hospital director informed us that all out of date equipment was removed after our inspection.
Cooden Lodge was untidy, four out of nine patient bedrooms had unclean shower areas, dirty window sills and skylights. The hospital director informed us they arranged a ward deep clean the day after our inspection and implemented two cleaning audits for each wards’ toilets and bedrooms.
One patient’s care record on Daffodil ward detailed an unjustified blanket restriction. Staff concluded they would arrange for removal of the restriction.
Risks identified following a number of recent incidents were not listed on the hospital’s risk register.

We rated The Langford Centre as good because:

There was a person-centred culture. We saw evidence of patient involvement in care planning. Patients had a comprehensive assessment in place that was individualised and person-centred with a focus on patient goals and recovery.

Patients had access to innovative psychological therapies and activities on the ward and in the community throughout the week as part of their treatment. The service had a robust multidisciplinary team who worked well together and were fully involved in patients’ care.

Patients experienced care and treatment that was compassionate, sensitive and person-centred. Staff morale was generally high and the wards supported each other. Wards were well-led and there was clear leadership at a local level. The ward managers were visible on the wards during the day and the multidisciplinary team were available to support patients and staff.

However:

There was a lack of learning following a serious incident where a patient in the hospital was subjected to a high number of episodes of inappropriate restraint throughout their several month admission in 2016. During our inspection five months later, we found that not all staff had been trained in restraint which meant there was a lack of learning from each incident to ensure staff were trained in appropriate restraint techniques. All of the service’s mandatory training completion levels, except for that in restraint training, exceeded their completion target of 75%. In the staff team, only 68% of permanent staff and 22% agency staff who regularly worked at the service received the provider’s approved restraint training. Another contributing factor to the incidents were that the ward manager was working across a number of wards, which meant that there was a lack of consistent oversight to manage staff practices. At the time of our inspection we found that the ward manager was still working across two wards.

Patients’ privacy and dignity were compromised on Pevensey ward because their physical weight and statistics were measured in the quiet lounge instead of their bedrooms.

Assessment of patients’ capacity was not always properly assessed and documented.

We gave an overall rating for the service of requires improvement because:

Patients’ privacy, dignity and safety were compromised on Daffodil ward because of a failure by staff to adequately assess risk when male patients were attending activities on the female ward.

We observed poor infection control in the laundry room on Pevensey ward. Staff completed daily ward environmental checks but it was not clear of the effectiveness of them.

The clinic rooms on the wards were small and patients’ weight and physical health observations were completed in the lounge, which compromised their privacy and dignity.

There was no recording of mandatory training for ‘bank’ and agency staff. Permanent staff were not aware of which agency staff could or could not assist with restraining patients if required.

The service imposed blanket restrictions on its patients. All patients were restricted because of the actions of individual patients.

We found little evidence of planning for discharge incorporated into patients’ assessments.

However:

The culture of the service was open and transparent with a drive for continual improvement. There was a person-centred culture. We saw evidence of patient involvement in care planning. Patients had a comprehensive assessment in place that was individualised and person-centred with a focus on patient goals and recovery.

Patients had access to innovative psychological therapies as part of their treatment. The service had a robust multidisciplinary team who worked well together and were fully involved in patients’ care.

Patients experienced care and treatment that was compassionate, sensitive and person-centred. Staff morale was generally high and the wards supported each other. Wards were well-led and there was clear leadership at a local level. The ward managers were visible on the wards during the day and the multidisciplinary team were available to support patients and staff.

There was a good provision of and access to therapeutic activities and strong links with external organisations.

Is the service safe?

Several areas of the building were dirty or in need of repair. The safeguarding policies and procedures were up to date and staff demonstrated a clear understanding about how to make a safeguarding referral.

Is the service effective?

There was a multi-disciplinary team of staff working within the service. Staff had received the necessary training and support to work effectively with people in the service. Audits had been carried out, but there was limited evidence to demonstrate that changes were implemented as a result.

Is the service caring?

We observed positive interactions between staff and people using the service. However, there was limited evidence of people's involvement in care planning and discharge planning. People's preferences, interests, aspirations and diverse needs were not always recorded.

Is the service responsive?

The provider sought the views of people using the service. All of the people had a care plan, however these were not always person centred. There was limited evidence of discharge planning, although most people had a care programme approach (CPA) meeting.

Is the service well led?

The service had up to date policies and these were accessible to all staff. There were processes in place for monitoring the service, however, there was limited evidence to demonstrate that changes had been implemented as a result.

Patients we spoke with told us that they were in a hospital that supported them in a way that suited them. One patient told us, "I am really happy, I have a part-time job, so I am really getting better." Others told us, "Good staff." Staff told us, "The staffing levels are better and we are doing well."

From reviewing care plans and talking to patients and staff, we found that patients views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

We saw the service ensured that staff were able to deliver care and treatment safely due to the training and audits in place. We saw that the staffing levels and skill mix were appropriate to support all the patients' needs.

Patients we spoke with told us that they were in a hospital that supported them in a way that suited them. One patient told us, "I have been here a long time now, they treat me well." Another patient said, "I don't like the food much, never enough to eat, but the staff are okay." Others told us, "Good place, but too many new faces."

Some of the staff we spoke with were new to the service and were still on their induction or had just finished their induction. They told us, "The senior staff have been very supportive and the training is good." Staff that had been working at the home for longer told us, "It is very busy and sometimes there are not enough experienced staff."

We saw the service ensured that staff were able to deliver care and treatment safely due to the training and audits in place. However, we saw that the staffing levels and skill mix were not adequate or appropriate to support all the patients' needs. There had been an increase in incidents on one ward, which some staff said was due to the introduction of new and inexperienced staff. We were also told that trips out had been cancelled and this affected patients' behaviour.

We saw that there was a complaints procedure in place and a log was kept of all complaints. The home had quality assurance systems to assess their performance and ensure improving standards. This included canvassing the views of patients who were receiving treatment and support, their relatives and visiting professionals.

Patients we spoke with told us that they were in a hospital that supported them in a way that suited them. One patient told us, 'The staff are here for us, they are pretty good.' Other patients said, 'There are more staff now to support us,' and 'We get to go out more and so we are happier.' One patient suggested more staff were needed to help with preparing them to live independently.

The staff we spoke with were well qualified and knowledgeable about patients needs and familiar with the support patients needed. We saw the service ensured that staff were able to deliver care and treatment safely due to the training in place. The staffing levels were adequate to support all their needs, including trips out. Untoward incidents in the home had been managed effectively with the introduction of more staff.

Patients we spoke with told us that they were in a hospital that supported them in a way that suited them. One patient told us, "I like it here, the staff are pretty good and are helping me." Another patient said, "I've been off treatment a couple of times and they've got me through it." Others told us, "The food is okay and we get to play football", and "I have made friends and that helps".

The staff we spoke with were well qualified and knowledgeable about patient's needs and familiar with the support patients needed. We saw the service ensured that staff were able to deliver care and treatment safely due to the training and audits in place. However, we saw that the staffing levels were not adequate to support all their needs, trips out had been cancelled. Agency staff were employed to increase numbers following our inspection.

The home had quality assurance systems to assess their performance and ensure improving standards. This included canvassing the views of patients who were receiving treatment and support, their relatives and visiting professionals.

Patients told us 'Its pretty good, we are here to get better and they do look after us' 'We have to wait for staff to take us out'.

We were told 'It's a good place to get better'. 'Don't always like to have new staff here'.

Patients said that the food was 'alright' but not very much choice. This was more specifically for vegetarian options.

The Langford Centre

All Inspections

1 and 2 March 2023

During an inspection looking at part of the service

10 -12 May 2022

During a routine inspection

20 October 2020

During a routine inspection

5-6 June, 2018

During a routine inspection

13 – 14 December 2016

During a routine inspection

20-21 July 2015

During a routine inspection

6 August 2014

During an inspection in response to concerns

29 August 2013

During an inspection looking at part of the service

30 May 2013

During a routine inspection

5 February 2013

During an inspection looking at part of the service

14 December 2012

During a routine inspection

27 October 2011

During an inspection in response to concerns