Archived: Cedar House

Cedar House hospital provides low secure inpatient services for adults with a learning disability or autism who have offending or challenging behaviour and complex mental health needs.

The purpose of this inspection was to follow up on the warning notice that was served by the Care Quality Commission immediately following the unannounced, focused inspection on 21 July 2020. We served the warning notice because the provider was failing to comply with Regulation 12 (Safe Care and Treatment) because of the following reasons:

• Failure to deploy enough suitably qualified, experienced and competent staff to deliver safe care along with a failure by the leadership team at both the hospital and provider level to recognise this
• Lack of robust risk assessment and management of risk resulting in a high number of assaults on staff and patients
• Not carrying out observations appropriately and safely
• Reliance on the use of ‘as required’ medication (PRN)
• Confusion and lack of understanding about the use of emergency equipment and emergency medicines.

We told the provider it must take immediate action to meet the requirements of the regulation

This inspection was an unannounced, focused inspection. We did not rate the service on this inspection. The previous rating of inadequate overall still stands and the hospital remains in special measures.

At the inspection we found:

• Staffing levels across the hospital had improved and the hospital managers were recruiting more staff and working towards maintaining maintain safe staff levels. An additional member of staff had been allocated for teams on Folkestone ward and the Enhanced Low Secure Service. This meant more staff were available to support observations and manage incidents. The staffing level on Poplar ward had improved and there was no longer only one member of staff working alone.

• We found most observation records we checked met basic standards.

• There was a reduction in over-reliance on as required medication (PRN), following an audit of PRN, and the hospital had started to introduce ways to reduce patient incidents via what it called Calm cards; these outlined behavioural coping strategies that were used before staff gave PRN.

• The hospital had implemented Positive Behaviour Support (PBS) champions in order to improve the usage of the PBS interventions and reduce incidents. They were working with an external organisation to further develop staff understanding and implementation of PBS. PBS is a recognised method for helping some patients with a learning disability to develop less-challenging ways of interacting with others.

• Managers were being supported to make improvements at the hospital. This included weekly calls from Huntercombe senior managers and input from external organisations, which were providing support to managers to reduce inappropriate placements and carrying out a project with staff to develop a shared vision for the future. Managers were actively focused on providing better care for patients who were inappropriately placed at the hospital.

• The reasons for low morale amongst some staff due to safety had been recognised and the service was working with staff to respond to their concerns and make changes that would benefit them.

• Managers had developed action plans for service improvements. The hospital had a plan in place to improve the environment and we saw new flooring being installed on some of the wards and some bedrooms and a dining room were being painted. There was a rolling programme of repairs.

• During the inspection, we observed positive staff and patient interactions and good use of distraction and de-escalation techniques by staff.

• There were now two emergency bags and two emergency response teams at the hospital and staff were better informed about the use of emergency medicines.

However

• The ward environments on Folkestone, Folkestone ELS, Rochester and Maidstone wards were not clean. There was no regular cleaner for the wards employed by the organisation at the time of the inspection. Night staff had been asked to clean the wards but day staff told us they also had to clean the wards at the same time as working with patients and carrying out their caring duties. Contract cleaners were employed to do a deep clean on the wards monthly and the provider was advertising for housekeeping staff. In laundry rooms on two wards we saw chemicals were open and potentially accessible by patients, and there was loose tubing and items that were potential trip hazards. Bathrooms and toilets were not clean on Folkestone ward and the Enhanced Low Secure Service.

• Between 22 July 2020 and 18 September 2020 there were 11 assaults on patients and 20 staff had taken time off work after incidents. Of the 830 incidents recorded, 11.8% resulted in minor or moderate injury to staff or patients. This meant we were not fully assured that the provider had assessed and mitigated the risks to patients and staff.

• Despite the improvements in staffing levels and the work being done to ensure safe staffing levels, staff we spoke to had concerns about the confidence and competence of staff, as many were new or agency and did not know patients well.

• Staff did not always develop holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff did not always store care records in one place. We found care plans on the electronic patient record system but also some were kept in a shared drive. Sometimes staff could not locate specific information they might need to guide their interventions with patients.

Physical health care plans were not always easy to locate in the electronic record system and some were kept in folders in a shared drive.

• Wards did not always keep detailed enough handover notes to ensure staff on the next shift knew about the patient’s needs.

• Two of the wards do not have a separate garden area from the shared hospital grounds, this meant that patients could not always access the grounds when the wards were busy and there were not enough staff on the ward. There were not always enough activities available to patients on wards

• Ward staff told us that some multidisciplinary team members did not have a presence on the wards and therefore lacked a real understanding of patients risks and challenges presented on wards. Ward staff did not feel supported by some members of the multidisciplinary team.

• Relatives and carers said they could not always visit their loved ones at the hospital and that the provider did not always respond to their concerns. Staff told us that restrictions due to Covid-19 had meant relatives and carers could not always visit their loved ones inside the hospital.

Although, there is still much work to do at Cedar House hospital there had been enough progress with improvements required as identified in the warning notice alongside plans in place to continue the improvements. We have therefore decided to lift the warning notice.

However, we will continue to monitor the hospital closely and will not hesitate to take action should the improvements not continue.

Following this inspection, the Care Quality Commission issued a warning notice due to immediate concerns about the safety of patients using the service. We required the provider to make significant improvements to the safety of the service by 7 September 2020. The provider decided to suspend any new admissions at this time while they address concerns raised.

This inspection was a focused inspection; we did not provide a rating. The purpose of the inspection was to follow up on concerns that were found at the last inspection in February 2020 where the hospital was rated inadequate and placed in special measures. At the last inspection we found that the hospital was not always able to meet the complex needs of some of the patients. There was high use of restraint on patients and for long periods of time. Some patients had been in long term segregation for longer than was necessary. The environment was unclean and damaged in places. Ligature risk assessments were carried out but did not clearly state mitigation to reduce the risks. There was a lack of presence of senior and multi-disciplinary team members on the wards, and some staff did not always know patients well and what their needs were. We also had concerns raised about patients’ safety due to the high number of incidents at the hospital.

On 21 July 2020 we undertook an unannounced focussed inspection at Cedar House, the inspection continued remotely on 23, 24 and 27 July 2020. During the inspections we found:

• Staff and patients told us there were not enough staff to meet the needs of the patients and that they did not always feel safe. The staffing attendance register confirmed there were not always enough staff on duty. One ward often had only one member of staff to support five patients on night shifts. Staff were often deployed to other wards to help out due to lack of staffing, this then left their ward and patients who required a certain level of staffing short. This meant there was an increased risk of harm to patients and staff.

• There was a high number of incidents of aggression resulting in harm from patients to other patients or patients to staff. Subsequently, there were a high number of incidents of restraint used on patients. Staff were regularly off sick due to assaults on them which resulted in injury or stress. Following incidents there was a lack of learning or improvements made.

• There was only one emergency equipment bag for the entire hospital. In this bag there were some emergency medicines used should a patient go into respiratory distress which can be a side effect of taking benzodiazepine medicines. Not all staff were aware that these medicines were at the hospital and there was mixed knowledge of this within the management team also. This placed patients at risk should they need this emergency medicine.
• We reviewed medicines records on Folkstone and Folkstone enhanced low secure (ELS) wards. We found there was high use of PRN (as required) medicines used to manage patients’ behaviour and some staff told us this was used before other de-escalation techniques were used.

• Care plans and positive behaviour plans used by staff providing day to day care for patients were conflicting and did not give clear direction of how staff should meet patients’ needs. These care plans were not person centred or written appropriately for patients with a learning disability.

• There was no section at the front of the long files which gave brief summaries of patients’ needs and risks. This meant that should staff need to check information on a patient quickly, this was not easy to find.

• Staff told us that ward managers, senior management and the clinical team did not spend much time on the wards. This meant that staff and patients did not get the support and input from other members of the team consistently.

• We carried out observations and found that although staff managed patients’ behaviours well, there were little other interactions between staff and patients.

• Patients physical health needs were not always monitored effectively or as regularly as required.

• During our inspection we were given conflicting information from staff and the management team with regards to patients’ needs, staffing levels required and what emergency equipment was available.

• Our findings from the other key questions demonstrated that governance processes did not operate effectively in identifying improvements needed, or where they did there was no clear plan that ensured these changes were made.

• Staff morale was low due to lack of safe staffing levels and the high number of incidents in the hospital.

However:

• The hospital was clean throughout.

• Some improvements had been made since our last inspection in February 2020. The provider had begun works to improve the environment of the hospital.

On the basis of this inspection, the Chief Inspector of Hospitals has recommended that the provider be placed into special measures.

We rated Cedar House inadequate because:

• The hospital was not always able to adequately meet the complex needs of some of the patients. These patients had behaviours that were very challenging for staff to manage but the measures in place to manage their needs and risks (such as long-term segregation and use of physical restraint) had impacted negatively on their quality of life.

• There were high levels of restraint at the hospital. Staff who were unfamiliar with patients did not always follow de-escalation techniques before restraint was used.

• All wards we visited looked tired and showed signs of damage which could present a safety risk for patients. Four of the six wards were visibly unclean. We raised this at the time of the inspection and undertook a further visit five days later and found that short term repairs to the environment had been made. All the wards at the service still looked bare.

• The hospital had insufficient systems and processes in place to ensure all environmental risks were identified and mitigated. The ligature risk assessment did not identify how some of the identified risks should be mitigated.

• Whilst there were always enough staff on each shift, there was an increasing vacancy rate and increasing use of agency staff, many of whom were often unfamiliar with the patients. Therefore, some permanent staff members felt there were not enough staff who knew patients well enough to provide good quality care and meet patient needs at all times.

• We found blanket restrictions on all the secure wards. Button batteries were not allowed on the wards. Patients had not had individual risk assessments to decide whether this restriction was necessary.

• A small number of patients had been receiving care and treatment at the hospital for too long. Senior managers were working with commissioners to identify alternative placements and support the transfer of patients.

• Senior managers were not visible in the service and nursing staff felt they did not understand the daily challenges on the wards. Some nursing staff felt that the psychology team were rarely present on the wards. Staff from different disciplines appeared to work in isolation and there was a disconnect between the nursing team and the wide multi-disciplinary team. Whilst ward managers were felt to be supportive, they were not based on the ward which affected their availability to lead and oversee care. Feedback from staff was that they did not always have enough time, training or support to provide person centred care for people.

• Support staff had a limited understanding of why some patients could have section 17 leave and others could not.

However:

• Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff recognised incidents and reported them appropriately. The senior management team had effective working relationships with stakeholders to review patient related incidents.

• The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medicines on each patient’s physical health. They knew about and worked towards achieving the aims of STOMP (stopping over-medication of people with a learning disability, autism or both).

• Staff provided a range of treatment and care for patients based on national guidance and best practice; this included access to psychological therapies. Patients had access to occupational therapies. Staff supported patients with their physical health and encouraged them to live healthier lives.

• Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They supported patients to understand and manage their care, treatment or condition. Staff actively sought patient feedback on the quality of care provided and enabled them to contribute to decisions about how the hospital operated. They ensured that patients had easy access to independent advocates. Staff informed and involved families and carers appropriately.

• Staff supported patients to access a range of therapeutic activities, opportunities for education and developing skills for employment within the hospital and local community.