Archived: Meadow Lodge

We rated Meadow Lodge as inadequate because:

• Neither the provider nor the local management team had been able to promote a stable, positive culture within the service. There was a high turnover of local managers and the provider had sent in additional managers to support the service. However, these frequent changes in the management structure had caused confusion amongst the staff team and they were unclear who was providing support to the local manager or had management oversight of the service. For example, the provider sent a manager from another service to support the local manager, but staff had only seen them once and were not clear if they had responsibilities or oversight in running the service.
• Due to the instability of the local management team and pressures within the service there was conflict in the team at all levels. Agency staff reported not feeling welcome or supported by the team when they arrived for shifts. Staff did not feel listened to and said that decisions were made without their involvement or consultation. Nursing staff said they did not have the opportunity to contribute to discussions about the strategy for their service. In the six months prior to the inspection nursing staff were present at only two of the six held monthly clinical governance meetings. There was a disconnect between the nursing team and the local management team
• The local management team did not have robust governance processes in place to ensure there was oversight of when staff were due supervision or whether they had attended all mandatory or additional training as required. Staff did not receive regular supervision, including clinical supervision in line with the provider’s policy.
• The local management team did not have a robust process for supporting staff following incidents, learning from incidents or making improvements to the service. There was no process to debrief staff following incidents and the service had not made improvements to the observation procedure following a number of incidents involving agency staff sleeping on duty. Both the provider and the local management team were aware of the issue relating to this, but this had not been addressed and did not feature as a risk on the service’s risk register.
• On seven occasions over a six-week period, registered general nurses (RGN) from an agency were left in charge of shifts. These nurses had little knowledge of mental health or child and adolescent mental health and had no experience of working in these areas so could not safely take charge of shifts. Following the first occurrence, the provider identified an action to put in place a safer system of work but this action wasn’t taken and RGNs, without relevant knowledge or experience were left in charge of six subsequent shifts. These were not recorded as incidents. In addition, on-call arrangements were not robust. The RGNs and staff generally were unclear who they should contact in the event that they should need advice or someone with experience to come into the service to deal with an issue. Not all permanent staff had completed mandatory training or additional training required to undertake their role effectively and safely.
• Staff were not making appropriate safeguarding referrals consistently to the relevant authorities. Some incidents were not categorised as safeguarding that should have been and stakeholders told us that staff had not always referred some cases that they should have. The service did not always raise concerns with relevant organisations in cases of poor practice. For example, informing the Nursing and Midwifery Council (NMC) when an agency nurse displayed poor practice or acted outside of the NMC code of practice (The Code) whilst they were working at the service.

However:

• Staff went above and beyond when supporting young people during incidents. We saw CCTV footage showing staff putting themselves in harm’s way to prevent a young person from injuring themselves. We saw that young people and staff had a good rapport. Young people were seen positively engaging with staff following incidents of restraint. Staff used restraint as a last resort, without excessive force, and only when de-escalation techniques had failed.
• Staff were completing observations of young people as directed in their care plans and we found no occurrences of staff asleep at night. This had previously been raised as a concern by the service through notifications to the Care Quality Commission.
• All young people’s risk assessments, risk management plans and care plans were person-centred and regularly reviewed and updated. Young people were involved in their care planning and had copies of their care plans.
• The service was going through a period of enhanced public scrutiny. Local managers and the provider’s senior management team provided support to staff, young people and their parents following the publication of allegations at the service.

• Staff did not always ensure the young people received urgent and emergency treatment. There was no policy or procedure for staff to follow in a medical emergency. The staff trained as first aiders did not provide first aid to young people on a number of occasions despite the young people requiring first aid intervention. Staff did not record physical and neurological observation of the young people as required to identify if a young person’s physical health was deteriorating. Nurses did not update care plans and risk assessments to reflect young peoples’ needs. Agency staff, including registered nurses who took charge of shifts, did not receive an induction to the hospital. Managers did not notify the young people and their families when errors in their care and treatment had been made and did not offer an explanation or apology.

• We issued a warning notice telling the hospital it must make immediate improvements in how staff responded to young people who need hospital treatment, that the hospital needed a policy and procedure about the management of medical emergencies, that staff needed to carrying out and record physical and neurological observations when clinically indicated, that care plans and risk assessments needed to be updated following changes to the young person’s risk, that all agency staff received and induction to the hospital and that staff followed their duty to act in an open and transparent manner with young people and their families.

• When we returned on 20 December 2018 found that managers had made staff aware of their responsibility to ensure the young people received urgent or emergency medical assessment and treatment without delay. The ward manager had circulated a policy and procedure and displayed it in the hospital and staff had signed a record to say they had read the them and discussed them with the ward manager. Staff were recording physical and neurological observations when needed and the quality of the record had improved and were robust. Staff had updated risk assessments and care plans to reflect the young peoples’ changing needs. All registered nurses had received an induction to the hospital. The senior management team had circulated guidance on the duty of candour and introduced a checklist to show when it had been used, staff had signed a record to say they had read the guidance and discussed their responsibilities with the ward manager.

• There had been one incident involving a young person where they had not received a medical assessment and treatment following an injury for over 12 hours. This occurred after the inspection on the 30 November 2018 but before we issued the warning notice. On this occasion, staff had not signed all recordings of physical and neurological observations.

• Following our second inspection on the 18 December 2018 we made the decision to leave the warning notice in place. The hospital had been placed on enhanced surveillance by the regional quality surveillance group, chaired by NHS England following our recommendations. We continue to work with NHS England and other partner organisations to monitor the hospital closely. We will return to inspect the hospital shortly to ensure the changes the provider has made are embedded and to ensure young people are kept safe.