The Care Quality Commission
  • Mental Health
  • Independent mental health service

Southern Hill Hospital

Overall: Requires improvement read more about inspection ratings

Mundesley, Cook's HIll, Gimingham, Norwich, NR11 8ET 0333 220 6033

Provided and run by:
Southern Hill Limited

All Inspections

12 January 2022

During an inspection looking at part of the service

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the service.

We inspected specific safe, effective and well-led selected key lines of enquiry for the service.

We rated safe and well-led domains as requiring improvement as breaches of regulation were found. The effective domain was rated as good. We did not inspect the caring and responsive domains. The overall rating for this service is requires improvement. The previous rating of good for the domains caring and responsive remain. The report for the previous inspection can be found here:

Southern Hill Hospital (cqc.org.uk)

We found the following areas the provider needs to improve:

  • Staff did not always follow the provider’s use of rapid tranquilisation policy.
  • Incidents were recorded and actions documented, however it was not clear from the documentation and staff meeting records if lessons learnt from incidents had been considered or shared with the staff team as this had not been recorded.
  • There was a lack of information for patients informing them of their rights displayed within the wards, however managers advised that patients are given a booklet on admission telling them about their rights.
  • Some areas of the wards needed redecoration.

However:

  • At the time of inspection, we did not find that all records had been completed. However, following inspection the service provided evidence of a physical health check audit for 175 patients demonstrating the provider had followed its’ own policy and National Institute for Health and Care Excellence (NICE) guidance.
  • Physical interventions were used as a last resort and the patient safety officer team provided regular and consistent support to staff on each ward. The service was also part of the restraint reduction network.
  • Staff had completed and were kept up-to-date with their mandatory training. All compliance rates for mandatory training courses were above the hospital target of 85%.

10-11 March 2020

During a routine inspection

We rated Southern Hill Hospital as good because:

  • The service provided safe care. The ward environments were clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
  • 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 and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to a 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 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.
  • The service managed beds well and patients were discharged promptly once their condition warranted this.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

  • Although the provider generally administered and dispensed medication safely, staff did not consistently prescribe and manage medicines safely. We found one example of a medication which was out of date, one prescription error and one example of staff administering a medication that the patient reported they were sensitive to, without recording a clear rationale or discussion with the patient. Staff did not consistently record clinic room temperatures or fridge temperatures. One of the clinic rooms on Lincoln ward was untidy, had cobwebs on the windowsill and did not display ‘clean’ stickers which staff used in the other rooms, despite having them available.
  • The provider did not have a system in place for signing patient records in and out so staff could locate them at all times.
  • The environment occasionally made it difficult to maintain the safety of patients easily. The staircase to the outside space on Lincoln ward did not have a handrail and the overspill on Cavell ward was situated some distance from the main ward.
  • Staff did not receive standalone safeguarding children training.

27 - 28 November 2018

During a routine inspection

We rated Southern Hill as requires improvement because:

  • The provider had not ensured the patient had a care plan which was holistic, included agreed goals, a review date and the patients voice, in a way the patient understood. This had not been identified as a need by the management team. The patients had not routinely been offered a copy of the care plans.The patient had to rely on memory or ward staff to reflect on actions agreed at multidisciplinary meetings.
  • Staff did not consistently implement systems to ensure the security of the environment on the PICU ward. The provider had not ensured the premises used by the service were safe for their intended purpose. There was a lack of effective systems, checks and processes in place. There was a failure to meet best practice guidance as per the national association of psychiatric intensive care units.
  • The seclusion room did not meet all the specifications recommended in the Mental Health Act code of practice.

However:

  • We saw evidence of a culture were staff used least restrictive practices, using techniques requiring physical intervention as a last resort. Where it was necessary, these incidents were reported and staff and patients held a debrief. There was a lead staff member who reviewed any restraints for learning.
  • The hospital employed a nurse who was dedicated to ensuring the physical health needs of the patients were met. The nurse had developed systems to ensure information was captured on admission and identified actions were carried out. We saw one-page care plans for staff to follow, aimed at supporting the person to address their physical health needs. Staff received training during induction and beyond to ensure all staff received the appropriate skills and awareness to carry out basic physical health monitoring, and the nurse was available on site to respond to queries.