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Archived: Cygnet Whorlton Hall Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 25 September 2019

We inspected Whorlton Hall due to concerns raised by the Panorama programme into alleged abuse of patients at this hospital.

We have taken enforcement action against the registered provider in relation to our concerns about this location. This limits our rating of safe, effective and well-led to inadequate, and the rating overall for Whorlton Hall to inadequate.

At the time of inspection, there was an ongoing police investigation which meant we were not able to review all documentation, or speak to patients, so whilst we inspected these domains, we were unable to rate the caring and responsive.

  • The service did not have effective systems in place for ensuring that staff adhered to the provider’s policies and procedures. This included adherence to safe practice in administering ‘as required medication’ and monitoring patients after rapid tranquilisation, keeping records that demonstrated that staff were suitable to work at the hospital and undertaking the daily environmental risk checks.

  • Staff used physical restraint on 1348 occasions in the year leading up to the inspection. They also used rapid tranquilisation on three occasions. The Resuscitation Council (UK) recommends that staff using restraint or rapid tranquilisation should receive training in immediate life support as a minimum standard. Staff at Whorlton hall had not received this training.
  • The provider’s restrictive interventions reduction programme had not been effective. Staff continued to use physical restraint frequently and the number of times it was used had increased.
  • Staff did not follow best practice with respect to mental capacity and best interests. Rather than undertake mental capacity assessments on a decision-specific basis, staff made over-arching assessments which covered a number of different areas. Staff made decisions in patients’ best interests for patients assessed as lacking capacity. However, a number of the best interest documents failed to record how the patient, family, carer or advocate had been involved in the best interest decision making process.
  • We found a number of instances where staff were not following the care plan. These included decisions about the gender of staff carrying out observations on patients and the importance of using Makaton and other communication aids.
  • Recruitment procedures established to ensure staff employed in the service were of good character or had the necessary qualifications, competence, skills and experience required to carry out their role were not operated effectively.

However:

  • Care plans were personalised, holistic and recovery orientated.
  • Staff ensured that patients had access to physical health care services.
  • There was access to a well-equipped activity hub at the hospital which enabled a range of educational and social activities to be facilitated.
Inspection areas

Safe

Inadequate

Updated 25 September 2019

We have taken enforcement action against the registered provider in relation to our concerns about this location. This limits our rating of safe to inadequate.

  • Staff frequently used physical restraint and had used rapid tranquilisation on three occasions in the year leading up to the inspection. The Resuscitation Council (UK) recommends that staff using restraint or rapid tranquilisation should receive training in immediate life support as a minimum standard. Staff at Whorlton hall had not received this training.
  • On two occasions that staff had used rapid tranquilisation, they had not recorded the necessary physical health observations.
  • The provider’s restrictive interventions reduction programme had not been effective. Staff continued to use physical restraint frequently and the number of times it was used had increased.
  • In the month leading up to the inspection, staff had not completed the daily environmental risk assessment checks on half of the occasions they should have done.
  • The manager who was present at the time of the inspection did not usually work at Whorlton Hall and could not locate information about the skills, training and experience of agency staff. This meant that they could not assure themselves that these staff were suitable. This was because there was no system in place to access this information. The information was provided to the inspection team at a later date.
  • There were a number of different case files for each of the patients. In a service with high
  • staff turnover that frequently employed agency staff, this potentially posed a risk to the quality and safety of patient care. Whilst we noted that a large number of agency staff used by the hospital were used on a regular basis, it would be difficult for staff, and in particular new staff, to find specific items of information.
  • Two of the seven patient bedrooms were completely bare apart from a bed. During the inspection, staff were unable to provide evidence as to why this was the case. Evidence submitted after the inspection did not provide adequate information to indicate that the rooms were bare due patients’ sensitivities. Some information provided referenced patient sensitives but no there was no evidence that this had been regularly reviewed or assessed. In addition, there were no decision specific capacity assessments or best interests decisions documented about these particular aspects of care.

Effective

Inadequate

Updated 25 September 2019

We have taken enforcement action against the registered provider in relation to our concerns about this location. This limits our rating of effective to inadequate .

  • Staff did not follow best practice with respect to mental capacity and best interests. Rather than undertake mental capacity assessments on a decision-specific basis, staff made over-arching assessments which covered a number of different areas. Staff made decisions in patients’ best interests for patients assessed as lacking capacity. However, a number of the best interest documents failed to record how the patient, family, carer or advocate had been involved in the best interest decision making process.

  • Although, in general, care plans were personalised, holistic and recovery orientated, we found a number of instances where staff were not following the care plan. These included decisions about the gender of staff carrying out observations on patients and the importance of using Makaton and other communication aids.

However:

  • Staff ensured that patients had access to physical health care.

Caring

Insufficient evidence to rate

Updated 25 September 2019

We have not rated caring because we did not speak with patients or carers during this inspection due to an ongoing police investigation.

We found the following issues that need to improve:

  • One patient had a care plan that specified that staff should communicate with the person using Makaton and visual aids.We observed two occasions when staff were not taking this approach.

  • We found one occasion where staff did not safeguard confidential information appropriately.

However:

  • Staff informed and involved families and carers appropriately.

  • Staff made sure that patients had access to an advocate and encouraged them to make use of them.

Responsive

Insufficient evidence to rate

Updated 25 September 2019

At the time of inspection, there was an ongoing police investigation. Due to the investigation, we were unable to gather sufficient evidence to rate this key question.

  • Patients had their own ensuite bedrooms and those that required it had access to a private lounge.

  • Patients were encouraged to make use of the community they lived in where this was appropriate.

  • The food was of a good quality and patients could make hot drinks and snacks at any time.

  • There was access to a well-equipped activity hub at the hospital which enabled a range of educational and social activities to be facilitated.

Well-led

Inadequate

Updated 25 September 2019

We have taken enforcement action against the registered provider in relation to our concerns about this location. This limits our rating of well-led to inadequate.

  • Effective governance systems were not in place to ensure that all policies and procedures were adhered to by staff working at the hospital.

  • Despite the measures put in place at the service to reduce restrictive practices, there were ineffective processes in place to ensure that staff minimised the use of restraint; the number of uses of restraint was increasing at the hospital and remained high.

  • There were a number of concerns relating to medication administration and monitoring found throughout our visit.

  • There was not a system in place to ensure that daily environmental risk checks were being carried out, this meant that gaps in these checks went unnoticed by the provider.

  • We could not find information that we were looking for in patient records. We felt this could make it difficult for new staff to deliver safe and effective care and treatment.

  • There were several examples of discrepancies contained within different elements of the care records.

  • We found a detailed forensic history contained within one patient record, which was easily accessible to all staff.

  • The system in place to allow the management team to effectively allocate agency staff on duty was poorly maintained and therefore ineffective.

  • Recruitment procedures established to ensure staff employed in the service were of good character or had the necessary qualifications, competence, skills and experience required to carry out their role were not operated effectively.

However:

  • Patients were given the opportunity to be involved in the development of services through regular resident meetings and a regional peoples parliament.
Checks on specific services

Wards for people with a learning disability or autism

Inadequate

Updated 25 September 2019