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Archived: Cygnet Whorlton Hall Inadequate

Reports


Inspection carried out on 12 to 17 May 2019

During a routine inspection

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 carried out on 7 and 8 March 2018

During an inspection looking at part of the service

We did not rate Whorlton Hall at this focused inspection.

We found the following issues that the service needs to improve:

  • There were no processes in place to assess and monitor the impact of staff working excessive hours. Managers knew that staff were working up to 24 hour shifts and had no system in place to assess and mitigate the risk and impact of this on patients or staff
  • The service relied heavily on the use of bank and agency staff. Not all agency staff were up to date with mandatory training, and there was no internal system in place to review the training compliance of agency staff
  • Individual staff supervision was not taking place in line with Danshell’s policy and supervisory bodies

We also found the following areas of good practice:

  • Staff were supported after incidents took place and de briefing sessions were carried out after incidents
  • Care plans were holistic and contained the patient voice

Inspection carried out on 4 and 5 September 2017

During a routine inspection

We rated Whorlton Hall as good because:

  • The service was clean and tidy with a fully equipped clinic room. The service complied with the Department of Health’s guidance on eliminating mixed sex accommodation by keeping male and female bedrooms separated. There were rooms where patients could spend time in private. Health and safety checks were made to ensure the building was safe and environmental risk assessments were up to date and contained details of all ligature points in the building.
  • There were enough staff in place to meet the needs of patients, bank and agency staff were familiar with the way the service operated and knew what the patients’ needs were and staff sickness absence were at 4%, which was low. Staff were qualified, experienced, received regular supervision, were appraised, received mandatory training and had access to specialist training. A regional occupational therapist provided staff with advice and support in relation to the care and treatment of patients with autism. Staff knew about Danshell’s safeguarding and whistleblowing procedures and received information about learned lessons from incidents and complaints to improve practice within the service. Danshell reported on 31 May 2017 that there had been no complaints received about Whorlton Hall in the previous 12 months. Staff were motivated and morale within the team was positive.
  • We observed staff interacting with patients in a kind, respectful and dignified manner throughout our inspection and patients and carers who spoke with us said staff treated them well and as individuals. They also told us that they were given the opportunity to provide feedback on care and treatment via patient forums, carers’ meetings and house meetings. A patient satisfaction survey in which nine patients participated was completed in September 2016. The responses to each question indicated that between 82% and 87% of patients were happy with the service they received.
  • Patients were not placed in seclusion and physical restraint was only used as a last resort because staff were trained in de-escalation practices. Danshell also had a policy in place to ensure that any children visiting the hospital were kept safe. Risk assessments were in place for patients. Care and treatment plans were person-centred, recovery based and holistic and contained evidence that patients’ physical health was monitored and any issues identified were addressed. The service’s use of observations was appropriate to meet the needs of each patient.
  • Mental Health Act and Deprivation of Liberty Safeguards documentation was in order. Staff received mandatory training in the Mental Health Act and Mental Capacity Act and audits took place to ensure staff complied with the Acts. Staff regularly reminded patients of their rights.
  • Information was available on a wide range of topics in a variety of formats such as easy-read and foreign languages, which included how to make a complaint, patients’ rights and details of patients’ advocacy services. Hot drinks and snacks were available to patients 24 hours a day; the quality of the food was good with options to meet dietary and cultural needs. Patients could personalise their rooms and accessed their chosen place of worship within the community.
  • Key performance indicators, clinical governance mechanisms and audits were used to monitor practice and improve service delivery. Staff could add items to the service and provider’s risk register. Staff agreed with Danshell’s visions and values and their team objectives were based around them.
  • Danshell’s sports coordinator had been nominated for a Royal College of Psychiatrists award for innovation and best practice in relation to how their work had improved physical health for patients, including those at Whorlton Hall.

However:

  • Curtain and shower rails in 12 rooms at the service were not of the collapsible type used to prevent suicide by hanging. However, these were included in the service’s environmental risk assessment and risks were rated, each patient had a risk assessment in place and the levels of observations were tailored according to each patient’s needs, which mitigated this. The service manager was also able to refuse any admissions that were unsafe due to the presence of ligature risks.
  • Although the building was clean and tidy, there was a smell of urine in one of the male bedroom areas.
  • Doors to rooms did not have signage on them to say what they were used for and were all painted white that made them look the same. This made it difficult to navigate around the building and risked people entering rooms being used for sensitive and personal discussions. Male patients did not have an in-house laundry service but female patients did which meant male and female patients were not being treated equally.
  • During our inspection, a room being used for a patient’s multidisciplinary team slammed shut, which caused notable alarm to the patient.

Inspection carried out on 16 November 2016

During an inspection looking at part of the service

We rated Whorlton Hall as requires improvement because:

  • The provider had not taken sufficient action to address the requirement notice we issued following our inspection in March 2016. Although resuscitation equipment was clean and in date an essential stock item for anaphylaxis which we identified at our March 2016 inspection was not available at the time of our inspection.
  • There were gaps in cleaning records and domestic staff vacancies meant that some days there was not a domestic on duty.
  • Some minutes from governance meetings were brief and there had been gaps in monthly internal service reports. This had the potential to affect the organisations ability to effectively monitor performance and quality.
  • The provider had not completed all the requirements for a patient being cared for away from other patient who was in long term segregation as defined by the Mental Health Act code of practice.
  • A patient who had been given as required high-dose antipsychotic medication regularly refused physical health monitoring. The patient’s refusal was not always recorded.
  • It was difficult to locate items in some paper care records.

However:

  • The service had been proactive in addressing significant staffing and management issues which had occurred between June and August 2016. Senior managers in the organisation had put safeguards in place to support new managers. Active recruitment to vacant posts was continuing and a new post of deputy manager had been created.
  • The provider was making good progress in addressing actions highlighted in recent audits and internal reviews. We saw improvements had taken place with regard to the environment, staff training and record keeping.
  • Staff completed risk assessments of patients at admission and on an ongoing basis.
  • Low morale amongst staff had been recognised and the service had worked actively with staff to respond to their concerns and make changes that would benefit them. Staff reported things had improved and they enjoyed their jobs.
  • Senior manager support was continuing to maintain the improvements which had been made. An action plan was in place to ensure improvement was maintained and outstanding actions were monitored.

Inspection carried out on 15 August 2016

During an inspection looking at part of the service

Whorlton Hall is an independent hospital in Barnard Castle, County Durham, which cares for people living with a learning disability or autism and complex needs, and for people who have additional physical or mental health needs and behaviours that challenge.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

We inspected Whorlton Hall in March 2016 and published our report in June. We rated the hospital as good overall but as requires improvement for safe.

This inspection was prompted by concerns about the quality of care that were brought to our attention since June.

We did not rate the safe domain for Whorlton Hall during this inspection because we did not carry out a full inspection. However, our findings during this inspection meant that we did rate the provider in the effective domain.

We found the following:

  • We saw one patient who we considered to meet the Mental Health Act definition of long term segregation but were not identified as such by the provider.
  • The hospital had had recent changes in management. A newly appointed registered manager had left at short notice resulting in temporary management arrangements needing to be put in place. An interim manager was in place and a permanent manager had been recruited. Staffing levels had not always been sufficient to keep staff and patients safe. This had resulted in concerns regarding the care of patients. At the time of our visit we saw that the provider had taken positive steps to ensure there were sufficient numbers of staff on duty to keep patients and staff safe.
  • Some areas in the hospital were unclean despite the hospital having domestic staff. The provider had an improvement action plan which included a review of cleaning rotas.
  • Care plans identified risks but did not always describe how to manage these risks.

Inspection carried out on 3 and 4 March 2016

During a routine inspection

We rated Whorlton Hall as good because:

  • Patients received care in a clean and safe environment. When we visited in August 2015 the external environment had not been adequately assessed and a number of hazards in the grounds were placing patients, staff and visitors at risk of harm. These hazards were no longer present when we visited in March 2016.
  • There were enough staff on shifts of different disciplines and the service was recruiting to fill the vacant posts for qualified nurses and support workers. When we visited in August 2015 it was unclear if staffing levels met the needs of the patients. A review of staffing levels had since been undertaken.
  • Staff were kind and respectful to patients and recognised their individual needs.
  • Staff had been trained and knew how to make safeguarding alerts.
  • Staff had received training in the Mental Health Act and the Mental Capacity Act. When we visited in August 2015 few staff had received this training.
  • Staff morale was good and the team worked well together.
  • Governance processes identified where the service needed to improve. This had led to improvement plans being put into place for the service.

However:

  • Emergency equipment was out of date and the service lacked the medicines required in an emergency which their policy described as “essential stock”.
  • There were some discrepancies between medicine labels and the prescription chart. The provider’s medicine policy did not advise staff how to manage these discrepancies. Some medications with limited life after opening did not have the date of opening recorded. There was an excess of stock of one medication.
  • Carers did not always feel involved in their relatives’ care.