Archived: Cedar House

Updated 24 July 2023

Cedar House is a specialist hospital managed by Coveberry Limited. The hospital provides assessment and treatment in a low secure environment for people with a diagnosis of learning disability and autistic people, including those who have a forensic history, those requiring positive behaviour support, and complex mental health needs.

At the time of the inspection they had 18 people at the service.

At the time of the inspection the service had 5 operational wards, along with three purpose-built annexes. These included:

• Folkestone ward – a nine-bed ward for males and included one annexe which was non-operational at the time of our visit
• Maidstone ward – an eight-bed ward for females
• Tonbridge ward – an eight-bed ward for males
• Rochester ward – a six-bed ward for males, two of which were contained within annexes
• Poplar ward – a step down unit for five males. This ward was located outside the secure perimeter fence.

Enhanced Low Secure (ELS) ward, which provided five beds for males, remained closed at the time of the inspection and we did not visit this ward.

Cedar House is registered to provide the following regulated activities:

1. Assessment or medical treatment for persons detained under the Mental Health Act 1983
2. Diagnostic and screening procedures
3. Treatment of disease, disorder or injury

The hospital had a registered manager in post at the time of our inspection.

The CQC last inspected the location in November 2022 when we found that the provider had made some improvements, but not fully met all the requirement notices. The provider had introduced a new comprehensive governance system but had not embedded this into the hospital’s daily practice. The provider recognised that they had actions to complete and that more work was needed to embed the improvements, to ensure they would be sustained permanently. Following the inspection in November 2022, the conditions on the registration of the hospital which prohibited the service from admitting people without prior written agreement from CQC were removed. The provider was also issued with requirement notices. We told the provider to make the following improvements:

• The provider must ensure the lighting across the hospital is suitable for the people admitted to the hospital. (Regulation 15)
• The provider must ensure that restrictive practices are reviewed and restrictions on people’s access to the community is based on individual risk. (Regulation 13).
• The provider must ensure that care plans are consistent in quality. (Regulation 9)
• The provider must ensure that people and relevant others are involved in planning their care and that this is clearly recorded. Where people refuse to engage in completing their care plans, this must be clearly documented (Regulation 9).
• The provider must ensure that staff are up to date with their training in immediate life support and medication administration and reach the compliance rate set by the hospital (Regulation 18)
• The provider must ensure that all staff received regular supervision. (Regulation 18).
• The provider must embed in practice the new clinical model which the guidance set out in Right Support, Right Care, Right Culture. (Regulation 9).
• The provider must ensure that people have regular access to necessary therapies, including psychology, occupational therapy and speech and language therapy. (Regulation 18).
• The provider must ensure that all people are able to utilise their Section 17 leave and all rationale for cancelled Section 17 leave must be documented clearly. (Regulation 17)
• The provider must ensure that all risks, including emerging and developing risks, are included on the hospital risk register. (Regulation 17).
• The provider must ensure that the model for effective governance of performance, risks, quality of care and learning from incidents is fully embedded in practice. (Regulation 17)

During this inspection we found some improvement and many of the requirement notices had been met. However, at the last inspection in November 2022 we highlighted the need for sustained improvement for governance processes to be fully embedded and this had only been partially achieved.

What people who use the service say

Overall the feedback we received from people using the service was positive, which showed an improvement since the last inspection in November 2022 when feedback from people was mixed.

Ten out of the 11 people we spoke to felt that staff were respectful, caring and compassionate. Most people told us they felt valued by staff who showed genuine interest in their well-being and quality of life. Although, 2 out of the 11 people told us that night staff were less supportive.

Most people said there were lots of activities to do and that there was enough staff to facilitate this. Although, 1 person said that community leave could sometimes be cancelled because of not enough staff who could drive the company vehicles.

Most people told us that staff were working on plans for them to move on and that they had been involved in decisions surrounding those plans.

Some people said that the food had improved and that there were lots of options. Although, most people also told us that they would prefer more healthy options.

Updated 24 July 2023

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

The Care Quality Commission (CQC) conducted an unannounced inspection of Cedar House on the 16 and 17 May 2023. The inspection was to check if the improvements required following the inspection in November 2022 and detailed in an action plan submitted by the provider in June 2023 had been made.

Our overall rating of this service stayed the same. However, our rating of well-led improved and the service has therefore exited from special measures.

We have identified breaches in relation to risk management and the quality and assurance systems in place at this inspection. We have issued the provider with a warning notice because processes to enable the systematic review and management of ligature risks were not robust. Audits used to oversee the safety of the service were completed but governance around how ligature risks were systematically reviewed and actions carried out were not evident or documented effectively. Furthermore, systems and processes in place were not robust enough to ensure oversight of the quality and safety of the service, experience of service users and accurate record keeping.

We rated it as requires improvement because:

• Local governance systems in place to effectively assess, monitor and improve the quality and safety of the service required further embedding. Ligature audits were not always reviewed thoroughly to help manage the risk to patients, staff did not always record clinic room temperatures routinely to ensure medicines were stored safely, care and treatment records following incidents were not always accurate or complete, and the review of people’s restrictions for accessing kitchen areas were not always thorough. These had not been identified by the provider’s internal governance processes.
• Staff did not always record or share key information to keep people safe when handing over their care to others.
• A systematic process for sharing lessons learned with staff at ward level was not embedded. Records of discussions about actions implemented because of lessons learnt were not well recorded in team meeting minutes and these were not regularly reviewed with all staff.
• Staff were not always assessing people’s risk safely prior to section 17 leave. This meant that there was a risk of people being allowed to leave the hospital without the proper risk assessments conducted in a timely manner prior to leave.
• Staff were not consistently completing all their mandatory and statutory training. Only 40% of eligible staff had completed training in the safe administration of medicines. Managers did not ensure that all staff had completed the required competencies and mandatory training prior to administering medicines independently.
• Some areas of the environment remained tired and did not fully meet the needs of people using the service. Lighting had previously been identified as not suitable for autistic people. However, measures to reduce or remove the risks within a timescale that reflected the impact on people using the service were not effective.
• Staff were not always aware of the principles of ‘right support, right care, right culture’. Most staff below ward manager level were unable to tell us about the new clinical model of care and how this underpinned their work with people using the service.

However:

• People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood each person’s individual needs.
• People were protected from abuse and staff followed good practice with respect to safeguarding.
• People made choices and took part in activities which were part of their planned care and support. The staffing provision for psychological therapies had improved and this aligned with the new clinical model of care. A multidisciplinary team worked well together to provide the planned care.
• People received care, support and treatment that met their needs and aspirations. Care focused on people’s quality of life and followed best practice. Staff ensured care plans were personalised, recovery focussed and holistic. People were involved in planning their care.
• People had clear plans in place to support them to return home or move to a community setting. Staff worked well with services that provide aftercare to ensure people received the right care and support they went home.
• The provider engaged with other organisations to improve the care offered at the hospital. Staff used national outcome measures to identify the effectiveness of their service.
• The provider offered professional development and training opportunities.
• Staff understood their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, Mental Health Act 1983 and the Mental Capacity Act 2005.

Updated 24 July 2023