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

Archived: Cedar House

Overall: Requires improvement read more about inspection ratings

Dover Road, Barham, Canterbury, Kent, CT4 6PW (01227) 833700

Provided and run by:
Coveberry Limited

Important: The provider of this service changed. See old profile

All Inspections

16 and 17 May 2023

During an inspection looking at part of the service

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.

08 November and 09 November 2022

During an inspection looking at part of the service

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 conducted an unannounced inspection of Cedar House on the 08 and 09 November 2022. The inspection was to check if the improvements required following the inspection in January 2022 and detailed in an action plan submitted by the provider in June 2022 had been made.

Our rating of this service improved. We rated the service requires improvement, however because the service remained inadequate in well-led the service remains in special measures.

We rated it as requires improvement because:

  • Lighting on the wards had been identified as not suitable for autistic people.
  • It was not clear how staffing numbers were reached as the hospital staffing ladder only described when staffing numbers could be reduced, not raised.
  • People and families reported that peoples’ section 17 leave (permission for detained people to leave the hospital) was often cancelled and staff did not record how often leave was cancelled.
  • Staff did not always record handovers on the agreed template.
  • Staff were not consistently completing all of their mandatory and statutory training. Only 66% of staff had completed training in immediate life support and only 45% of eligible staff had completed training in medication administration.
  • Senior managers had not recorded all current or emerging risks on the hospital risk register. For example, that significant numbers of staff members were sleeping on night shifts.
  • The provider was not identifying trends and themes from incidents.
  • Staff did not always ensure care plans were personalised, recovery focussed or holistic.
  • People were not always involved in their care planning. All families we spoke to told us they were not involved in care planning and did not know what was in the care plans.
  • Staff told people they could only access the community during daylight hours.
  • We saw evidence that senior managers had developed governance processes, but we found that these were not yet fully embedded. Therefore, the governance system was not yet giving managers assurance about the quality of care and treatment provided.

However:

  • The provider had installed CCTV across the hospital to monitor people and incidents and people’s observations were set at an appropriate level.
  • All wards now had access to secure outside space.
  • Vacancy rates were reducing, and the provider was actively recruiting international staff.
  • Staff understood how to safeguard people and 95% of staff were compliant with safeguarding adults training. All staff had completed their learning disabilities training.
  • 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 treated people with dignity and respect and the service focussed on discharging people.
  • People felt they were helped to keep in touch with their families.
  • People felt confident in complaining and staff felt they could raise concerns with senior managers.
  • Staff told us that managers were supportive and staff felt valued.
  • The hospital had a peer support relationship with a local NHS provider and was better connected with the local care pathways.

18, 19, 20 and 25 January 2022

During a routine inspection

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, challenging behaviour and complex mental health needs. At the time of the inspection they had 32 people at the service. The service has six wards, along with three purpose-built annexes. These included Folkestone ward – a nine-bed ward for males, Enhanced Low Secure (ELS) which provides five beds for males and includes one annexe, 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 are contained within annexes and Poplar ward – a locked rehabilitation ward for five males. This ward was outside the secure perimeter fence.

On 18, 19, 20 and 25 January 2022 we carried out an unannounced comprehensive inspection at Cedar House. This was in response to concerns we received about the care and treatment being provided, as well as information we had around governance changes and staffing issues. During the inspection we found a number of areas of concern.

On 27 January 2022, following our inspection visits, we served the provider with a letter of intent telling the provider that we required them to provide us with assurance that they would make immediate and ongoing improvements to address the concerns, otherwise we would use our powers under Section 31 of the Health and Social Care Act 2008. This letter outlined concerns that people were not being provided with safe care and treatment. This included insufficient levels of interaction and observation from staff; a lack of cleanliness and poor maintenance across the hospital; the seclusion room not meeting the Mental Health Act (1983) Code of Practice and not being an environment to keep people safe; peoples’ Positive Behaviour Support (PBS) plans not being delivered in an effective way and staff not being sufficiently trained, competent and supported in delivering the care needed for the people using the service. The provider was required to submit an action plan by 31 January 2022 that described how it was addressing our concerns.

The provider’s response did not provide enough assurance that the actions the provider was taking addressed the immediate concerns. Due to the serious nature of the concerns, we used our powers under Section 31 of the Health and Social Care Act 2008 to take immediate enforcement action and imposed urgent additional conditions on the provider’s registration on 2 February 2022. Section 31 of the Health and Social Care Act 2008 Act is an urgent procedure whereby CQC can vary any condition on a provider's registration in response to serious concerns.

The condition prevented the provider from admitting any new people to Cedar House without the prior written agreement of the Care Quality Commission. The provider was also required to provide a detailed action plan to address the following: to improve systems of governance around reviews of incidents and observation levels; to ensure that care provided is therapeutic, person centered, proactive and takes a preventative approach using Positive Behaviour Support (PBS); to make improvements to the environment, including the seclusion room and one person’s annexe, to ensure these are suitable environments to meet the needs of people with learning disabilities and autistic people; to ensure that staff are appropriately trained with the correct skills to deliver safe and effective care to people with learning disabilities or autism and that there is appropriate support and supervision. We also placed a condition requiring the service to provide fortnightly updates as to the progress, monitoring and audits of the implemented action plan.

We have progressed further enforcement action, but the outcome is still to be determined. CQC continues to closely monitor the hospital.

We took this urgent action as we believed that people would or may be exposed to significant risk of harm if we did not do so. We expect providers to guarantee autistic people and people with a learning disability the choices, dignity, 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 or autistic people.

Our rating of this service went down. This inspection rated Cedar House as inadequate and placed them into special measures.

We rated it as inadequate because:

  • People could not always be observed in all parts of all wards, and observation levels were not always maintained as prescribed in care plans. During a review of CCTV footage, we saw that a person requiring continuous observation did not receive any for over an hour.
  • People’s care and support was not provided in a safe, clean, well equipped, well-furnished and well-maintained environment which were suitable for people's sensory and physical needs. Folkestone and Enhanced Low Secure (ELS) were both decorated with extremely bright colours and were also noisy which would be overwhelming for people with sensory processing difficulties. Some relatives told us that their loved ones found the ward environments noisy and the lighting very bright. All wards were tired, unclean and showed signs of disrepair including damaged flooring, boarded up windows, stained bathroom suites, broken external vents, rotten window frames, damaged curtains, damaged furniture, dirty doors, leaking baths and sewage issues, broken fixtures and perspex screens for TV units being marked and smeary.
  • We found a range of concerns with the hospital environment which negatively affected care. People did not always have access to outside space as some wards did not have a secure outside area. Some people required staff assistance to access fresh air and exercise. The environment of one annexe did not uphold the basic rights of privacy, dignity or humane treatment. Food, drink and personal hygiene items were being passed through a side window adjacent to the main hospital entrance and main walkways and the environment lacked any comfort other than a bed. In addition, the hospital seclusion room bathroom could be directly observed by staff and provided no privacy and dignity for the person using these facilities.
  • People did not always receive care and treatment that kept them safe or understood and met their needs and aspirations. Staff did not understand how to implement effective PBS plans. The PBS plans we reviewed were mostly used by staff to assist with the management of challenging behaviours, but not as an overall holistic approach to a person’s care or for the day to day understanding of people’s behaviour. Care plans were not consistent in quality and assessment of the persons physical, psychological and social care need. Most people did not have clear plans in place to support them to return home or move to a community setting. We were told that discharge planning started when a person was ready, rather than upon admission with care focused towards goals and outcomes.
  • We observed staff engagement with people using the service, on the wards we inspected, and by a review of CCTV following incidents. We saw that staff were not always consistently and actively engaging with the people they were working with and assisting them with activities. On ELS, Folkestone and Rochester wards, we observed that interaction with people being cared for was infrequent. At the time of inspection, on the wards we visited there was little evidence of meaningful activity taking place with patients. Most people told us that they were just stuck on the ward. Relatives told us their loved ones spend all day watching TV and that they had no access to education or work opportunities.
  • Staff did not always provide a range of treatment and care for people based on national guidance and best practice. At the time of inspection, the service was reviewing how psychology services were delivered to people at the hospital. Staff reported a lack of psychology presence on the wards and felt that this had impacted people within the service. Although, the service had a speech and language therapist (SaLT) staff told us that they were only available two days per week which wasn’t enough to meet the needs of people at the hospital.
  • People did not always have access to information in appropriate formats. We saw that not all people had communication passports. These are practical tools about people with complex communication difficulties who cannot easily speak for themselves. In addition, the service did not consistently display information on complaints, advocacy and other local services within all communal areas.
  • Staff were not comprehensively reviewing the use of restrictive practices to reduce them. For example, the hospital had a reducing restrictive interventions risk assessment and action plan, however some areas had not been reviewed since February or March 2021 and a revised draft policy and action plan supplied by the provider was due to be embedded by February 2022.
  • Staff did not always understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice. The service did not provide specific training on the Mental Health Act (MHA) and the Mental Health Act Code of Practice. The service provided a Mental Health Awareness e-learning course, however, this was not included within the mandatory training list and staff did not always keep up to date. People, relatives and staff told us that staff shortages often meant that Section 17 leave, which was permission granted to leave the hospital for those detained under the Mental Health Act (1983), and outdoor activities were cancelled and that there was a reduced ability for people to engage in activities. This included people’s ability to take Section 17 leave to smoke off the hospital grounds.
  • The service did not ensure care, support and treatment was delivered by trained staff and specialists able to meet people’s needs. The service induction programme was offered to permanent and flexi/bank staff and was insufficient in providing staff with the necessary knowledge and skills to deliver effective care to those with a learning disability and autistic people. Staff also did not receive adequate training on other necessary areas including the Mental Health Act (MHA), Safeguarding, Safe Observations and Therapeutic Engagement. Most relatives told us they felt staff lacked training specific to learning difficulties and autism and did not understand their relatives’ complex needs.
  • Managers did not ensure that staff had regular supervision and appraisal. Not all staff received regular supervision, with some staff stating that they have supervision and others not. Some staff had to request their supervision, rather than there being a formal supervision process in place. Staff also did not understand who was responsible for facilitating their supervision. Managers told us that the supervision model within the hospital had recently been reviewed.
  • Most relatives told us they were not involved in making decisions or planning of their relatives care and had not been asked for their views. Relatives we spoke with told us that staff also did not help families to give feedback on the service and that the complaints procedure had not been explained to them. Some relatives told us they would not feel comfortable raising concerns to the provider.
  • The multidisciplinary team did not always support each other to make sure people had no gaps in their care. Some staff told us that information was not always communicated to them in a timely way from the multidisciplinary teams and ward managers, and between disciplines where records were not updated. This sometimes led to delays in delivery of care. We observed that team meeting documents were inconsistent and lacked any assurance that necessary information was being delivered between ward and senior levels.
  • The service had incorporated Right Support, Right Care, Right Culture into their current quality improvement action plan, however this was still not embedded into the culture, environment and model of care within the service.
  • Leadership was not always effective and governance processes did not always ensure the service kept people safe, protected their human rights and provided good care, support and treatment. Not all ward managers were based on the wards in which they managed, making them less accessible to staff. Leaders did not recognise the necessity for staff to have consistent support and training to meet the needs of the people using the service. There were a lack of processes and systems in place to address concerns, including requirement notices issued previously. This meant that there had been little to no change in areas where improvement would have been expected.
  • Managers did not always share lessons learned with the whole team and the wider service. The hospital held learning review meetings to explore any learning from incidents, safeguarding concerns and complaints. These were further discussed within the monthly internal clinical governance meetings and quarterly lesson sharing across the division. However, staff told us that there was a lack of information shared by managers. Systems in place, such as the audit schedule and incident reviews were not effective in identifying issues of performance and risk and ensuring these were managed and improved. The completed audit document did not identify actions required to improve in the areas where the audit indicated that improvements were needed. We saw that audits had identified previous issues with cleanliness and infection control compliance, but these issues were still current.

However:

  • The service had some processes in place to safely administer and record medicines use. Medicines were stored safely and securely. Medicines for use in emergencies were easily accessible to staff. Staff reviewed each person’s medicines regularly and provided advice on their medicines. Staff could access advice from a clinical pharmacist either during in person visits that occurred at least monthly or by telephone or email outside of these times. There was a weekly meeting where people’s treatment including medicines were discussed by a multidisciplinary team of healthcare professionals. Staff were able to demonstrate the impact of people’s medicines on their treatment and how care plans would be updated with new treatment plans if needed.
  • People’s risks were assessed, recorded and reviewed regularly by the multidisciplinary teams, including after any incident and at monthly multidisciplinary meetings. People were involved in managing their own risks whenever possible. People were engaged in developing their care and PBS plans to help them understand how they viewed their needs and communication styles and what helped them at times of upset or anger.
  • We had feedback that from people we spoke with who said that staff treated them well and behaved kindly.
  • Most staff understood their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, and the Mental Capacity Act 2005.
  • When discharge was agreed, staff worked well with services that provide aftercare to ensure people received the right care and support in place they went home. They also held multidisciplinary discussing and planning meetings to support the person and keep them informed of plans and changes.
  • People could give feedback on the service and their treatment and staff supported them to do this. We saw community meeting minutes for ELS, Folkestone, Maidstone, Poplar and Rochester wards and could see that regular community meetings took place on these wards which gave people the opportunity to develop and improve the service.

8 and 9 June 2021

During a routine inspection

Cedar House offers low secure services for people with a learning disability or autism who have a forensic history, challenging behaviour and complex mental health needs.

We rated it as requires improvement because:

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, 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 or autistic people.

The overall, model, size and scale of this service is not in keeping with right support, right care, right culture. The design and layout of the hospital building is institutional and does not support the delivery of modern, effective care for people with learning disabilities and autism. The provider has endeavoured to make improvements to the environment, but the current buildings will not meet the standards that are now expected for the provision of effective care for people who use learning disability and autism services in line with Right support, right care, right culture. Despite the improvements that have been made there is still further work to be completed; some kitchens had limited access at the time of inspection, meaning people did not have full access to kitchen facilities at all times while work was being carried out. Communal areas on some wards needing painting and repair due to damage to the walls and on Folkestone ELS ward one ceiling was damaged and there was writing on the walls and scratches on walls and windows.

The hospital had been taken over by Coveberry Limited in November 2020. Whilst the new provider had made some improvements there was still improvements to care and practice that needed to be progressed and embedded in order to ensure sustained improvement and consistently good care was provided to all people at the hospital.

The service occasionally did not have enough staff. This meant that people did not always have access to activities; staff confirmed this was the case.

We noted that due to the pandemic some refresher training for some staff such as basic life support and food safety had been delayed. Most staff had regular supervision, but some staff were not given supervision in the timeframes set in the providers policy. The hospital was in the process of ensuring staff were offered supervision appropriately. Some staff fed back they did not always feel supported and felt some pressure due to staffing challenges such as when there was a number of agency or temporary staff on shift.

Care records were in the process of being moved to a new system, so were not always consistently easy to find. This meant that should staff need to access information this could not always be done in a timely way. We saw no impact of this but if staff could not find required information in a timely manner there was a risk of people not getting care in line with their care plans.

Positive behaviour support plans (PBS) were being used, but at the time of inspection were only introduced on three of the six wards. The other wards were still using individual support guidelines (ISG) but staff told us that using PBS and the training they had for this had improved the quality of care and reduced incidents. PBS was being implemented across the service but it was a working progress and was still needed on the other wards to have a consistent and robust model of care being used across all wards.

The provider had an improvement plan in place to address the improvements needed. In order to ensure further improvements and that improvements are sustained this needs to be adhered to and improvements made in a timely manner in the plan.

However;

People’s care and support was provided in a clean environment. The service provided care, support and treatment from trained staff and specialists able to meet people’s needs.

People were supported to be as independent and had as much control over their own lives as was possible in a secure environment. Their human rights were upheld.  

People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood each person’s individual needs. People had their communication needs met and information was shared in a way that could be understood. Staff were committed in their roles in ensuring people and their needs were always put first. The care they provided was person centred.

People’s risks were assessed regularly and managed safely. People were involved in managing their own risks whenever possible. If restrictive practices were used, there was a reporting system in place and there were comprehensive reviews to try and reduce the use of these practices.  

People made choices and took part in activities which were part of their planned care and support. Staff supported them to achieve their goals. People’s care, treatment and support plans, reflected their sensory, cognitive and functioning needs. 

People received care, support and treatment that met their needs and aspirations. Care focussed on people’s quality of life and followed best practice. Staff used clinical and quality audits to evaluate the quality of care.

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. 

People had clear plans in place to support them to return home or move to a community setting (as appropriate). However, some people had not been able to move on as quickly as would be expected due to lack of appropriate services available to them. Staff worked well with services that provide aftercare to ensure people received the right care and support in place they moved on.