The Care Quality Commission (CQC) has rated an Elstree rehabilitation service inadequate and placed it in special measures, after it found shortfalls in measures to ensure patient safety.
CQC inspected Cornerstone House, run by Vision MH Limited, in April after receiving a high number of notifications relating to patients self-harming and requiring hospital treatment.
The service was previously rated outstanding. It is now rated inadequate and has been placed in special measures.
Stuart Dunn, CQC head of inspection for mental health and community services, said:
“When we inspected Cornerstone House, we were not assured all reasonable steps were being taken to protect people from avoidable harm.
“It was concerning that action wasn’t always taken to keep patients safe after self-harm incidents and access to items which could be used to self-harm including crochet hooks, pens and batteries were not always risk assessed.
“Systems and processes to safely administer medicines were not always followed which resulted in a high number of medication errors, which meant people weren’t being treated safely, or effectively.
“There was also no system in place to manage patient concerns and some patients told us they felt it was “not worth making a complaint”’ as managers did not respond or take action to prevent re-occurrence.
“Behind these issues was a lack of oversight from the service’s leaders. Managers had not acted to appropriately address or review ongoing patient self-harm incidents, medication errors and patient risks.
“However, staff told us they felt respected, supported and valued and felt able to raise concerns without fear of retribution.
“Leaders know where they must improve, and we will continue to monitor the service closely to ensure this happens. We won’t hesitate to take further action to protect people if we are not assured care is being delivered safely.”
Inspectors found staff did not always treat patients with compassion and kindness or respect their privacy and dignity. They had not always involved patients and families when writing care plans.
In addition, staff did not have access to the risk register and were unaware of its contents.
However, the wards were clean, well equipped and fit for purpose. Staff effectively followed infection control policy and COVID-19 guidance. All staff and visitors had their temperature recorded on entry to the building.
As the service is in special measures, it will be inspected again within six months. If there is insufficient improvement, CQC will use its enforcement powers further to protect patients from the risk of harm and hold the service’s leaders to account.
Following the inspection, CQC told Vison MH Limited that it must make several improvements at Cornerstone House, including:
- Staff must treat patients with compassion and kindness
- Remedial action must be taken to address the blind spots on the ward
- Staff must respond to patient’s physical healthcare needs in a timely way
- Appropriate actions must be taken in response to identified patient risk and self-harm
- All incidents must be reported in patient’s clinical records
- Actions must be taken to address the ongoing high number of medication errors
- All staff must be up to date with all aspects of their mandatory training, including Mental Capacity Act and Deprivation of Liberty (DoLs) and ligature awareness
- Staff must undertake physical health observations for all patients following the administration of rapid tranquillisation, line with the provider’s policy.
Full details of the inspection are given in the report published on our website.
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