CQC takes further action at Suffolk mental health hospital

Published: 17 September 2021 Page last updated: 17 September 2021

The Care Quality Commission (CQC) has taken further action after it found a Suffolk mental health hospital had not improved patient care.

CQC carried out a focused inspection of St John’s House, in Palgrave, near Diss, in July to check on progress following a previous inspection where it was rated inadequate and placed in special measures due to concerns around patient safety, incident management, staffing and the use of restraint.

The 49-bed hospital is run by Partnerships in Care, part of the Priory Group. It cares for adults living with learning disabilities and associated mental health issues.

During the latest inspection, further concerns were highlighted that showed unacceptable care. Inspectors found that insufficient progress had been made regarding patient safety, staffing, risk management and adherence to patient care and risk needs.

Due to the serious level of concerns found, previous conditions CQC placed on the provider remained in place, including restricting admissions to the hospital and further urgent conditions were imposed to prevent harm and to protect patients. Following this, the provider decided to close this location and they are working to find alternative care services for patients.

Stuart Dunn, CQC head of inspection for mental health and community services, said:

“Our latest inspection of St John’s House found an unacceptable service where insufficient improvements had been made to protect patients from harm and abuse and the number of safety incidents remained high.

“Staff weren’t responding appropriately to patients who were self-harming, with one patient not being sent to hospital quickly enough after swallowing a foreign object, despite complaining of abdominal pain.

“We reviewed CCTV footage and found staff were sometimes asleep when they should have been observing patients to make sure they were safe. This was all the more concerning as we identified this as a concern during the previous two inspections of this service, demonstrating a lack of improvement to keep patients safe.

“Incidents of restraint remained high and not all staff had the right training to carry it out safely. In addition, staff were not following hospital policy when using soft handcuffs with patients during safety incidents.

“Services must inform CQC and other statutory bodies when they identify safeguarding concerns such as these to ensure patient safety. This service’s continued failure to refer all instances of abuse and thoroughly investigate concerns has put its patients at prolonged risk of harm.

“Following our inspection where additional enforcement action was taken, the provider made the decision to close this service.”

The service was short-staffed and heavily dependent on agency workers, many of whom were not adequately trained or experienced. Permanent staff had completed their mandatory training, but reported they were concerned about working with agency workers as they were not always competent.

Staffing levels were below the number needed to consistently maintain patient observation levels and male staff were often placed on female patient observations due to a shortage of female staff. This led to a potential self-harm incident when a female patient was left alone in a bathroom due to the male staff member not being able to enter. This posed a significant risk to the patient as there was a delayed response in assisting them.

Following the inspection, CQC told the hospital that it must make several improvements, including:

  • Patients must be offered appropriate support and protection following a safeguarding incident
  • Staff must follow national guidance and the provider’s policy when using mechanical restraint on patients, including seeking appropriate approval, ensuring patients have an individual care plan for the use of handcuffs and ensuring staff are adequately trained in the use of handcuffs
  • Patients in long term segregation must always have access to drinks
  • All allegations of abuse or reportable safeguarding incidents must be notified to the appropriate authorities
  • The provider must ensure that the reporting of incidents is clear, accurate and details the rationale for decisions made in relation to patient care and safety
  • Patients must be transferred to A&E, without delay, following incidents when this is required.

Full details of the inspection are given in the report published on our website.

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About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.