The Care Quality Commission (CQC) has downgraded the rating for Essex Partnership University NHS Foundation Trusts long stay and rehabilitation mental health wards from good to requires improvement, following an inspection of their ward at 439 Ipswich Road in November.
439 Ipswich Road provides care for up to 11 adults. The service consists of a main house with 8 bedrooms, as well as a smaller building with two more bedrooms and self-contained flat.
CQC has downgraded the trust’s rating for long stay or rehabilitation mental health wards from good to inadequate for safe. It has also lowered their rating from good to requires improvement for caring. Inspectors again rated them requires improvement for effective and well-led, and good for responsive.
The trust as a whole remains rated requires improvement.
Stuart Dunn, CQC deputy director of mental health in the East of England, said:
“We were concerned to find leaders at 439 Ipswich Road weren’t always acting quickly on safety concerns raised by their staff or the people in their care, although they did respond quickly when we raised them.
“Staff had reported safeguarding incidents affecting people’s physical or sexual safety, but leaders hadn’t thoroughly investigated or reported them to the local authority or CQC. Because they failed to do so, they didn’t learn from them or make changes, which left some people at risk of repeated harm.
“We found the trust had also admitted two people without risk assessments, due to bed shortages or pressures on other wards. However, this meant staff were missing information they needed to protect these people and others in the service.
“One person had reported a large hole in the garden fence to the trust, because they were having suicidal thoughts and were concerned they could leave through it easily. At the time of our inspection the service was caring for some people detained under the Mental Health Act, for whom this wasn’t safe.
“We raised these findings to the trust as urgent concerns, needing immediate action. Leaders have since completed retrospective incident reports and shared these with the local authority and the police where appropriate. They have increased the number of staff to protect people and organised community meetings to discuss sexual safety.
“They have risk-assessed everyone on the ward and moved some people to other services more appropriate for their needs. The garden fence has been fixed, and the garden as a whole made safer.
“While this is appropriate, leaders knew about these issues and should have acted earlier. We’ve shared our full findings with them and will continue to closely monitor the service to ensure people are kept safe while long-term improvements are made and embedded.”
Inspectors found:
- While there were enough nursing staff to support people, they had limited face-to-face access to clinicians or clinical psychologists.
- Some staff raised concerns that people’s information wasn’t always being kept confidential.
- The service didn’t always maintain the home environment safely. Inspectors found ligature and fire risks, as well as broken appliances in the garden.
- People had a mixed view of the activities at the service, and many reported they got bored.
- When some people reported money missing, staff advised them to lock their money up but the service didn’t take further action to reduce the risk of this.
However:
- People told inspectors the staff were friendly, supportive, and respectful. Staff responded to people’s preferences.
- Staff supported people to make their own decisions and build independence through tasks such as shopping and cooking.