The Care Quality Commission (CQC) has rated St Mary’s Hospital in Warrington, requires improvement and issued them with a warning notice to ensure people’s safety following an inspection in July.
The inspection was carried out to follow up on information of concern regarding the safety of patients. Inspectors visited Cavendish ward and Leo wards and looked at how safe and well-led these areas were.
St Mary’s Hospital, ran by Elysium Healthcare, provides inpatient care for men aged 18 years and older. Cavendish ward is a 17-bed ward for men with an acquired brain injury and Leo ward is a 12-bed assessment, treatment and rehabilitation ward for autistic men
Following the inspection, the service has been told it must make significant improvements by 30 November, to ensure that it protects people from abuse and improper treatment, and that it has adequate systems and processes in place to effectively safeguard people from harm.
The rating for safe has declined from requires improvement to inadequate. However, the service’s overall rating remained the same, and well led remained rated as requires improvement. We did not inspect or re-rate effective, caring or responsive.
Karen Knapton, CQC head of hospital inspection said:
“When we returned to St Mary’s Hospital, it was disappointing to see some areas of safety had deteriorated since we last inspected.
“It was concerning that best practice wasn’t always followed when staff had to use restrictive interventions on people. Inspectors saw several occasions where staff used unsafe techniques to handle people which put themselves and patients at risk of harm.
“Staff didn’t always know what incidents to report and how to report them. There had been some potential safeguarding incidents recorded on CCTV on Cavendish ward that had not been reported appropriately. It is vital incidents of concern get reported so preventative measures can be taken to keep people safe.
“For example, CCTV footage we reviewed showed staff preventing someone from leaving their bedroom for a sustained period even though this person wasn’t deemed to require such restrictions.
“However, it was reassuring that managers had brought in a service development and wellbeing lead to work with staff in the service, with a focus on supporting staff on Cavendish ward where most of the concerns were found.
“While on site, we received mainly positive feedback from people using the service,
“We will continue to monitor the service closely and will return to check if the necessary improvements have been made. If we find this is not happening, we will not hesitate to take further action to keep people safe.”
The latest inspection found that:
- Staff had mixed views about the support they received following incidents. There were policies in place for staff to have debriefing sessions following incidents, but it was not clear if these always happened
- The wards had enough doctors but did not always have enough nurses and support staff.
- Staff and managers agreed that the absence of leadership on the ward had left staff feeling unsupported on Cavendish ward
- The level of detail in risk assessments was variable and not always up to date
- Leaders weren’t always visible, and staff didn’t always feel supported by their managers.
However:
- The service had enough day and night medical cover and a doctor available to go to the ward quickly in an emergency
- Staff had completed and kept up to date with their mandatory training
- Patients had individual positive behavioural support plans that described how staff should respond to their needs and support them
- There was evidence that changes had been made as a result of feedback.