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Provider: St Andrew's Healthcare Requires improvement

Reports


Inspection carried out on 23 and 24 Octoer 2019

During an inspection looking at part of the service

  • The provider’s leadership team had a comprehensive knowledge of current priorities and plans were in place to address these. Many of these were in their infancy.

  • The provider had not always responded to concerns raised by CQC in a timely manner. Despite board meeting minutes acknowledging inspection findings, we were told of a two-year backlog to address some issues. Board meeting minutes also contained statements which demonstrated senior leaders had not fully accepted the serious nature of concerns raised, or ratings applied, following some inspections.

  • The provider’s systems for sharing learning within and across the organisation were variable and inconsistent. The provider did not have fully effective systems to share learning across different pathways and services. Senior leaders recognised this need.

  • The provider’s recent changes and improvements to the governance structures did not equate to a fully integrated approach at the time of inspection. Staff were able to detail how it would be and when they expected to have an integrated governance dashboard in place. There was minimal evidence of scrutiny or challenge, to either corporate or clinical governance, being delivered by the non-executive directors at governance committees.

  • There was a lack of clarity regarding operations and governance processes taking place in the same committees and whilst the staff believed it worked currently, there was a potential risk of conflict of interest, as best practice and policy development could be influenced by operations managers. The provider may wish to consider separating governance and operations at the highest level to mitigate the risk for potential conflict.

  • The link between the risk register and strategic assurance framework (SAF) was unclear from those we spoke to during the well led review. The escalation process between ward and integrated practice units (IPU) and then IPU to clinical governance, and upwards to the charity executive committee, were also unclear. Ongoing development of these structures was noted.

  • The provider had robust systems and processes for monitoring compliance with the Mental Health Act.

  • The board reviewed performance reports that included data about the services, which included an integrated clinical governance report. An integrated performance report was under development and near completion.

  • The provider had made improvements in IT systems and infrastructures which lay the foundations to fulfil larger plans.

  • The provider was actively engaged in collaborative work with external partners, to share and learn, network, and work in partnerships with a focus on looking at gaps in treatment pathways for people struggling with their mental health.

  • There were various mechanisms for staff to feedback and engage. As the culture evolved staff were using these more.

  • The provider was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

  • The provider had invested in a research team with an allocated budget and a focus on research projects that were practical and meaningful to care, and services provided.

  • Staff did not consistently feel confident to raise concerns without fear of reprisals. The provider had not afforded the appropriate protection to one staff member under The Protected Disclosures Act 2014.

  • The mortality report did not evidence a robust and comprehensive analysis of mortality and lessons learned.

  • Mental Health Act governance did not include regular reporting to the board. This was only done through exception and was not a routine report. Therefore, there was a risk the board may not be fully sighted of all concerns identified, for example from Mental Health Act review reports. The Chief Nurse provided information and allocated responsibility to relevant teams, in-line with processes for CQC actions. The assurance and appraisal of Hospital Managers needed to align to the Mental Health Act requirements.

  • The provider had not yet embedded a formal and consistent approach to quality improvement. Audit activity was undertaken by both a quality team and clinical audit. There appeared to be confusion between audit and quality improvement. A formal and consistent approach to quality improvement was yet to be embedded. It was recognised that revised governance structures required further development prior to launching formal quality improvement. Innovations were still encouraged following a plan-do-study-act (PDSA) methodology including body worn cameras, reducing restrictive interventions, and admission projects.

    However:

  • The provider had a newly formed leadership team with many of the skills, abilities, and commitment to provide high-quality services. There was now a clearer focus on clinical leadership, alongside an identified need to further define and develop the assurance function within a non-executive director/governor role.

  • We recognised that the appointment of a chair, through a robust external process, had paved the way for future non-executive director recruitment and engagement.

  • Senior leaders were visible and approachable. The provider had a programme of visits to all services.

  • The board and senior leadership team had a clear vision and set of values that were at the heart of all the work across services. They were working hard to make sure staff at all levels understood them in relation to their daily roles. There was an authentic desire to live the values and embed these within the recruitment process to build a robust and consistent culture.

  • The provider’s work around staff wellbeing, development, and recruitment and retention were recognised as strengths and were having a positive impact. Examples included opportunities for support workers to complete nurse training, vicarious trauma teams, and recruitment assessment centers were recognised as strengths and were having a positive impact.

  • The provider promoted equality and diversity in their day to day work and when looking at opportunities for career progression.

  • The provider had developed and embedded data systems, which were showing early promise to give greater oversight of issues facing the provider. The safety framework dashboard was underpinned by a good process and ability to illustrate trends and graphs by facility and by group.

  • Incidents of staff use of physical restraint of patients were increasing. The provider had a reducing physical interventions plan but, at the time of inspection, this had not led to a reduction in restraint incidents.

  • The provider’s process for recording and monitoring duty of candour requirements was not fully effective. We found some discrepancies between the duty of candour register and the details in the quality report. We were aware of plans for review of policy and process.


CQC inspections of services

Inspection carried out on 9 - 12 September 2014

During a routine inspection

We rated St Andrew’s Healthcare overall as requiring improvement because we identified concerns in both the safe and well-led domains.

We rated the safe domain as requires improvement because we found the following:

  • Environmental concerns including, actions from ligature audits were not completed in the Essex location. There were blind spots in some seclusion rooms and bedrooms.
  • Medicines in the Birmingham hospital were not stored and disposed of safely.
  • Care and treatment records were incomplete.
  • Staffing Concerns including, a high use of bureau (bank and agency) staff. Night time cover on wards was a concern as staff were frequently moved from allocated wards to address shortfalls. There was only one doctor providing waking cover with a second doctor on call to the Northampton site between 11pm and 8am.
  • We had concerns with the assessing and management of risk. We were concerned with the number of prone restraints being used in the CAMHS wards. Risk assessments and care plans around the use of prone restraint were not always in place.
  • We also identified concerns with seclusion practices including poor recording and reviewing. We also saw that seclusion rooms were used for “time out”.

We rated the well-led domain as requires improvement because we found the following:

  • The governance systems were not effective as there were variations in quality of service between hospital locations and between services in the same hospital or core service area. Even though we found that the board assurance framework and charity wide risk register, had identified many of the risks during our inspection.
  • In some services staff morale was low. Staff working on the CAMHS wards told us they felt underappreciated by those senior managers and often felt not listened to as the provider was focused on other services areas. Staff from the learning disability wards told us they found it difficult working with high numbers of bank and agency staff in challenging environments.
  • Some managers were managing more than one service. This was affecting their availability and effectiveness.

In the core services inspected we saw evidence of good practice. This was being delivered by caring and professional staff who were working collaboratively. However this was not the case in the learning disability service or the child and adolescent learning disability wards. Where we found that;

  • Information was not produced in an accessible format for people.
  • The staff we spoke with did not have a good knowledge of the safeguarding policy or procedures.
  • There were issues with the use of and recording of seclusion. This included using seclusion facilities for “time out”.
  • Notifications of incidents that required reporting to the CQC had not been made.
  • There was a high use of bureau (bank and agency) staff which meant that staff did not always know the patients. The handovers that we observed were not comprehensive.
  • We saw the use of a generic, restrictive risk safety system rather than individual risk assessments based on patient needs. These plans were often not discussed with or explained to the patient in a way that they understand. We were concerned that not all care and treatment was patient centred and relevant to the patient group.
  • Managers and staff had a very limited understanding of children’s rights in the CAMHS services which meant care was not always planned in accordance with children’s rights.

The board, executive team and senior managers had recently undergone changes in key roles including a new chairman, chief executive and chief finance officer. People who use the services, staff and external stakeholders told us of new initiatives and plans to develop the service.

Before and during our inspection, people told us that most staff treated them with kindness, dignity and respect.

The provider managed risks and identified and investigated safeguarding concerns. Staff were aware of their role to identify and report all concerns and risks. However in the Essex service actions identified in the ligature risk assessment had not been completed on Audley ward. Care and treatment records were incomplete for one patient who had long term physical healthcare needs.

We visited all of the wards where detained patients were being treated. In the majority of the care records, which related to the detention, care and treatment of detained patients, the Mental Health Act (MHA) and the code of practice had been followed.

The provider was providing evidence based treatments in line with best practice guidance. Patients were being supported to make choices and gave informed consent where possible.

The provider was using outcome measures to judge the effectiveness of the treatment provided.

The governance processes were not fully supported by robust quality assurance systems. Many of these systems were new and had not always identified poorly performing services in a timely manner. This meant that although the provider understood its broad areas of risk it did not always identify all of the areas of concern early enough.

St Andrew’s Healthcare was providing a caring service for people across all locations. We saw throughout the inspection staff treating people with kindness, dignity and compassion. The feedback received from people who used services and their visitors was generally positive about their experiences of the care and treatment provided by the provider. However there were concerns identified on the learning disability wards. We were told that patients’ and carers’ were not involved in the planning of care. The care plans were not being produced in a person centred way and these were not available in an accessible format to assist patients to understand them.

Staff worked well together to meet people’s needs and that they were able to respond to individual needs and preferences.

The provider was in a period of change. The governance system for executives and non-executives was changing from a charity to a health provider and people were being appointed with health experience to effectively offer challenge. Lines of communication from the board and senior managers to frontline services were seen as a priority and people told us that the new chief executive had more presence in the clinical areas. Staff felt well supported by their immediate line managers. However the organisations vision and values were not fully embedded across the provider.

The main challenge for the provider was to ensure that governance processes were supported by quality assurance systems. This has meant that in each domain there are areas of very positive work but also areas where improvements are required.

There were variations in the quality of service provided between locations and services in the same locations or core service area. As a consequence there are a number of compliance actions relating to different services and it is our view that the provider needs to take steps to improve the quality and safety of their services. We will be working with them to agree an action plan to help improve the standards of care and treatment.