25 November 2021 and 9 December 2021
During an inspection of Child and adolescent mental health wards
Hertfordshire Partnership University NHS Foundation Trust provides child and adolescent services throughout the county. There are approximately 250,000 children and adolescents (under 18 years) in Hertfordshire. For the core service child and adolescent mental health wards, Hertfordshire Partnership University NHS Foundation Trust has one location.
Forest House is a 16-bed unit that provides specialist inpatient care and treatment for young people living in or outside Hertfordshire, aged 13 to 18 years, requiring admission as a Tier 4 provision. The unit is based at Radlett in Hertfordshire and the beds available are for female, male and non-binary gender young people. At the time of inspection three of these beds are specifically for young people with eating disorders.
The service aims to help young people and their families cope with psychological, social, emotional and behavioural problems. Young people have access to a school on site to support educational needs during their admission.
At the time of inspection, the unit had reduced the bed numbers to 13 to enable additional building works on the High Dependency Unit (HDU) area. A further decision to reduce the overall capacity to 10 beds was made before 25th December 2021. The 20th January 2022 was when Forest House had two further discharges and were, therefore, able to reduce the overall capacity to 10. It was not safe or appropriate to discharge earlier in consideration of the individual young people.
During 2020 and 2021, the Forest House service encountered a significant increase in the acuity of the presentations of the young people who were admitted to it. This was in part as a consequence of the pandemic, and the well-publicised deterioration in the mental health of some individuals. At the same time, half of the General Assessment Unit beds in the East of England region (both NHS and Private) were closed to new admissions for young people, which meant more reliance on the Forest House unit and less availability to other alternatives to access an inpatient bed, and to treat and care for more young people. Additionally, young people suffering from eating problems and needing access to trust services had risen by 50%, with a corresponding increase of admissions required, but there were insufficient specialist inpatient beds within the region and nationally to admit these young people to. The impact of this change in the volume and presentation of the client group at Forest House, meant that the young peoples’ length of stay had increased in many cases and the risk that young people presented with had also increased, with more incidents of self-harming, increased violence, aggression, verbal and racial abuse as well as behavioural difficulties. Staffing challenges arose as a consequence of the above changes, as those presenting required more safe and supportive observations and expert care.
Forest House was last inspected in March 2019 and was rated as outstanding overall.
We carried out this unannounced focused inspection of Forest House unit because we received information giving us concerns about the safety and quality of the service. We visited the ward on 25 November 2021 and 9 December 2021 and carried out remote interviews of young people and staff between 7 December and 30 December 2021. We primarily focused on specific key lines of enquiry within the safe and well-led domains and some key lines of enquiry within effective, responsive and caring domains.
Following this inspection, the trust was served with a Section 29A warning notice as the Care Quality Commission formed the view that the quality of health care provided at the trust’s inpatient service for children and young people required significant improvement. The trust was required to take immediate action to make improvements at this service.
We rated the safe, effective, caring, responsive and well led domains.
SUMMARY OF FINDINGS
- Access to a clinical psychologist was limited to young people which reduced the ability to provide therapeutic interventions in line with best practice.
- There were a number of vacancies within the therapy team and the ongoing refurbishments had also impacted on room availability to enable therapists to conduct therapy sessions.
- Staff did not consistently enforce the unit’s mobile phone policy to ensure the safety and wellbeing of all young people on the unit.
- The unit did not have effective systems in place to ensure staff administered and recorded administration of medication to young people in accordance with their prescription charts.
- Staff did not adhere to the trust guidelines when completing physical healthcare checks for young people following administration of medication administered for the purpose of rapid tranquilisation.
- There was insufficient management and oversight of the running of the service to ensure all policies, procedures and local governance arrangements were maintained, monitored, accurately documented and effective.
- There were not always enough suitably trained, competent, skilled and experienced staff to deliver safe care and treatment and develop therapeutic relationships with the young people. Compliance with key training requirements did not meet the trust target.
- Some young people told us they did not always feel listened to and did not feel safe on the unit due to bullying by other young people and felt this was not managed appropriately by staff.
- Staff morale within the unit was poor. Some staff described low morale due to significant staff changes, increased level of acuity of young people accessing the service, incidents of assault, the impact of major refurbishment within the unit and difficulties with maintaining staffing levels.
- Most parents and carers were dissatisfied with the level of care and treatment offered to young people and there were delays in the response from the trust to formal complaints.
However:
- Staff knew about potential ligature anchor points and mitigated the risks.
- Most regular staff worked hard and showed compassion and kindness to the young people they supported.
- Whilst risk management plans were not always up to date, we found overall the risk assessment and care plans to be holistic and person centred.
- The trust had taken the decision to keep Forest House operating to the maximum capacity possible, despite recent challenges, in order to provide appropriate placements for young people and support the wider healthcare system. At the time of the inspection, all other similar units across the East of England had either closed to admissions or had significantly reduced their bed numbers.
How we carried out the inspection
During the inspection we:
- Spoke with the clinical director and interim senior service line lead
- spoke with head of nursing and service line lead for tier 4 children and adolescent mental health services
- spoke with a total of ten staff which included the modern matron, team leaders, lead therapist, counsellor, psychologist, nurses and health care workers
- spoke with six young people
- spoke with eight parents & carers
- spoke with one external social worker
- reviewed eight care plans and risk assessments
- reviewed three care records and 4 observation records
- observed a daily handover meeting
- reviewed a range of policies and procedures, data and documentation relating to the running of the service.
You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.
What people who use the service say
We spoke with six young people who said they felt there were enough staff present on the unit but two told us that often staff were busy. Three young people said there had been incidents or bullying on the ward and this was not managed appropriately by staff, they felt unsafe on the ward and not listened to by staff. Three young people said there was a lack of therapeutic interventions, including psychology, although another young person said they had accessed art therapy three times per week. One young person told us staff were respectful and polite but three did not and that their concerns were not always addressed, some staff lacked empathy and there was lack of consistency with staffing. One young person told us they felt their complaints were disregarded and another said a lot of the time their views were not heard. However, one young person said a number of staff were helpful.
One young person told us activities were often cancelled due to staff shortages. The current refurbishments on the unit also impacted on the ability to access quiet space areas.
We spoke with eight parents who said that overall, the quality of care for their children was very poor. They cited that communication between staff and themselves was poor and they were not always consulted regarding their child’s care or there was a delay in them being updated following an incident on the unit.
The parents of one young person told us there was no single point of contact for families to alleviate a lot of the confusion around the care and running of the unit. Most parents did not feel their children’s needs were being met and there were significant delays in response to complaints they had made. Three parents told us their child’s self-harming behaviour had increased since admission to the unit. Some parents said they were frustrated at the lack of therapeutic support available to their child and there was a lack of psychiatrists and consistent staffing within the unit. Some expressed a lack of meal support and expertise from staff for young people with a diagnosis of an eating disorder.