We carried out this unannounced focused inspection because we received information giving us concerns about patient safety and quality of the service on Oak Unit.
This was a focused inspection, looking only at Oak Unit, the psychiatric intensive care unit.
Our rating of this service stayed the same and was rated as good. Our rating of safe went down from good to requires improvement. That is because we found breaches of regulations and issued Requirement Notices telling the service provider what it must improve.
In these circumstances the rating linked to the area of the breach is normally limited to requires improvement.
(See the Areas for improvement section for more information.)
- See our website for more information about our Ratings principles
This report describes our judgement of the quality of care at this location. It is based on a combination of what we found when we inspected and a review of all information available to CQC, including information given to us from patients and the public. For this inspection, we looked at the safe and caring domain.
Hertfordshire Partnership University NHS Foundation Trust provides acute wards for adults of working age and psychiatric intensive care across six wards, over three sites. Oak Unit is a 12 bedded, male only, psychiatric intensive care unit (PICU), which is housed in a purpose-built premises at Kingsley Green, Radlett. The unit provides care and treatment for patients who are experiencing an intense period of mental distress and are very unwell. There were 11 patients admitted to the unit when we carried out this inspection, one of whom was on leave away from the ward. All patients on Oak Unit were detained under The Mental Health Act 1983.
The Acute wards for adults of working age and psychiatric intensive care units service was last inspected in March 2019, when it was rated good.
During this inspection we found:
- The ward used regular bank and agency staff to cover vacancies, which meant there were enough staff deployed on the unit.
- Staff carried out regular safety audits of the environment.
- The ward layout was deemed to be safe and risks were well managed.
- Staff understood how to protect patients from abuse.
- Staff were generally discreet, respectful, and responsive when caring for patients. We observed a number of positive interactions between staff and patients.
- Patient care records showed that staff made sure patients understood their care and treatment and found ways to communicate with patients who had communication difficulties.
- Staff were supporting one patient to develop and display some artwork on the ward.
- Patients had easy access to an independent advocate, who visited regularly.
- Staff were regularly required to carry out continuous patient observations for longer than the recommended time of two hours, some without being allocated a break.
- Not all staff had easy access to clinical information, and it was not easy for them to maintain high quality clinical records.
- Staff turnover, vacancy rates and sickness levels were high.
- The temperature on the ward was uncomfortably hot and could not easily be adjusted by staff. However, there were plans in place to mitigate this.
How we carried out the inspection
This inspection was unannounced, meaning the provider did not have advanced notice of the inspection.
The inspection team visited Oak Unit on 18 and 19 October 2022. We further visited on 31 October 2022.
During the inspection we:
- visited the ward and observed how staff cared for patients
- toured the clinical environments, including the clinic room and reviewed emergency equipment
- reviewed three patient care records
- spoke with seven patients
- spoke with two carers
- spoke with the independent advocate
- carried out a variety of observations on the ward including serving of lunch, ward based activities and a group cookery session
- reviewed how staff managed patient safety incidents by examining CCTV footage and incident paperwork
- observed one staff handover
- interviewed five staff including nurses, nursing assistants and a ward manager
- reviewed patient observation records, staffing rotas and patient observation allocation sheets and minutes of recent patient “mutual help” meetings
- reviewed data supplied by the trust, documents, policies and procedures relevant 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 seven patients and two family carers, and we reviewed one written compliment. Patients gave us mixed views about how they experienced the care and treatment they received.
All but one patient told us there were enough staff on the ward. Three patients told us they felt safe and supported by staff. However, three patients told us they did not always feel safe on the ward because some patients were threatening and had been physically aggressive, assaulting them or others. One said they felt unsafe by the practice of physical restraint, because they found the experience abusive and degrading, but noted that “98% of staff are respectful”. However, another patient told us they had experienced physical restraint and “staff were always gentle”. Two patients told us they had raised their concerns with staff about not feeling safe but had not received suitable assurances. One said staff had not responded helpfully and the other told us that they had not any feedback since they raised the issue. However, another patient told us “everything I’ve raised has been dealt with”.
Two patients told us that while there were always enough staff on the ward, a lot of them were carrying out safe and supportive observation duties, so when patients asked them for something, they were not able to help with their query or request. However, if staff were available, they could speak to them about their feelings. One patient told us that staff were “great, amazing and incredible”. The minutes we reviewed from a sample of the patient “mutual help” meetings, showed numerous positive “thank you” comments from patients to staff.
One patient told us they became agitated when the lounge was noisy and overcrowded. Another said the ward was so noisy, they couldn’t hear their telephone conversations. Patients on Oak Ward have access to a quiet lounge and their bedrooms. If the ward environment is over stimulating, patients can be supported to access these areas.
One patient told us if they bought vaping machines from the trust, that they costed almost double the price that they could buy them for in the community. They felt this was unfair. Another told us if the machine on the ward where they bought vapes was empty and this caused “tensions to rise”. Another they also told us the times set for patients to be able to go outside and use their vaping machine coincided with a staff handover meeting, which meant there were not always enough staff to support them to use their vapes at the time they were scheduled to use them. They said this was frustrating and it made them angry.
One patient told us that staff were not always consistent in their responses, indicating some were more boundaried in their approach than others. They also told us that some overseas staff were unwilling to talk to patients about their sexuality and often spoke to each other in a language the patients didn't understand. Another patient told us that some situations with other patients “escalate unnecessarily," because “staff don’t listen to patients and resolve things quickly”.
Some patients told us there were lots of activities for them to participate in, such as art and craft, playing music, chess games with the occupational therapist, a smoothie making group, cooking sessions, a walking group and using the gym. However, others told us there were not enough activities, and they were bored. All the patients told us they could go outside for fresh air, but some noted there was no shelter for them to use while vaping, so they could be cold and wet. A separate outside area, the courtyard, which had a shelter was being refurbished and not accessible to patients. Patients had monthly Mutual Help Meetings, where they could discuss issues with staff. At these meetings, they were able to request additional activities, such as board games, access to specific PlayStation games or devices to access social media. These would then be taken forward for a multidisciplinary team meeting for a review to the appropriateness of the requests and actioned if deemed appropriate.
Family carers told us they were often kept waiting for between 30 minutes and an hour before their relative was brought to see them for their arranged visits. They felt this was too long to be kept waiting. They told us they were not as not fully involved in their relative’s care as they would have liked to have been and were not given opportunities to provide feedback about the service or given information about how to make a complaint if they were unhappy with the service. One family carer told us that their relative felt there were not enough staff on the ward and the ward round meeting that they were invited to attend was set at a fixed time on the same day every week, which was inflexible.