Cheswold Park Hospital

We are placing Cheswold Park Hospital in special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We rated Cheswold Park Hospital as inadequate because:

• When we inspected the hospital in August 2015, we found breaches of four regulations and rated it overall as ‘requires improvement’. Although the hospital had made some efforts to improve services, not enough had been done to remedy the breaches and to maintain improvements in the long term. We also found new problems that the hospital needs to put right, which resulted in our lower rating of ‘inadequate’.
• Staff did not monitor patients’ physical health regularly and effectively and the hospital still did not have an effective system for monitoring patients’ physical health. Staff had not assessed all risks to patients with long-term health conditions and those self-medicating. They had not prepared comprehensive care plans to ensure that they received the right support, care and treatment to meet their physical health needs, enable safe self-medication and keep them safe.
• Staff did not manage medicines correctly. They did not ensure that all medication was stored appropriately or securely. They did not keep records on stock acquired from other wards and so might not have been able to identify any stock discrepancies. Staff did not always ensure that patients took the medication they were given.
• Records to ensure that patients were kept safe and to manage and mitigate risks to them did not contain sufficient information or all of the relevant information. Positive behavioural support plans did not contain information to enable staff to de-escalate incidents. Environmental risk assessments did not always identify risks or contain plans to manage or reduce them. One audit of ligature anchor points (places to which patients intent on self-harm could tie something to strangle themselves) was inaccurate and some staff were unaware of ligature risks.
• Staff did not follow safety procedures. This included observation of patients, checking electrical equipment and contents of first aid boxes. The provider had undertaken work to remove fixed ligature anchor points from patient ensuite bathrooms. However, four communal bathrooms continued to have standard taps and the provider had not improved the ability for staff to see patients in their bedrooms.
• The hospital imposed a number of blanket restrictions on patients’ freedom when restrictions should be based on individual risk assessments. Staff on Brook and Don Wards restricted shaving times. Some staff and patients on Don Ward told us that punitive measures were used for patients deemed not to conform to behavioural rules. Staff used physical and mechanical restraint to control and restrict a patient that was not always proportionate to the harm or risk of harm posed by the patient. This was not in line with the Mental Health Act and the code of practice.
• Staff searched all patients on return from section 17 leave (granted to patients detained for treatment).
• The provider did not ensure that areas of the hospital were clean or well maintained. Areas of the hospital were visibly unclean, with debris on floors and surfaces. Ward kitchens were worn and tired.
• The Isle Suite used for long-term segregation did not promote recovery, comfort, dignity and confidentiality, and did not meet the requirements of the Mental Health Act code of practice. The suite was not clean and contained debris and stains in all areas. There was no cleaning schedule for the suite and there were no hand washing facilities for staff. The suite did not have any furniture except a mattress. It did not contain the patient’s personal items, except for stickers on the walls and curtains and the patient was unable to make telephone calls in private. The hospital had not sought an external review of the patient’s circumstances and records did not show evidence that staff had informed the local safeguarding team of the commencement of long term segregation. Documentation of some multidisciplinary reviews contained language relating to continuing seclusion; it was not clear on one record whether an approved clinician had completed the review. Records did not show input of any structured programmes of therapy and activity.
• The care and treatment records for one patient did not show how staff had assessed the patient’s capacity to make decisions not applicable to their detention under the Mental Health Act. The provider’s policy did not clearly explain the rights of the Lasting Power of Attorney or the scope of their role.
• Staff prescribed medications for mental disorder for some patients that did not match those stated on consent to treatment forms. This was not in accordance with the Mental Health Act and code of practice. Reviews completed by a community pharmacy identified 47 errors in relation to Mental Health Act paperwork and prescribed medicines between July and September 2016.
• Some patients raised concerns about their experience of using the service. They had concerns about the quality and variety of food provided, did not like the way that staff treated them, and were not happy with their involvement in meetings about their care and treatment. Some carers raised concerns about communication and their involvement in meetings. Over half of patients’ care plans reviewed did not show evidence of patient involvement or reflect the views of patients. Twenty five percent of patient care plans contained vague and ambiguous statements. Observations showed some staff did not maintain professional boundaries with patients. Community meeting minutes for some wards showed mainly information that staff communicated to patients and not the involvement and views of patients.
• The hospital’s leadership and governance structure was unclear and complex. Governance committee meeting minutes did not provide assurance that actions were completed. The provider’s systems and processes did not ensure that staff carried out their responsibilities. Staff, including senior managers, did not understand the duty of candour. The records of investigations and serious incidents records did not show evidence of the duty of candour being applied. Staff investigating serious incidents did not follow the provider’s policy and investigations completed did not show evidence of lessons learned. The registered person did not submit notifications to the Care Quality Commission of statutory notifiable incidents in five cases and a further two incidents were submitted with delays.
• Systems and processes were ineffective and did not ensure that the provider had oversight to ensure that staff files were up to date with the required registrations, qualifications, references, and disclosure and barring service checks to ensure they were fit and proper to carry out their roles. Staff did not receive the necessary training to meet the care certificate standards and not all staff received regular supervision and appraisal.
• The provider had not obtained the required information to meet the requirements for the fit and proper persons for the organisations directors.
• The paper-based system for patient care and treatment records was cumbersome. This meant that staff could not easily access records when needed.
• The provider had not updated some of its policies to reflect changes in the organisation.
• Team meeting minutes did not contain sufficient information to be an accurate record of meetings and the minutes for Don Ward did not promote morale and engagement of staff.
• The hospital audit programme was not fit for purpose. Staff had not completed actions including re-auditing later, not all audits had action plans and those that had did not all have timescales.
• Staff did not uphold the privacy and dignity of patients as they administered patients’ medication through a hatch from clinic rooms; other patients and staff could see patients taking their medication.

However:

• The provider had reduced the number of restraint and seclusion episodes significantly since the introduction of a No Force First approach.
• The hospital provided a range of psychological therapies. Dedicated trained staff ran a dialectical behavioural therapy based helpline.
• Patients participated in providing positive behavioural support training to staff.
• An occupational therapy activity timetable and a dedicated recovery college provided a range of activities and courses.
• Senior managers in the organisation were visible and accessible to patients and staff. Ward representatives attended weekly meetings to report ward performance to the senior management team.

We found the following issues that the provider needs to improve:

• The provider did not have effective systems and processes to identify issues in infection control and incident management. Staff displayed poor hand hygiene and infection control practices. They had not identified all risks in an infection control risk assessment and this did not contain sufficient information to manage and mitigate risks.
• The provider had not taken timely and reasonable steps to assess, monitor and mitigate the risks to the physical health of a patient. Care and treatment records did not contain mental capacity assessments when making decisions about some aspects of physical health.
• The patient risk assessment did not identify all risks and the risk management plan did not address and mitigate risks. Staff did not discuss risks at staff handover.
• Care plans did not contain enough detail to reflect the care required and staff had not involved the patient in their development. Staff did not always follow the patient’s communication care plan. They did not have immediate access to the patient’s records, as these were stored in an office away from the suite.
• In over half of the incidents of restraint used, it was not proportionate or in response to risk. Staff that reviewed incidents did not make recommendations, record actions or lessons learnt after incidents. The provider did not have effective systems to have oversight of incident management and did not identify these issues.
• Not enough dedicated staff were available when needed and this meant that the patient had to wait staff to be available to enter the suite or get items that they needed. There continued to be limited input from some disciplines of the multi-disciplinary team.
• The patient did not have privacy and dignity when using the bathroom or holding telephone calls.
• The secure garden did not contain a shelter from adverse weather.
• Senior management staff lacked understanding about the use and application of positive behavioural support. They acknowledged that they did not currently have any expertise in adaptive behavioural scales, applied behaviour analysis or positive behaviour support within their substantive staff.
• The registered person did not speak respectfully when they described a patient and their needs.
• Training in learning disability and personality disorder was not up to date.

However, we found the following areas of positive practice:

• Since our last inspection in February 2017, the provider had installed a handwashing sink and a drain in the suite. They had arranged for an external hospital to review the long-term segregation every three months.
• Staff entered the suite more frequently and for longer duration and the suite was more personalised and contained some furniture.
• The provider had commissioned a sensory integration assessment.
• Staff who regularly worked with the patient knew the patient well, treated them with respect, praised and encouraged them.