Archived: St Andrew's Healthcare - Womens Service

Updated 5 October 2022

St Andrew’s Healthcare Women’s location has been registered with the CQC since 11 April 2011. The service does not have a registered manager in post but does have a nominated individual as required, and a controlled drugs accountable officer. At the time of the inspection, the provider had applied to change its registration with the Care Quality Commission to one location instead of multiple registrations across one site. A new application for a registered manager was in progress at the time of the inspection.

This location consists of four core services: acute wards for adults of working age and psychiatric intensive care units; long stay/rehabilitation mental health wards for working age adults; forensic/inpatient secure wards; wards for people with learning disabilities or autism.

St Andrew’s Healthcare Women’s location is registered to provide the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983.
• Treatment of disease, disorder or injury.

This location has been inspected ten times. The last comprehensive inspection of this location was in July and August 2021. The location was rated as inadequate overall and placed into special measures. Safe was rated as inadequate, effective rated requires improvement, caring rated inadequate, responsive rated requires improvement and well led rated as inadequate.

Urgent enforcement action was taken following the previous inspection because of immediate concerns we had about the safety of patients on the forensic inpatient or secure wards, long stay or rehabilitation mental health wards for working age adults and wards for people with learning disabilities or autism. We imposed conditions on the provider's registration that included the following requirements:

• that the provider must not admit any new patients without permission from the CQC;
• that wards must be staffed with the required numbers of suitably skilled staff to meet patients’ needs;
• that staff undertaking patient observations must do so in line with the provider’s policy;
• that staff must receive required training for their role and that audits of incident reporting are completed.

Following this inspection, we wrote to the provider on 9 May 2022, to vary one condition to allow, from 10 May 2022, that St Andrews Healthcare Women’s service may admit up to a maximum of 1 patient per week to each ward without seeking permission from the Commission. The admissions cannot be carried over to following weeks should an admission not occur. All other conditions outlined in the section 31 notice of decision from July 2021 remained applicable. The provider was required to provide CQC with an update relating to these conditions on a fortnightly basis.

We also issued requirement notices for breaches of the following regulations:

• Regulation 9 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Person-centred care.
• Regulation 10 Health and Social care Act 2008 (Regulated Activities) Regulations 2014 Dignity and respect.
• Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment.
• Regulation 13 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safeguarding service users from abuse and improper treatment.
• Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance.
• Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Staffing.
• Regulation 18 CQC (Registration) Regulations 2009 Notification of other incidents.

At this inspection, we found that the provider addressed most of the issues from the last inspection of 2021. However, safe staffing (a national challenge in the ongoing pandemic of COVID-19) and gaps in observations records remained an issue on forensic inpatient wards and remained a breach of regulation 12 and 18. In addition, at this inspection, we identified breaches in regulation 10, 12, 15, 17 and 18 but are related to different issues from the last inspection in 2021.

The overall rating for this service has improved to requires improvement. At this inspection, wards for people with a learning disability or autism and long stay or rehabilitation wards for adults of working age have improved the overall rating from inadequate to requires improvement. Psychiatric intensive care service has remained the same as requires improvement. Forensic inpatient or secure wards have remained as an overall rating of inadequate. As a result of the ratings, this location remains in special measures.

The following services and wards were visited on this inspection:

Acute wards for adults of working age and psychiatric intensive care units:

• Bayley, a psychiatric intensive care unit with 10 beds for women.

Forensic inpatient/secure wards:

• Maple ward, a 10-bed medium ‘blended’ secure service for women.
• Willow ward, a 10-bed medium ’blended’ secure service for women.
• Bracken ward, a 10-bed medium ‘blended’ secure service for women.

This service was one of three hospital sites chosen by NHS England to pilot a blended setting of medium and low security levels, to reduce overall length of stay in hospital.

Long stay / rehabilitation wards for working age adults:

• Silverstone ward, a longer term high dependency rehabilitation unit for women over 18, with emotionally unstable personality disorder (EUPD) and disordered eating, 12 beds.
• Naseby ward, a longer term high dependency rehabilitation unit for women over 18, providing comprehensive dialectic behaviour treatment (DBT) with a diagnosis of borderline personality disorder (BPD), 12 beds.
• Watkins House a longer term high dependency rehabilitation unit for women over 18, six beds.
• 37 Berkeley Close, a community rehabilitation unit for women over 18, three beds.

Wards for people with learning disabilities or autism:

• Oak ward, a 10-bed medium secure service for women with learning disabilities and/or autistic spectrum conditions
• Church ward, a 10-bed low secure service for women with learning disabilities and/or autistic spectrum conditions
• Sycamore ward, a 4-bed medium secure enhanced support service for women with learning disabilities and/or autistic spectrum conditions.

What people who use the service say

We spoke with 34 patients and 10 carers.

Wards for people with a learning disability or autism: people said that they felt well supported by kind, caring and engaged staff who were interested in their well-being and did their best to provide them with the support they needed. People told us that staff tried their best to accommodate leave and took them out on group outings, but they did not always have sufficient staff to carry out some activities. Four people told us that they liked the food but that the options could be improved.

Long stay or rehabilitation wards: Patients told us they felt safe. Two patients told us that they felt the service had aided their recovery more than any other and that staff that staff were generally kind, caring and took the least restrictive approach. They told us that staff only used restraint when it was needed, and patients were given a debrief afterwards. However, one patient told us that staff did not always consider the impact on patients who witnessed the use of restraint. Two patients told us that they felt the service could benefit from more staff as staff tend to focus more on the patients with the highest support needs. Three patients told us that the ward had several bank staff. One patient told us that the regular bank staff were caring and understood their needs, but two patients told us that bank staff were not responsive to their needs. Patients were involved with their care plans, had good access to physical healthcare and had access to activities organised by the Occupational therapist. Two patients told us that they often had to wait a while for repairs to be carried out, we saw that patients frequently raised repair issues during community meetings.

Forensic inpatient and secure wards: all patients told us that they had received advice regarding their medications. Six out of nine patients said they had been involved in their care planning. Four patients told us that there was a lack of health food options and that the quality of the food was variable. Two patients described the furniture as uncomfortable. However, six patients told us that there were often not enough staff on the ward, another patient said the number of staff on duty on the day of inspection was ‘fake’ adding that ‘half the staff don’t work on this ward’. One patient told us that ‘the staff we have are amazing’. Three patients told us that their planned activities had been cancelled. Two patients told us that their escorted leave had been cancelled.

Psychiatric intensive care unit, we spoke to four patients. The patients' comments were overwhelmingly positive with lots of activities in the unit particularly, pamper sessions where they could get their nails done and access foot spa’s. The unit had a shared electronic device which patients could use to make video calls and a shared phone. Patients could also use their own phones to check emails. One patient felt the unit was the safest place ever, and staff were always available when needed but were always busy. Patients were given leave to attend church for private prayers. One patient was pleased with the physical health doctor visit, however, was told by staff to use mouthwash but their preference was dental floss. They were also not offered a dental appointment. Risk items were only removed if the patient had informed a staff member and were kept in locked lockers. One patient was not involved in their care plan.

We spoke with five carers.

One carer told us ‘at the moment it’s great, the social worker is fantastic, and that there were regular updates from staff. A second carer told us that staff ‘keep us up to date’, adding that they attend meetings and speak to both the social worker and care coordinator regularly. A third carer told us that staff inform them of any issues, that staff ‘keep them in the loop, and described the service was ‘totally and utterly amazing’. However, one carer told us that there had been problems with communication, adding that ‘no one had sought the families’ opinion’. Two carers told us there were not enough staff on the ward and one carer raised concerns regarding the number of male agency staff on duty at night.

Updated 5 October 2022

Our rating of this location improved. We rated it as requires improvement because:

• Across all services, the provider was challenged to ensure staffing numbers met the needs of patients and we found in some cases, patient activities had been cancelled or postponed. There was a high use of regular bank staff and agency staff.
• Staff had not always followed the provider’s policy on patient observations in two services. We found gaps in observation records.
• Therapy provision on wards for people with a learning disability was below establishment and affected the delivery of therapeutic activity. One of the long stay or rehabilitation wards, which supported patients with secondary needs associated with disordered eating, did not have access to a specialist dietician.
• Staff did not always ensure that the privacy and dignity of all patients was respected and maintained. Staff did not always demonstrate the values of the organisation when supporting patients.
• Environments on wards for people with a learning disability or autism wards were not always maintained due to untimely responses to complete repairs and manage estates issues.
• One seclusion room did not have a shower and whilst the provider had made progress in the processes to plan, fund and source a shower in the seclusion room, it remained without a shower.
• Two services did not make timely repairs to the environment when issues were raised.
• In two services, care plans did not always reflect how to manage patients with physical health issues. Staff on long stay or rehabilitation wards staff did not ensure patients had a care plan in place for the use of rapid tranquilisation. Staff on forensic inpatient or secure wards did not always undertake and record physical health observations following rapid tranquilisation.
• Blanket restrictions continued to be in place on most wards. In wards for people with a learning disability or autism, seclusion occurred in areas other than a seclusion room and staff did not always record it correctly in line with the MHA Code of practice. Staff on forensic inpatient or secure wards reported a high number of incidents that required restraint and staff did not undertake searches in line with the provider’s policy.
• Not all staff in wards for people with a learning disability or autism knew how to find patient information on the electronic record.
• We found staff did not always safely manage medicines and act on audit results on three services we inspected.
• In three services, governance processes in place did not always ensure checks and audits were effective enough to ensure care delivery was improved. For example, gaps in environmental checks, long term segregation reviews, and medicines management checks were not followed up.

However:

• The provider had recently implemented a new system for calculating the right numbers of staff required, based on the acuity of patient need. This was enhanced with a bleep holder system which reviewed the real time staffing situation in addition to the electronic system. This meant senior staff could move staff to where need indicated it was higher on some wards. There were meeting three times in a 24-hour period to review staffing across all wards.
• When restrictive practices were used, there was a reporting system in place and there were comprehensive reviews to try and reduce the use of these practices. We noted ward teams had made improvements to reducing restrictive practice since our last inspection.
• The provider as part of a national pilot, had developed a new clinical model (co-produced with staff and patients), which was a blended approach including low and medium security.
• Managers ensured that staff had relevant mandatory and specialist training, regular supervision and appraisal. Managers dealt effectively with poor practice and the provider had made significant improvement in following policy and procedure to deal with outcomes of investigations.
• People and those important to them, including advocates, were actively involved in planning their care. Multidisciplinary teams worked well together to provide the planned care.
• Staff understood their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff worked well with services and external organisations that provided aftercare to ensure people received the right care and support when they went home.

Updated 10 February 2015

• There was a need to assess and treat patients based on individual risk and identified needs, rather than placing emphasis on generic, restrictive risk management processes.
• Agency and bank staff did not have adequate information about individual patient care and any safeguarding protection plans on the wards where they are working.
• The complaints process was not always clearly displayed on the wards in formats people can understand.
• Feedback from the outcome of complaints was not shared with the complainant on all occasions. 
• Seclusion facilities were being used for de-escalation and time out.

Updated 16 September 2016

• Bayley ward is a medium secure inpatient ward that can accommodate up to 10 children and adolescent males with learning+ disabilities / autistic spectrum disorder.

• Heygate ward is a medium secure inpatient ward that can accommodate up to 10 children and adolescent males with learning disabilities / autistic spectrum disorder.

• Fenwick ward is a low secure inpatient ward that can accommodate up to 10 children and adolescents females with neuro-disability / autistic spectrum disorder.

• Richmond Watson ward is a low secure inpatient ward that can accommodate up to 12 children and adolescent males with complex mental health needs.

• Church ward is a low secure inpatient ward that can accommodate up to 10 children and adolescent males with neuro-disability / autistic spectrum disorder.

• Boardman ward is a low secure inpatient ward that can accommodate up to 11 children and adolescent females with complex mental health needs.

• Heritage ward is a low secure inpatient ward that can accommodate up to 12 children and adolescent females with complex mental health needs.

• John Clare ward is a low secure inpatient ward that can accommodate up to nine children and adolescent females with complex mental health needs.

Updated 16 September 2016

• Rose ward is a medium secure male ward.

• Tallis, Tavener, Althorp, Berkeley Close (1st floor) are male locked wards.

• Berkeley Close (ground floor) is a female locked ward.

• Berkeley Lodge, 37 and 38 Berkeley Close and 19 The Avenue are locked units

• Walton is for male patients with Huntingdon’s disease.

• Harper – specialist ward for male and female patients with Huntingdon’s disease.

Updated 5 October 2022

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

The service did not meet the model of care set out in Right Support, Right Care, Right Culture. The service was on a hospital site with other mental health services and was designed to provide a service to 24 people over three wards.

People were supported by staff to pursue their interests.

The service worked with people to plan for when they experienced periods of distress so that their freedoms were restricted only if there was no alternative. Staff did everything they could to avoid restraining people. The service recorded when staff restrained people, and staff learned from those incidents and how they might be avoided or reduced.

The service gave people care and support in a safe, clean, well equipped, well-furnished and well-maintained environment that met their sensory and physical needs. However, some areas of the hospital, in particular the bathrooms and one seclusion room, required further work to meet these standards. The provider was in the process of obtaining funding for renovating the seclusion room.

People had a choice about their living environment and were able to personalise their rooms.

People benefitted from the interactive and stimulating environment, and the service endeavoured to make further improvements in providing sensory spaces for people on the wards.

Staff supported people to make decisions following best practice in decision-making. Staff communicated with people in ways that met their needs.

Staff supported people to play an active role in maintaining their own health and wellbeing.

Right care

Staff promoted equality and diversity in their support for people. They understood people’s cultural needs and provided culturally appropriate care.

People received kind and compassionate care. Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs. However, this was not always the case with night staff on Church ward. The management team was in the process of reforming the culture on this ward.

The service did not have enough appropriately skilled staff to meet people’s needs and keep them safe, which meant some activities such as leave could not go ahead.

People could communicate with staff and understand information given to them because staff supported them consistently and understood their individual communication needs. People who had individual ways of communicating, using body language, sounds, Makaton (a form of sign language), pictures and symbols, could interact comfortably with staff and others involved in their treatment/care and support because staff had the necessary skills to understand them.

People’s care, treatment and support plans reflected their range of needs and this promoted their wellbeing and enjoyment of life.

Right culture

People received good quality care, support and treatment because staff were trained to support their needs. However, the service did not always have enough staff which meant that people’s programme of support was not always delivered in time.

People were supported by staff who understood best practice in relation to the wide range of strengths, impairments or sensitivities people with a learning disability and/or autistic people may have. This meant people received compassionate and empowering care that was tailored to their needs.

Staff knew and understood people well and were responsive.

People and those important to them, including advocates, were involved in planning their care.

Recommendations from external bodies were not always taken on board and these decisions were not always justified. This meant that staff did not always evaluate the quality of support provided to people and embed learning into practice.

People’s quality of life was enhanced by the service’s culture of improvement and inclusivity.

Senior managers of the hospital and senior ward-based staff had taken steps to address a closed culture that was identified at our last inspection. This included reviewing blanket restrictions, revising professional boundaries, introducing new meeting structures and ward rules. Managers sought to embed a culture promoting transparency, respect and inclusivity.

Our rating of this service improved. We rated it as requires improvement because:

• On Oak ward, we found water stains in bathrooms and showers where water had been left to dry, because the drainage was not sufficient enough to allow the water to flow away. Staff had not escalated these issues to estates management, leading to an unpleasant environment for patients.
• The seclusion room on Church ward did not have shower facilities. The provider had plans to improve this, but these had not yet commenced.
• The staffing on each of the wards did not meet the recommended establishment levels, this led to some people’s Section 17 leave being postponed or cancelled. Also, staff were not always able to take their breaks and support the activities provision.
• People with physical health issues such as epilepsy, did not have appropriate care plans to manage bathing.
• Staff did not complete people’s enhanced and general observations in accordance with the provider policy and we found numerous gaps in the observations’ records.
• Staff did not record or review seclusions appropriately when a person was secluded outside of the seclusion room, for example in their bedroom.
• Some staff did not know how to access people’s care records on the electronic records system. This meant staff could not find the most up to date plan of how to care for people using the service.
• We found some expired medicines in the clinic rooms on the wards, and that staff did not act on previous audits where this was found.
• We found that staff were not aware of learning from complaints, incidents and internal and external investigations.
• The wards did not have adequate psychology and occupational therapy provision for people on the wards.
• On Church ward, staff behaviour did not always display the values of the organisation and people told us that attitudes of staff at night were not always kind and respectful.
• Not every ward had a dedicated sensory room, but access to one in the same building. Some rooms had sensory equipment that was available for people to use.
• The service did not have robust governance processes in place to ensure that due consideration was given to recommendations from external reviews and ensure that actions were followed up.

However:

• People’s care and support was provided in an environment that was otherwise safe, clean, well equipped, well-furnished and well-maintained which met people's physical needs.
• People were protected from abuse and poor care. The service had appropriately skilled staff to keep them safe.
• People were supported to be independent and their human rights were upheld.
• People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood each person’s individual needs. People had their communication needs met and information was shared in a way that could be understood.
• People’s risks were assessed regularly and managed safely. People were involved in managing their own risks whenever possible.
• When restrictive practices were used, there was a reporting system in place and there were comprehensive reviews to try and reduce the use of these practices.
• People made choices and took part in activities which were part of their planned care and support. Staff supported them to achieve their goals.
• People’s care, treatment and support plans, reflected their sensory, cognitive and functioning needs.
• People received care, support and treatment that met their needs and aspirations. Care focused on people’s quality of life and followed best practice. Staff used clinical and quality audits to evaluate the quality of care.
• The service provided care, support and treatment from trained staff and specialists able to meet people’s needs. Managers ensured that staff had relevant training, regular supervision and appraisal.
• People and those important to them, including advocates, were actively involved in planning their care. A multidisciplinary team worked well together to provide the planned care.
• Staff understood their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, Mental Health Act 1983 and the Mental Capacity Act 2005.
• People were in hospital to receive active, goal-oriented treatment. People had clear plans in place to support them to return home or move to a community setting. Staff worked well with services that provided aftercare to ensure people received the right care and support when they went home.
• Staff supported people through recognised models of care and treatment for people with a learning disability or autistic people.
• Leaders had delivered a project to address poor culture found at the last inspection. We found culture had improved, and values of staff were better demonstrated between each other, their teams and caring for people.

Updated 5 October 2022

Our rating of this service stayed the same. We rated it as inadequate because:

• Staff had not maintained patients’ dignity. On Bracken ward we observed two incidents where staff had kept the door of the toilet ajar when observing a patient in the day area. Other patients on the ward could hear the patient in the toilet.
• The provider had not ensured that ward areas were always well maintained.
• Staff had not always followed the provider’s policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm.
• Staff had not ensured the physical security of Willow ward.
• Staff had not always recorded patient’s vital signs (in line with the National Institute for Health and Care Excellence (NICE guidance) when using rapid tranquilisation.
• Staff had not always recorded in the patient’s clinical records, the rationale for seclusion, or the time that a period of seclusion had ended.
• Staff had reported a high number of drug errors in Willow ward.
• Patients reported that they did not always have access to healthy snacks (e.g. fruit), that there was a lack of healthy food options on the menus.

However:

• The provider had removed 26 blanket restrictions following our last inspection.
• Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.
• Staff developed a comprehensive care and personal behavioural plan for each patient that met their mental and physical health needs. All patients we spoke to stated that they had been involved in the development of both their care and behavioural support plans.
• Staff provided a range of care and treatment in line with best practice and national guidance (from relevant bodies e.g. National Institute for Health and Care Excellence (NICE)).Examples included National Institute for Health and Care Excellence (NICE) guidance on personality disorder, assessment and treatment, Antisocial personality disorder: prevention and management and self-harm: assessment, management and preventing recurrence.
• Staff took part in a range of clinical audits, benchmarking and quality improvement initiatives.

Updated 5 October 2022

Our rating of this service improved. We rated it as requires improvement because:

• The wards did not always have enough nurses.
• Governance processes did not always ensure that ward procedures ran smoothly. Staff did not record all the medicines they had disposed of. Staff did not always ensure that both paper and electronic medicine records were accurate, up to date and correctly identify how staff should give medicines to patients.
• Staff did not always create care plans for physical healthcare conditions.
• Staff did not ensure that patients had a care plan in place for the use of rapid tranquilisation in line with policies and procedures.
• One ward team did not have access to a specialist dietician, which was required to meet the needs of patients.

However:

• The service provided safe care. The ward environments were safe and clean. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
• Staff developed recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service worked to a recognised model of mental health rehabilitation.

Updated 16 September 2016

• O’Connell ward is a locked ward for male older adults.

• Compton is a locked ward for male and female older adult patients.

• Foster is a locked ward for male older adults.

• Cranford is a medium secure ward for male older adult patients.

Updated 5 October 2022

Our rating of this service stayed the same. We rated it as requires improvement because:

• Daily checks of the ligature cutters were not always completed. Staff recorded when ligature cutters were used but did not record when they were checked daily in line with their policy.
• Patients had access, without supervision, to the main courtyard, however, there was a large opening in the ground of the courtyard that had been there for over 10 months without repair.
• Staff did not follow the provider’s policy and record all the medicines they had disposed of.

However:

• The ward environments were clean. The wards had enough nurses and doctors. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.