The Care Quality Commission
  • Mental Health
  • Independent mental health service

Archived: Child and Adolescent Mental Health Services (CAMHS)

Overall: Requires improvement read more about inspection ratings

Billing Road, Northampton, Northamptonshire, NN1 5DG (01604) 616000

Provided and run by:
St Andrew's Healthcare

All Inspections

8, 9, 10 September 2020, 30 September 2020 and 8 October 2020.

During a routine inspection

The Child and Adolescents Mental Health service is now based in Smyth House, a refurbished building situated on St Andrew’s Healthcare Northampton site. Smyth House has three ten bedded wards.

At the time of inspection, the service was still based in Fitzroy House and we inspected seven wards. We completed a follow up visit to Smyth House and inspected one ward. Further details can be found later in the report.

This service was last inspected in December 2019. The service was rated inadequate overall and continued to be in special measures which they were placed in July 2019. We issued an urgent Notice of Decision under section 31 of the Health and Social Care Act 2008, imposing conditions on the provider. We told the provider it must make immediate improvements to ensure young people were kept safe through ensuring staff only use approved restraint techniques, that seclusion practice complies with the Mental Health Act, that incidents are investigated in a timely manner, that safety checks and observations are carried out robustly and that staff treat young people with kindness and adopt practices that are least restrictive and not punitive. In addition, we told the provider it must ensure it fosters a positive culture and that the service is overseen by effective leaders who have appropriate processes in place to always ensure oversight of the service.

At this inspection we rated St Andrew’s Healthcare Child and Adolescents Mental Service as requires improvement because:

  • Whilst the service had made several improvements senior leaders had not yet achieved consistency of standards across all wards. Governance processes and aspects of practice were inconsistent across all wards and not yet fully embedded.
  • There were inconsistencies in safety practices across the wards. Staff on Meadow, Maple, Brook and Bracken wards (four out of eight wards) did not always ensure a safe environment. On Maple and Bracken ward we found plastic rubbish liners in children and young people’s toilets which could be used to self harm. We did not find this issue on the remaining six wards. Five staff across Meadow, Brook and Bracken wards did not wear protective masks correctly and we identified issues relating to infection risks for two young people on Acorn and Berry wards. However, we raised this with the ward manager who implemented new infection control processes for both young people whilst we were on site.
  • Not all staff managed risks to children and young people and staff effectively. Staff on Bracken, Brook and Maple wards did not always follow the provider’s policy and procedures on the use of enhanced support when observing children and young people assessed as being at higher risk harm to themselves or others. This was managed effectively on all other wards. We found one example of staff observing the same young person for 11 hours of their shift on Brook ward. Staff routinely observed for periods of four hours and above on Brook ward. Staff did not always record children and young people’s presentations and risk factors correctly on Bracken and Maple wards. The provider reported 249 incidents of children and young people self harming, across seven wards, whilst on enhanced observations between 1 May 2020 and 31 August 2020.
  • Levels of staff restraint of children and young people, including prone restraint and use of rapid tranquillisation had increased on Acorn, Meadow and Maple wards since the last inspection, although had reduced more recently. Staff on Maple ward did not always follow National Institute of Clinical Excellence guidance or the providers policy when using rapid tranquillisation. In one example they did not monitor a young person's physical health after rapid tranquillisation. We did not find this issue on the remaining seven wards.
  • Not all staff followed systems and processes when safely prescribing, administering, recording and storing medicines. There was missing medication on Brook ward. Staff had not always recorded medicine fridge temperatures on Bracken and Maple ward. Staff had not disposed of expired medical equipment on Maple and Bracken wards.

However:

  • The provider had made a number of improvements that we told it needed to be made following our inspection in December 2019. There were new hospital leaders in place who had taken action to change the culture of the service and staff reported a shift to people taking responsibility and raising issues in an open and honest way. Leaders displayed the values of the service and ensured staff worked with children and young people in ways which were supportive and not punitive. We saw an overall improvement in seclusion and restraint practice, safeguarding investigations and staff had stopped using punitive language in children and young people’s records. Leaders implemented new governance systems, improved their processes and acted to address poor staff conduct quickly.
  • Generally, we found that staff went the extra mile for children and young people; carers told us staff hired a soft play centre out of hours for a young person's birthday and staff supported a young person to cook with his mum via video calls during the coronavirus pandemic. Staff treated children and young people with kindness, dignity and respect on seven of the eight wards inspected. We observed positive and relaxed interactions between staff and children and young people. We observed care delivered by staff that demonstrated staff knew the needs of the children and young people on the ward. Young people told us staff were kind and supportive and good at helping them stay calm. Carers spoke positively about staff and told us staff supported them to keep in contact with their relative throughout the coronavirus lockdown.
  • Staff involved children and young people and their carers in their treatment and care. The service placed strong emphasis on children and young people’s feedback about the new wards and made changes to plans throughout the transformation process to meet their requests. Staff encouraged children and young people, and their carers to be partners in their care through co-production work and monthly carer’s meetings. The service trained carers in trauma informed care to deliver training to staff through sharing their experiences as a parent. Staff described this as “powerful, thought-provoking and extremely insightful”.
  • Staff provided a wide range of care and treatment interventions suitable for the children and young people on the wards. The interventions were those recommended by, and delivered in line with, guidance from the National Institute of Health and Care Excellence. Interventions included a full therapy programme and the use of recognised rating scales to assess and record severity and outcomes.
  • Staff and children and young people had access to an extensive range of rooms and equipment to support treatment and care. Children and young people had access to the provider’s school for educational activities. Staff ensured that children and young people had access to appropriate spiritual support. The service had a multifaith area and access to chaplaincy support, which included access to leaders from different religions including Christianity, Islam and Wicca.
  • The teams included, or had access to, the full range of specialists required to meet the needs of children and young people on the ward. Staff had the right experience, qualifications, skills and knowledge to meet the needs of the children and young people. Teams held regular and effective multidisciplinary meetings.
  • The service supported learning, continuous improvement and innovation. The service published research into dialectical behaviour therapy outcomes and adverse childhood experiences in relation to the impact of physical health on mental health. The provider set up a developmental trauma centre with the aim of being a centre of excellence for trauma informed care.

On this inspection we found that the service made enough improvements and we are lifting the hospital from special measures.

03- 05 and 17-18 December 2019

During a routine inspection

We rated St Andrew’s Healthcare Adolescents Service as inadequate because:

  • Patients were at risk of continuing harm. The service did not always manage patient safety incidents well. Managers had not investigated incidents thoroughly, or in a timely manner. Staff did not always use approved restraint techniques, which resulted in staff dragging patients along the floor or physically injuring patients during restraint. Senior staff told us they observed CCTV footage of these incidents and were concerned that other staff present had not acted to intervene. Staff did not always keep patients safe from harm whilst on enhanced observations. The provider reported 212 incidents of patients’ self harming whilst on enhanced observations between 1 September 2019 and 30 November 2019. Staff did not always make sure they shared clear information about patients and any changes in their care. Staff did not always complete required safety checks in line with the providers policy and procedures.
  • Staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk of harm to themselves or others. We found staff on enhanced observations for the same patient for between three to ten hours. We found staff completed observations continually throughout a shift for up to three different patients. Staff completing extended periods of enhanced observations may be less likely to maintain the levels of concentration required to maintain patient safety. We found examples of staff not completing observation records.
  • Staff did not always treat patients with kindness, dignity and respect on four wards. Staff referred to a patient who identified as male as her/she, this upset the patient and continued after the patient complained. We found staff recorded an incident of bullying behaviour between patients as “a bit of fun”. We found examples of a punitive culture on some wards. Staff criticised and sanctioned patients, without justification, for talking to other patients and cooking different meals to those planned.
  • The leadership, governance and culture did not always support the delivery of safe, high quality, person centred-care. Leaders did not always understand the issues, priorities and challenges the service faced. The provider’s governance processes had not addressed staff failures to follow the provider’s procedures. There was no evidence that the provider undertook regular and effective audits of these issues. We were not assured that the provider acted to keep patients safe from harm. The provider did not oversee patient risks effectively. We found that evidence to support serious incident investigations was not preserved. There was a lack of leadership during serious incidents. Investigations into serious incidents were not completed in a timely manner.
  • We were concerned about the culture within the organisation in relation to the perception of the regulator and the message leaders relayed to staff and patients. Comments made in board papers downplayed the significant concerns raised in the last Adolescents inspection. A senior leader requested wording in a safeguarding report was changed from ‘dragged’ to ‘moved along’ in relation to use of non-approved restraint techniques.
  • Use of restraint and seclusion had significantly increased since the last inspection. The provider reported 2,266 incidents of restraint from 01 February 2019 to 31 July 2019. This was an increase of 29% since the last inspection. Use of prone restraint increased by 44% since the last inspection. Use of seclusion increased by 79% since the last inspection.
  • The service did not have enough nursing and support staff to keep patients safe. We reviewed four incidents where staff shortages impacted on patient safety. Between 01 May 2019 and 31 July 2019 managers were unable to fill 17% of shifts, bank staff filled 50% of shifts and agency staff 35% of shifts.
  • Staff did not always identify and meet patients’ needs. Staff had not completed physical health assessments on admission for three patients reviewed and two patients had no care plan. Staff had not taken action to meet the physical healthcare needs of three patients.
  • Although staff compliance with the Mental Health Act Code of Practice in relation to seclusion and long term segregation had improved, we found 21 examples where practice did not meet the code in 22 records reviewed, for example, staff not recording their role in review records and care plans lacking detail.

However:

  • The provider made improvements since the last inspection. They introduced a new leadership team, ensured safe environments and made significant changes to blanket restrictions. The service had been working with external partners, including NHS trusts with outstanding ratings to help the service improve.
  • Staff and patients had access to an extensive range of rooms and equipment to support treatment and care. Patients had access to the provider’s school for educational activities. Each patient had an individualised timetable to meet their needs. Staff ensured that patients had access to appropriate spiritual support. Staff supported patients to access a range of leave activities, including football matches and horse riding.
  • Staff completed comprehensive mental health assessments for patients. Staff provided a range of care and treatment interventions suitable for the patient group. The teams included or had access to the full range of specialists required to meet the needs of patients on the ward.
  • Senior leaders were visible in the service and approachable for patients and staff. Staff spoken with told us that the operational lead and clinical leads for the service were visible on the wards. Staff told us that the chief executive officer visited regularly and had been particularly supportive following the last inspection.
  • Staff involved patients in decisions about the service. The provider introduced a new recruitment process, which involved patients as equal partners in deciding on staff to recruit.

19-21 March and 18 April 2019

During a routine inspection

We rated St Andrew’s Healthcare Adolescents service as inadequate because:

  • Staff did not always treat patients with kindness, dignity compassion and respect. Eleven of the 15 seclusion rooms did not include furnishings such as a bed, pillow, mattress or blanket. We reviewed 13 episodes of seclusion where staff had not provided the patient with a mattress or chair. Observation records for nine episodes of seclusion detailed 28 entries describing the patient sitting or lying on the floor. Staff, on one occasion, did not respect a patient’s privacy and dignity when changing the patient’s clothing and did not ensure that female staff assisted with this for female patients. It was the inspection team’s view that this practice was uncaring, undignified and disrespectful.
  • Managers had not ensured that they consistently identified or addressed safety concerns quickly enough. There were sharp edges on door frames in seclusion rooms and extra care suites, blind spots in seclusion rooms and pieces of exposed sharp metal in extra care suites. Staff did not always follow safety procedures in relation to cutlery checks and food hygiene. Staff did not always check emergency equipment and medicines. Staff did not always record, accurately, the events that took place during incidents. There was discrepancies between incident reports, staff recollection and the images captured on CCTV.
  • Staff did not follow best practice when using seclusion and long term segregation. We have raised this issue with the provider on 12 separate occasions following previous inspections of their locations. Medical, nursing and multidisciplinary reviews had not taken place as required by the Mental Health Act Code of Practice. Staff had not always completed seclusion care plans for patients, had not involved advocacy, or informed the local authority when required. Staff secluded three patients for longer than necessary.
  • Staff applied blanket restrictions without justification. All wards had imposed set snack times for patients. Other restrictions included access to drinks and takeaways, patients not allowed to wear shoes on Meadow. Staff on Willow ward locked the patient’s en suite rooms which meant patients had to request staff to unlock them for access. and staff locking en suites on Willow. Managers told us that patients themselves had requested set snack times and to not have shoes on wards. Staff provided minutes of community meetings, however only records for two wards indicated patient agreement.
  • Managers had not always ensured that there were the required numbers of staff on all shifts. Managers had not filled 13% of shifts between 1 and 31 March 2019. Managers had used bank and agency staff to cover 47% of shifts. Staff shortages sometimes resulted in staff cancelling escorted leave, appointments or ward activities. Staff on Fern, Maple and Willow wards told us that the high use of bank and agency staff impacted on patient care as risk events increased due to inconsistencies in patient care.
  • The leadership, governance and culture did not always support the delivery of high quality, person-centred care in relation to the comfort of patients in seclusion and the application of blanket restrictions. The arrangements for governance did not always operate effectively. Governance arrangements had not always identified that staff practices were sometimes in breach of the Mental Health Act Code of Practice. The provider had not addressed issues with restrictive practices and the environment previously raised by the CQC. Provider audits had failed to address the issues with restrictive practices. Managers did not always deal with risk issues appropriately or in a timely way. Although the provider had carried out work to rectify hazards, it was incomplete. The provider did not have a system to check that the maintenance team had completed required works satisfactorily.

However:

  • Managers had completed up to date ligature audits and risk assessments identifying all potential ligature points. Managers had displayed ligature ‘heat maps’ in each ward office highlighting high risk areas on the wards. Ligature cutters were located throughout the ward areas in secure boxes.
  • Staff had completed a risk assessment for each patient, which they updated regularly and after any incident. Staff identified and responded to changing risks to, or posed by, patients. Staff had completed comprehensive mental health assessments and developed care plans to meet identified needs.
  • Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and delivered in line with, guidance from the National Institute of Health and Care Excellence. Interventions included a full therapy programme and the use of recognised rating scales to assess and record severity and outcomes. The teams included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff had the experience, qualifications and the right skills and knowledge to meet the needs of the patient group. Teams held regular and effective multidisciplinary meetings. Managers ensured that staff received the necessary specialist training for their roles.
  • Staff and patients had access to an extensive range of rooms and equipment to support treatment and care. All patients and carers spoken with reported that the environment and facilities were very good. Patients had access to the provider’s college for educational activities. Each patient had an individualised timetable to meet their needs. There was a specially designed classroom for patients with autistic spectrum disorders. Patients had opportunities for work experience and access to the provider’s on-site light industry workshop. Staff ensured that patients had access to appropriate spiritual support. The service had a multi-faith area and access to support for different religions.
  • Leaders were visible in the service and approachable for patients and staff. Staff spoken with told us that the chief executive officer and operational and clinical leads for the service were visible on the wards. Staff told us that they felt respected, supported and valued. Staff said the management culture had changed for the better. A trauma nurse and occupational health service supported staff’s physical and emotional health needs. The provider had invested in a programme of support to promote staff well-being.

31 October 2018, 6 – 7 November 2018 and 17 January 2019

During a routine inspection

We did not rate this service because this was a focused inspection.

We found:

  • The provider had identified that they were not able to meet the care needs of three patients with very complex problems and behaviours that staff found challenging. For all three, the provider had worked actively to facilitate discharge without success. In one of these cases, the patient had been subject to repeated and prolonged periods of seclusion and segregation for about 18 months before the inspection visit. The staff at St Andrew’s had decided that this was necessary to reduce risk to the patient concerned, to other patients and to staff.
  • We found one example where staff had not worked with a patient in the least restrictive way. They had applied restrictions despite the patient demonstrating reduced risk behaviours. Staff justified this based on the historic risks of the patient as opposed to the patient’s current presentation.
  • There were gaps in some observation records; one example being staff not recording hourly checks in two records. Staff also recorded one patient’s behaviour as being settled for sustained periods of time, without ending seclusion as required by the Mental Health Act Code of Practice.
  • The provider had not facilitated independent reviews of patients' in long term segregation in line with the Mental Health Act Code of Practice which states that ‘where long-term segregation continues for three months or longer, regular three-monthly reviews of the patient’s circumstances and care should be undertaken by an external hospital’. Staff employed by St Andrews had carried out the ‘independent reviews’ of patients in long-term segregation on these wards. Although these staff members worked in a different St Andrew’s hospital, or were from a different service on the same site, in CQC’s view this is not consistent with the intention of the Mental Health Act Code of Practice.
  • During the three months between 31 July 2018 and 31 October 2018, the service had recorded 57 incidents of staff injury. These included staff being punched, kicked, scratched and pushed to the floor and being stamped upon. During one incident, five different staff had to attend the local accident and emergency department for injuries to the face, head and abdomen.
  • Some staff did not feel that the provider gave consistent support after incidents and that managers delivered de-briefs for ‘significant’ issues only. This affected their morale, particularly when incidents related to staff assaults.
  • Four carers reported that staff had not informed them of incidents involving the person they cared for in a timely way. One carer told us that the provider did not offer them a de-brief after they had witnessed an incident involving their relative.
  • Staffing levels and skill mix had sometimes contributed to the cancellation of planned activities.

However:

  • Staff worked actively to protect patients from avoidable harm. They assessed patient risk and updated risk assessments regularly and following incidents. Staff conducted observations of patients in line with their care plans. Staff used de-escalation and distraction techniques to reduce the need to use physical restraint.
  • Staff recorded the clinical justification for placing restrictions, for example, seclusion and long term segregation, on patients and made decisions based on the assessed risk to the patient, risk to other patients and risk to staff. Staff developed positive behaviour support plans and those who worked directly with the patients were aware of the contents of these plans and these directed the interventions used to care for patients.
  • In eight out of nine cases that we reviewed, staff worked in collaboration with the patient concerned to reduce restrictions at the earliest opportunity.
  • The care and treatment interventions provided by staff were in line with best practice and evidence based guidance. Care plans reflected the holistic needs of the patient. The service employed a range of staff to work with patients to meet their needs including occupational therapists, teaching staff and clinical psychologists. Staff of all disciplines regularly tried to engage patients in education, therapy sessions and activities. Staff recorded the outcomes of sessions or if the patients declined to take part.
  • Patients told us that staff generally treated them with respect. Patients were involved actively in developing their care plans and knew their content. Those patients being cared for in seclusion or segregation had access to and understood their re-integration plans. All patients knew of the advocacy service and how they could access this should they need to. Staff displayed knowledge of individual patient need and the goals patients were working towards.
  • Staff encouraged patients to keep in contact with people important to them. This took place via face to face visits or via telephone or video conferencing.
  • The service provided premises appropriate to the age of the patient group. Staff encouraged patients to personalise their space. This included patients who were in long-term segregation. Staff encouraged patients to engage with sessions and activities when in seclusion and long-term segregation to continue to work towards their individual treatment goals.

15 to 19 May 2017

During an inspection looking at part of the service

We rated St Andrews Healthcare Adolescent services as requires improvement because:

  • Internal doors throughout the building, between wards did not have automatic door closures. Staff had to ensure that all doors were firmly closed behind them, as they sprang open. This could cause a delay if staff were responding to an incident.
  • Each ward had only one qualified nurse on duty throughout the night. Therefore nurses were unable to take proper breaks. Use of agency staff at nights had led to permanent staff completing medication administration across different wards, as not all agency staff had the required log in details to the electronic system. Bank and agency staff could not always fill vacancies requested, meaning that wards had to work below establishment numbers.
  • Staff had received training in the Mental Capacity Act. However, knowledge was minimal during discussions.
  • Staff did not always explain the rights to detained patients in a timely way.
  • Qualified staff did not have adequate knowledge around Gillick competence and Fraser guidelines.
  • We saw two patients being searched in a communal area by staff, where others could see.
  • Patients were unable to access drinks freely and had to ask staff for refreshments.
  • Staff did not have an understanding of the vision and the values of the hospital.
  • Staff reported that senior staff, above the modern matron level, were not visible on the wards.
  • Staff did not keep formal records of supervision. The service could not be sure of the quality of supervision for staff, or be ensured that issues were being followed up appropriately.
  • Staff were regularly being moved across the service to cover shortfalls elsewhere, meaning staffing was not adequate.
  • Not all senior qualified staff had an understanding of the hospital risk register, how this was reviewed and updated.
  • Some staff we spoke with felt excessive pressure was put on them to meet hospital objectives, for example when admitting patients. Ward staff felt undervalued by senior staff throughout the organisation.
  • Ward staff did not feel that they were given many opportunities to give feedback or input into service development.

However:

  • Staff completed comprehensive assessments of patients in a timely way following admission.
  • Patients had a physical health assessment on admission, and on-going monitoring of physical health when needed.
  • Patients had access to a wide range of psychological therapies.
  • Qualified staff had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
  • Patients were involved in their care planning and positive behavioural support plans.
  • Learning from incidents was cascaded to ward staff.
  • Most staff knew of the whistle-blowing process and felt they would raise concerns if necessary. We were told by the provider that the service director and clinical director regularly spent time on the wards. The provider demonstrated that the vision and values of the hospital were discussed at staff induction and during team meetings.
  • Each ward had one ward manager, which provided consistency for both staff and patients. There were governance processes in place to monitor quality, performance and take appropriate action following serious incidents. There were weekly manager and matron meetings to review issues, monthly quality and safety meetings which included the managers, clinicians and compliance manager. There were weekly bed management meetings to review bed numbers.
  • Staff felt supported by one another, and felt that there was good team working across the service, to do the best for the patients.

7-8 February 2017

During an inspection looking at part of the service

We did not rate this service.

We found:

  • We found that not all patients in seclusion or segregation had care plans in place.
  • Not all patients had signed the paper copy of their PBS plans. It was difficult to ascertain if they were involved with the writing of the plans held electronically. Staff had not recorded if patient had declined.
  • Staff reported that they had not received formal training around PBS, although the psychologist took the lead and invited all staff to regular meetings to discuss implementation of these.
  • From a sample of records looked at, we found that four out of 12 patients did not have a restraint care plan in place.

However:

  • Staff we spoke with followed positive behavioural planning (PBS) and placed emphasis upon least restrictive practices. Patients had comprehensive PBS plans within the electronic records, as well as shorter versions, in paper form, held on the wards. This enabled staff to have easy access to plans. They were in easy read versions where appropriate.
  • Staff were trained to use restraint as a last resort, with emphasis upon de-escalation and the prevention of aggression. Staff did use prone (face down) restraint, but this was for the shortest time possible. This was reflected in documentation seen.
  • Data provided showed a downward trend in the use of restraint, including prone restraint.
  • Staff recorded incidents of restraint accurately, in line with the provider’s policy.
  • Staff received mandatory training and most staff were up to date with this.
  • Staff were kind and respectful during interactions observed, and tried to do the best for the patients.
  • Staff involved carers of patients when it was appropriate. Two carers we spoke with confirmed this.
  • Patients had been able to contribute to ideas around the new building. This included choosing all new ward names.

13 to 16 June 2016

During a routine inspection

We rated St Andrew’s Healthcare Northampton as requires improvement because:

  • Not all seclusion rooms considered the privacy and dignity of patients. Staff used closed circuit television (CCTV) to monitor patients. However, monitors were visible to staff from the office and to patients on entering or leaving the adjacent low stimulus room. In adolescent services, one seclusion room had a faulty two-way intercom system. Care records confirmed that the room was used regularly and recently. In older adults services the provider did not always reduce the risk from blind spots.
  • In forensic services, the receptionist controlled access to three buildings from one reception area and used CCTV monitors to control access. When reception staff were away from their desk, access to the building was delayed for patients.
  • On Seacole ward there were issues with controlling temperatures on the ward. This was because of the air exchange system sending columns of cold air directly downwards when the ward gets above 28 degrees. The provider told us they were going to fit a safe diffuser over all of the ducts to try to diffuse the cool air over a larger area. On Seacole ward, the furniture in the night lounge was torn and dirty. In the psychiatric intensive care unit (PICU) some bedrooms, bathroom and shower areas were dirty and carpets were not clean. We could detect a strong smell of urine in some bedrooms. The shower areas upstairs did not provide comfort or promote dignity and privacy. There was a shower curtain on some, but not all showers. The door to the room did not lock and patients needing the toilet could enter. We observed staff searching patients in communal areas on two wards. One ward lacked appropriate signage and other relevant information for patients with neuro rehabilitation needs. Staff restricted access to patients wishing to use their bedrooms, and this was not individually risk assessed.
  • There were ligature points in the psychiatric intensive care unit and the provider did not ensure all patients’ risk assessments and care plans included the management of specific environmental ligature risks. There was no recorded evidence of staff and patients having an immediate debrief following an incident. A debrief is an opportunity for staff to reflect on the incident, review what action was taken, any immediate lessons learned and to offer support to patients and staff.
  • The provider had high vacancy rates in forensic, neuropsychiatry, older adults and rehabilitation services. This was particularly high for registered nurses. The provider used bureau (St Andrew’s bank staff) and agency staff to fill vacant shifts. However, a significant number of shifts remained unfilled. Staff told us when shifts were not filled, staff moved between wards to meet patient need or wards worked short of staff. Staffing levels at night were particularly low.
  • In rehabilitation, adolescent and forensic services, staff did not always complete physical healthcare monitoring following administration of rapid tranquilisation or commencement of seclusion. Staff did not always complete physical healthcare monitoring for patients prescribed specific medications and staff did not complete the relevant chart regularly or appropriately. Staff in forensic services did not always document fully what patients had been offered or received. There were gaps in records where staff had not signed the entries. In rehabilitation services, staff did not always respond appropriately to a decline in a patient’s physical health and did not use observation tools to review and assess the response needed.
  • Not all staff had completed training in the Mental Health Act (MHA) or the Mental Capacity Act (MCA). Staff did not receive annual MHA training and the provider could not demonstrate that staff had received training in the revised MHA code of practice. This meant that staff were not working to the most recent guidelines. Staff did not read patients their rights under section 132 of the Mental Health Act in some wards. If patients did not understand their rights, staff did not always make further attempts. On PICU, forensic, rehabilitation and older adult’s wards staff had not uploaded the MHA legal detention papers in full to the electronic system. Some records had part of the paperwork uploaded.
  • In some services staff did not assess patient’s capacity to consent to treatment appropriately. Staff documented patients did not have capacity but did not give a rationale as to why they had made this decision nor document any discussion. Mental capacity assessments were not decision specific. Consultants did not always accurately complete medication consent paperwork (T2 and T3 forms). Staff kept some information in paper format.
  • The provider did not have an effective management supervision structure. Supervision was highlighted as an issue in learning disabilities, older adults and rehabilitation services. Supervisions occurred monthly by peers rather than line managers in some areas. We saw that some staff had different supervisors each month. This meant there was no consistency and managers could not be sure that supervisors were addressing performance issues.
  • Not all groups of staff felt engaged with the developments and changes to the service.

However:

  • There had been improvements since the last inspection. Leadership had been strengthened and new ways of working implemented to improve the patient experience. The provider had improved governance systems and carried out recruitment drives to attract staff. There had been an overall decline in the use of agency staff over the preceding 12 months.
  • Most wards were safe, visibly clean, homely and well furnished. Patients could access garden areas and open spaces. Patients held their own mobile phones wherever possible and had private access to a landline telephone that had direct lines to advocacy and other services. Wards had a range of rooms for care and treatment and rooms for patients to meet visitors in private. Wards had seclusion rooms, low stimulus rooms and extra care suites for patient use. Patients could personalise their bedrooms and had lockable spaces to secure possessions. The provider had procedures for children visiting. Staff provided a range of activities for patients and activities were available seven days a week.
  • On most wards, staff updated patients’ risk assessments regularly and included patients’ individual needs. Staff in forensic services completed regular ligature risk assessments and wards contained very few ligature risks. Staff managed known risks with nursing observations and individual risk assessments. Staff had quick access to ligature cutters and pocket masks (for use in mouth to mouth resuscitation) in different areas of the wards. Staff used positive behavioural support plans with patients effectively.
  • Staff undertook comprehensive assessments and developed care plans that were thorough, holistic and patient centred. With the exception of rehabilitation, adolescent and forensic services, staff monitored the physical health of patients regularly and developed physical health goals and treatment for patients. Staff used outcome measures such as health of the nation outcome scale and specific tools for acquired brain injury patients. Physical healthcare services included dentistry and podiatry. Practice nurses from the GP surgery attended the wards to address patients’ physical healthcare needs. Staff made prompt referrals for any further specialist physical healthcare input.
  • Staff were passionate about their job and knew patients well. Patients told us staff worked hard and were kind to them. Most staff treated patients with dignity and respect and were responsive to patients’ individual needs.
  • We saw leadership at ward manager level. Managers said they felt supported and staff said they felt valued. Senior staff monitored incidents and discussed outcomes in team meetings. Some senior staff gave examples of learning from incidents for their ward. Staff told us morale was increasing following a period of change over the last two years and told us their managers were supportive. Multidisciplinary teams worked effectively across all wards.
  • The provider had ongoing recruitment and retention programmes to attract new staff. Staff received training in safeguarding and made appropriate referrals. There was a range of psychological interventions available for patients which patients were encouraged to attend. Staff trained in British sign language (BSL) were available to patients on Fairbairn ward. The provider had an induction programme for new staff and was supportive of further learning opportunities for all permanent staff. Staff received annual appraisals and most staff received regular supervision. Staff attended regular team meetings and recorded any actions and outcomes from these.
  • In some wards, Mental Health Act 1983 (MHA) paperwork was in order and stored securely. MHA administrators had a thorough scrutiny process. Some staff used the Mental Capacity Act to assess capacity for individual decisions. There were appropriate systems for managing and recording complaints. Patients had access to independent advocacy services. This meant that they were able to receive independent support to help them express their views and assist with any appeal against their detention under the MHA if they so wished.
  • Managers had access to dashboards for their teams, which gave details of staff compliance with mandatory training. Nurse managers reported they received prompts from the provider’s training department when staff’s mandatory training or refreshers were due.
  • The provider managed quality and safety using a variety of tools. There was a dashboard for monitoring ward performance, quality and safety against agreed targets. There was a monthly lessons learnt bulletin for staff. Staff told us they knew the whistleblowing policy and felt they could raise concerns without fear of victimisation. Managers were visible on the wards and staff felt supported by operational managers and clinical nurse leads.
  • The managers told us, and we saw the documents to show, they were offering an ‘Aspire campaign’, which supported healthcare support workers to undertake their nurse training. The provider would pay these staff a bursary to support their training, following which they would return to work at St Andrew’s for a minimum of two further years. The provider had plans to support 20 staff a year in this scheme.

10 July 2014

During an inspection in response to concerns

We visited Fenwick ward only during this inspection. During our inspection visit, we spoke with six members of staff and seven people who used the service. We also spoke with the ward manager, and the registered manager of the Adolescent Service.

We observed some good interactions between staff and people who used the service.

People’s physical healthcare needs were met to ensure their wellbeing.

We found that the service was provided to people who had a range of needs which meant that some people could be at risk of not having their individual needs met.

People told us and we saw that staff supported them to attend their weekly meeting with the team of professionals that worked with them. People said this helped to reduce their anxiety when at their meeting.

We saw that people were not always engaged in meaningful activities, which could impact on their health and wellbeing.

People told us that they liked the food and there was enough food provided. Some people told us they would like more choice of food. People were offered a balanced and nutritious diet.

Robust systems were in place to ensure that people were safeguarded from harm and abuse.

At our previous two inspections to Fenwick ward we found that records were inaccurate. We found improvements had been made at this inspection, however, further improvements were needed to ensure that people were not at risk of receiving inappropriate care and treatment.

18 March 2014

During an inspection looking at part of the service

We went back to review the improvements that the provider had made following an

inspection visit to the John Clare unit and Fenwick ward during September 2013.

The John Clare unit is a 12 bedded assessment ward for patients with complex mental health needs who present a risk to themselves or others. The Fenwick ward is a 10 bedded ward for patients with a learning disability and mental health needs.

The inspection team comprised of a compliance inspector and a specialist mental health advisor.

During our inspection visit, we spoke with four members of staff and six patients. We also spoke with the ward managers for John Clare unit and Fenwick ward, and the registered manager of Adolescent Services. We looked at patients and staff records, which were available on the wards.

Most patients on the John Clare unit told us that the level of care and staffing levels had improved since our last visit. One patient said “It’s a lot better, and some staff have made good changes on the ward”. They told us that there were more permanent staff working on the ward. Another patient told us that the ward had a “calmer environment” and most of the patients got on well with each other. Patients on the Fenwick ward also told us that there had been improvements made to the ward. One patient told us “The art room is nice and I have been playing football in the courtyard everyday”.

We found that the provider had made improvements to care planning at the service and the staff on John Clare unit were using de-escalation techniques in order to keep people safe and maintain a calm environment. We also found that the provider had made improvements to the environment and had plans to make further improvements. We also found that a system of staff supervision was in place in order to support workers. We found that staff had maintained accurate seclusion records. However, some care records contained inconsistent and inaccurate information.

12 December 2013

During an inspection looking at part of the service

We conducted an inspection visit at St. Andrews Adolescents Service on 25 and 26 September 2013. We found that the provider was not meeting the essential standards of quality and safety in relation to cleanliness and infection control, the safety and suitability of premises, staffing, supporting workers and assessing and monitoring the quality of service provision. We issued warning notices and informed the provider they were required to be compliant with the relevant requirements by 13 November 2013.

We conducted a follow up unannounced site visit on 12 December 2013 to check the provider had made improvements to the relevant requirements.

The inspection team consisted of two CQC compliance inspectors, a specialist advisor and an expert by experience. We visited four wards. These were the John Clare unit, the Boardman ward, the Heritage ward and the Fenwick ward. We spoke with seven staff and 14 patients. We spoke with the ward managers for John Clare unit and the Fenwick ward, the registered manager of the Adolescent Service and the Nominated Individual for St Andrew’s Healthcare.

We found that the provider had taken account of our previous inspection findings and had introduced some additional quality monitoring measures. However further improvements were still needed to meet full compliance with the regulations.

25, 26 September 2013

During a routine inspection

During our scheduled inspection visit of the St Andrews Adolescents service, we went back to visit the Fenwick ward to review the improvements they had made following a review of compliance in March 2013.

The inspection team was led by a CQC inspector who was accompanied by a specialist mental health professional and an expert by experience. We spoke with four patients and five staff working on the ward. We also spoke with the acting ward manager and the registered manager.

Patients on the Fenwick ward told us that they got on with most staff who worked on the ward. One patient told us “the staff are very nice and they never shout”. They also told us that there were inadequate numbers of staff working on the ward and this meant that sometimes their activities were cancelled.

We also visited the John Clare unit. We spoke with four patients, six members of staff and the ward manager. The patients told us that most staff treated them in a respectful way. However, they also told us that there were not enough staff working on the ward. One patient told us “today there are not enough staff to go roller skating”.

During our inspection visit, we found that the provider had not completed the improvements on the Fenwick ward as identified in their action plan. We also identified some additional concerns in regards to care and welfare, safeguarding people who use services from abuse, assessing and monitoring the quality of the service and maintaining records.

6 March 2013

During a routine inspection

During our inspection visit of St Andrews adolescence services, we visited the Fenwick ward, which is a ten bedded medium secure ward situated within the Malcolm Arnold House. On the day of the visit there were nine patients receiving care on Fenwick ward and one patient who was being nursed within the extra care facility on the ward.

The inspection team was led by a CQC inspector who was accompanied by a practicing specialist mental health professional. We used a variety of methods including observation skills to find out how patients needs were being met on the ward. We spoke with one patient, six members of staff and reviewed the care records of three patients.

One patient told us that the staff treated them nicely and that they had a named nurse and key worker who were responsible for their care. They told us that they had made progress while receiving treatment on the ward and that they went out into the local community and enjoyed doing a range of activities. However, they also told us that sometimes they were not able to access the local community because there were not enough staff on duty to accompany them on their visit.

During our inspection visit, we found that there were some concerns relating to the level of staffing on the ward, and the arrangements in place for supporting the staff. We also had some concerns about the level of cleanliness and infection control on some areas of the ward and the safety and suitability of premises.

8 March 2012

During an inspection looking at part of the service

Patients were happy about the ward environment and told us that it had been improved since our last visit to the service in 2011. They had enjoyed being involved with choosing the colours and some of the painting within the ward.

19 August 2011

During a routine inspection

On the day of the visits compliance inspectors and a mental health act commissioner sought comments from patients on John Clare and Church wards

We spoke with six patients about their care and support. Patients said they felt respected and involved in decisions regarding their care and treatment. All of the patients we spoke to said that they recieved support to cope with behaviours that placed them or others at risk of harm. Patients said they knew how to make a complaint about their care, and they could speak to the unit manager if they felt unsafe.

People said that they were unhappy with the maintenance of the ward both cleanliness and state of carpets. One person said that the air conditioning and central heating was often not working well in their room. One person we spoke with on Church ward said that they were settled, involved in many of the activities available on site at the Northampton location and that staff treated them with respect. Patients also said that they were involved in reviewing their care plans and aware their care and treatment is closely monitored.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.