Archived: The Huntercombe Hospital - Roehampton

The CQC is placing the service into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made, and there remains a rating of inadequate overall or for any key question, we will act in line with our enforcement procedures. We will begin the process of preventing the provider from operating the service. This will lead to cancelling the provider's registration at this service, or 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.

During this inspection, we found that the service had addressed some of the issues we found following the August 2016 inspection. However, we also identified a number of serious concerns about the safety and quality of the service. Some of these were areas of continuing non-compliance and others were new concerns.

We rated the service inadequate overall because:

• Staff at this service used rapid tranquilisation regularly on patients. We found in 24 of the 35 incidents of rapid tranquilisation, staff did not follow best practice guidance in relation to monitoring the physical health of patients after rapid tranquilisation. Staff did not record patients’ vital signs every 15 minutes for the first hour and every hour until ambulatory as per the service’s policy. The lack of physical health monitoring post rapid tranquilisation meant patients were at risk of avoidable harm.
• At the previous inspection in August 2016, we found that staff did not always consistently record the reasons why a patient’s risk had changed. At this inspection, we found this had not improved. Patient risk assessments did not show the reason why the patient’s assessed level of risk had changed. We also found at this inspection that where patients had specific risks there were not always management plans in place.
• At the previous inspection in August 2016, we found that staff did not always record the reasons for administering ‘as required’ medicines to patients. At this inspection, we found this had not improved on Upper Richmond Ward.
• Staff did not meet patients’ physical health needs. Staff did not consistently record patients’ daily National Early Warning Scores (NEWS) to assess and monitor patients’ physical health risks and escalate concerns when their patient might be deteriorating. The service had no arrangements in place for staff to encourage patients to give up smoking or refer patients on to smoking cessation services.
• Staff imposed an inappropriate and unsafe blanket restriction on the wards. A water cooler in the communal areas did not have cups available for patients to use to get themselves a drink of water. Staff said they locked cups away due to the risk of some patients using plastic cups to self-harm. However, removing the cups altogether put all patients at risk of dehydration.
• At the last inspection in August 2016, we found that staff used a high number of agency staff. At this inspection, we found that, whilst recruitment was taking place, this still needed to improve. The service had experienced a recent increase in the use of agency staff, due to an increase in acuity of patients and increase in the staffing establishment.
• Staff did not complete up to date ligature risk assessments and could not always identify where ligatures were present on the wards and how patients would be kept safe.
• Staff did not report all incidents that should be reported. This included some incidents of physical restraint.
• We observed that sometimes staff did not effectively engage patients when they started to become aggressive or aroused. We observed staff telling patients to ‘calm down’ when they became agitated rather than using effective de-escalation techniques. Staff engaged minimally with patients when carrying out one-to-one observations. The service had not yet implemented a reducing restrictive practices programme on the wards to reduce violence and aggression.
• At the previous inspection in August 2016, we found that staff did not complete personalised care plans. Staff did not accurately reflect the individual needs and preferences of the patient. At this inspection, we found this had not improved. Patients had generic care plans that only referred to their mental state and did not always include patients’ specific needs or reflect their preferences.
• Patients shared bathrooms. Each bathroom had a small panel on the outside of the door for staff to observe patients in the bathrooms. On Upper Richmond Ward, we found that all panel covers were open and three out of the seven covers were broken and therefore could not be closed. This meant that any person walking past the bathroom door could peer in. This did not promote privacy for the patients.
• The service did not provide any activities at weekends.
• We concluded that senior managers in the hospital did not have the skills, knowledge and experience to provide leadership of the quality required to maintain safe and effective care. Ward managers could not explain how they maintained quality and ensured that care met fundamental standards.
• Governance arrangements were not robust and quality assurance processes did not ensure that patients and staff were kept safe. For example, the managers did not have clear oversight of the use of rapid tranquilisation and high dose antipsychotic therapy across the hospital. Ward staff team meetings did not have a standard agenda and this meant that opportunities to discuss incidents and complaints did not always take place, which could impact on the ability of ward staff to learn and improve the safety of the service. The service risk register did not contain the pertinent risks that faced the wards.
• Systems to provide assurance were not working well. At the last inspection, in August 2016, we found that audits did not contain a clear plan when improvements were needed. At this inspection, this had not improved. Managers conducted audits but they had no specific timescales for when staff needed to complete actions by. The provider was not monitoring whether improvements were taking place as needed. Staff had not fully implemented the requirements and recommendations from the past two CQC inspections.
• Whilst the service had systems in place to engage and receive feedback from staff, patients and relatives they were not working effectively. The provider’s staff survey 2018 had a low response rate at only 28% of staff completing it. No relatives had completed the friends and family survey. On the wards patients did not receive clear feedback on whether concerns raised at community meetings had been addressed.

However:

• At the last inspection in August 2016, we found that the provider did not keep cleaning records up-to-date or ensure that all areas of the ward were kept clean. At this inspection, we found this had improved. Staff kept cleaning records up-to-date and cleaned the ward environment.
• The provider had procedures in place to address safeguarding concerns and staff had received training in safeguarding adults. Staff reported patient on patient assaults as a safeguarding concern. The service had fully equipped clinic rooms with emergency equipment checked regularly. Seclusion facilities allowed clear observation and two-way communication, and had washing facilities. The layout of the wards allowed staff clear lines of sight to observe patients at all times when in the communal areas. 
• The service had a full range of multidisciplinary staff to provide care and treatment to patients. Staff received regular managerial supervision. Staff morale was good and staff reported feeling supported by their managers and teams. The service had recently set up an academy for staff to attend further training. Staff mandatory training had improved at the service and the majority of staff had completed training to keep patients safe from harm and abuse.
• Patients completed an annual survey to provide feedback on the service they received. The response was largely positive.
• Each ward had a full range of facilities and rooms available to safely provide care and treatment to patients. The service had a fully equipped gym for patients to use. Patients had access to basic mobile phones to make phone calls in private.
• Staff spoke positively about being supported by their managers and working as a team. Staff received regular supervision in line with the provider’s policy.

Due to the concerns we had after the inspection, we asked the provider to take immediate action. This was because we were concerned the service did not adequately assess and manage the risk of patients. The service did not provide patients with access to drinking cups to get themselves a drink of water. The service did not ensure staff carried out the required rapid tranquilisation physical health monitoring on all patients. The service did not safely manage medicines. The service needed to address this by 21 June 2018. We also had concerns that the service did not ensure patients’ care plans were personalised and met their needs. The service needed to address this by 12 July 2018.