Archived: St Andrew's Healthcare - Nottinghamshire

Updated 15 August 2019

St Andrews Healthcare Nottinghamshire is a 66 bedded independent hospital for men detained under the Mental Health Act. At the time of the inspection there were 47 patients using the service. Patients admitted include those with a diagnosis of autism and Asperger’s syndrome; and have either established or suspected borderline learning disabilities. They may also have additional mental health needs, and a history of offending or challenging behaviour. The service accepts referrals from across the United Kingdom. The hospital consists of four wards:

Newstead ward is a 16 bedded low secure ward for men who have a primary diagnosis of autistic spectrum disorder.

Wollaton Ward is a 17 bed medium secure ward for males with autistic spectrum disorder.

Thoresby ward is a 14 bed medium secure ward for men with mild or borderline learning disability. Patients may also have mental health needs and/ or a history of offending or challenging behaviour.

Rufford ward is an 18 bed low secure ward for men with autistic spectrum disorder or learning disability.

St Andrews Healthcare Nottinghamshire is registered with CQC to provide treatment of disease, disorder or injury and assessment or medical treatment for persons detained under the Mental Health Act 1983.

This location has been inspected ten times. The last inspection was in October 2018. The location was rated as inadequate overall; inadequate for safe, requires improvement for effective, inadequate for caring, good for responsive and inadequate for well led.

We took enforcement action for breaches of the following regulations:

Regulation 10 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Dignity and respect.

• Patients privacy and dignity were not always respected. Patients basic needs were not always met. We observed a patient being ‘pat down’ searched in front of other patients in the communal area on Thoresby ward. Staff were not responding to patients requests when in seclusion. Staff records in one instance, were disrespectful and used inappropriate language.
• Patients told us that some staff were punitive, disrespectful and sometimes ignored them.

Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Safe care and treatment.

• Staff were not compliant with the Mental Health Act Code of Practice. Doctors and nurses were not always completing reviews as required. Staff were not always completing observations. Staff had not always completed seclusion care plans.
• Managers had not ensured safe environments. We found unidentified ligature risks on Newstead ward and an out of date ligature assessment on Thoresby ward. We identified blind spots in the en-suite areas of Newstead and Rufford seclusion rooms. On Wollaton ward, staff were not adhering to infection control principles when dealing with laundry and clinical waste.
• Staff use of restraint had increased. Over six months there were 220 episodes of restraint. This was an increase since this previous inspection when there had been 355 episodes of restraint over twelve months. These were highest on Wollaton ward with 126 restraints for 11 different patients.
• Management of actual and potential aggression training did not enable staff to intervene to keep all patients safe.
• The provider had not ensured staff working on Thoresby ward had the specialist training to support patients safely.

Regulation 13 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Safeguarding service users from abuse and improper treatment.

• Patients on Thoresby ward voted on whether another patient’s seclusion could be ended or not.
• Staff were keeping patients in seclusion for longer than required.

Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Good governance.

• Leaders and governance arrangements did not assure the delivery of high quality care. Managers had not ensured that staff worked within the legal frameworks of the Mental Health Act and Mental Capacity Act. We identified staff practices in breach of both these acts and use of inappropriate language in patient care records.
• Leaders did not ensure compliance with recognised standards. Thoresby ward operated as a therapeutic community but was not accredited against Royal College of Psychiatrists’ service standards and was not always able to evidence compliance with these standards.

We issued requirement notices for breaches of the following regulations:

Regulation 11 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Need for consent.

• Staff were not compliant with the Mental Capacity Act. We reviewed 24 patient records and ten had no evidence that staff had assessed capacity.
• Staff on Thoresby ward, operating as a therapeutic community, were not completing capacity assessments with patients prior to their admission to the service. There was no evidence in patients records that they had consented to undergo the model of treatment provided on the ward.

Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Staffing.

• The provider had not ensured all staff working on Thoresby ward received training in therapeutic communities.

We found that the provider had addressed some, but not all of the issues from the last inspection. The issues that remain are identified later in this report.

Updated 15 August 2019

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

• Managers did not ensure safe and clean environments. The ward layouts did not allow staff to observe all parts of the ward. We identified blind spots on all wards. There were no mirrors fitted to mitigate these. The extra care area and annexe on Thoresby ward were visibly dirty, we raised this with the provider and the occupied annexe was clean when we checked the following day. Staff were not labelling all opened food items in fridges, we found unlabelled items in fridges on all wards. However, managers had completed new ligature assessments, ensured all staff were aware of ligature risks and implemented new infection control procedures.
• Staff did not always manage seclusion appropriately. Staff were keeping some patients in seclusion for longer than required. We reviewed 20 seclusion records and found three instances of this. However, this was for hours rather than days as found previously. The practice of patients voting on whether to end another patient’s seclusion had ended. Doctors and nurses were not completing reviews as required in 15% of records, multi-disciplinary reviews had not taken place as required in 18% of records and staff had not completed seclusion care plans as required in 9% of records. This was an improvement since the last inspection.
• Staff did not always manage patient risks. On Thoresby ward, one patient’s information sheet did not highlight a serious risk issue. Staff did not always follow policies and procedures for use of observation.
• Staff had not always recorded and investigated incidents appropriately. We found examples of staff not recording incidents in both the patients notes and on the incident database. We found examples where staff described incidents of physical aggression between patients as ‘playfighting’. 
• Managers told us that Thoresby ward was providing a new model of therapy based on a personality disorder service, adapted for patients with mild or borderline learning disabilities. At the time of our visit this model was not embedded as staff required training in order to deliver the therapies.
• Staff had not ensured hard copies of positive behavioural support plans were up to date on Rufford ward and staff on Newstead and Thoresby ward did not know where the hard copies of the positive behavioural plans were kept.

However:

• Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Patients told us that the service had improved since our last inspection. We reviewed 20 seclusion records and found no examples of staff not responding to patients requests or of inappropriate and disrespectful language in patients’ records. The provider had updated their search policy and staff conducted pat down searches of patients in private. We did not observe any punitive or disrespectful treatment of patients.
• The provider had made significant progress in addressing the issues we found at the previous inspection. The provider made management changes, implemented new governance systems, improved their auditing processes and acted to address poor staff conduct. The provider stopped Thoresby ward operating as a therapeutic community. Staff use of restraint and seclusion had decreased. Staff felt respected, supported and valued. Staff were very positive about their experience of working at the service and told us they were well supported.
• A patient was holding ‘masterclasses’ for staff and patients to help them understand the needs of patients with autism. Staff supported the patient to design the content of the programme. 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 teams had effective working relationships with other relevant teams within the organisation and outside the organisation and engaged with them early in the patient’s admission to plan discharge.
• The service supported several patients to use their leave for special events and outings. These included one patient being supported to go on home leave to his family in Northern Ireland twice in recent months, another patient was supported to go to a concert in London and staff supported two other patients to attend football matches, including one at Wembley.

Updated 10 February 2015

There were systems and processes to monitor staffing, incidents and safeguarding, which were summarised in a ward dashboard. Up to date environmental audits and plans were not available on the wards. Resuscitation equipment was not checked on a weekly basis. We found staffing skill mix and deployment affected the patient experience. Patients were concerned about the turnover of medical staff. Staff and patients understood and applied the safeguarding processes well.

The hospital provided data for the first quarter of the year that showed almost one third of activities planned were not taken up by patients. However the patients we spoke with told us that there were not enough nurse led activities for them to do.

Thorsby ward had introduced the concept of a therapeutic community which was being embedded. There was an initiative called “meaningful conversations” which had been introduced to facilitate dialogue between nurses and patients which patients were positive about. There was a mixed picture about the way patients felt were treated by staff. We observed some staff to be caring and compassionate; we also observed one staff member swearing in the office and heard that there had been problems with staff attitude on Rufford ward.

There was an active patient representative group “our voice” who had formulated an action plan for changes that they felt were required.

We found that patients knew how to make complaints. Patients told us their complaints were rarely fully addressed and often do not receive clear responses. Out of 25 formal complaints only one had been fully upheld.

Patients did not consider that ward leaders were visible. Staff supervision was provided, however not consistently.

Updated 15 August 2019