Archived: Bloomfield Court and 5,6 Ivy Mews

Updated 3 November 2016

Bloomfield Court and 5, 6 Ivy Mews is an independent hospital for patients with learning disabilities, autism and mental health needs provided by Sequence Care Limited. The service is registered with CQC to provide: assessment or medical treatment for persons detained under the Mental Health Act 1983, diagnostic and screening procedures, and treatment of disease, disorder or injury.

The service can accommodate up to fifteen patients and consists of: Bloomfield Court a ward for male patients, Jasmine Court, a ward for female patients; Ivy Mews which has six two-storey individual patient units. All the buildings are inside a secure perimeter. Statutory services commission the service.

At the time of the inspection, there was no registered manager in post. However, we met the new hospital manager who advised that she was applying to CQC for registration as the manager of the service.

Updated 3 November 2016

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 take action 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 providers' 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

We rated Bloomfield Court and 5, 6 Ivy Mews as inadequate because:

• There were a high number of incidents of violence in the service that staff did not always report. There were also a high number of patient restraints. Fewer than half of the staff had undertaken training in approved restraint techniques.

• There were not enough qualified nurses on duty in the service. The provider had not filled a significant number of bank and agency shifts. Forty percent of staff had left the service in the previous year.

• Most care plans were not specific or detailed, and did not meet all of the patients’ needs. Patients were not involved in the development of their care plans. Staff did not support patients appropriately to make decisions about their care or treatment.

• There were low completion rates of staff training. Staff did not have the skills needed to meet patients’ needs.

• The wards, and Ivy Mews, were not clean or well maintained and appeared institutional. The environment did not promote comfort and recovery.

• There were no ligature-free fixtures in some patients toilets and bathrooms. The entrance gate and doors to the service were not secure.

• Some staff did not know how to respond if they observed or heard about poor care, neglect or abuse. Referrals to the local safeguarding team were delayed by staff.

• One patient had been deprived of their liberty without lawful authority for almost 18 months. Another patient’s care constituted long-term segregation. This patient did not have multidisciplinary reviews in accordance with the Mental Health Act Code of Practice.

• Two patients had been in the service for four years. There was little progress in their care and treatment and no clear discharge plans.

• The systems and processes in the service were not effective. They did not effectively assess, monitor and improve the safety and quality of the service.

• The service had five managers or acting managers in the three years before the inspection. There was a lack of clinical and non-clinical leadership in the service.

• The management team were out of touch with day-to-day events in the service. There was little understanding of the extent of the improvements needed.

• We informed the provider of our serious concerns regarding the safe care and treatment of patients - Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider voluntarily made a commitment to stop all admissions of patients to the service immediately until all areas of non-compliance had been resolved. The provider also produced an action plan. The Care Quality Commission will monitor the progress of the action plan closely.

• We identified concerns regarding other areas of the service. We have taken action regarding these concerns.

Updated 15 April 2016