The Langford Centre

Updated 7 June 2023

The Langford Centre provides low secure forensic, high-dependency rehabilitation and acute inpatient mental health services to male and female working-age adults. Most patients are detained under the Mental Health Act (1983).

The service is provided by Bramley Health Limited.

The hospital is purpose built and provides seventy-six beds over six wards:

• Fairlight Ward (16 beds) is an inpatient acute ward for females,
• Cooden Ward (15 beds) is an inpatient acute ward for males,
• Arlington Ward (10 beds): is an inpatient acute ward for males,
• Seaford Ward (8 beds) is a high-dependency rehabilitation ward for males,
• Balmoral Ward (11 beds) is a high-dependency rehabilitation ward for females,
• Pevensey Ward (16 beds) is a low secure forensic ward for males,

The Langford Centre is registered to provide:

1. Treatment of disease, disorder or injury
2. Assessment or medical treatment for persons detained under the Mental Health Act 1983
3. Diagnostic and screening procedures

The hospital had a registered manager at the time of our inspection. The hospital director was fairly new in post, although the hospital was being overseen by other long standing senior managers whilst the new hospital director settled into their role.

The Langford Centre was last inspected in May 2022, when a comprehensive inspection was carried out of all the wards except Arlington ward which was non-operational at the time of the inspection. The hospital was rated requires improvement overall.

On 15 May 2022, a few days after the inspection, a patient sadly died after fixing a ligature to the sash-style window in their bedroom on Cooden ward, an acute mental health ward. Due to the concerns we identified during that inspection, we used our powers under section 31 of the Health and Social Care Act to take immediate enforcement action and placed a number of conditions on the provider’s registration. This meant that the provider could not admit patients to Fairlight or Cooden wards, the two acute mental health wards for adults of working age, without seeking written permission from the CQC. The CQC also required the provider to make improvements to how ligature risks were identified and managed on Cooden and Fairlight wards, and to how individual patient risks were assessed on Fairlight ward. The urgent conditions were subsequently lifted and the provider was able to admit patients to Fairlight and Cooden wards from 9 June 2022. This was because the provider had taken prompt action to make improvements to keep patients safe. The provider worked in collaboration with the local mental health NHS trust to make some immediate improvements to the service.

At the previous inspection in May 2022, the provider had been issued with requirement notices. We told the provider to make the following improvements:

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

• The provider must ensure improvements to how ligature risks are safely assessed and managed are sustained and embedded, and that ligature risk assessments continue to be developed by a suitably trained person. Regulation 12(2)(d)
• The provider must ensure patient observations are completed intermittently rather than at set times. Regulation 12(1)(2)(b)
• The provider must ensure nursing staff with the appropriate skills are rostered to work on each shift to safely meet the needs of patients, and that staff receive the necessary specialist training to ensure they are skilled and competent to carry out their roles. Regulation 18(1)
• The provider must ensure improvements to assessing patient risk in a comprehensive and timely manner are sustained and embedded. Regulation 12(2)(a)(b)
• The provider must ensure staff are trained to safety search patients to keep them safe from risks posed by contraband items. Regulation 12(1)(2)(b)
• The provider must ensure blanket restrictions are systematically reviewed and appropriate for patients based on clinical risk, and that patients can secure their personal items in a lockable space independently. Regulation 13(1)(4)(b)(c)(5)
• The provider must ensure all essential clinical information is appropriately managed and routinely accessible to staff. Regulation 17(1)(2)(c)
• The provider must ensure patients are involved in planning their care and treatment. Regulation 9(1)(c)(3)(a)(c)(d)(g)
• The provider must ensure that patients can access an appropriate amount of occupational therapy led therapeutic activities, including during evenings and at weekends. Regulation 9(1)(a)(b)
• The provider must ensure patients can easily access independent mental health advocates (IMHAs) on the wards. Regulation 9(1)(3)(c)(d)(f)
• The provider must ensure appropriate governance systems are in place to assess, monitor and improve the quality and safety of the service. Regulation 17(1)(2)(a)

Long stay or rehabilitation mental health wards for working age adults:

• The provider must ensure ligature risks are safely assessed and managed and that ligature risk assessments are developed by a suitably trained person. Regulation 12(2)(d)
• The provider must ensure clinical waste including used sharps are managed safely to minimise the risk of injury and infection. Regulation 12(1)(2)(h)
• The provider must ensure staff safely monitor the physical health of patients who have received medicine by intramuscular rapid tranquilisation to help identify significant potential physical health deterioration, and that staff have access to the necessary emergency medicines to manage a physical health emergency. Regulation 12(1)(2)(b)(f)
• The provider must ensure patients can easily access independent mental health advocates (IMHAs) on the wards. Regulation 9 (1)(3)(c)(d)(f)
• The provider must recruit to the ward manager posts on Seaford and Balmoral wards. Regulation 18(1)
• The provider must operate effective governance systems to enable the provider to assess, monitor and improve the quality and safety of the service. Regulation 17(1)(2)(a)
• The provider must adhere to an inpatient rehabilitation model and ensure the anticipated length of stay, patient discharge plans and multidisciplinary staffing provision, including occupational therapy and consultant psychiatry, align with this model. Regulation 9(1)(3)(a)
• The provider must ensure that each patient has a plan for their discharge from the service. Regulation 9(1)(3)(b)
• The provider must ensure patients have access to a key to their own bedroom where this is clinically appropriate. Regulation 13(1)(4)(b)(c)(5)
• The provider must ensure all essential clinical information is appropriately managed and routinely accessible to staff. Regulation 17(1)(2)(c)

Forensic wards:

• The provider must ensure ligature risks are safely assessed and managed and that ligature risk assessments are developed by a suitably trained person. Regulation 12(2)(d)
• The provider must ensure patients have the appropriate support to develop their daily living skills, including the ability to cook and prepare meals with appropriate support from an occupational therapist. Regulation 9(1)(a)(b)(2)(3)(b)
• The provider must ensure patients can easily access independent mental health advocates (IMHAs) on the wards. Regulation 9(1)(3)(c)(d)(f)
• The provider must ensure all essential clinical information is appropriately managed and routinely accessible to staff. Regulation 17(1)(2)(c)

During this inspection we found some improvement and many of the requirement notices had been met. However, at the last inspection in May 2022 we highlighted the need for sustained improvement for how environmental ligature risks were safely assessed and managed. Furthermore, we identified the requirement for governance processes to be fully embedded and these had only been partially achieved. As a result, the CQC used its urgent powers under section 31 of the Health and Social Care Act 2008 and issued the provider the Letter of Intent. The letter instructed the provider to provide assurance of its immediate action to improve the assessment and management of ligature risks. In response, the provider supplied evidence of revised ligature audits which were an accurate reflection of ligature risks on the wards and the mitigation actions for these risks. The provider also acted promptly by removing or reducing identified ligature risks which had not previously been identified, supplied staff with appropriate ligature cutting equipment in line with their policy and rolled out additional ligature awareness training for all staff.

What people who use the service say

During this inspection we spoke with a total of 22 patients. We also undertook a short observational framework for inspection (SOFI) assessment on all wards to observe how staff were caring for patients. A SOFI is an observational tool used to help us collect evidence about the experiences of people who use the service, especially where people may not be able to fully describe this themselves because of cognitive or other problems. It enables inspectors to observe people’s care or treatment looking particularly at staff interactions.

The feedback we received from these patients was positive. Patients told us that most staff were caring and treated them with respect and kindness. People we spoke with felt safe at the hospital and told us that staff were responsive to their needs.

During the SOFI assessments we observed that staff treated individual patients with respect, dignity, kindness and the staff team were caring and flexible with the individuals to meet their needs.

Updated 7 June 2023

The Langford Centre is an independent mental health hospital providing care and treatment to working-age adults with severe mental illness or a learning disability. The service provides one low secure forensic ward, two high-dependency mental health rehabilitation wards and three acute mental health wards for adults of working age.

The Care Quality Commission (CQC) conducted an unannounced inspection of The Langford Centre on the 1 and 2 March 2023. The inspection was carried out to check if the improvements required following the inspection in May 2022 and detailed in an action plan submitted by the provider in October 2022 had been made.

One of the acute mental health wards for adults of working age (Arlington ward) had recently opened in September 2022 and this was the first time we had inspected this ward.

Due to the concerns we identified during this inspection, the CQC used its urgent powers under section 31 of the Health and Social Care Act 2008 and issued the provider a Letter of Intent. The letter instructed the provider to provide assurance of its immediate action to improve the assessment and management of ligature risks. Subsequently, the provider supplied evidence of revised ligature audits which were an accurate reflection of ligature risks on the wards and the mitigation actions for these risks. The provider also acted promptly by removing or reducing identified ligature risks which had not previously been identified, supplied staff with appropriate ligature cutting equipment in line with their policy and rolled out additional ligature awareness training for all staff.

Our rating for The Langford Centre ​stayed the same​. We rated it as ​requires improvement​ because:

• Each of the three core services were rated as requires improvement overall. Potential ligature anchor points still existed across the wards which had not been identified on the providers’ ligature risk assessment document, despite the provider implementing a programme of works to minimise the presence of potential ligature risks after the last inspection in May 2022. A ligature anchor point is anything that could be used to attach a cord or other material for the purpose of hanging or strangulation.
• Equipment for managing ligature risk, such as wire cutters, were not available for staff to use in line with the provider’s policy. Staff did not know how many ligature cutters should be available on the wards and ligature cutters which were present were not always in working order.
• We issued a Letter of Intent because the governance was not robust enough to ensure that ligature risks were assessed and managed well. The governance processes around how ligature risks were systematically reviewed, and actions carried out were not evident or documented effectively, and this had not been identified by the provider. Although immediate improvements were made in relation to the assessment and management of ligature risks, these improvements needed to be sustained and embedded.
• Staff did not always follow systems and processes to safely administer, record and store medicines and did not routinely check medical equipment.
• Whilst the provider had recruited additional occupational therapy assistants, there was only one qualified occupational therapist working across the hospital. This meant that there was limited occupational therapy support, particularly on the high-dependency rehabilitation wards where patients needed to be supported for discharge to community settings after long stays in hospital.
• Although the provider had plans to review the service model for the two high-dependency rehabilitation wards, this service did not adhere to the current model. Whilst there had been some improvement, the length of stay for patients on the rehabilitation wards was over two years, which was much longer than the anticipated maximum stay of one year for this type of service, as outlined in the CQC’s brief guide for high-dependency unit specification.
• There were limited activities of daily living during weekends and evenings which were basic and nurse led.
• The quality and detail of patient care plans was inconsistent across wards. Patient care plans on Seaford and Balmoral wards did not always capture patient views or goals. Positive Behaviour Support (PBS) plans on Pevensey ward were not always tailored to patient’s needs and not updated regularly.
• Record keeping was inconsistent across wards. Staff recorded patient clinical information on both paper and electronic records, which posed a risk that all the information they needed to deliver safe care and treatment would not be accessible or up to date. Some staff reported that there was a lot of duplication and that documents were often disorganised and difficult to find.
• Patients’ privacy and dignity was not maintained. On Arlington ward, staff searched patients returning from leave in an area which could be observed by others. On Seaford and Fairlight wards, staff did not routinely close the nursing office door which meant confidential discussions including patient identifying information could be overheard.
• A hospital wide systematic process for sharing lessons learned from incidents and complaints was inconsistent and not embedded.

However:

• Staff treated patients with compassion and kindness and understood the individual needs of patients. All patients we spoke with were positive about their experience using the service. Staff felt there was an inclusive culture and found their managers approachable.
• The provider had made progress with international nurse recruitment which had improved staffing levels and reduced the use of agency staff. Leaders ensured shifts had appropriate staff skill mix to ensure temporary staff had the right skills and experience to safely meet the needs of patients. Staff received support from ward managers and had access to clinical supervision and appraisals.
• Staff carried out comprehensive risk assessments for all patients. They understood their responsibilities in relation to safeguarding and knew how to identify issues of potential abuse and how to escalate these.
• The provider was taking proactive steps to enable patients to access Independent Mental Health Advocacy (IMHA) services on admission and routinely throughout their admission by referral, despite ongoing challenges regarding the IMHA service provision.
• Staff understood their roles in relation to the Mental Capacity Act 2005 and the Mental Health Act 1983 (MHA) and the application of the MHA was monitored closely by MHA administrators

Updated 18 December 2020

Updated 7 June 2023

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

• Staff did not always ensure that all potential ligature points were thoroughly risk assessed and that there were sufficient mitigations in place to reduce or remove such risks. There were potential ligature anchor points across the ward that had not been identified on the providers’ ligature risk assessment document.
• The governance was not sufficiently robust enough to ensure that risks were managed well. Managers had not received training on how to complete a ligature risk assessment document. Staff were not always using the most up to date ligature policy document. Items for managing ligature risk such as wire cutters which were identified on the ligature risk assessment documents were not on the wards.
• The service was not storing and recording medicines in line with best practice. There were different packages of methadone stored in the controlled drugs cupboard. Staff were also storing illicit substances, such as cannabis, which had been confiscated from patients in the controlled drugs cupboard. There were no audit trails or record of all items in the controlled drugs cupboard.
• The ward office was cluttered with paper files and disorganised. There were different versions of the same document which could be confusing for staff. Staff reported that there was a lot of duplication and documents were often difficult to find. Staff also reported that the ward office could be very hot. The clinic room door could be easily accessed by patients from outside putting the dispensing clinician at risk.
• Patients were bringing in illicit substances unto the wards. Although staff reported that they had received security training, it was not clear how patient were able to bring illicit substances unto the wards which could put patients and staff at risk.
• Not all staff had completed their training in managing patients with Autism & Learning Disability.
• There were concerns around restrictive practices which were not recognised as blanket restrictions and therefore regularly reviewed. For example, patients were not allowed into the kitchen to make snacks or hot drinks. However, the provider reported that this was for safety reasons. 
• Some patients’ positive behavioural support (PBS) plans were not tailored to their needs. For example, psychology had identified that a patient met the criteria for autism spectrum disorder (ASD), but there were no PBS plans to support them. In addition, there were no autism specific care plans for this patient. The PBS plans were not regularly updated.
• While we saw that new staff members were given an induction, managers did not ensure that staff had read and signed to show they understood the policies and procedures. In addition, the induction documents were not audited.

However,  

• The ward was clean and well maintained. The wards had enough nurses and doctors. Staff followed good practice with respect to safeguarding. 
• Staff carried out a comprehensive assessment of patient risk. Most patients had care plans that were tailored to their needs. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
• 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. 
• Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• Staff spoke very highly of their leaders. They felt there was opportunities for growth and career development.

Updated 7 June 2023

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

• The ward environments were not safely managed. The ligature risk assessments were not robust enough and some staff told us the ligature maps were difficult to interpret.
• Staff did not always follow systems and processes to safely administer, record and store medicines and did not routinely check medical equipment. The blood glucose machines on both wards were not maintained as required by the manufacturer to ensure that they were working effectively. The fridge thermostat on Balmoral ward was faulty and a replacement had not been fitted. Staff did not keep accurate cleaning records.
• The service was currently designated as a high-dependency rehabilitation unit model, although the provider had plans to review this. Whilst there had been some improvement, patients continued to stay at the service for much longer than the anticipated maximum of one year for this type of service. Many patients were continuing to experience delayed discharges because the rehabilitation model was not clear enough.
• Patients did not have access to the appropriate amount of occupational therapy cover required by a high-dependency rehabilitation service, to meet the needs of patients. There were limited activities of daily living during weekends and evenings which were basic, and nurse led.
• Patient care plans did not always capture patient views or goals. Staff did not always record whether family or carers wanted to be involved in the patient’s care.
• The provider used both paper and electronic records. Ward staff had to routinely access electronic records to print and store in patients’ files. This posed a risk that printed information could be old and not accurate if information had been updated in electronic format but not printed.
• Patient privacy and dignity was compromised. On Seaford ward, telephone conversations about patients could be heard outside the nursing office because staff did not routinely close the office door.
• The provider did not have appropriate local governance systems in place to effectively assess, monitor and improve the quality and safety of the service. Ligature risks were not always assessed and managed appropriately to help manage the risk to patients, and this had not been identified by the provider’s internal governance processes.
• A systematic process for sharing lessons learned from incidents and complaints with staff was not embedded.

However,

• Staff treated patients with compassion and kindness and understood the individual needs of patients. Patients reported that staff were genuinely kind, they made them feel safe and supported them emotionally.
• Patients could access independent mental health advocates (IMHAs) on a referral basis. Posters were displayed to help patients who did not know the role of an IMHA or how to contact them.
• Staff assessed and managed risks to patients and themselves well. The service had improved their oversight of post rapid tranquilisation physical health monitoring.
• Staff achieved the right balance between maintaining safety and providing the least restrictive environment possible to facilitate patients’ recovery. Each patient had their own bedroom with an en-suite bathroom which they could personalise. Patients had access to their bedroom key to lock their bedroom doors and were assigned a lockable space to secure personal items.
• Ward environments were well maintained, and staff followed good practice with respect to safeguarding.
• Both wards had a permanent ward manager. Staffing levels had improved leading to reduced rates of agency nursing staff being used. Both wards had registered nurses who were registered mental health nurses. Staff received appropriate mandatory training, supervision, and appraisal.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

Updated 7 June 2023

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

• The ward environments were not safely managed. The tools and audits used by staff did not adequately assess and manage potential ligature anchor points. A ligature point is anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Some staff did not know how many ligature cutters were available on the ward.
• The provider used both paper and electronic records. Clinical records such as the doctors initial clerking in documentations and patient risk screening were stored electronically. These were printed and subsequently stored in patients’ files. This posed a risk that printed information could be old and not accurate if information had been updated in electronic format and not printed.
• Patient privacy and dignity was compromised. The lobby area where patients were searched on their return from leave on Arlington ward had clear glass doors. This meant the people from outside the ward could see patients being searched by staff. On Fairlight ward, telephone conversations about patients could be heard outside the nursing office because staff did not routinely close the office door.
• Controlled drugs were not safely managed. On Fairlight and Cooden ward, staff were not utilising the index in the controlled drug register. This posed a risk of controlled drug mismanagement.
• The provider did not have appropriate local governance systems in place to effectively assess, monitor and improve the quality and safety of the service. Inaccuracy and inconsistencies between the way ligature risks had been assessed on each ward had not been identified by the provider.

However,

• Staff observed patients safely. Patients were routinely observed by staff at different frequencies dependent on individual clinical risk. These observations were completed at intermittent times. This meant patients were unlikely able to predict when staff would observe them. Staff observed patients in bedrooms using door viewing panels which were closed when not in use.
• Staff assessed patient risk on admission. Initial risk screens were completed by the doctor on duty, these were accessible to staff. Records of the admission assessments were stored in electronic format and a paper copy was stored in patient’s file. The minutes of handover meetings between staff, where they discussed how to manage patient risk, were accessible to staff.
• Staff involved patients in planning their care. Care records we reviewed demonstrated patient’s involvement or staff attempts to involve patients in their care. These were updated regularly by staff with the involvement of patients, and patients were given copies of their care plans.
• Each patient had their own bedroom with an en-suite bathroom. Patients personalised their bedrooms with pictures and personal items. Patients had access to their bedroom key to lock their bedroom doors and there was no lockable space in patient bedrooms to secure personal items.
• Managers ensured there were enough staff with appropriate skills rostered to work on each shift to ensure that all patients` needs could be met. Training compliance was high for most of the mandatory training.
• The service had appropriate medical cover which included access to out of hours doctors. Each ward had a junior doctor located on the ward, working Monday to Friday to support patients and to manage new admissions.
• Although the lobby environment had clear glass which compromised patient's privacy, staff were trained to safely and effectively search patients for contraband items that may pose a risk of harm to patients using a handheld metal detector. Patients were searched on their return to the ward with their consent. When patients declined to be searched staff would risk assess the patient and observe the patient more frequently based on the risk.
• Each ward had safeguarding champions who met monthly with the senior leadership team to review all safeguarding issues across the wards.
• Patients could access independent mental health advocates (IMHAs). The advocate visited the wards on a referral basis. Posters were displayed to help patients who did not know the role of an IMHA or how to contact them.