Archived: Priory Hospital Blandford

This inspection was a focussed inspection so therefore did not provide a rating. The purpose of the inspection was to see if the provider had made significant improvements to the service following the issue of a section 29 warning notice in May 2019.

• Staff, with the support of managers, had improved their assessment and management of patient risk. They reported that the service had become more settled since the previous inspection. Positive behavioural support plans were being used more effectively. The number of incidents of restraint had reduced. Assaults on staff had reduced, and staff felt better supported. Young people and staff reported that they felt safer on the wards.
• The provider had updated their process for under-taking the initial assessment of young people being considered for an admission. This was to ensure that they were able to meet the individual needs of the young people. This amended assessment had not yet been implemented but had been approved by commissioners.
• Staff had worked hard to improve young people’s care planning. Care plan documentation was more comprehensive. They included risk management plans. The care plans were more recovery focussed, highlighting the goals and the interventions needed to achieve them.

However:

• At the previous inspection there had been incidents where young people had been able to lift the bricks out of the patio which could be used to harm staff, other young people or themselves. At this inspection these bricks were still easy to lift out and were associated with ongoing incidents. But, staff showed an increased awareness of the risks associated with the garden at Oak Ward and the need to help keep young people safe. They had put in a process of regularly checking the garden to help minimise the risk.
• The records of observations were unclear, meaning that staff might not know how often individual observations were meant to take place.

We rated Priory Hospital Blandford as inadequate because:

• CQC took enforcement action and issued a warning notice due to concerns about the safety of young people at the hospital. Staff did not have a detailed understanding of the specialist nature of a learning disability CAMHS service. Staff did not comprehensively assess the risks of the young people accessing the service. We reviewed risk documentation for seven young people on the wards and found inadequate assessment and documentation of risk in all records. Staff and young people said that they felt unsafe on the wards and that there had been patient on patient assaults and bullying, and assaults on staff. Many staff did not have the experience and skills to manage the complex presentation and needs of the young people on the ward.
• Pre-admission assessment was not comprehensive enough to ensure all information about risks and needs of young people was available to staff. Following admission, staff did not always complete initial assessments in a timely manner and the assessments lacked detail meaning information around young person’s needs could get missed. Care plans were not young people centred; nursing staff had not written them in the young person’s voice. There was a lack of young people’s views and discussion recorded in the plans, so it became unclear how staff devised the plans with young people.
• The hospital had found it difficult to recruit permanent staff and there was therefore a heavy reliance on agency workers many of whom had little knowledge or experience of working with young people who had learning disabilities and autism and complex needs. This also impacted on the continuity of care being delivered. Not all agency staff received appropriate training or regular supervision.
• The garden for Oak Ward was not safe and hazards in the garden were impacting on the behaviours of young people and the response by staff. There were loose bricks and nails that young people had made attempts to use as weapons or could use to harm themselves; staff had restrained young people to prevent potentially dangerous situations occurring.
• Incidents showed inappropriately high use of physical restraint as an intervention. There had been 138 restraints out of 250 incidents involving eight different young people over a three-and-a-half-month period. Staff did not report all incidents, particularly around physical assault and racial abuse and the quality of reports were poor. This meant that incidents could be missed and therefore not escalated to external bodies such as safeguarding or CQC.
• Staff did not follow procedures for monitoring young people in long term segregation (LTS) as set out in the Mental Health Act 1983: Code of Practice. Records showed that medical staff did not always prescribe and administer medicines in accordance with agreed treatment plans. Staff had continued to give a young person medication beyond an agreed date to stop the medication because the prescribing doctor had not discontinued the prescription. Arrangements were not in place to ensure this could not happen. This meant that medication could be being given unlawfully.
• Young people said that communication with them was poor. There was poor and disconnected communication around planning care and treatment from staff to young people. Staff did not plan discharge effectively and there was limited evidence of discharge planning in the care records. The hospital had not planned effectively for the transfer of a young person to an adult hospital for a young person approaching their 18th birthday.
• The hospital did not, at the time of the inspection, have the ability to provide safe and effective support to young people with an eating disorder, this was due to delays in support from a dietician. At the time of the inspection the service did not have an occupational therapist. This meant that young people did not have assistance coping with the effects of their disability on various activities and occupations. The hospital had previously arranged for a sensory trained occupational therapist from another Priory hospital, but this had stopped.
• Some young people told us that the staff did not treat them well and did not behave in a caring manner towards them. Young people spoke about not being involved with care planning or their treatment. Young people said that there was limited activity on the wards and that they often got bored. Young people said that the food was poor quality. Families we spoke with said that they found the service disorganised.
• At the time of the inspection the hospital was not well-led. The leadership team did not have a clear understanding of the issues on the wards. Staff did not feel supported by the leadership team. Staff said they did not feel safe, listened to or supported by managers.
• The governance arrangements were not robust and did not provide assurance or provide information or support improvement to the quality of the service or protect young people from avoidable harm. Quality walk rounds, and audits of records had not addressed issues with safe and effective record keeping or helped young people feel safer on the wards.

However:

• Staff had assessed the environment for ligature risks and rated the risks to identify if action needed to be taken to reduce, mitigate or remove the risk. The hospital complied with guidance on same sex accommodation, was visibly clean and staff were able to observe all parts of the ward.
• Staff followed procedures to monitor physical health after the administration of rapid tranquilisation. Staff monitored young people’s physical health at agreed intervals and responded to changing physical health concerns. Staff used recognised rating scales such as Health of the Nation Outcome Scales Child and Adolescent (HONOSCA) and the Children’s Global Assessment Scale (CGAS).
• Young people’s medicines were stored safely, and staff followed procedures to monitor physical health after the administration of rapid tranquilisation.
• Staff demonstrated a knowledge of the Mental Capacity Act and Gillick Competency.
• The hospital had committed to only admitting a low number of young people on opening and to building the number of young people slowly as staff were recruited and their ability to meet complex needs developed.
• The education area was well equipped and staffed by teachers that helped young people keep up to date with school work.
• The new hospital director told us they were keen to provide increased support and supervision to the staff team. They had brought in ‘Treat Tuesday’ to boost morale, buying the staff team doughnuts for example. The provider had a risk register and business continuity plan in place which helped them manage risks. The hospital had set up a ‘your say forum’ for staff to feedback.