Archived: Eldertree Lodge

Updated 20 August 2021

The inspection

This was a targeted inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to review the management of people’s safety.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by three inspectors.

Service and service type

Oakwood House provides care and support to people living in seven ‘supported living’ settings, so that they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

The service did not have manager registered with the Care Quality Commission. The service was being managed by the provider's senior management team. A new manager for Oakwood House has recently been appointed.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because the service is small, and people are often out, and we wanted to be sure there would be people at home to speak with us.

What we did before the inspection

We reviewed all the information we had received about the service. The service had not been asked to complete a provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. We took this into consideration when reviewing our findings.

During the inspection

We spoke with all seven people who used the service and five relatives about their experience of the care provided. We spoke with 12 members of staff including the provider, deputy manager, senior care workers, care workers and members of the behaviour support team.

We reviewed a range of records. These included two people’s care records, medicine records and accident and incident forms. We looked at a variety of records relating to the management of the service, including policies and procedures and on the second day of inspection we reviewed CCTV footage.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at Court of Protection documentation and training records. We also spoke with the multi-disciplinary team responsible for supporting people at the service.

Updated 20 August 2021

Eldertree Lodge is an independent mental health hospital provided by Coveberry Limited. It is a 41-bed hospital providing specialist inpatient treatment and longer-term high dependency rehabilitation services for adults aged 18 years and over in locked wards specifically for patients with a learning disability or autism. Coveberry Limited also provide a supported living service, Oakwood House, through the registration of personal care at Eldertree Lodge. Oakwood House was not visited as part of this inspection. An inspection of Oakwood House is planned and upon completion the inspection report will be available on our website www.cqc.org.uk.

On 23 and 25 March 2021, we completed an unannounced, focused inspection of Eldertree Lodge in response to information of concern about the care and treatment provided there.

Following the inspection, we served the provider with a letter of intent under Section 31 of the Health and Social Care Act 2008, to warn them of possible urgent enforcement action. We told the provider we were considering whether to use our powers to urgently impose conditions on their registration. The effect of using Section 31 powers is serious and immediate. The provider was told to submit an action plan within 24 hours that described how it was addressing our concerns. Their response did not provide enough assurance they had acted to address immediate concerns.

Due to the serious nature of the concerns we found during this inspection, we used our powers under Section 31 of the Health and Social Care Act 2008 to take immediate enforcement action and imposed additional conditions on the provider’s registration. This included a condition to restrict the provider from admitting any new patients to Eldertree Lodge without the prior written agreement of the Care Quality Commission.

This inspection rated Eldertree Lodge inadequate and placed it into special measures.

You can read our findings from our all of our previous inspections by selecting the ‘all reports’ link for Eldertree Lodge on our website at www.cqc.org.uk.

This inspection which commenced on 20 May 2021 was an unannounced, focussed inspection to see what improvements the provider had made. Our inspection focussed on the concerns we raised to the provider following our previous inspection.

Following the 20 May 2021 site visit, we issued the provider with a requirement to provide documentation and closed circuit television recordings specific to high level incidents of restraint and incidents where a patient had made an allegation against a member of staff causing harm. We made this request because we identified concerns about the use of restraint with patients. The requirement was issued under Section 64 of the Health and Social Care Act 2008.

On receipt of this information, we carried out a further unannounced site visit on 3 June 2021. During this visit we reviewed closed circuit television camera footage from six incidents specific to one ward from 27 February 2021 to 13 April 2021. We also looked at closed circuit television camera footage from eight incidents that occurred between 6 May 2021 and 14 May 2021. These incidents were randomly sampled from Ash, Chestnut and Birch wards.

Due to the seriousness of the concerns we identified during this inspection, we sent a letter to the provider detailing our concerns and giving them opportunity to provide documentary evidence that risks were being managed, and patients were safe. However, the provider’s response did not fully address all areas of our concerns. We sent a further letter setting out our concerns and giving the provider another opportunity to provide assurances through documentary evidence. Again, the provider’s response failed to address all areas of our concerns, provide adequate detail of risk management and assure us patients remained safe at the service.

On 14 June 2021, we sent the provider an urgent Notice of Decision detailing our decision to vary the provider’s conditions of registration to remove regulated activities at Eldertree Lodge. The variation removed inpatient treatment and high-dependency rehabilitation services at Eldertree Lodge from 17 July 2021. The notice also detailed conditions on the provider’s registration to ensure the removal of regulated activities was managed in a safe way for patients.

We made this decision because:

• We believed patients continued to be exposed to a risk of harm. Staff actions or omissions in care did not always protect patients from avoidable harm. Closed circuit television camera footage showed staff ill treatment and abuse of patients.
• Staff did not always manage incidents and behaviours that challenge well. Closed circuit television camera footage showed staff sometimes used inappropriate restrictive techniques with patients and behaved unprofessionally during incidents.
• Staff did not always safeguard patients from abuse. Staff failed to identify, record and notify actions or omissions in care that exposed patients to the risk of harm.
• We were not assured the provider always referred staff to registered bodies for further investigation following incidents of concern.
• Governance processes did not always work well. The provider’s improvement plan did not demonstrate sufficient improvements. The provider’s response to concerns raised to them did not provide assurance patients would remain safe from avoidable harm.
• Staff continued to not always use correct infection prevention and control measures to keep patients and staff safe. Staff continued to not always follow national COVID-19 guidance.
• We found a continuation that not all ward areas were clean, safe and well maintained. Many ward areas continued to have increased risks of slips and falls, ripped or broken furniture and damaged paintwork, and maintenance work had not always been completed to a good standard.
• We continued to find out of date food in ward kitchen areas.
• The provider continued to rely on temporary staff to maintain safe staffing of the hospital. The hospital did not always have enough appropriately skilled and experienced staff to ensure patient’s needs were identified and met.
• The provider did not always make notifications to external bodies. Staff did not always record enough detail of the incidents and concerns they notified to external bodies.
• Staff did not treat patients with compassion and kindness. They did not respect patient’s privacy and dignity. Not all staff understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
• Leaders did not have a good understanding of the services they managed and were not always visible in the service and approachable for patients and staff. Although the provider had introduced ward manager roles the impact of these roles was not seen.