Montague Court

Updated 1 June 2023

Montague Court is a long-term complex care locked rehabilitation mental health hospital for up to 18 male patients. It is registered to provide care and treatment to people detained under the Mental Health Act. The organisational goal is to support individuals to realise their potential. They aim for improvement and developments in quality of life leading to a gradual progression through the recovery pathway and eventual discharge. At the time of our inspection there were 16 patients’ resident at Montague Court. All of them were subject to detention under sections of the Mental Health Act. The patient group displayed complex co-morbid conditions that require longer inpatient rehabilitation to stabilise. Most patient referrals come from high dependency rehabilitation units. The hospital was last inspected in September 2018 and was rated as outstanding overall. The inspection was undertaken as we had been notified of concerns regarding training compliance, staff supervision and lack of staff and patient involvement at the hospital.

What people who use the hospital say

Feedback from patients that use the hospital was positive. We spoke with four patients, they stated that they felt cared for and safe. They also stated that they felt staff knew them well and they were treated as individuals. All patients we spoke with said they could go out into the courtyard whenever they liked to smoke which was not always the case at their previous hospital. We were also told that there was plenty of activities on offer, but three patients said they had to “be in the mood” to participate. We were told about recent day trips which they said were very enjoyable, movie and music group sessions and the breakfast club where patients decided what they would like, and staff supported them to cook it.

Updated 1 June 2023

The Chief Inspector of Hospitals, Dr Sean O'Kelly, is placing Montague Court into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that here remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to 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. Our rating of this location went down. We rated it as inadequate because:

• The hospital did not provide an environment which was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff could not observe patients in all parts of the hospital. We saw multiple blind spots throughout the three floors which were not mitigated by mirrors or individual risk assessments. We saw multiple ligature points which had been identified on the ligature risk assessment, however the mitigation documented was not followed. We were concerned that there were insufficient alarms to keep staff, visitors, and patients safe.
• Staff did not routinely check medical equipment. Blood glucose monitoring machines were not routinely checked or calibrated.
• Staff did not always develop care plans which were holistic and recovery-orientated and record the patient’s involvement in developing their plan. Staff did not regularly review and update care plans according to the provider’s expectation of six-monthly updates and a monthly review.
• Staff did not receive regular supervision and annual appraisals. Clinical and managerial supervision rates were 32% and appraisal rates were 52%. Managers did not hold regular team meetings; we saw two sets of meeting minutes from the 12 months prior to this inspection.
• Staff did not follow General Data Protection Regulations (GDPR) to keep patient information confidential.
• The governance systems in place were not sufficient to identify potential risk to patients. Significant risks were identified that the hospital had not recognised, assessed, monitored, and mitigated. This represented significant failings in the overall hospital governance processes as the hospital was not aware of the level of risk regarding multiple issues.

However:

• We spoke with four patients, all said staff worked with and supported them. Throughout the inspection we saw that staff treated patients respect, offered choice of food and drinks. We observed staff were responsive when caring for patients. We saw evidence that staff sought feedback from patients on the quality of care provided in the “house” meeting minutes which were held on a weekly basis.
• Staff used a full range of rooms and equipment to support treatment and care. There was a dedicated activity centre which had a therapy kitchen, IT suite and games room. The hospital had quiet areas and a room where patients could meet with visitors in private, including a dedicated family room. Patients had access to their own mobile phones.
• The hospital had enough nursing and support staff to keep patients safe, they had 2.5 whole time equivalent (wte) vacancies for registered nurses and 1.5 wte vacancies for healthcare support workers. The hospital had reducing rates of agency nurses as substantive roles were being filled, as there was an active recruitment process in place. The hospital used three main agencies and requested staff familiar with the hospital to ensure continuity for patients. We saw all bank and agency staff had a full induction and understood the hospital procedures before starting their shift.

Following this inspection, we issued the service with a warning notice served under Section 29 of the Health and Social Care Act 2008. We found the service was failing to comply with Regulation 17(2)(c)(d) Good Governance, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found the service had failed to ensure the quality of the care and service provided was regularly monitored, assessed and mitigated to protect patients from the risks of avoidable abuse and harm.

Managers failed to provide an environment which was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Standards of cleanliness at the unit were below what people should be able to expect. The hospital was visibly dirty with food debris on both furniture and the floor. We saw engrained dirt on the staircase and high- and low-level dust on skirting boards and cupboards. The patient kitchen had a damaged worktop which exposed porous areas and the patient fridge door was significantly soiled.

Managers had failed to ensure staff could observe patients in all parts of the hospital. We saw multiple blind spots throughout the three floors of the building which were not mitigated by mirrors or individual patient risk assessments. We saw multiple ligature points which had been identified on the ligature risk assessment, but the risk mitigation actions documented were not followed by staff. Ligature knives were stored in locked rooms with no signage to indicate their presence. Managers had also failed to ensure there were sufficient alarms to keep staff, visitors and patients safe.

Managers had failed to ensure staff routinely checked medical equipment. Blood glucose monitoring machines were not routinely checked or calibrated.

Managers failed to ensure staff had developed care plans which were holistic and recovery-orientated and recorded the patient’s involvement in developing their plan. Staff did not regularly review and update care plans according to the providers policy of six-monthly updates and a monthly review.

Managers failed to ensure staff received regular supervision and annual appraisals. Clinical and managerial supervision rates were 32% and appraisal rates were 52%. Managers did not hold regular team meetings; we saw only two sets of minutes from the 12 months prior to inspection.

Managers failed to ensure staff followed General Data Protection Regulations (GDPR) to keep patient information confidential.

Managers did not have governance systems in place that were sufficient to identify potential risk to patients. Significant risks were identified that the hospital had not recognised, assessed, monitored and mitigated. This represented significant failings in the overall hospital governance processes as the hospital was not aware of the level of risk regarding multiple issues.

Updated 1 June 2023

Our rating of this location went down. We rated it as inadequate because:

• The hospital did not provide an environment which was safe, well maintained and fit for purpose. Staff could not observe patients in all parts of the hospital. We saw multiple blind spots throughout the three floors which were not mitigated by mirrors or individual risk assessments. We saw multiple ligature points which had been identified on the ligature risk assessment, however the mitigation documented was not followed. We were concerned that there were insufficient alarms to keep staff, visitors, and patients safe.
• Staff did not routinely check medical equipment. Blood glucose monitoring machines were not routinely checked or calibrated.
• Staff did not always develop care plans which were holistic and recovery-orientated and record the patient’s involvement in developing their plan. Staff did not regularly review and update care plans according to the provider’s expectation of six-monthly updates and a monthly review.
• Staff did not receive regular supervision and annual appraisals. Clinical and managerial supervision rates were 32% and appraisal rates were 52%. Managers did not hold regular team meetings; we saw two sets of meeting minutes from the 12 months prior to this inspection.
• Staff did not follow General Data Protection Regulations (GDPR) to keep patient information confidential.
• The governance systems in place were not sufficient to identify potential risk to patients. Significant risks were identified that the hospital had not recognised, assessed, monitored, and mitigated. This represented significant failings in the overall hospital governance processes as the hospital was not aware of the level of risk regarding multiple issues.

However:

• We spoke with four patients, all said staff worked with and supported them. Throughout the inspection we saw that staff treated patients respect, offered choice of food and drinks. We observed staff were responsive when caring for patients. We saw evidence that staff sought feedback from patients on the quality of care provided in the “house” meeting minutes which were held on a weekly basis.
• Staff used a full range of rooms and equipment to support treatment and care. There was a dedicated activity centre which had a therapy kitchen, IT suite and games room. The hospital had quiet areas and a room where patients could meet with visitors in private, including a dedicated family room. Patients had access to their own mobile phones.
• The hospital had enough nursing and support staff to keep patients safe, they had 2.5 whole time equivalent (wte) vacancies for registered nurses and 1.5 wte vacancies for healthcare support workers. The hospital had reducing rates of agency nurses as substantive roles were being filled, as there was an active recruitment process in place. The hospital used three main agencies and requested staff familiar with the hospital to ensure continuity for patients. We saw all bank and agency staff had a full induction and understood the hospital procedures before starting their shift.

Following this inspection, we issued the service with a warning notice served under Section 29 of the Health and Social Care Act 2008. We found the service was failing to comply with Regulation 17(2)(c)(d) Good Governance, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.