We carried out a focused inspection of wards for adults of working age and psychiatric intensive care units run by Devon Partnership NHS Trust. This was a focussed inspection, so we did not rate the service during this inspection. The requires improvement rating relates to the rating awarded at the previous inspection.
The wards are registered to provide the following regulated activities;
- Assessment or medical treatment for persons detained under the Mental Health Act 1983.
- Treatment of disease, disorder or injury.
- Diagnostic and screening procedures.
We visited Delderfield ward and Moorland View ward. Delderfield is one of two 16-bedded wards at The Cedars in Exeter. Moorland View is one of two 16-bedded wards at North Devon District Hospital. Both wards are acute inpatient wards that provide assessment, care and treatment for adults with mental health needs.
At the time of our inspection Ocean View, the neighbouring acute adult inpatient ward to Moorland View ward, was being used as a ward for a small number of patients who were being tested for Covid-19 prior to admission as part of the trust’s infection prevention and control strategy.
Ocean View ward was suspended in early June 2019. Ocean View and Moorland View staff teams merged to become one 24-bedded ward to support safe staffing.This was due to difficulties recruiting staff, especially registered nurses. On 30 November, the bed numbers on the merged ward were further reduced to 16 beds following the death of a patient to support safe staffing and manage patient acuity.
We visited Delderfield ward and Moorland View ward due to concerns about patient safety incidents involving ligature incidents and patient deaths. There had been a number of patient safety incidents involving ligature incidents and patient deaths including a patient death on Delderfield ward in March 2020 and two patient deaths on Moorland View ward in September 2019 and November 2019. These were in addition to other serious incidents involving patients self-harming.
On 18 June 2020, following this inspection, we sent the trust a letter of intent under section 31 of the Health and Social Care Act 2008 identifying our serious concerns about the safety of patients on Delderfield ward and requesting the trust submit information to explain how it would make immediate improvement. Section 31 of the Health and Social Care Act 2008 Act is an urgent procedure whereby CQC can vary any condition on a provider's registration in response to serious concerns. A letter of intent sets out our intention to take urgent action if the provider does not assure us that it will make the required improvements urgently. The trust responded to the letter of intent on 22 June 2020 with an action plan. However, we did not feel it set out clearly enough what action would be taken so asked for further assurance. The trust responded on 1 July 2020 setting out further immediate actions it was taking/would take to ensure the safety of patients.
In the Section 31 letter of intent we told the trust we were concerned about the management of environmental risks including ligature risks. The environmental ligature risk assessment shown to us on Delderfield ward was not the latest version as the interim manager told us they did not have access to it. This version had not been updated following recent serious incidents.
We told the trust we were concerned that on Delderfield ward, patient’s observations and intentional rounding were not sufficient to keep patients safe. Staff only randomised formal patient observations if they determined that the patient was at particular risk. This was contrary to the Trust’s engagement and observation policy which stated observations should not be predictable or entirely regular. The predictability of observations exposed patients with self-harming behaviours to a risk of having the opportunity to hurt themselves.
We told the trust we were concerned about the quality, recording, oversight and effectiveness of observations and intentional rounding on Delderfield ward. There was a lack of oversight of observations, despite incidents taking place when observations were missed, or when observation levels had not been sufficient to prevent self-harm.
We asked the trust to tell us how it would improve the quality and oversight of observations and intentional rounding to improve its ongoing assessment and understanding of patients’ well-being, progress and fluctuating risks and in order to appropriately care for patients.
We told the trust we were concerned about a lack of response to audits and a lack of learning from serious incidents. There had been a delay in completing the investigations into recent serious incidents, including the patient deaths. There was evidence of learning from serious incidents on Moorland View ward. However, on Delderfield ward, minimal local learning had taken place following a death in March 2020 and staff said they were waiting for the outcome of the root cause analysis or simply did not know if there was any learning from the death that took place in March.
We had no concerns about the induction process on Moorland View ward where agency staff were monitored during their shift. However, we told the trust we were concerned about the lack of a robust system to ensure agency staff were inducted to the Delderfield ward. An induction checklist was in place, however if staff said they had worked shifts on the ward before, this was not checked to ensure their induction and training was up to date.
We told the trust we were concerned about staff training because staff on both wards told us they had not been formally trained in ligature risk assessment and management. The inspection team reviewed an audit that showed staff felt under skilled in risk assessment. Staff did not receive formal training in patient observations and there was no formal process on Delderfield ward for checking patient observations had been completed.
Delderfield ward had implemented a daily security check on Delderfield ward three weeks prior to the inspection. The daily security check helped raise staff’s awareness of ligature risks on the ward and staff generally found it useful. There was a lack of action to rectify risks because works had been delayed due to the Covid-19 pandemic. In response to the pandemic, in early March, contractors were removed from site by their firm management teams. The Trust advised us it had no involvement in or control over this decision.
In the Trust’s response to our letter on 22 June 2020, the Trust assured us that the Director of Nursing and Professions had visited Delderfield ward to discuss the initial findings and immediate actions with the staff and leadership on the ward. The Trust provided us with an action plan on 22 June 2020 to address our initial findings. The trust provided us with an up to date copy of the ligature risk assessment for Delderfield ward that had been updated in April 2020. However, the environmental ligature risk assessment lacked details of actions taken to mitigate risks so we asked for further assurance. The trust confirmed wards were now ensuring observations were unpredictable for all patients. The trust told us it had briefed staff on the use of the engagement and observation policy, reminding staff to complete observations at variable intervals. The trust told us it had introduced measures to ensure induction was more robust, reviewing the local induction checklist for all agency staff workers on all shifts, regardless of whether or not they had previously worked on the ward. The Trust advised that simulation training in ligature risk assessment and management was being developed for roll out at the end of July 2020.
We wrote to the trust again on 26 June 2020 to request further assurances. We asked for confirmation that the interim manager on Delderfield ward had access to the environmental risk assessment. We asked for more detail about reviewing and auditing of engagement and observation and for confirmation that patients were receiving unpredictable and irregular observations. We noted that Delderfield ward had introduced a weekly audit of engagement and observation. However, this audit was happening daily on Moorland view and we asked the trust to assure us that a robust and regular review of engagement and observation was taking place. We asked the trust to confirm that agency and bank staff on Delderfield ward were being provided with individual supervision and being included in discussions about changes to the observation levels of patients. We asked for further clarification on the risk training being provided to staff and to tell us how it would ensure staff were sufficiently trained, competent and confident in intentional rounding, observation and the assessment and management of patient risk. We asked for more detail about how the trust ensure learning is discussed and disseminated effectively on Delderfield ward. We asked for an update on the expected completion date for the root cause analyses for each of the deaths on Moorland view and Delderfield ward. We told the trust that the risk register they had provided to us for Delderfield ward did not appear to be an active document and that it lacked detail. We asked for assurance of the trust seeking a permanent manager for Delderfield ward. We asked for assurances about the timeframes of the work being conducted by the trust’s ‘preventing and managing ligature events in inpatient settings group’.
The trust wrote to us again on 1 July 2020 and it advised the interim manager had had access to the environmental risk register but had now left the ward. It provided us with its audits of observations for Delderfield ward. These showed that comprehensive observations were taking place in line with trust policy. The trust advised it would be ensuring all staff feel engaged, understand and participate in clinical discussions and decision making. The trust told us it had introduced a three times daily audit of the recording of observations on Delderfield ward. The trust provided Delderfield ward’s updated risk register and it was comprehensive. The trust confirmed that temporary bank and agency staff were being offered supervision. The trust provided confirmation of the governance process for ensuring learning from incidents and audits is discussed and disseminated.
However;
We found positive and proactive leadership on Moorland View and that risks were being managed well.
Staffing levels were safe on both wards. The trust had an active recruitment programme and it was supporting existing staff to undergo nurse training.
Handover were effective on both wards. Handovers were detailed and covered dynamics between patients, physical health risks and patients’ risk.
All patients and carers that we spoke with said staff enabled them to have contact with one another. This was particularly welcomed during the Covid Pandemic lockdown period. Patients, families and carers gave good feedback about staff, describing them as helpful, approachable, supportive, caring, and respectful.
All patients said they were involved in planning about their discharge and families and carers said they were suitably involved in discharge planning.
Patients on both wards talked about enjoying being able to use the gardens which were well maintained, spacious and offered a calming environment
Staff felt the culture on both wards was good and that staff were caring for each other and towards patients. Staff felt respected, supported and valued.
As this was a focussed inspection, specifically to follow up on issues of concern about patient safety, therefore did not rate the service and the rating from the previous inspection still applies.
We conducted an unannounced focused inspection looking at specific areas of the following two key questions:
- Is it safe?
- Is it well led?
During this inspection, the inspection team:
- Visited Delderfield ward and Moorland View ward
- spoke with the ward managers
- spoke with 16 staff including registered nurses, healthcare assistants, support workers and student nurses
- spoke with patients
- spoke with carers
- spoke with stakeholders of the service
- looked at 14 care and treatment records of patients
- attended a handover meeting on Delderfield ward
- looked at a range of policies, procedures and other documents relating to the running of the wards.