The Care Quality Commission (CQC) has rated an independent mental
health service inadequate for the second time in four months,
after it found known risks affecting patient safety had not been
addressed.
CQC inspected St John’s House, Palgrave, in April. The service is
run by Partnerships in Care, which is part of the Priory group,
and had 35 patients at the time of inspection.
The unannounced inspection was undertaken to determine whether
the hospital, which cares for adults with learning disabilities
and associated mental health issues, had made improvements after
it was rated inadequate overall and placed in special measures
following an inspection last year. Its ratings for being
effective, caring and responsive to people’s needs were suspended
after that inspection, and these were assessed on the latest
visit.
In addition to being rated inadequate overall following the
latest inspection, the service was rated inadequate for being
safe, effective, caring and well-led. It was rated requires
improvement for being responsive to people’s needs.
Stuart Dunn, CQC head of inspection for mental health and
community services, said:
“Our previous inspection identified several areas
where St John’s House needed to improve its care of its patients.
These included ensuring people at risk of self-harming were
observed appropriately, and measures to protect people from abuse
were in place.
“We reported these issues to its leaders, so they knew what they
needed to address.
“Disappointingly, our latest inspection found the overall quality
of care had not improved and many of the issues we previously
raised remained unchanged. These included failings regarding
patient observations, staffing arrangements and record keeping –
all of which presented risks to patient safety.
“The hospital remains subject to enforcement action following
last year’s inspection, and we continue to monitor it closely. We
will take further action to protect people if they are at
immediate risk of harm, or if the service does not evidence how
it will meet its obligations to its patients.”
CQC’s latest inspection of St John’s House found instances when
staff were asleep while they should have been observing patients.
This was also an issue identified during the previous
inspection.
Inspectors identified a reliance on agency workers who did not
always know the service or have the right training to support its
patients. Consequently, people did not have regular individual
time with a designated staff member, affecting the support
patients received to have timely access to external
specialists.
This issue was worsened because documentation, including for risk
assessments, was not always comprehensive. This meant staff did
not always have easy access to all relevant information to inform
the care they offered.
Similarly, learning was not always captured following patient
safety incidents, including when patients had self-harmed. This
meant leaders did not use all the information available to them
to prevent future incidents occurring.
However, there were some areas where the hospital was exhibiting
good practice, including for infection prevention and in ensuring
patients in long-term segregation had access to activities.
Following the previous inspection, CQC placed conditions on the
hospital, including preventing it from admitting new patients
without CQC agreement. These conditions remain following the
latest inspection.
If enough improvement is not made, CQC will use its enforcement
powers further to protect patients from the risk of harm and hold
the service’s leaders to account. If CQC takes further action,
details will be published as soon as legal restrictions
permit.
Following the latest inspection, CQC told the Priory group it
must make several improvements at St John’s House, including:
- Employing enough staff with the right training and ensuring
they receive adequate supervision.
- Undertaking patient observations in line with care plans and
policies.
- Ensuring areas for patient seclusion and long-term
segregation are safe, fit for purpose and protect patient
dignity.
- Supporting reintegration for patients in long-term
segregation.
- Ensuring staff know the location of emergency equipment,
including ligature cutters and the defibrillator.
- Responding appropriately to patients’ physical health needs.
- Complying with the duty of candour.
- Ensuring patients sectioned under the Mental Health Act have
safe access to leave.
- Ensuring patients have personalised care plans, updated in
line with changes to their needs, and ensuring all staff are
familiar with these.
- Protecting patient dignity during restraint by, where
possible, preventing other patients from observing.
- Reviewing and actioning all safety incidents, including for
safeguarding, so changes are made as a result of learning.
- Using good governance to identify areas for improvement and
ensuring assurance systems and processes are in place.
The report will be published on CQC’s
website tomorrow (Friday 9 July).
