St Matthews Hospital

Updated 13 August 2019

St Matthews Hospital is a low secure, rehabilitation, independent hospital which is part of the St Matthews group. The hospital provides care and treatment for up to 16 male patients with a primary diagnosis of mental health. At the time of inspection 11 patients were using the service. Some of which were detained under the Mental Health Act, had Ministry of Justice restrictions, others were informal.

The hospital had a registered manager at the time of inspection. A registered manager is a person who has registered with the CQC to manage the service. Registered persons have a legal responsibility for ensuring the service meets the requirements of the Health and Social Care Act 2008, and associated regulations.

The hospital was registered with the Care Quality Commission to carry out the following regulated activities.

• Treatment of disease, disorder or injury
• Assessment or medical treatment for persons detained under the Mental Health Act 1983.

St Matthews has been registered with CQC since 24 January 2011. Since this time, the service has been inspected four times. The most recent inspection was conducted March 2018. The hospital received a rating of requires improvement for the safe domain and the well led domain and were rated as good in caring, responsive and effective therefore over all the provider was rated as requires improvement. Following the previous inspection, the provider was told they must take the following action to be compliant with the health and social care regulations:

• The provider must ensure that all staff receive mandatory training.
• The provider must ensure that ligature risk assessments are in place and include robust mitigation for identified risks.
• The provider must address the issue of blanket restrictions in relation to patients’ access to fresh air and pat down searches.

We found the provider had taken appropriate action to address two of these concerns.

Updated 13 August 2019

We rated St Matthews hospital as overall good because:

• The provider had established the staffing levels required to meet the needs of the patients. The hospital manager had the autonomy to increase staffing levels if required. Staff training was all above 75% compliant. Staff received regular supervision and annual appraisal in line with the company policy. All wards complied with the Department of Health guidance on eliminating mixed sex accommodation. There was suitable medical cover and on call cover throughout the week.

• We reviewed 11 care and treatment records and found evidence that patients received a comprehensive risk and physical health assessment on admission. Patients were involved in developing their care plans and were outcome focused. The hospital offered a range of psychological interventions recommended in the National Institute for Health and Care Excellence guidelines.

• Patients knew the complaints process and had access to an independent mental health advocate if requested. Staff were aware of the provider’s whistle blowing policy and knew their responsibilities in relation to safeguarding. Staff told us they felt confident to raise concerns to senior managers without being victimised.

• The manager had oversight of the hospital. Performance was monitored by completing regular audits and the outcomes were recorded on key performance indicator dashboards. This meant the manager could monitor performance over a period of time to ensure continuous improvement.

However:

• We found the provider had completed a ligature assessment and had taken steps to mitigate the risks. However, the provider did not have a formal action plan in place to remove ligature anchor points in line with NHS England’s standard contract for low secure services. This states that, Low secure services “will meet” the best practice guidance from the Royal College, and that in low secure service wards: furnishings minimise the potential for fixtures and fittings being used as weapons, barriers or ligature points.

• There were blind spots throughout the ward areas which meant staff were not able to have clear lines of site. There was evidence of some convex mirrors used however not all blind spots were mitigated appropriately.
• We found some maintenance issues that were not identified or reported. For example, Radiator covers throughout were damaged.

Updated 13 August 2019