15 September 2020
During an inspection looking at part of the service
Cedar House hospital provides low secure inpatient services for adults with a learning disability or autism who have offending or challenging behaviour and complex mental health needs.
The purpose of this inspection was to follow up on the warning notice that was served by the Care Quality Commission immediately following the unannounced, focused inspection on 21 July 2020. We served the warning notice because the provider was failing to comply with Regulation 12 (Safe Care and Treatment) because of the following reasons:
- Failure to deploy enough suitably qualified, experienced and competent staff to deliver safe care along with a failure by the leadership team at both the hospital and provider level to recognise this
- Lack of robust risk assessment and management of risk resulting in a high number of assaults on staff and patients
- Not carrying out observations appropriately and safely
- Reliance on the use of ‘as required’ medication (PRN)
- Confusion and lack of understanding about the use of emergency equipment and emergency medicines.
We told the provider it must take immediate action to meet the requirements of the regulation
This inspection was an unannounced, focused inspection. We did not rate the service on this inspection. The previous rating of inadequate overall still stands and the hospital remains in special measures.
At the inspection we found:
- Staffing levels across the hospital had improved and the hospital managers were recruiting more staff and working towards maintaining maintain safe staff levels. An additional member of staff had been allocated for teams on Folkestone ward and the Enhanced Low Secure Service. This meant more staff were available to support observations and manage incidents. The staffing level on Poplar ward had improved and there was no longer only one member of staff working alone.
- We found most observation records we checked met basic standards.
- There was a reduction in over-reliance on as required medication (PRN), following an audit of PRN, and the hospital had started to introduce ways to reduce patient incidents via what it called Calm cards; these outlined behavioural coping strategies that were used before staff gave PRN.
- The hospital had implemented Positive Behaviour Support (PBS) champions in order to improve the usage of the PBS interventions and reduce incidents. They were working with an external organisation to further develop staff understanding and implementation of PBS. PBS is a recognised method for helping some patients with a learning disability to develop less-challenging ways of interacting with others.
- Managers were being supported to make improvements at the hospital. This included weekly calls from Huntercombe senior managers and input from external organisations, which were providing support to managers to reduce inappropriate placements and carrying out a project with staff to develop a shared vision for the future. Managers were actively focused on providing better care for patients who were inappropriately placed at the hospital.
- The reasons for low morale amongst some staff due to safety had been recognised and the service was working with staff to respond to their concerns and make changes that would benefit them.
- Managers had developed action plans for service improvements. The hospital had a plan in place to improve the environment and we saw new flooring being installed on some of the wards and some bedrooms and a dining room were being painted. There was a rolling programme of repairs.
- During the inspection, we observed positive staff and patient interactions and good use of distraction and de-escalation techniques by staff.
- There were now two emergency bags and two emergency response teams at the hospital and staff were better informed about the use of emergency medicines.
However
- The ward environments on Folkestone, Folkestone ELS, Rochester and Maidstone wards were not clean. There was no regular cleaner for the wards employed by the organisation at the time of the inspection. Night staff had been asked to clean the wards but day staff told us they also had to clean the wards at the same time as working with patients and carrying out their caring duties. Contract cleaners were employed to do a deep clean on the wards monthly and the provider was advertising for housekeeping staff. In laundry rooms on two wards we saw chemicals were open and potentially accessible by patients, and there was loose tubing and items that were potential trip hazards. Bathrooms and toilets were not clean on Folkestone ward and the Enhanced Low Secure Service.
- Between 22 July 2020 and 18 September 2020 there were 11 assaults on patients and 20 staff had taken time off work after incidents. Of the 830 incidents recorded, 11.8% resulted in minor or moderate injury to staff or patients. This meant we were not fully assured that the provider had assessed and mitigated the risks to patients and staff.
- Despite the improvements in staffing levels and the work being done to ensure safe staffing levels, staff we spoke to had concerns about the confidence and competence of staff, as many were new or agency and did not know patients well.
- Staff did not always develop holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff did not always store care records in one place. We found care plans on the electronic patient record system but also some were kept in a shared drive. Sometimes staff could not locate specific information they might need to guide their interventions with patients.
Physical health care plans were not always easy to locate in the electronic record system and some were kept in folders in a shared drive.
- Wards did not always keep detailed enough handover notes to ensure staff on the next shift knew about the patient’s needs.
- Two of the wards do not have a separate garden area from the shared hospital grounds, this meant that patients could not always access the grounds when the wards were busy and there were not enough staff on the ward. There were not always enough activities available to patients on wards
- Ward staff told us that some multidisciplinary team members did not have a presence on the wards and therefore lacked a real understanding of patients risks and challenges presented on wards. Ward staff did not feel supported by some members of the multidisciplinary team.
- Relatives and carers said they could not always visit their loved ones at the hospital and that the provider did not always respond to their concerns. Staff told us that restrictions due to Covid-19 had meant relatives and carers could not always visit their loved ones inside the hospital.
Although, there is still much work to do at Cedar House hospital there had been enough progress with improvements required as identified in the warning notice alongside plans in place to continue the improvements. We have therefore decided to lift the warning notice.
However, we will continue to monitor the hospital closely and will not hesitate to take action should the improvements not continue.