Archived: Meadow Lodge

Updated 26 April 2019

Meadow Lodge is an independent inpatient child and adolescent mental health service (Tier 4 CAMHS). The service provides specialist care and treatment for male and females aged between 13 and 17 years. The service is registered for 10 young people and is split between a two-bedded high dependency area and an eight-bedded general adolescent unit. Young people can be admitted informally with parental consent, if under 16 years, or detained under the Mental Health Act (MHA) 1983. Meadow Lodge is commissioned by NHS England to provide assessment and treatment for children and young people with complex emotional, behavioural or mental health difficulties that require inpatient treatment. The service accepts young people with a learning disability or an autistic spectrum disorder if their primary diagnosis is a mental health condition. The service is part of a specialist mental health services division of Huntercombe (Granby One) Limited.

The Care Quality Commission (CQC) registered Meadow Lodge to carry out the following regulated services: treatment of disease, disorder or injury, assessment or medical treatment for persons detained under the MHA and diagnostic and screening procedures. At the time of the inspection the service had a newly appointed manager in place that was in the process of applying to the Care Quality Commission to become the registered manager.

Four female young people were resident at the time of our inspection; one was detained under section 3 of the Mental Health Act (MHA). Two young people were discharged during the inspection.

Meadow Lodge has been inspected on three previous occasions by the CQC. In April 2018 we conducted an announced comprehensive inspection six months after it was registered with CQC. Following this inspection, the service was rated as requires improvement overall, with safe and effective rated requires improvement and caring, responsive and well-led rated as good. The service was issued four requirement notices for breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We told the provider it must take the following actions to improve Meadow Lodge:

• Care plans needed to be person-centred and the young people should be involved in developing their care plans.
• The anti-climb fence needed to be fit for purpose. The fence in place posed as a significant ligature risk and no action had been taken by the provider to mitigate this.
• The provider did not ensure that referral forms were completed in full, which could lead to the hospital accepting inappropriate referrals.

In September 2018 we were made aware of concerns through our anonymous whistleblowing process and through notification made directly to us by the provider. As a result of the concerns raised, and information from other sources, including reporting by The Huntercombe Group, Meadow Lodge was placed under enhanced multi-agency surveillance.

In November 2018 we conducted an unannounced focused inspection of the service following a notification directly from the provider that identified staff had not ensured that young people received urgent and emergency treatment when needed. Following this inspection, we issued the service with a warning notice under regulation 12 and regulation 20. We found that the service was not meeting the requirements to provide young people with safe care and treatment and that staff were not following their requirements under duty of candour.

Following this inspection, the service voluntarily stopped taking admissions to concentrate on addressing the concerns raised. The commissioners of this service supported this decision.

In December 2018, we conducted an unannounced focused inspection to determine if the service had met the requirements of the warning notice. Whilst the service had made significant improvements, the changes had not been fully embedded, and the warning notice remained in place.

Following this inspection in February 2019, we found the service had met all the requirements of the warning notice and lifted the warning notice. Although the service remained closed to admissions.

Following this inspection, we were informed by NHS England that the service was due to close following a restructure of child and adolescent mental health services in the south region, which determined that Meadow Lodge would not be required. The planned closure date is scheduled for 18 April 2019.

Updated 26 April 2019

We rated Meadow Lodge as inadequate because:

• Neither the provider nor the local management team had been able to promote a stable, positive culture within the service. There was a high turnover of local managers and the provider had sent in additional managers to support the service. However, these frequent changes in the management structure had caused confusion amongst the staff team and they were unclear who was providing support to the local manager or had management oversight of the service. For example, the provider sent a manager from another service to support the local manager, but staff had only seen them once and were not clear if they had responsibilities or oversight in running the service.
• Due to the instability of the local management team and pressures within the service there was conflict in the team at all levels. Agency staff reported not feeling welcome or supported by the team when they arrived for shifts. Staff did not feel listened to and said that decisions were made without their involvement or consultation. Nursing staff said they did not have the opportunity to contribute to discussions about the strategy for their service. In the six months prior to the inspection nursing staff were present at only two of the six held monthly clinical governance meetings. There was a disconnect between the nursing team and the local management team
• The local management team did not have robust governance processes in place to ensure there was oversight of when staff were due supervision or whether they had attended all mandatory or additional training as required. Staff did not receive regular supervision, including clinical supervision in line with the provider’s policy.
• The local management team did not have a robust process for supporting staff following incidents, learning from incidents or making improvements to the service. There was no process to debrief staff following incidents and the service had not made improvements to the observation procedure following a number of incidents involving agency staff sleeping on duty. Both the provider and the local management team were aware of the issue relating to this, but this had not been addressed and did not feature as a risk on the service’s risk register.
• On seven occasions over a six-week period, registered general nurses (RGN) from an agency were left in charge of shifts. These nurses had little knowledge of mental health or child and adolescent mental health and had no experience of working in these areas so could not safely take charge of shifts. Following the first occurrence, the provider identified an action to put in place a safer system of work but this action wasn’t taken and RGNs, without relevant knowledge or experience were left in charge of six subsequent shifts. These were not recorded as incidents. In addition, on-call arrangements were not robust. The RGNs and staff generally were unclear who they should contact in the event that they should need advice or someone with experience to come into the service to deal with an issue. Not all permanent staff had completed mandatory training or additional training required to undertake their role effectively and safely.
• Staff were not making appropriate safeguarding referrals consistently to the relevant authorities. Some incidents were not categorised as safeguarding that should have been and stakeholders told us that staff had not always referred some cases that they should have. The service did not always raise concerns with relevant organisations in cases of poor practice. For example, informing the Nursing and Midwifery Council (NMC) when an agency nurse displayed poor practice or acted outside of the NMC code of practice (The Code) whilst they were working at the service.

However:

• Staff went above and beyond when supporting young people during incidents. We saw CCTV footage showing staff putting themselves in harm’s way to prevent a young person from injuring themselves. We saw that young people and staff had a good rapport. Young people were seen positively engaging with staff following incidents of restraint. Staff used restraint as a last resort, without excessive force, and only when de-escalation techniques had failed.
• Staff were completing observations of young people as directed in their care plans and we found no occurrences of staff asleep at night. This had previously been raised as a concern by the service through notifications to the Care Quality Commission.
• All young people’s risk assessments, risk management plans and care plans were person-centred and regularly reviewed and updated. Young people were involved in their care planning and had copies of their care plans.
• The service was going through a period of enhanced public scrutiny. Local managers and the provider’s senior management team provided support to staff, young people and their parents following the publication of allegations at the service.

Updated 26 April 2019

Me adow Lodge is an independent inpatient child and adolescent mental health service.