• Mental Health
  • Independent mental health service

Archived: Meadow Lodge

Overall: Inadequate read more about inspection ratings

Little Hill, Exeter Road, Chudleigh, Newton Abbot, Devon, TQ13 0DD (01626) 855000

Provided and run by:
Huntercombe (Granby One) Limited

Important: The provider of this service changed. See old profile

All Inspections

14 - 15 February 2019

During a routine inspection

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.

30 November 2019 and 18 December 2018

During an inspection looking at part of the service

  • Staff did not always ensure the young people received urgent and emergency treatment. There was no policy or procedure for staff to follow in a medical emergency. The staff trained as first aiders did not provide first aid to young people on a number of occasions despite the young people requiring first aid intervention. Staff did not record physical and neurological observation of the young people as required to identify if a young person’s physical health was deteriorating. Nurses did not update care plans and risk assessments to reflect young peoples’ needs. Agency staff, including registered nurses who took charge of shifts, did not receive an induction to the hospital. Managers did not notify the young people and their families when errors in their care and treatment had been made and did not offer an explanation or apology.
  • We issued a warning notice telling the hospital it must make immediate improvements in how staff responded to young people who need hospital treatment, that the hospital needed a policy and procedure about the management of medical emergencies, that staff needed to carrying out and record physical and neurological observations when clinically indicated, that care plans and risk assessments needed to be updated following changes to the young person’s risk, that all agency staff received and induction to the hospital and that staff followed their duty to act in an open and transparent manner with young people and their families.
  • When we returned on 20 December 2018 found that managers had made staff aware of their responsibility to ensure the young people received urgent or emergency medical assessment and treatment without delay. The ward manager had circulated a policy and procedure and displayed it in the hospital and staff had signed a record to say they had read the them and discussed them with the ward manager. Staff were recording physical and neurological observations when needed and the quality of the record had improved and were robust. Staff had updated risk assessments and care plans to reflect the young peoples’ changing needs. All registered nurses had received an induction to the hospital. The senior management team had circulated guidance on the duty of candour and introduced a checklist to show when it had been used, staff had signed a record to say they had read the guidance and discussed their responsibilities with the ward manager.
  • There had been one incident involving a young person where they had not received a medical assessment and treatment following an injury for over 12 hours. This occurred after the inspection on the 30 November 2018 but before we issued the warning notice. On this occasion, staff had not signed all recordings of physical and neurological observations.

  • Following our second inspection on the 18 December 2018 we made the decision to leave the warning notice in place. The hospital had been placed on enhanced surveillance by the regional quality surveillance group, chaired by NHS England following our recommendations. We continue to work with NHS England and other partner organisations to monitor the hospital closely. We will return to inspect the hospital shortly to ensure the changes the provider has made are embedded and to ensure young people are kept safe.

10 - 11 April 2018

During a routine inspection

We rated Meadow Lodge as requires improvement because:

  • The service’s ligature audit, completed in March 2018, had not included an action plan or completed dates for all identified ligature anchor points, including the bedrooms which were identified as high risk. Some ligature points had not been identified. The environment had a number of ligature points that were mitigated by observations until improvements could be made.
  • The back garden had an anti-climb fence that was not fit for purpose. The fence would not prevent an individual from climbing onto the roof and was a significant ligature risk.
  • The service did not meet their mandatory compliance targets for first aid training. It was not clear from the rota if a trained first-aider was on duty.
  • Care plans were not always person-centred or recovery focussed.
  • The service did not always complete a thorough referral and assessment process and we found incomplete referral forms.
  • Feedback received by CQC from family members and carers said that there was a lack of communication from the service and they did not have a named point of contact.

However:

  • Young people were positive about the service and told us they were happy and cared for.
  • Staff were enthusiastic and motivated to do their job and also spoke positively about the service.
  • The service had received 21 compliments in the past 6 months.
  • The service has close links with the Devon Children and Families Partnership (DCAFP; previously Devon Safeguarding Board) and safeguarding supervision is provided regularly. The safeguarding policy has also been co-written by the DCAFP.
  • There is a commitment towards continual improvement and learning from incidents.
  • The service offers a range of therapeutic interventions, including positive behaviour support (PBS), and a ‘DECIDER’ group, which is a shortened version of dialectical behaviour therapy (DBT). The service also runs music, baking, arts and mindfulness groups
  • The service was well furnished and decorated to a high standard.
  • Young people were involved in the service and felt confident to feedback and raise complaints to the manager.
  • The service had a full-time chef who prepared all meals from scratch daily. They encouraged young people to try new foods and have a healthy, balanced diet.
  • Young people had access to two pygmy goats on site, which were used as therapy animals.

7-22 September 2017

During an inspection looking at part of the service

We did not rate the Huntercombe Group following the well-led review as we only rate individual services for independent providers.

We found the following issues that the service provider needs to improve:

  • The Huntercombe Group had been unable to recruit and retain a sufficient number of nurses with experience in CAMHS across the five services that were open at the time of our inspection. This resulted in services relying heavily on temporary staff to cover shifts. We concluded that this shortage of experienced nursing staff was one of the factors that impacted adversely on the safety of these services. Although the provider had made efforts to recruit, across the five services that were open at the time of the inspection, there were a total of 44 whole time equivalent (WTE) vacancies for registered nurses out of a total required workforce of 109 WTE - a vacancy rate of 40%. Meadow Lodge had the highest vacancy rate (50%); followed by Stafford (48%). The lowest vacancy rate for registered nurses in any of the five services was at Cotswold Spa (29%). These figures did not include long-term contracted nurses and block booked agency staff filling substantive roles as a means to mitigate against high vacancies.
  • The Huntercombe Group had not put in place a programme of specialist training of its workforce to mitigate the low numbers of experienced staff.
  • Although the Huntercombe Group had investigated and identified lessons to learn from the serious problems identified at Huntercombe Hospital Stafford, the system for ensuring that these lessons were put into practice was immature and not embedded across all of the hospital sites.
  • There was no identified member of the senior leadership team accountable for the CAMHS service delivery across The Huntercombe Group. This hindered the organisation’s ability to standardise good practice across the specialism. This was reflected in our findings across the services of inconsistent implementation of policies, sharing of good practice and embedding of lessons learnt across teams.
  • We identified a number of significant lapses in governance. There was no effective corporate oversight of the provision of mandatory and role-specific training for staff and no effective system in place to ensure that staff in all services received consistent and regular supervision and appraisal. We found a lack of detail in the minutes of the various provider level governance meetings including the delivery board and quality assurance group. The minutes did not capture the discussion of data relating to performance or adverse incidents. Although senior management were able to inform us what had been discussed at these meetings, the minutes and papers of the meetings did not record this detail.
  • The staff engagement strategy was not consistently embedded across all CAMHS services. Staff, at some services, reported they did not feel consulted or engaged in changes to practice and service developments. They did not feel the systems and processes in place supported an open culture for whistle blowing.

We found the following areas of good practice:

  • The Huntercombe Group had a clearly stated vision and objectives. Managers worked to ensure all staff at all levels understood them in relation to their daily roles. All staff, including temporary workers, received an induction to their service.
  • There was evidence of some improvements in the governance of services since our inspections of Huntercombe Hospital Stafford and Watcombe Hall. The organisation’s early warning escalation system, quality dashboard, quality assurance framework and quality improvement forums provided a range of data.
  • There was a programme of regular audits intended to identify issues and inform improvements.
  • The provider had a number of initiatives that involved young people. For example, the ‘you said, we did’ initiative encouraged young people to be champions of their peers’ views; and the ‘glamour for your manor’ initiative encouraged young people (and staff) to submit proposals for improvements to their ward environment.
  • Several wards had registered with the Royal College of Psychiatrists’ Quality Network for Inpatient Child and Adolescent Mental Health Services (QNIC), and some wards had already received QNIC accreditation.

23 May 2013

During a routine inspection

We the Care Quality Commission (CQC) completed a planned inspection of James House. We also followed up on concerns from our inspection of 14 and 17 December 2012. Concerns on our last inspection were that patients had not received sufficient information about their rights. Care records had not been up to date. Information about entry and exit for informal patients was not clear and quality assurance systems were not sufficient. At this inspection we found that the hospital had made improvements.

We talked with five patients. All five told us they were involved in the planning of their care and treatment. They confirmed they had been given information on their rights.

Staff had a good understanding of people's needs. Patient's told us that the staff had met their needs as agreed in their care plans. One patient said 'They're really good here. The staff and supportive and they listen to me'.

The hospital is a locked unit. Informal patients confirmed that they were able to leave the building whenever they wished.

Patients told us that they felt safe. Staff were knowledgeable about different types of abuse and how to raise concerns if they had any.

Staff told us that they felt supported. We saw that staff had been appropriately recruited.

Records relating to patients care and treatment were in date and accurate.

We found that the hospital had made improvements to their quality assurance systems.

14, 17 December 2012

During an inspection in response to concerns

This report is based on a visit that was carried out as part of a co-ordinated responsive inspection.

Overall we found that patients at James House were being supported well. We did however find that some of the arrangements for involving patients in their care arrangements was inconsistent.

Patients did not in all cases receive sufficient information about their rights or have this information given to them at appropriate intervals to ensure their understanding.

We found that although staff had a good understanding of patient's needs some of the records relating to patients's care and treatment were out of date.

We did not find evidence of overly restrictive practice at the service. However, we did find that information about entry into and outside the unit for informal patients was not clearly available to them. Patients were not always provided with clear documentation about changes to their leave arrangements.

We found that the hospital was in the process of making improvements to their quality assurance systems. However, we found that some of the current systems were not sufficient. Some care records were out of date, and some files were poorly maintained which could make accessing information difficult. We also found that some incident reports were not fully completed and did not demonstrate action taken or lessons learned.

12 June 2012

During an inspection looking at part of the service

We, the Care Quality Commission (CQC), visited James House, unannounced on the 12th June 2012. We visited the service to look at progress made with concerns identified at the last inspection in September 2011. These were in relation to the emergency admission process, and some staff training. During our visit we also spoke with and had lunch with people using the service; talked with the staff and management; looked at the ways that medication was managed and stored; looked at some of the records kept; and looked around the accommodation.

People that we spoke with on our visit had been involved in the drawing up and reviewing of their care plans, most of which had been signed by them to indicate their agreement. They also participated in writing "thoughts and feelings books" with staff support. The plans we saw had identified goals for people to help meet their needs and aspirations.

Some elements of people's care plans were dictated by legislation, but people were given clear information about their rights and access to specialist independent mental health legal services and advocacy.

People we spoke with spoke well of the service and the staff. We saw people being treated with respect for their individuality and wishes, and involved in making choices about how they spent their time. One person showed us work they had completed in the art groups run by the service, which reflected their hobbies and interests. A staff member showed us work produced by the photography group.

The service ran a series of activities for each person each day. One person told us they cooked their own evening meal on one night each week with the support of staff. Other people had been shopping, doing photography, doing environmental studies or conservation work, cleaning with staff or learning life skills. One person had a local job and another was seeking voluntary work.

The service had a computer that people living there could use with restrictions on access.

We saw people discussing issues openly with staff on duty and being given clear information about boundaries. People living at the service had opportunities to make their views known in regular house meetings which they could call if they wished to discuss something. They could also make their views known via formal questionnaires, which were last circulated in April 2012, results of which were collated.

An independent mental health advocate visited the service weekly, and led a monthly forum for people living there. Information was available for people on how to access the Mental Health Act commissioners, and one person living at the service had participated in supporting CQC at a national level in developing policy.

20, 21 September 2011

During a themed inspection looking at Learning Disability Services

Members of the team made the following observations about James House whilst on site: -

'The sign at the entrance to the property is poor and needs to be better'. They were concerned it was difficult to read.

'The door handles around the property were difficult to use'.

'There was a lot of pink for an all male environment'.

'The gardens were beautiful but there were no activities considering the age and gender of the service users, e.g. a basketball net, goal posts, a football'.

'People could clearly make choices about the decoration in their bedrooms'.

'It felt like a nice place to live, people were treated with respect, there were positive relationships between staff and people in James House'.

'There was a relaxed and calm atmosphere'.

Other comments people made to us included: -

One person said he did not have a copy of his care plan but it was safer in the office, and it had pictures in it so it was easier to understand. The same person said they could go to the cinema if they requested and they are planning to go to college to complete a computer course.

One relative said they were frustrated by their son's clinical meetings being held so early as it made it difficult to attend. All three of the relatives we spoke to said they thought James House was a good place, the staff are nice and they are made welcome when they visit.

An expert by experience CQC team member (a person who has used services) spoke to three people about their care at James House. People explained that in most cases their care coordinator or social worker had decided they should move to James House. Each person agreed that they had been asked about their needs or support (at time of admission). The time taken to be admitted to James House varied between 'same day' (emergency) and three months. Two of the three people said staff had spoken to their family about their care. All of the people spoken with agreed they had been involved in creating their care plans, one person said 'if I have an idea my nurse will put it in my care plan'. When asked whether they had a copy? People said, 'It's in the office and I can look at it when I want too'. All people agreed that staff followed their care plans. Each person said they had an advocate (who was independent of James House). Other comments included, 'Staff show me how to cook properly and sensibly', 'If someone does not like something on the menu, they can have something else'.