Updated 21 July 2017
We are placing Watcombe Hall into special measures.
Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.
We rated Watcombe Hall as inadequate overall because:
- The provider had not undertaken all of the actions that we told them take following our inspection in February 2016. It had not ensured that all staff had access to appropriate and regular supervision and appraisal. The provider had not ensured that staff were following up physical health observations systematically when young people declined physical health checks. There were gaps in recording of physical health observations and lack of monitoring. The provider did not consistently meet its own policy to respond to complaints within 25 days. Although the provider had reviewed what restrictions should be placed on all patients regardless of their individual risk, staff were still being inconsistent in applying these ‘blanket restrictions’. We found issues around section 17 leave, consent and capacity and section 62 urgent treatment orders and delays in requesting second opinion appointed doctors to review the medication of people detained under the Mental Health Act.
- Following our inspection in February 2016, we had the rated the services as requires improvement overall but with a rating of good for caring, responsive and well led. During our follow up visit in May 2017 we were concerned enough to re-inspect all the key questions. We changed the rating in safe and effective from requires improvement to inadequate and well led and responsive from good to inadequate. The rating for caring was changed from good to requires improvement.
- The leadership of the service was not robust. The unit manager and clinical manager were both off work and there was confusion and speculation amongst staff and young people about the long term management of the unit.
- There were a high number of incidents in the service; including 18 serious incidents in the first three months of 2017. This has led to 38 staff injuries in the previous six months, staff feeling overwhelmed and staff leaving the service. Young people said they did not feel safe.
- New and agency staff had not completed an induction and staff had not had regular supervision and training. Some staff said they did not feel confident to carry out their role. Stakeholders were concerned about staff training and staff consistency.
- Young people were not attending regular education and therapy sessions. The service was ‘firefighting’ from one incident to another and as a result young people were bored and under stimulated.
- Governance processes had not alerted the provider in a timely manner that the service was deteriorating.
- We were concerned that the service was not meeting Regulations of the Health and Social Care Act (Regulated Activities) Regulations 2014. We issued a letter of intent to advise the provider of p
- The provider sent an action plan within the agreed timescale.
- The provider voluntarily closed the service to admissions in agreement with us and in liaison with NHS England on 11 May 2017.
The letter of intent identified the following issues:
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Watcombe Hall was not safe and the impact of multiple issues had affected the safety of the unit for children and young people and the staff.
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There were 354 incidents involving restraint in the last six months.
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Patients were at risk when staff responded to incidents and had been left unobserved or had attended the incident with the member of staff.
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There were 38 staff injuries in the last six months.
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There was a lack of formal debriefing following incidents
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Staff turnover impacted on the quality and consistency of the care being delivered to children and young people.
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New staff were not adequately trained, inducted and supervised.
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Access to fresh air for young people was overly restricted and some young people were not going outside on a day to day basis. There was also a lack of therapeutic activities.
We asked the service to take immediate action on the following:
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To deploy sufficient, appropriately trained and competent staff for the safe management of the unit.
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To ensure sufficient observations of the young people to ensure they were not left unattended or required to accompany staff attending to incidents involving other young people.
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Ensure that the environment was safe. This included addressing the PICU fence, external doors and access to upstairs bedrooms.
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Ensure young people had regular access to fresh air and exercise.
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Ensure all young people to received timely appropriate care and treatment including for their physical health needs.
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We also required the provider to send us a daily update of any incidents and to provide assurance that any staff on duty had completed an appropriate induction and training.
The provider voluntarily closed the service to admissions in agreement with us and in liaison with NHS England on 11 May 2017. On 19 May, the provider submitted an action plan which confirmed that the provider had taken action to address the immediate safety issues. The provider has submitted regular action plan updates since this inspection.
We made six requirement notices for the provider to address which are detailed later in the report.