Archived: Shrewsbury Court Independent Hospital

Shrewsbury Court is an independent hospital that previously provided long stay/rehabilitation mental health inpatient care for working-age adults. Over the last 12 to 18 months the provider has been undertaking a move towards delivering a different model of care, from purely long stay/rehabilitation, to providing a long stay/rehabilitation and an inpatient service for those with learning disabilities and autism.

The previous rating of ‘good’, given for the long stay/rehabilitation core service, on 10 November 2020, remains the same for long stay/rehabilitation wards only. We will return to inspect this core service at some point in the near future.

There are now only two wards that provide long stay/rehabilitation care with care for people with a learning disabilities and autism provided on three of the wards.

At this inspection we only inspected the core service ‘wards for people with learning disabilities and autism’ and have therefore, only provided a rating for this service.

We expect those that provide services to people with a learning disability and autistic to be able to demonstrate how their service meets the needs of patients in line with current guidance and best practice. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability or autistic people. This guidance requires that people with a learning disability are guaranteed the choices, dignity, independence and good access to local communities that most people take for granted.

On 24 August 2021 following our inspection, we served the provider with an urgent notice of decision to impose conditions on their registration under Section 31 of the Health and Social Care Act 2008. Section 31 of the Health and Social Care Act 2008 Act is an urgent procedure whereby CQC can vary any condition on a provider's registration in response to serious concerns. We took this urgent action as we believed that people would or may be exposed to the risk of harm if we did not do so.

The conditions placed require the provider not to admit or readmit any patients to Lavender, Aspen, Mulberry wards and Aspen Annex without prior agreement from CQC. In addition, the conditions require the provider to confirm in writing the actions they will take immediately and in the longer term to ensure medicines are managed safely, that there are robust systems of governance in place to ensure clear oversight of the care being delivered, ongoing monitoring and that improvements will be made in a timely manner.

As a result of our serious concerns about this service CQC’s Chief Inspector of Hospitals has placed this service in 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. The service will be kept under review and, if needed, could be escalated to urgent enforcement action, including that described, at any time.

We rated ‘wards for people with learning disabilities and autism as inadequate because:

• The service was not providing safe care. The inspection team had to ask the provider to remove obvious and significant ligature anchor points on the first day of the inspection. The provider removed these when asked but had not identified these as a high risk. The ligature assessment that had been undertaken did not clearly explain to staff how to manage the identified ligature risks. The actions described to reduce the risk were the same regardless of the risk that had been identified.

• The required actions identified in the fire risk assessment documentation, regarding gaps between fire doors and frames, had not been fully completed. In May 2021 an external consultant in fire safety identified that that fire compartmentation was not fully effective across the premises and there were “excessive gaps between fire doors and door frames”. We also noted gaps between fire doors during our tour of the property. The remedial action needed to make fire doors efficient was not included in the risk register or addressed in the provider’s action plan documents. The providers could not be assured the doors were able to perform their primary function of protecting patients and staff in the event of a fire and of their safe evacuation from the building. There was also a lack of oversight of the fire risk action plan from senior leaders.

• The wards and outdoor areas were not clean which placed patients and staff at risk of harm and at risk from the spread of infection. We saw dirty marks on doors and door frames and some were damaged; bedframes were also dirty. There was graffiti on walls in some patients bedrooms that had not been cleaned off or painted over when previous patients had been discharged, there was litter in the courtyards which patients accessed and in Aspen ward there was a strong smell of urine which were extremely unpleasant. The Infection Prevention Control (IPC) audits for the purpose of preventing the spread of infections were not consistent with what we found on inspection.

• The wards environment were not safe or maintained to an appropriate standard. There were fixtures and fittings in need of repairs. For example, some of the sofas were in need of repair or replacement. On Aspen ward tape had been used to try and seal the edges of a door to an en-suite facility to try and stop the strong smell of urine, due to a broken toilet, seeping out. We found damaged windows and a range of damaged equipment. On Lavender ward cleaning chemicals and paint were stored in cupboards that patients were meant to keep their toiletries and one cupboard had exposed wires which were a risk. The provider did not have clear plans in place for when action would be taken to address the replacement or maintenance required.

• Patient risks were not always well managed, and staff were not responding to the changing risks of patients. Care plans in Aspen and Lavender ward were not person centred and patients were not involved in the planning of their care although staff had provided them with copies of their care plans. Some records were written using disrespectful language their descriptions showed a lack of understanding of on how to support patients with a learning disabilities and autistic patients. Staff, at times, failed to recognise that some patients showed signs of frustration and anxiety when they were not able to communicate their needs. There was a lack of understanding by some staff on how to manage situations when patients became frustrated because they were not able to express their needs clearly.

• Holistic assessment and an individualised behaviour support plan (or equivalent) were not in place or reviewed regularly in Aspen and Lavender ward. Staff did not have the skills needed to develop and implement positive behaviour support plans. Where positive behaviour plans were in place staff were not reviewing them and they were not consistently followed. Training had not been provided to support staff to implement positive behaviour support plans effectively.

• Medicines were not managed safely and not all staff had been assessed as competent in administering and managing medicines safely. Staff did not always undertake physical health checks as required following the administration of some ‘as required’ (PRN) medicines. Staff had not fully completed medicines administration records, patients’ allergies were not documented on their medicine charts and charts were not stored according to the providers policy or recognised good practice guidance.

• Staff were not following good practice guidance in relation to minimising the use of restrictive practices. Individual patients’ protocols were not in place to consistently administer medicines prescribed to be taken “when required”. We found an excessive use of when required medication (PRN) to manage agitation and no plans in place to reduce the use of PRN by adopting other types of intervention. The provider and ward staff were not aware of the national programme ‘Stopping Over Medication of People with a Learning disability, Autism or both’ (STOMP) and this had not been discussed by the multidisciplinary team.

• Staff lacked an understanding of section 17 leave (permission to leave the hospital) when this was agreed with the Responsible Clinician and/or with the Ministry of Justice. Documentation was not clear on the restrictions attached to patients with section 17 leave agreed by the Ministry of Justice. We found examples of patients going on leave without the appropriate section 17 leave form in place.

• There were a number of blanket restrictive practices in place on the wards without clear clinical rationales and without being regularly reviewed. For example, restrictions and rules included, ‘patients must have a tidy room’, ‘attend to their personal hygiene’ and ‘attend the morning meetings and activities’. If all patients did not adhere to these restrictions, they were not allowed to have their section 17 leave.

• Accessible Information Standards were not followed. Patients were not provided with easy read information which could help them understand or communicate effectively with support. Not all staff were aware of the specialist needs of patients in their care. For example, patient’s communication needs were not identified, and adjustments made on the way information was shared.

• Patients were not provided with lockable storage to keep their possessions safe.

• Patients feedback about activities and opportunities for improving daily living skills was variable. One patient said they found the activities boring and another said they were not able to access the OT facilities as they were not confident using stairs.

• Patients were not able to prepare refreshments and snacks as facilities were kept in the office and they were not given access to this area; another aspect of restrictive practice in place without clear rationale.

• The staff were not supported through training and supervision. Not all staff had completed the mandatory training provided and the provider was not providing appropriate mandatory training to support staff to carry out the duties of the role. For example, not all staff had attended training that increased their insight into how to care for patients with learning disabilities and autism. Some staff were restraining patients without having completed training on how to restraint patients safely.

• While there were sufficient numbers of staff on the wards, not all staff were skilled or experienced in meeting the needs of patients with learning disabilities and autism. Staff did not receive regular supervision and not all staff had an annual appraisal.

• The culture of the service did not reflect best practice guidance for supporting patients with a learning disability or autistic people. Senior managers and staff did not understand the underpinning principles of Right support, right care, right culture guidance, or how these could be used to develop the service in a way which supported and enabled people to live an ordinary life, enhance their expectations, increase their opportunities and value their contributions.

• Senior leaders did not have a clear understanding of what was required to provide a service for people with a learning disability and autism. They lacked insight into the needs of the patients and were not sufficiently skilled, experienced and knowledgeable themselves to identify what patients needed and what staff working on the wards needed to do to deliver high quality care to patients.

• Senior leaders did not have enough oversight of all the safety concerns and risks. Governance systems lacked clarity and were not robust enough to effectively manage, monitor and aid improvement of services. Systems and processes were not effectively audited and evaluated to ensure effective practice and respond to the needs of patients with protected characteristics.

• Leaders did not have the skills and abilities to run the service effectively. There was a lack of clear clinical oversight of the wards and leaders had little knowledge of what was happening at ward level, including how care was being delivered or the standard of that care. Whilst a risk register was in place this did not reflect all risks found in the service or any means of effectively managing these.

However:

• We found that generally there was the number of registered nurses and support staff on duty on each shift that the provider had identified should be on duty but that’s staff did not always have the appropriate skills and experience. Staff told us that sometimes the wards were short-staffed. There were enough doctors on duty.

• Staff understood their role in safeguarding patients and followed the correct procedures when they had concerns.

• Staff assessed patient’s mental capacity appropriately. There was a record of whether the patient had capacity to consent to treatment on admission and regularly thereafter, including at each three-month period. There were capacity assessments where there was a reason to believe a patient may lack capacity.

• Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

• Patients felt able to approach staff with complaints. However, there was no easy read information on the wards informing patients how to make complaints.

• Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, information on the location of emergency equipment was not displayed on the clinic room door in Aspen ward.

• The ward staff worked well together as a team.

• Care plans in Mulberry ward were person centred. However, we did not find this on Lavender and Aspen wards.