Baldock Manor is an independent hospital that provides a rehabilitation and intensive care service, to people who have needs related to their mental health and who are detained under the Mental Health Act 1983, Mental Capacity Act 2005, or are voluntarily staying at the hospital.
Following our inspection, we served a Notice of Decision because of the immediate concerns we had about that safety of patients. We told the provider it must not admit any further patients until further notice, it must review care plans, observation levels for patients, incidents, its systems and process for oversight of incidents and care, ensure it had enough suitably qualified, experienced staff on all shifts and that staff had adequate knowledge about the use of the Mental Capacity Act. We told it that it must provide CQC with an update relating to these issues on a weekly basis.
The provider has complied with these requirements. All patient care plans and observations have been reviewed and systems and processes are now in place for their ongoing review. The provider has reviewed its incident reporting system and process for the review of incidents. Notifications to external bodies have been made as required. Staff have been tested for competencies around patient observations, diabetes, choking and the Mental Capacity Act. The provider has produced weekly staffing figures, which have confirmed that most shifts have been covered.
We rated Baldock Manor as Requires Improvement because:
- The number of incidents for the provider had increased between September and October 2019. Staff across both wards reported 131 incidents in October 2019. Leaders had not always ensured that all incidents had been reported and that referrals had been made to external bodies as required. The provider had not reported all incidents that required a safeguarding notification and had not made notifications to external bodies including local authorities and the Care Quality Commission as required.
- The provider had a 75% vacancy rate for qualified staff to lead and manage care and a 21% vacancy rate for support workers. We heard how staffing issues adversely affected patient care. Whilst agency staff were provided with an induction, during inspection some staff did not have a full understanding of patients’ risks or care planned needs.
- Whilst we accept that managers had updated the ligature assessments for the wards, these were not available to staff.
- There were several restrictive practices in place. Patients on Radley and Mulberry did not always have free access to outside space and fresh air. Patients on Radley only had access to cold, hot drinks and snacks on request to staff over the 24-hour period.
- Leaders had not always ensured that services were safe, clean and well maintained.
- Staff were not all aware of the identified ligature points or how to manage these risks.
- Staff were not fully adhering to infection control requirements. Staff were wearing nail varnish, were not bare from the elbow and were wearing jackets on the ward when completing personal care tasks with patients.
- Some staff did not display a good understanding of the Mental Capacity Act and the provider cared for patients who lacked capacity to make decisions. Staff did not know how to apply the main principles to their work.
- The provider did not ensure that training in the Mental Health Act or safeguarding children was mandatory.
- Although managers at the hospital were fully committed to the service they were not fully aware of all aspects of their roles and did not have the knowledge or skills to run the service effectively.
- The provider had not fully ensured that effective governance systems were in place. The provider did not have an effective system to oversee and assure itself of the quality of the services and ensure patients were kept safe and received good quality care.
- The provider did not have a clear model for the rehabilitation service. This service was supporting people with dementia which was not appropriate.
- Managers did not have immediate access to business information relating to staffing, patient observations, incidents, safeguarding referrals and notifications to support them to carry out their role. Leaders could not clearly explain how the teams were working to provide high quality care.
- Ward areas and patient bedrooms were sparse, and patients on Radley did not have access to alarms.
- There was little evidence of rooms being personalised. Not all care plans were comprehensive or met the needs identified during assessment.
- Care plans were not always recovery-orientated or written from the patient’s perspective. There were no best interest assessments to support the care plans written in the third person.
- The information shared at handovers was not always understood by staff.
- Patients and carers interviewed stated that staff did not always communicate with patients, families and carers so that they understood their care and treatment. Patients and carers told us that staff did not fully inform and involve all families and carers.
However:
- There had been a reduction in seclusions and an overall reduction in patient restraints.
- The provider delivered mandatory training for all staff. The majority of staff had completed their mandatory training (99%). Staff had the required mandatory skills and knowledge to meet the needs of the patient group.
- Staff had access to regular supervision and appraisal.
- Staff had completed comprehensive mental health assessments and risk assessment for patients. Staff used recognised rating scales to assess and record severity and outcomes.
- When interacting with patients, staff attitudes and behaviours generally showed that they were discreet, respectful and responsive. Patients said staff treated them well and behaved appropriately towards them.
- Staff had enabled patients to give feedback on the service they received and ensured that patients could access advocacy.
- Staff supported patients during referrals and transfers between services, and supported patients to maintain contact with their families and carers.
- Staff described an improvement in the culture of the hospital. Staff felt respected, supported and valued. Leaders were very visible in the service, were approachable for patients and staff.
- Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.