• Mental Health
  • Independent mental health service

Sturdee Community Hospital

Overall: Requires improvement read more about inspection ratings

52-62 Runcorn Road, Leicester, Leicestershire, LE2 9FS (01628) 278699

Provided and run by:
Sturdee Community Limited

All Inspections

28 to 29 November 2023

During an inspection looking at part of the service

Our rating of the service stayed the same. We rated it as requires improvement because:

  • Medicines were not always safely managed.
  • Patients did not always have regular one-to-one sessions with their named nurse.
  • Staff did not always assess risk well.
  • Patients and some staff raised concerns about the difficulty in communication at times due to a number of staff who do not speak English as a first language.
  • Information systems were not always effective due to paper based systems which staff found difficult to navigate.
  • Governance processes did not always work effectively to ensure good oversight of quality and performance data and that ward procedures ran smoothly. The processes in place did not always identify gaps in recording and whether care plans, risk assessments and risk management plans were in place or up to date.
  • Audits in place did not always work effectively to monitor the quality and safety of care provided or ensure improvements were made where necessary.

However:

  • Staff followed good practice to safeguard patients. Staff were able to recognise and report abuse appropriately.
  • Staff knew what incidents to report, how to report them and they were appropriately recorded on the patient information system.
  • Staff minimised the use of restrictive practices. Staff undertook patient observations and had good knowledge of individual patient risks.
  • Staff were up to date with their mandatory training.
  • Staff felt as though they were respected, valued and supported.

Following this inspection, we issued the service with a warning notice served under Section 29 of the Health and Social Care Act 2008. We found that the service was failing to comply with Regulation 17 Good governance.

We found the service had failed to operate effective systems or processes to ensure the compliance with the requirements of regulation 17. We found the service was not maintaining accurate, complete or contemporaneous records. We found issues with the governance of medicines and we found environmental issues that had been identified as previous issues had not been acted on.

09 August 2022

During a routine inspection

Our rating of this location improved. We rated it as requires improvement because:

  • Audits in place did not always identify safety concerns such as fire doors not closing or risks such as section 17 leave forms not being completed in line with regulation.
  • Staff did not accurately document patient injuries after incidents had occurred.
  • All patients did not have access to a call system panic buttons, strip alarms, or personal alarms which would allow them to call for assistance in an emergency.
  • Not all staff had received training in monitoring physical health of patients (NEWS(2)).

However:

  • The ward environments were clean. Staff minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff knew how to identify a deterioration in patients mental health, which may put staff and patients at risk.
  • The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity. Patients’ and carers comments were positive about the service.
  • The service had access to the full range of specialists required to meet the needs of patients.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The manager ensured that staff received training, supervision and appraisal.
  • The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

18, 22, 26 November and 7 December 2021

During an inspection looking at part of the service

We carried out this unannounced focused inspection following the notification of a serious incident on one of the wards and we received information of concern about the safety and quality of the services.

We did not look at all key lines of enquiry during this inspection. However, the information we gathered, the significance of the concerns and clear impact on patients provided enough information to make a judgement about the quality of care and to re-rate the provider.

We found that the provider was failing to comply with Regulation 12 Safe Care and Treatment, Regulation 15 Premises and Equipment and Regulation 17 Good Governance. As a consequence and under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, we issued three warning notices to the provider as set out in the enforcement section of this report.

In addition, the Care Quality Commission is placing the service 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.

Our rating of this location went down. We rated it as inadequate because:

  • The service did not always provide safe care. Not all ward environments were safe and well maintained. The wards did not always have enough nurses. Staff did not always assess and manage risk well.
  • The service did not always record or investigate patient incidents or complaints.
  • The governance processes at the service did not ensure ward procedures ran smoothly or patients Mental Health Act detention papers, section 17 leave forms and patient rights and legal position adhered to the Mental Health Act Code of Practice.

However:

  • Staff minimised the use of restrictive practices and always had access to medical cover.

26 and 27 November 2019

During a routine inspection

Sturdee Community Hospital is located in Leicester, the hospital provides rehabilitation for female patients with complex mental health disorder, some of whom were detained under the Mental Health Act 1983.

We rated Sturdee Community Hospital as good because:

  • The hospital had enough nursing and support staff to keep patients safe and had low vacancy rates. Managers supported staff who needed time off for ill health. The sickness rate across the hospital at the time of the inspection was 1%. Managers accurately calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants for each shift. Managers could adjust staffing levels according to the needs of the patients.
  • Staff assessed and managed risks to patients and themselves well. They achieved the right balance between maintaining safety and providing the least restrictive environment possible in order to facilitate patients’ recovery. Staff followed best practice in anticipating, de-escalating and managing challenging behaviour. As a result, they used restraint only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.
  • Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected patients’ assessed needs, and were personalised, holistic and recovery-oriented. Staff followed National Institute for Health and Clinical Excellence guidelines for rehabilitation in adults with enduring mental health issues. Staff identified patients’ physical health needs and recorded them in their care plans. Staff supported patients to access physical health care, including specialists as required. Staff met patients’ dietary needs, and assessed those patients needing specialist care for nutrition and hydration. Staff helped patients live healthier lives by supporting them to take part in healthy eating programmes or giving advice.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Staff were discreet, respectful, and responsive when caring for patients and gave them help, emotional support and advice when they needed it.
  • The hospital met the needs of all patients, including those with a protected characteristic. Protected characteristics under the Equality Act 2010 are age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage and civil partnership and pregnancy and maternity. Staff helped patients with communication, advocacy and cultural and spiritual support. Patients were supported to access spiritual support in the community and at the hospital, however the multi faith room was located on the first floor. This meant that patients with mobility issues would have difficulty accessing this facility.
  • Managers at all levels in the hospital had the right skills and abilities to run a service providing high-quality sustainable care. They understood the service they managed, and it followed a recognised model for rehabilitation care. Patients and staff knew senior managers, said they were very visible and could approach them with any concerns. Leadership opportunities were available for staff below manager level for example senior nurse roles and rehabilitation assistants.

However:

  • Cleaning records were incomplete. Managers did not have oversight of the cleaning audits for the hospital. We found areas that were visibly dirty and out of date, unlabelled food in a therapy kitchen.
  • Patients had access to spiritual, religious and cultural support, however the multi faith room was on the first floor and not easily accessible for patients with mobility issues.

01 August 2018

During an inspection looking at part of the service

We did not rate this service.

We carried out this inspection to monitor progress following the warning notice issued after the focused inspection in April 2018.

We found the provider had addressed most of the issues identified in that warning notice including:

  • Safe and proper prescribing, administration and storage of medications. Managers had adequate oversight and governance structures to monitor the management of medicines within the service, including regular audits and action plans. Managers had increased their community pharmacist visits from quarterly to weekly, starting 09 August 2018. The pharmacist carried out external audits and scrutiny of the providers medication and prescribing practice, and provided advice, focussed staff training and consultation.
  • Managers ensured staff recorded all incidents including medication errors, in line with their incident reporting policy.

However, we found the following areas the provider needs to improve:

  • Whilst staff had improved the monitoring of controlled drugs we found occasional gaps in the controlled drugs record where staff had not recorded the previous or carried forward page numbers. The standard operating procedures for medicines management was not easily accessible, this was in electronic format only, and there was no computer access in the clinic. When we made the manager aware of this she told us she would arrange to have a paper copy made available in the clinic.
  • Some emergency equipment was out of date and had not been removed or replaced. Staff had not identified that the fridge in the clinic room was too small for the stock stored in it, airflow was restricted. The providers instructions for recording the fridge temperature range were not clear. Staff were not recording the actions they had taken to rectify inaccuracies in the daily clinic checklists.

25 April 2018

During an inspection looking at part of the service

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

  • The provider’s medicines management practice was unsafe in relation to the storage, dispensing and medicines reconciliation. Staff made numerous errors and omissions when handling controlled drugs. These practices did not follow the services local medicines policy or NICE guidance. Managers had not addressed the issues with medicines management identified at the inspections in May 2017 and December 2017.
  • Managers had not reviewed or updated the internal systems for reporting incidents.
  • The majority of the staff we spoke with reported they did not feel supported or listened to by hopsital management.

However:

  • Staff completed the initial assessment of the patients’ risks at the pre admission assessment and the multidisciplinary team updated the risk assessment once the patient had been admitted to the service.
  • Managers ensured they had the required amount of staff on the majority of shifts to meet the needs of the patients.
  • Staff reported that morale was ok and that they felt supported by their colleagues.

18-20 December 2017

During a routine inspection

We rated Sturdee Community Hospital as requires improvement because:

  • Managers had not ensured that the ligature audit was complete. There was no ligature audit for Aylestone unit or Foxton ward. Ligature points had been identified on Rutland ward including the blinds in the gym and sliding door in the corridor, but no action had been taken to reduce these specific risks. Managers had not identified blind spots throughout the service.
  • Staff were not following the “to take out” (TTO) medicines policy. Staff recorded the medicines fridge as above eight degrees on 28 occasions in a two-month period.
  • Doctors had not ensured that medication charts were written in accordance with guidance. We found one medication chart did not refer to the fact that Olanzapine and Lorazepam, prescribed for the same person, should not be administered within one hour of each other.
  • Staff administered insulin to a patient from the medication trolley that was out of date.
  • The hospital did not have an effective system of oversight for the delivery of its Mental Health Act administration functions. The hospital did not have a current or robust policy in place to cover the range of Mental Health Act administrator’s obligations. Managers had not provided the new mental health administrator with sufficient training, guidance and mentoring.
  • Managers did not ensure completion of quarterly external audits of all Mental Health Act paperwork.
  • Incident recording was variable. While staff reported incidents and notified to CQC, seven out of twenty records checked did not include what actions managers had taken, or what lessons they had learned.
  • The inspection team considered quarterly visits by an external pharmacist was not adequate. Visits that were more frequent may have picked up the issues found during the inspection.
  • Staff had not updated patients individual occupational therapy activity plans to reflect their current needs. Individual activity plans did not detail how the patient would achieve their identified goals.

However:-

  • Wards were visibly clean, well maintained and had good quality furnishings. The infection control policy was in date. Cleaning records were available. All staff carried personal alarms and ligature cutters.
  • Staffing levels at the hospital were good. The hospital had their full establishment of nurses and a multi-disciplinary team to meet the needs of their patients, and recruitment drives had been successful.
  • Ninety-four percent of staff had attended mandatory training.
  • Staff carried out full physical healthcare examinations as required. Staff completed separate and comprehensive physical healthcare records for each patient. Staff addressed specific issues such as pressure sores, and signs and symptoms of potential sepsis.
  • Communication systems in the hospital were effective. Staff, including support staff, catering and maintenance staff attended a range of in house meetings including daily briefings, community meetings, and integrated governance meetings. This ensured that all staff working at the hospital were familiar with the patients and their current needs. All staff felt informed about the wider issues affecting the hospital.
  • Patients and staff planned, facilitated and attended the weekly interactive academic teaching sessions on a Thursday morning.
  • There was a clear admission and discharge policy and procedure, overseen by the consultant psychiatrist in discussion with the multi-disciplinary team.
  • Staff understood the provider’s vision and values based on growth, recovery, ownership, warmth, and time and healing. A philosophy of positive risk taking and least restrictive practice underpinned the vision and values.
  • Managers made significant changes to policy and practice following feedback from previous inspections, complaints and incidents.

04 May 2017

During an inspection looking at part of the service

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

  • Doctors prescribed medication on more than one medication chart. We found that the same types of medication had been prescribed on both charts. If staff had administered the medication in the same 24 hours period it would have resulted in an overdose for the patient.
  • Staff recorded the monitoring of patients physical health in four separate documents. However, staff did not ensure that all four documents were fully completed specifically the National Early Warning Score form. Due to the duplicated records we found it difficult to ascertain baseline observations for patients and if staff had fully addressed all physical health concerns.
  • Staff did not seek medical intervention after monitoring a patient’s physical health and found that the patients’ blood sugar was outside of the normal limits.
  • Whilst managers had a clear oversight of incidents that had taken place within the hospital they did not have a robust system in place to ensure that incident forms were fully completed. We found incident forms were not completed fully or reviewed by a senior member of staff. In addition we could not be assured that incidents were recorded within patients care notes or discussed in ward rounds as ward round summaries were missing from patients’ case records.
  • Following a serious incident, managers had put measures in place to count cutlery. Whilst staff were following this new process, we found that the records showed a spoon had been missing for over five days. When we spoke with managers they were aware of this but no action had been taken to address it.
  • Senior managers did not have access to the services ligature audit during the inspection.
  • Managers had developed a red, amber green (RAG) rating system to assess patient’s risk. However, there was no guidance or procedures in place for staff to use the system.
  • Managers did not have a robust system to ensure that patients detained under the Mental Health Act had their rights explained to them and that the paperwork remained in order and up to date.
  • Mental Health Act papers were not examined by a suitable trained member of staff. The most up to date section 132 had not been filled correctly. Staff did not have immediate access to detention paperwork. Managers had partially addressed the concerns highlighted in regards to the two unlawful detentions. However, we found that the action plan was not robust and did not fully address the concerns.
  • The management of incident reporting was unclear. Managers could not fully explain why they continued to use a process that duplicated incidents forms which we found to be incomplete. Managers did not have processes in place to ensure that all incidents were fully recorded within the patient case notes.
  • There was no alert in place at the beginning of the patient’s case records to inform staff that the patient had physical healthcare issues that needed to be closely monitored. Whilst case records held this information we found it difficult to locate it quickly.
  • Whilst weekly multi-disciplinary meetings took place to discuss patient care and treatment this was not always recorded within the patients case notes.
  • Staff reviewed care plans on a monthly basis and recorded the review on a separate document. However, it was not clear that the patients had been involved in the reviews.
  • Policies and procedures were in place for staff to follow and were available online. However, the manager had not kept the paper copies of polices in date. This increased the risk of staff not adhering to the most up to date policies.
  • Managers did not have a robust recording system in place for monitoring patient’s physical health. Although staff had comprehensive discussions about the physical health needs of the patients the paperwork was duplicated and incomplete.
  • Managers had formulated an action plan to address issues that were identified from the last CQC inspection in November 2016. We reviewed this during the inspection. We found that although some actions were highlighted as achieved this was not the case.

However:

  • Since the last inspection carried out in November 2016 managers had adapted rooms on a closed ward so that patients had space to have one to one time in a private, quiet area of the hospital.
  • Throughout the inspection we observed positive team working and mutual support for staff. Staff commented that they felt supported by all members of the team from the clinical staff to housekeeping.
  • Patients we spoke with told us that staff were supportive with their mental health issues and any physical health issues. They felt that staff understood their individual needs.
  • Multidisciplinary handovers and briefing meetings between shifts were effective. The notes taken in handover were comprehensive, and showed that staff had discussed staffing levels, the physical health care needs of patients and specific nursing duties that needed to carried out during the shift.
  • 80% of staff had received regular in line with the services policy of four supervision sessions per year. In addition to this the managers provided supervision to regular bank staff that worked at the hospital.
  • Managers carried out investigations into serious incidents and highlighted areas of practice that need to be improved.

29-30 November 2016

During a routine inspection

We rated Sturdee Community Hospital as Good because:

  • Patients said they felt involved with the day-to-day running of the hospital and when planning their care needs.
  • We observed staff interacting with patients in a positive way, there were a variety of activities available seven days a week. Staff said there had been a lot of positive change over the last 9-12 months.
  • Staff and patients jointly facilitated a weekly program of interactive academic education sessions, these sessions contributed to staffs continuing professional development and patients’ knowledge and skills portfolios.
  • Staff used Health of the Nation Outcome Scales (HoNOS) and the recovery star to assess and record severity and outcomes for all patients. Staff carried out a range of audits and we saw how managers had made improvements.
  • The hospital had a policy and procedure for carrying out observations. Staff kept up to date records of observations carried out. Staff and patients used and understood the personalised red, amber, green (RAG) rating to manage identified risks.
  • Patients told us the variety and quality of food was good, and staff understood their needs. There was a range of activities available seven days a week and they were able to personalise their rooms and bed space.
  • Senior managers held two daily morning meetings to discuss patient’s needs, any concerns, or complaints and to address issues promptly. This ensured that all staff could attend the meeting.
  • Ninety two percent of staff had attended mandatory training, 100% of clinical staff had completed medication management training, and 84% of staff had completed safeguarding adults and children level one.

However:

  • Whilst the ligature audit included all ligature points, it did not give sufficient detail about how ward staff should manage the identified ligatures.
  • Healthcare support workers we spoke with did not fully understand the purpose of their supervision.
  • At the time of the inspection, the provider had not updated their statement of purpose to reflect their current service model. They informed us they were finalising this document and subsequently submitted it within ten days of the inspection.
  • There was no protected nurse time during routine medication administration.

15-16 September 2015

During a routine inspection

We rated this hospital as inadequate because:

• Although the staff had completed a ligature risk assessment, they had not taken action or developed a strategy to mitigate any risks.

• The hospital placed blanket restrictions on patients rather than assessing individual needs. For example, patients could not have a key to their room, they all had to use plastic beakers for hot drinks, and all visits had to be authorised by the multidisciplinary team (MDT), including adult family members.

• The hospital used high levels of agency staff meaning patients did not always know staff working on the wards.

• Rates of staff training were low for bank staff, meaning the service did not have adequately or appropriately trained staff on shift at all times.

• Patients’ care records did not include patients or staff comments where patients disagreed with aspects of their care plan.

• Staff could not provide us with a copy of their induction pack when asked. The hospital did not provide temporary staff with written guidance on the local health, safety and security procedures for the ward when they arrived on shift.

• The managers of the hospital did not recruit staff in line with the hospital policy. They did not carry out pre-employment checks thoroughly to make sure the staff were suited to work with the patient group.

• The hospital did not have effective discharge planning so could not ensure patients had safe and coordinated care when they were discharged.

• We found adjustments for people requiring disabled access were poor. The gym, new visitors /family room, and adapted kitchen were accessed via a steep staircase. There was no lift available.

• Patients had limited access to a full range of rooms and equipment to support care and treatment.

• Rutland ward did not have any quiet areas, where patients could meet visitors in private.

• Staff could not describe the vision and values of the organisation and they could not tell us who the senior managers of the service were.

• Senior managers failed to assess health and safety risks to the premises which impacted on the safety and wellbeing of patients.

• There was a lack of openness and transparency between the provider and the hospital director which resulted in the identification of risk, issues and concerns being discouraged.

• The hospital director had no administration support.

• Staff expressed concern about bullying and were reluctant to report concerns about the service to managers.

• The hospital director was appointed seven months before, but the hospital still did not have a registered manager.

However:

• Medical records and medicine management systems were good.

• Rutland ward and Aylestone unit areas were clean and well maintained.

• A full range of mental health disciplines and workers provided input to the ward.

• Patients’ had good access to physical healthcare, including access to specialists when needed.

• Care records were up to date and comprehensive, apart from including patient’s views.

• We observed effective staff handovers.

• There were effective working relationships with teams outside the organisation including joint risk meetings.

• Patients knew where and how to access advocacy services.

• Staff and patients interacted positively and we saw evidence that staff had an understanding of individual patients’ needs and preferences.

• Staff appeared interested and engaged in providing good quality care to patients.

• Most patients were involved in planning their care. Patients could attend the ward rounds fortnightly. Staff identified special occasions, such as patients’ birthdays. Patients and staff would celebrate and kitchen staff made fresh cakes.

• Kitchen staff prepared fresh meals that were good quality. Staff prepared fresh fruit for patients that was available in communal areas.

• Staff supported patients to purchase their own food. This was stored in the kitchen with appropriate individual labels.

• Ward staff worked well as a team and offered support to each other.

• The hospital director arranged for staff annual appraisals and supervision. Ninety five per cent of staff received three monthly clinical supervision.

8 April 2013

During a routine inspection

The Care Quality Commission received information of concern from a whistleblower. We decided to bring forward the scheduled inspection of the service and used the information provided by the whistleblower in deciding which outcomes we inspected.

When we inspected Sturdee Community Hospital one person was using the service. We were not able to speak with the person using the service or observe their care as health care professionals who were supporting the person on the day of our visit were concerned about the person's health and wellbeing. Staff we spoke with had a good understanding of the needs of the person using the service.

We looked at the records which recorded the care, treatment and support of the person. Records identified the care and treatment the person required and the health care professionals involved. We found records had been regularly reviewed to meet legal requirements and some records provided comprehensive information. We found gaps in some records which we discussed with the manager at the time of our inspection.

We found systems for the prescribing, storing and administration of medication to be robust. Registered nurses were responsible for the administration of medication.

Staff told us a number of systems were in place which provided them with support. Staff told us they were aware of their responsibility in raising concerns, including whistleblowing and safeguarding.

29 May 2012

During a routine inspection

We spoke with three people using the services of Opreco House and asked them whether they were involved in decisions about their care and treatment. We also asked them about their individual care and treatment plans. People told us they were involved in all aspects of their care and treatment and that things were clearly explained to them. People's comments included:-

'I've always been in control of the decision making process, if anything was unclear it was comprehensively explained to me.'

'I have signed my care and treatment plans; they are regularly reviewed with my involvement. I am aware of all my treatment options, which includes reviewing the medication I am prescribed. My treatment has been phased and gradual.'

Records and discussions with people using the service showed people were involved in all aspects planning and reviewing their care and treatment and that their consent was regularly assessed and sought.

People were encouraged and supported to access community services, which included community centres and higher education establishments as part of their care and treatment being their planning for the future.

People were made aware of the complaints system and had been given a copy of the services policy. People were given the opportunity to take part in monthly meetings to discuss general issues about the service they received, which included meals.