Archived: The Huntercombe Hospital - Roehampton

This was a focused inspection where we looked at the safe and well led domains. We carried out this inspection after anonymous concerns were raised with us and we received the outcome of recent safeguarding investigations. As a result of this inspection, our rating of safe domain went down from requires improvement to inadequate. Our rating of well led stayed the same and remains requires improvement. Our overall rating of this service did not change as a result of this inspection and remains requires improvement.

Due to concerns found during this inspection and the history of non-compliance over the last four years, we used our powers under section 17 of the Health and Social Care Act to propose the cancellation of the registration of this hospital location. The provider has the right to make representations about this proposal.

The areas for improvement identified at this inspection were as follows:

• High use of agency staff meant there was a risk that patients did not receive consistent and safe care. Seven registered nurses, out of a required establishment of 20, were employed by an agency. The hospital used agency staff to cover vacant posts and to support patients where their individual risks meant that enhanced observation was used. This meant that there could be significant numbers of agency staff working at any time. During our visit 75% of unregistered nurses (support workers) on Upper Richmond Ward at night were agency staff. This meant that there were staff frequently working in the hospital who did not know the wards or other staff. This impacted on the ability of the staff to work safely as a team to provide relational security.

• Wards were often noisy and there were frequent disturbances. One patient said they found the ward noisy and scary. Three patients said they had been assaulted by other patients. Patients had also expressed these concerns in community meetings and this was recorded in the notes of these meetings. We observed the wards to be noisy with frequent disruptions. This was also reflected in the records of incidents. Between 1 November 2018 and 20 November 2019, the provider notified the CQC of 140 allegations or incidents of abuse. There were eight notifications between 31 October and 6 November 2019. During this time, two incidents involved patients being slapped in the face in unprovoked attacks, three incidents of patients being punched in the face or head, one incident involving a fight between two patients and one incident of intimidating behaviour involving verbal and racist abuse. Data prepared by the hospital showed that between January and July 2019 there had been 80 assaults by patients on other patients and 56 assaults by patients on members of staff.

• The hospital was admitting patients with complex needs and then using high levels of enhanced observations. During our visit, on Upper Richmond ward, 20 staff were caring for 10 patients, seven of whom were on either 1:1 or 2:1 observations. This meant that the ward environment was very crowded and not therapeutic.

• There was more work to do to ensure that the use of restrictive interventions was being reduced as much as possible. The hospital did not have a restrictive interventions reduction programme, which had been recommended during our previous inspection in January 2019. The hospital was not benchmarking its use of restrictive interventions with similar services.

• Staff did not always use the correct techniques for restraining patients. Patients said they had been in pain during restraints. There had been three recent safeguarding investigations which concerned restraint being used inappropriately. These investigations found that some holds used by staff were not approved

• The service did not always manage patient safety incidents well. Managers investigated incidents, but the lessons learned were not shared with the whole team and the wider service. Actions from investigation reports were not always carried out.

• Staff did not always have easy access to clinical information. Agency staff did not have access to the electronic patient record or the electronic system for recording incidents. Some staff commented that it was difficult to absorb and retain the patient information that was shared verbally with them during shift handovers. Entries on patient care and treatment records were often quite brief.

• Systems and procedures to ensure the safe, effective running of the hospital were not robust. The hospital relied upon high numbers of agency staff to deliver services who did not have access to electronic recording systems, were not supervised and did not attend team meetings. An effective system to obtain feedback on agency staff performance was not in place.. On Upper Richmond Ward, there had not been a team meeting for almost five months. This meant that staff had not had the opportunity to discuss and learn from serious incidents and safeguarding investigations that had taken place during that time.

• There was more work for the provider to do to ensure that the culture on the wards at all times reflected the provider’s vision and values. During the night, permanent non-registered nurses were taking the lead for setting the culture. Whilst we saw that they were working hard to model the provider’s vision and values, safeguarding investigations in October 2019 indicated that a small clique of staff working in the hospital at night may have developed their own inappropriate culture.

• Whilst the hospital had robust systems to assess risk, weaknesses in governance frameworks, including the oversight of agency staff meant there was a potential risk that individual patient risks were not always managed or mitigated appropriately.

However:

• A new interim hospital manager had recently been appointed. They demonstrated a sound understanding of the services they managed, including the challenges and were implementing initiatives to improve the quality and safety of the service.

• Staff morale had recently improved. Staff felt respected, supported and valued. They felt able to raise concerns without fear of retribution.

• All wards were clean, well equipped, well-furnished and well maintained.

• The service used systems and processes to safely prescribe, administer, record and store medicines.

• The service maintained a risk register which was shared with staff and matched their concerns. Staffing of the hospital was included on the risk register.

Our overall rating of this service changed from inadequate to requires improvement. The service was removed from special measures following this inspection.

We rated it as requires improvement because:

• Further work was needed to safeguard against the risks associated with ligature anchor points on the wards. Not all staff were aware of the most up to date ligature risk assessment of the ward they worked on, where ligature anchor points were located, or the measures in place to mitigate and manage these. The hospital used a high number of bank and agency staff and ligature risks were not covered in their induction. However, the provider had ensured that an updated ligature risk assessment was in place for each ward, patients assessed as being at risk of fixing ligatures were subject to increased observations and a programme of anti ligature works was underway.

• Further work was needed to ensure governance arrangements were embedded as part of the hospitals ‘business as usual’ approach in assessing the quality and safety of the service. Some complaints had not been dealt with in line with the providers stated time frame.

• Further work was needed to strengthen the role of audits in ensuring the quality and safety of the service. The hospital had not ensured staff could use information from audits to improve individual records identified in the sample. On Upper Richmond Ward, staff were not routinely accessing the outcome of audits to drive improvement. Some audits, for example the risk assessment audit, were not comprehensive, as they did not consider whether identified risks had an associated management plan.

• There were limited opportunities for carers to give feedback on the service provided. Whilst the hospital had plans to develop different ways carers could feedback, no timescale for their implementation had been fixed.

• Although managers were maintaining safe staffing levels on each ward, and could increase staffing numbers as patient needs changed, a high number of nursing posts remained vacant. The provider had recruited some agency nurses to long term contracts, and the provider was actively looking to fill vacant posts, but the hospital’s continued reliance on bank and agency staff meant that there was an ongoing risk to the safety and consistency of care.

• Further work was needed regarding the use of restrictive interventions. A formal reducing restrictive interventions strategy had not been implemented and there had not been a reduction in the use of restrictive interventions such as restraint, seclusion and rapid tranquilisation since our last inspection. However, staff had received training in positive behaviour support and were confident to de-escalate. Initial steps had been taken to promote the least restrictive intervention including advance agreements with patients around how to safely administer medication without the need to restrain.

However:

• The service had made improvements since our inspection in May 2018 and had worked hard to address breaches of regulation and best practise recommendations. The service had implemented a clear framework of what should be discussed at team meetings. Staff were now aware of the service risk register and managers knew how to escalate issues to be considered in terms of risk to the service.

• The ward environments were clean and improvements had been made to ensure that patients could access drinking water freely.

• Staff assessed and managed risk well and improvements had been made to patient risk assessments. The service had improved its monitoring of physical health following administration of medication by rapid tranquilisation and now monitored the use of restrictive interventions including rapid tranquilisation.

• Staff followed good practice with respect to safeguarding and managed medications safely. Improvements had been made to ensure staff recorded rational for administering ‘as required’ medication.

• Improvements had been made since the last inspection to ensure staff completed daily physical health checks for all patients and that smoking cessation was available to all patients. The service was in the process of working towards smoke-free status at the time of the inspection.

• Reporting of incidents had improved since our last inspection and incidents were now routinely discussed and learning shared with staff during team meetings.

• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Care plans had improved since our last inspection and patients were more involved in their care. The service provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.

• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.

• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

• The quality of interactions between staff and patients had improved. Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.