Care Quality Commission calls for more improvements by Somerset Partnership NHS Foundation Trust

2 February 2011

The Care Quality Commission has told Somerset Partnership NHS Foundation Trust that it must take further action to improve the quality of care experienced by people at a mental health unit in Taunton.

CQC says that the trust has made a range of improvements on the Rydon ward, which provides care and treatment for adults with mental illness, but it is still failing to meet two of the essential standards of quality and safety.

Today’s report was produced in response to concerns first raised with CQC by the trust, and also by South West Strategic Health Authority and Somerset NHS last year. Three people who were being treated on the Rydon ward died in separate incidents between May and July.

The Rydon ward is one of Somerset Partnership Trust’s four wards at Cheddon Road in Taunton.

CQC Inspectors visited the ward unannounced in October to speak to patients and staff and to review changes made by the trust in an attempt to improve safety and security after the incidents.

The inspection team looked at a range of issues relating to the care and welfare of people who use services, the safety and suitability of premises and how well staff were supported.

Their report notes that the layout of the ward over two floors made observation of patients difficult. Rydon ward had already been due for complete refurbishment. After the incidents, the trust decided to improve safety by reducing the number of beds, and increasing the ratio of staff to patients.

The trust had also taken action to improve risk assessments, care planning, handovers between shifts, and observation and auditing procedures. An independent review was also commissioned to review ligature points and remove them if necessary.

The CQC inspectors concluded that Somerset Partnership NHS Foundation Trust was meeting five of the seven standards they reviewed, but was not compliant with two outcomes.

Care and welfare of people who use services

Inspectors found that people using the service did not receive information about their care and treatment and said they did not feel involved in their care. Some people’s records did not accurately reflect their needs and risks.

Records

When inspectors reviewed a random sample of records, they quickly identified inaccuracies or plans that did not reflect people's current needs and could mean they might not receive appropriate care. Old care plans remained as current on the electronic records system, even though they had been superseded, and were not updated promptly enough.

The trust has now been given until 1 March to produce its plans to show how it intends to achieve compliance. By law, providers of health care services have a legal responsibility to make sure they are meeting the essential standards of quality and safety.

Ian Biggs, regional director of CQC in the South West, said that his staff will return to Rydon House unannounced to check progress and to decide whether further action is needed.

He said: “Somerset Partnership Trust took action to make improvements after this series of tragic incidents and they took appropriate advice to make the ward environment safer for the people in their care.

“However, people we met on Rydon ward told us that they did not feel involved in their care and treatment and we found that the care plans that should keep track of their needs and their treatment were not always up to date.

“This was in marked contrast to what we found on a similar ward, also provided by Somerset Partnership Trust, where people did have copies of their care plans, which they felt contained an accurate record of their needs.

“While the reduction in bed numbers and increased staffing levels at Rydon ward have clearly improved the safety and security of the building, everyone recognises that the basic layout is not ideal. The complete reconfiguration of Rydon ward is still required, and we are assured that is in hand.

“We will monitor the trust’s progress and report back.”

Ends

For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

Notes to editors

• Rydon House at Cheddon Road in Taunton is a 32-bed adult inpatient unit providing assessment and treatment for adults, including people who are detained under the Mental Health Act.
• At inquests in Taunton, the Somerset coroner recorded an open verdict on one person who died from asphyxia by hanging. He recorded verdicts of suicide on another person who died from asphyxia by hanging and on a third person who died at Highbridge Railway station. All three had been inpatients at the Rydon ward.