The Care Quality Commission (CQC) has told Oxleas NHS Foundation Trust to make immediate improvements to its wards for older people with mental health problems and has served the trust with a warning notice.
In October, CQC carried out an unannounced focused inspection of the trust’s wards for older people with mental health problems, following the unexpected deaths of two patients, one on Scadbury Ward in February 2020 and one on Shepherdleas Ward in May 2019. Both patients died as a result of fixing ligatures to fittings in the wards.
The trust provides wards for older people with mental health problems across four locations: Shepherdleas Ward at Oxleas House and Oaktree Lodge at Memorial Hospital, both in Greenwich, Scadbury Ward at Green Parks House in Bromley and Holbrook Ward at the Woodlands Unit in Bexley.
Following the inspection, the core service of wards for older people with mental health problems was rated Inadequate overall and Inadequate in relation to whether it was safe and well-led, due to regulation breaches. The service was previously rated Good overall when it was inspected in March 2019.
CQC’s Head of Hospital Inspection (mental health and community health services), Jane Ray, said:
“During our inspection of Oxleas NHS Foundation Trust’s mental health wards for older people, we found out-of-date ligature risk assessments, a lack of clear mitigation for ligature points that were high risk and staff failing to implement actions from serious incident investigations. Essential information, such as learning from incidents and implementing action plans was not shared at ward level, resulting in a failure to protect patients from avoidable harm.
“We have now served a warning notice due to the serious nature of the concerns we had, and the trust is aware that improvements must be made immediately. Ligature risk assessments must take place at least annually and always after a serious incident has taken place with lessons from serious incidents shared with all staff. We will continue to monitor the service closely and will not hesitate to take further action to keep people safe if required.”
The service was rated Inadequate for the following reasons:
- Staff did not adequately assess all high-risk ligature points or regularly update ligature risk assessments (a ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation)
- Ligature risk reduction works were not due to commence until March 2021. Having identified ligature risk points, staff failed to clearly state what the risk management process would be in the meantime
- Ward ligature point risk assessments were not updated across all four wards after a serious incident took place on Scadbury Ward, leading to the death of a patient
- Governance processes did not operate effectively from directorate to ward level, resulting in a failure to protect patients from unavoidable harm
- Recommendations set out by the trust for staff to follow as a result of the incident were not implemented
- Managers had not shared lessons learned from the Scadbury Ward incident with staff and the wider service
- New staff were not made aware of ligature risks on the wards
Shepherdleas Ward cares for people over the age of 65 who have mental health needs. Oaktree Lodge provides care for people over 55 with long term mental health rehabilitation requirements. Scadbury Ward provides care for people over the age of 65 with mental health problems, such as depression, and Holbrook Ward is an intensive care unit for people with complex needs and behaviours related to dementia.
Full details of the inspection are given in the report published on the CQC website here.
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