The Care Quality Commission (CQC) has taken action after it found a Suffolk mental health hospital had not ensured its patients’ safety or dignity.
CQC inspected St John’s House, in Palgrave, near Diss, unannounced in December.
The 49-bed hospital is run by Partnerships in Care, part of the Priory group. It cares for adults living with learning disabilities and associated mental health issues.
The inspection was undertaken in response to concerns regarding patient safety, incident management, staffing and the use of restraint.
It found that risks to patient safety, dignity and wellbeing were not always well managed, and that some interactions demonstrated elements of abuse.
Staff had physically restrained patients, when they presented a danger to themselves and others, before other methods of de-escalation had been exhausted.
Some instances of restraint were disproportionate and used unauthorised techniques, including when a patient was pushed to the floor. This compromised patient dignity, damaged staff morale and caused physical injuries.
Areas used by patients who had been secluded had ligature risks and blind spots, compromising people at risk of self-harming. This issue was compounded because observations were not always undertaken correctly, including at least five instances captured by closed-circuit television where staff were asleep while they should have been monitoring patients.
The service was short-staffed, heavily dependent on agency workers, and it lacked essential equipment – including for resuscitation. There were also significant gaps in mandatory staff training, and personal protective equipment to help prevent the spread of COVID-19 was not always used appropriately.
Although staff understood how to identify abuse, and managers held monthly safeguarding meetings, the service had not always notified CQC or the local authority when safeguarding concerns had occurred. This is a statutory obligation to prevent a closed culture developing.
Following the inspection, CQC rated the service Inadequate and placed it in special measures. It was previously rated Good, following an inspection in 2018.
CQC continues to monitor the hospital closely, including through future inspections, and will use its enforcement powers further if there is insufficient improvement.
Dr Kevin Cleary, CQC deputy chief inspector of hospitals and lead for mental health, said:
“Our latest inspection of St John’s House found an unacceptable service where some staff interventions had demonstrated elements of patient abuse.
“Services we regulate must inform us when they identify safeguarding concerns to ensure patient safety. This service’s failure to transparently refer all possible instances of abuse to us and thoroughly investigate concerns has put its patients at prolonged risk of harm.
“The hospital must ensure its patients’ dignity and safety by only using physical restraint as a last resort. It must also ensure that it has enough staff, who have received the right training, so that patients receive the quality of care to which they are entitled.
“Following the inspection, we placed the service in special measures and prevented it from admitting new patients.
“Services in special measures are re-inspected within six months. We will use our enforcement powers further if satisfactory improvements have not made by the time of our next inspection.
“We continue to monitor the service closely.”
Following the inspection, CQC told the hospital that it must make several improvements, including:
- Addressing environmental risks, including for ligature points
- Adequately implementing infection prevention and control measures
- Ensuring staff have access to functional and checked resuscitation equipment
- Employing enough staff and ensuring they complete mandatory training
- Observing patients in line with care plans and policies
- Ensuring staff have necessary breaks
- Only using physical intervention as a last resort. When used, it should be applied safely, proportionately and out of view of other patients. Instances must be followed by physical health checks
- Providing regular access to outside space, lounge areas and activities for long-term segregated patients
- Completing records and care plans in line with policies, including completing segregation records in line with the Mental Health Act code of practice
- Comprehensively reporting all allegations of abuse to CQC, and thoroughly reviewing all safeguarding incidents to drive learning
- Using governance processes to identify problems and drive improvement.
Full details of the inspection are given in the report published online here.
Ends
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