The Care Quality Commission (CQC) has taken action at Eldertree Lodge in Market Drayton, following an inspection which found people using the service were at risk of harm.
An inspection of the hospital which provides specialist inpatient treatment and rehabilitation services for adults with a learning disability or autism, was undertaken in March due to serious concerns raised about the care being provided. These related to inappropriate patient handling techniques, poor staff behaviour, unsafe staffing levels and a lack of visible leadership. Some of these concerns had been raised by the service’s new provider which had taken over the hospital four months before the inspection.
During the inspection, many concerns were identified that showed patients were at risk of harm because systems to monitor the quality of care were either not in place, or not operating effectively.
Following the inspection, the provider was told to submit an action plan within 24 hours that described how it was addressing the concerns found. Their response did not provide enough assurance they had acted to address immediate concerns, so further enforcement action was taken which restricted the service from admitting any new patients without written agreement from CQC.
The provider was rated inadequate and placed in special measures. This means it is subject to close monitoring to help it improve its care and ensure patient safety. A follow-up inspection was carried out in May to check on progress and the inspection findings will publish soon.
Dr Kevin Cleary, CQC deputy chief inspector of hospitals and lead for mental health, said:
“When we inspected Eldertree Lodge, we found widespread and significant shortfalls in the way in which the service was led. We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity and independence that most people take for granted.
“We were concerned there had been incidents where patients had self-harmed whilst living at the service. There were not enough staff to safely provide nursing observations and all wards used a high number of agency staff many of who could not describe the needs of the patients in their care.
“Wards were not safe, clean, well-equipped or fit for purpose. Some bathrooms were damp and had visible mould and there was broken and dirty furniture throughout the hospital which posed a risk to patients. There were unlocked areas that contained hazardous materials and some seclusion rooms had blind spots meaning staff could not effectively observe patients.
“In addition, staff did not follow the provider’s COVID-19 infection control policy or national guidance. Throughout the inspection we saw staff not wearing face masks appropriately.
“This is why we took the decision to restrict admissions to the service until improvements are made. We will continue to monitor the service closely and have since returned to check on progress. We will not hesitate to take further enforcement action if necessary.”
There were many areas of concern found on inspection, including:
- Not all patients were treated with dignity and respect. Patients were not always happy with the care and treatment provided.
- Leadership was poor and staff did not always feel supported, valued or respected by senior leaders.
- The ward environments were not safe and clean. Staff did not always adhere to COVID-19 national guidance, putting staff and patients at risk.
- Not all staff were trained in the same restrictive techniques to ensure patients remained safe.
- Not all staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging. Staff were slow to deploy de-escalation techniques to prevent patients’ further distress.
- Risk to patients was not always managed well. Incidents were not investigated thoroughly, and associated learning was not adequately shared amongst staff.
- Governance processes did not always operate effectively at ward level and performance and risk were not managed well. Managers told us they were working to rectify several concerns since they took over the service, but many identified and unidentified issues remained.