The Care Quality Commission (CQC) has told South West London and St George's Mental Health NHS Trust that improvements are needed in Burntwood Villas, one of the long stay or rehabilitation mental health wards for working age adults, following a focused inspection which took place in April.
Inspectors carried out an unannounced inspection after receiving a copy of the investigation report into the death of a patient in August 2020. The trust had commissioned an independently chaired investigation into the death. The report of the investigation identified several failings in patient care, including care planning, physical health care, communication with primary care, lack of a rehabilitation focus and medicine management.
Following the inspection, the rating for the long stay or rehabilitation mental health wards for working age adults dropped from good to requires improvement. Ratings also dropped from good to requires improvement for the key questions which look at whether the service is safe effective and well led.
Jane Ray, CQC’s head of hospital inspection for London and lead for mental health, said:
“During our inspection of South West London and St George's Mental Health NHS Trust, we found a team that was committed to supporting and protecting vulnerable patients. People were cared for with dignity and compassion during a very difficult and challenging time for the trust.
“However, the conditions at Burtwood Villas were not ideal. The service had admitted several patients who did not meet the service inclusion criteria. These patients had complex health needs and we had concerns that the service did not have the right number of staff or the correct mix of disciplines needed to manage both the physical and mental health needs of the patients, which could impact on people’s care and put them at risk of harm. When we told the trust about these concerns, the leadership team immediately put plans in place to resolve this.
“Yet despite these pressures, there were examples of good practice and leaders were aware of current issues that need to be resolved. We will continue to monitor the trust and will return to check on the progress of improvements we’ve told them to make.”
During the inspection, CQC found:
- The service did not consistently admit patients in accordance with its inclusion and exclusion criteria, as stated in its policy, and some patients whose presentation had changed had not been transferred to more appropriate settings in a timely manner
- Some patients had higher care needs on admission, this placed an additional burden on staff because the service had not been adequately resourced to meet the physical and mental health needs of patients who fell outside of its scope
- Additional staff were needed to care for patients safely. When this was pointed out, the trust assured inspectors it would thoroughly review the care pathway for patients as well as the skill mix of staff going forwards
- Staff did not feel their concerns were acted on and significant risks faced by the service were not consistently documented or addressed
- Staff had not acted promptly to address concerns identified in a fire risk assessment
- The nurse call alarm was not well maintained and did not work adequately on the day of our inspection
- Staff did not always follow infection prevention and control policies. Two of four staff were not wearing face masks appropriately when the inspection team arrived at the service.
There were a number of positive findings though. Inspectors observed:
- Staff received appropriate mandatory training and followed good practice with respect to safeguarding, reported incidents and shared learning when things went wrong
- Staff managed challenging behaviour well and did not use restraint or seclusion on the unit
- Staff assessed and monitored patients’ physical health consistently and regularly
- The ward teams included or had access to a 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 multidisciplinary team. The leadership team were mostly new in post but had a good understanding of what a high-quality rehabilitation service should look like
- There were processes in place to ensure learning from incidents, and a recovery plan was in progress addressing gaps in care identified in a serious incident investigation report.
Full details of the inspection are given in the report published on our website.
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Read the report published on our website for Long stay or rehabilitation mental health wards for working age adults.