The Care Quality Commission (CQC) has told Surrey and Borders NHS Foundation Trust that it must make improvements to its acute wards for adults of working age and psychiatric intensive care units to keep patients safe.
A team of inspectors from the Care Quality Commission visited the trust including the Abraham Cowley Unit in June 2020 to look at the quality of care and specifically areas relating to ligature risks. During this focused inspection inspectors visited Blake ward and Clare ward at the Abraham Cowley Unit (ACU) to inspect the safety of the service, with a particular focus on ligature risks.
The decision to inspect the hospital was taken following the deaths of two patients on Clare ward on 15 April and 10 May 2020. Both patients had died by means of fixing a ligature to fittings on the ward.
CQC wrote to the trust following the inspection highlighting serious concerns surrounding patient safety on The Abraham Cowley Unit. CQC required the trust submit information to explain how it would make immediate improvements. The letter also explained that if the trust could not provide assurance about the urgent improvements needed, CQC would move to take action to ensure the improvements were made. The trust responded positively and set out the immediate actions it was taking to ensure the safety of patients.
This was a focused inspection to follow up on concerns surrounding patient safety. Therefore, the service rating remains unchanged.
CQC’s Deputy Chief Inspector for Hospital Inspection ( and lead for mental health), Kevin Cleary, said:
“We found a number of concerns relating to patient safety on the Abraham Cowley Unit and we told the trust it must make urgent improvements. The trust needs to ensure systems are in place to keep people safe, that it can mitigate risks to people’s safety.
“Following our inspection, inspectors gave the trust leadership team feedback of their findings including those concerns which required an urgent response. The trust knows what it must do to ensure it improves its services. In the meantime, we continue to monitor the trust closely and will not hesitate to take action if the trust fails to make the necessary improvements.”
Inspectors found staff completed an annual risk assessment of the ligatures in the ward however, they were concerned that effective controls to manage ligature risks remained in discussion with no real time scales for completion of remedial action several months after two fatal incidents. The ligature assessment on Blake ward had not been updated following the deaths on Clare ward. On Clare ward inspectors saw that some the ‘quick win’ work identified by the trust to mitigate ligature risks had been completed.
At the time of the inspection there had been ligature and risk specific training rolled out for the staff on Clare Ward. However, inspectors did not see any formal training for staff in the management of ligature or environmental risks on Blake ward. The trust later confirmed training had been developed for roll out and would be completed by 29 June.
Following the death of two patients on Clare ward we found the trust had made changes to admissions for the adult acute wards. High risk patients were now being admitted to Blake and Anderson ward only. All high-risk admissions to ACU require a senior clinical conversation before any admission is agreed. Out of hours admissions of any patients unknown to the ACU were now going to Farnham Road, the trust’s other acute mental health hospital. They were only transferred to the ACU following a clinical discussion that the patient could be adequately cared for at the ACU. This meant that high risk patients were not being admitted straight onto Clare ward.
At the time of the inspection staff were not managing the use of the dormitory shower rooms safely on Blake Ward. Since the inspection, the trust has now put in place a process. When a patient is using the shower a member of staff remains present in the dormitory until the shower is no longer in use; after this, the shower is immediately locked. This was extended to all showers, not just dormitories showers to further share learning from the outcome of the enhanced ligature audit processes.
Full reports of inspectors’ findings will be published on CQC’s website at the following link: www.cqc.org.uk/provider/RXX
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