A focused Care Quality Commission inspection at a mental health trust covering East London, Luton and Bedfordshire has provided assurance that the trust is learning from serious incidents and taking steps to keep patients safe.
Although CQC inspectors did not rate the service they did find that the trust had made improvements in the Luton and Bedfordshire acute wards for adults of working age and psychiatric intensive care units (PICU).
The trust had investigated and used the learning from four unexpected deaths that occurred between December 2016 and July 2017. It had also made progress in addressing the recommendations from a previous CQC inspection in June 2016.
The trust was working in partnership with the police to reduce patient access to illegal substances on the wards. Staff had received training on suicide prevention and the management of physical health conditions.
Staff thoroughly assessed risks to patients and provided care which addressed their needs. There had been improvements in staff updating risk assessments following incidents since our last inspection. Patients reported that staff involved them in planning their care and treatment.
The size of Ash ward had been reduced from 27 beds to 19 beds which allowed staff to have better oversight of patients. However, some wards continued to have bed numbers in excess of Royal College of Psychiatrist guidance.
Ward procedures had changed across the service with more focus on the security and safety of wards. There were measures in place to restrict contraband items - but these needed further embedding.
The recruitment and retention of nursing staff continued to be problematic for the trust. A number of initiatives were underway to recruit staff. In the interim, the trust had employed locum agency nurses to ensure that patients were cared for by a consistent staff team. Staff reported their morale was good and felt that the service was improving.
Overall, medicines were managed safely. At the previous inspection CQC found that clinic rooms were sometimes hot, which could affect the efficacy and safety of medicines. During this inspection inspectors saw that whilst there had been improvements, the clinic room on Townsend Court had been hotter than the recommended temperature on some occasions and staff had not rectified this.
CQC found the following issues that required improvement:
- Staff did not always make the appropriate checks on the physical health of patients after rapid tranquilisation. This may have put the health of patients at risk.
- Staff were not consistently reporting incidents such as breaches of security. This meant that there may have been lost opportunities to learn from incidents to make improvements to the safety of service.
- Staff did not keep adequate records on cleaning and maintaining equipment. Staff take up of basic life support and immediate life support training was below 75%.
Dr Paul Lelliott, Deputy Chief Inspector (and lead for mental health), said:
“It’s good to see that the trust has learnt from serious incidents and made some improvements in the quality of care at East London NHS Foundation Trust’s acute wards for adults of working age and PICUs in Luton and Bedfordshire."
“However, I would like to see care for patients improve further, when we next inspect this service. I was though pleased to see that patients reported that staff involved them in planning their care and treatment.”
You can read the report in full on our website. Go to the list of services on the right hand side of the screen and click on ‘Acute wards for adults of working age and psychiatric intensive care units’.
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