The Care Quality Commission (CQC) carried out an inspection at Rose Lodge in Hebburn, South Tyneside, part of Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust in February.
Rose Lodge is a standalone assessment and treatment inpatient unit for adults aged 18 and over with learning disabilities, autism, mental health problems or severely challenging behaviour.
The unannounced focused inspection was carried out after receiving information of concern. The service was not rated at this inspection, and inspectors looked at the safe domain only. The trust’s overall rating for wards for people with a learning disability remains as good.
Following this focused inspection, a comprehensive inspection of all wards for people with a learning disability and autism was carried out. The findings from this will publish in due course.
Debbie Ivanova, CQC’s director for people with learning disabilities and autistic people, said:
“When inspectors visited Rose Lodge, they found a ward that wasn’t delivering safe care to people, with some staff feeling unsafe due to continued short staffing.
“There was high use of agency staff with some shifts falling below safe staffing levels. This led to staff not having time to fully meet people’s needs or manage risks properly to prevent them coming to harm.
“Several people had significant physical health issues that required regular monitoring. We found that this monitoring was not always taking place.
“We were pleased to see, however, that a new clinical manager with a significant background in learning disability nursing had started working on the ward. A physical health nurse was also new in post. During the inspection we escalated concerns to the trust, and they responded quickly to these concerns.
“Following the inspection, the trust took action and implemented a robust action plan to give assurances that people were receiving safe care.
“Inspectors have returned to the service since this inspection and a further report will be published in due course.”
Findings from the inspection, included:
- Managers did not investigate all incidents thoroughly and the threshold for investigation was unclear
- The service did not have enough nursing and support staff to keep people safe
- Staff were not always receiving training on how to recognise and report abuse, appropriate for their role with some staff not up to date with their safeguarding training
- Risk management plans lacked detail on how staff should manage risks and what measures they should take to manage physical health conditions
- Managers did not routinely investigate incidents and share lessons learned with the whole team and the wider service
- When things went wrong, staff did not always apologise and give people honest information or suitable support
- Managers did not routinely review CCTV footage, including after incidents and there was no process in place to trigger further investigation into an incident.
However:
- Staff interacted with people in a positive way throughout the inspection
- Inspectors reviewed four incidents on CCTV and observed some good practice in staff using de-escalation techniques and low-level holds
- Managers made sure all locum staff had a full induction and understood the service before starting their shift.