The Care Quality Commission (CQC) has rated Woodbourne Priory Hospital in Edgbaston, Birmingham inadequate overall, following an inspection in May.
Woodbourne Priory Hospital has seven wards and is registered to provide care and treatment to children, young people and adults with mental health conditions, including those whose rights are restricted under the Mental Health Act. It is owned by the Priory Group which merged with Partnerships in Care in November 2016.
This unannounced focused inspection was carried out to look at how safe and well led the service was. This was in response to the prevention of future deaths document that the coroner published following their hearing into the death of a person who was using services at Woodbourne in September 2020.
The coroner highlighted five areas of concern impacting on the safe care of patients and contributing to the death. These were record keeping, record keeping quality, risk assessments, serious incidents and the security of the courtyard fences. At this inspection all wards were visited to gain assurance that these concerns had been addressed.
Following the inspection, the overall rating for the service has dropped from good to inadequate. Well-led has also dropped from good to inadequate. Safe has declined from requires improvement to inadequate, and effective, caring and responsive to people’s needs has remained rated as good.
Additionally, at this inspection the provider was issued with a letter of intent under Section 31 of the Health and Social Care Act 2008. They were told CQC were considering using powers to urgently impose conditions on their registration.
The provider was told to submit an action plan within a short timescale that described how it would significantly and rapidly address CQC’s concerns. The provider’s response gave enough assurance they had addressed immediate concerns and therefore CQC did not progress with urgent enforcement action.
Since this inspection, CQC has received information of concern unrelated to the prevention of future deaths document, and carried out a further inspection in August. Following this inspection, the ratings have been suspended
CQC can suspend ratings whilst investigating information of concern. This ensures that people looking for information about an organisation, can be confident that ratings are an up to date accurate reflection of the care being provided.
Craig Howarth, CQC head of hospital inspections for mental health and community mental health services, said:
“When inspectors visited Woodbourne Priory Hospital it was concerning that the management team had not fully responded to information from the coroner’s inquiry. Following our inspection, the provider now knows what issues must be addressed as a matter of urgency to keep people safe.
“During the inspection we found systems and processes put in place following a serious incident hadn’t been fully embedded yet. The service must change processes to ensure a timely review of incidents is carried out and the ongoing monitoring of risks are regularly reviewed by the clinical leadership team.
“It was concerning that at our inspection, staff couldn’t directly observe patients in all outside areas of the wards without physically escorting them. However, since the inspection, staff had completed risk assessments of six outside garden and courtyard areas and removed or reduced any risks they identified. The provider had also updated their risk assessments following concerns raised during the coroner’s inquiry.
“Overall, we found a number of actions had been addressed. However, there is still more work to be done to address some remaining environmental issues.
“The service has submitted an action plan which addresses the concerns raised during the May inspection. However, since then, we have received further information of concern unrelated to the prevention of future deaths document, and carried out a further inspection in August to ensure people are receiving safe care. The findings will be published in a report in due course.
“We will continue to monitor the service closely and will return to check on progress to ensure improvements have been made and embedded.”
Inspectors found:
- The service did not always provide safe care. Staff assessed and managed risk but not always responsively
- There was inappropriate admission onto Acer Ward. We were told that admissions would be limited to transfers from acute wards in the hospital as patients recovered and presented lower risks. When we reviewed recent admissions, we established that some patients had been admitted directly onto the ward that did not fit the admission criteria of low risk
- Work was ongoing to address groundwork in the garden area of Beech Ward.
However
- The daily ‘flash’ meetings allowed for an early review of incidents and the opportunity for lessons to be shared.