The Care Quality Commission
  • Mental Health
  • Independent mental health service

Schoen Clinic York, Wellen Court

Overall: Good read more about inspection ratings

Haxby Road, York, YO31 8TA (01904) 404400

Provided and run by:
Newbridge Care Systems Limited

Important: This service was previously registered at a different address - see old profile

All Inspections

Tuesday 01 - Wednesday 02 November 2022

During a routine inspection

Our rating of this location improved. We rated it as good because:

  • The service provided safe care, the ward environments were safe and clean, the wards had enough nurses and doctors and staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full 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 and with those outside the ward who would have a role in providing aftercare.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
  • The service was well-led and the governance processes ensured that ward procedures ran smoothly.

However:

  • Staff, below medical level, could not always describe their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005
  • There were challenges with the current premises in terms of space to support treatment and care.
  • Patients fed back and quality audits showed that there were issues with the choice and quality of food provided.
  • There was evidence that a decision made in a multidisciplinary meeting was not followed through and notes did not fully reflect the decision-making process.

25 and 26 January 2022

During a routine inspection

We are placing Schoen Clinic York in special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Our rating of this location went down. We rated it as inadequate because:

  • We have taken urgent enforcement action against the registered provider following our inspection.
  • The service provided care that put patients at the risk of physical and psychological harm because their needs, including dietary needs, were not always met, patients’ risks and environmental risks from ligature anchor points were not assessed properly and not managed or mitigated sufficiently.
  • The service had warning signs of a closed culture. Staff did not always provide holistic and person centred care that met patients’ needs and staff did not always treat patients with compassion and respect. Some staff reported a culture where they could not raise concerns without fear of retribution and bullying and harassment from managers. Staff did not always report incidents and safeguarding issues that occurred appropriately internally and externally.
  • The premises were not fit for purpose because there was not enough space for patient care and staff to work at the service to support patients. Two sheds had been erected in the garden and there was no space for a female only lounge to be compliant with eliminating mixed sex accommodation.
  • The provider had not implemented the new model of care effectively and staff did not have the skills or tools to deliver the new model of care in practice.
  • There were issues in relation to emergency equipment, safe medicines management, the nurse call alarm system and staff training was not all up to date. There was no training in learning disabilities or autism. There were also issues with a patients’ rights being regularly explained under the Mental Health Act and the language in one risk assessment that was too medicalised.
  • Governance systems and processes were not effective in identifying issues with quality and safety and this meant that there was insufficient oversight of what was happening in the service.

However:

  • The service had recruited to almost all the vacancies in the service.
  • There was a clear framework of meetings from ward to the provider’s board.
  • Some patients told us that some staff treated them with kindness and compassion.
  • Assessments on admission to the service were comprehensive.
  • Following our urgent enforcement action, the registered provider has taken action and started to make improvements to safety and quality in the service.