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

Pathfinder Ashness House

Overall: Good read more about inspection ratings

2-6 Jersey Avenue, Stanmore, HA7 2JQ

Provided and run by:
Pathfinder Group Healthcare Limited

All Inspections

08 and 09 December 2022

During a routine inspection

We carried out an unannounced, comprehensive inspection of Pathfinder Ashness House. We have rated the service for the first time. After a focused inspection in September 2022 identified serious concerns, we went back to check the provider had made improvements.

The hospital had made progress in addressing the concerns identified at the last inspection. This included clearly documenting when staff restrained patients. Staff ensured they clearly documented patients’ physical health observations after they administered rapid tranquilisation. Staff adequately monitored the administration of rapid tranquilisation through robust audits.

At this inspection we rated safe, caring, responsive and well-led as good and effective as requires improvement.

We rated this location as good because:

  • The service had addressed the concerns raised at the last inspection in September 2022. The service had made improvements to how they managed and safely restrained patients. Staff had made improvements to how they carried out observations and engagement with patients. Staff had improved how they documented patients’ physical health observations after they administered rapid tranquilisation.
  • The service had enough nursing and medical staff, who knew the patients and received essential training to keep people safe from avoidable harm. Although the unit had a high number of vacancies, the service had enough staff on each shift to support patients safely. The service provided staff with emergency scenario training to help staff prepare for a medical emergency.
  • Staff managed medicines safely and regularly reviewed the effects of medications on each patient’s mental and physical health.
  • The ward environment was safe and clean. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients undergoing rehabilitation. The service had a full-time responsible clinician. Managers ensured that staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who had 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 provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Staff felt respected, supported and valued. They said the provider gave them opportunities for development and career progression. They could raise any concerns without fear.

However:

  • Staff did not always discharge their roles and responsibilities under the Mental Health Act 1983 in a timely way. Patients detained under the Mental Health Act did not always have their rights explained to them in a way they could understand. An audit of the Mental Health Act patient files did not effectively monitor how the Mental Health Act was implemented at the hospital.
  • Staff had not displayed written information to inform patients of what items were prohibited. Not all staff knew about what restrictive practices there were on the ward.
  • Staff used some generic statements in patients care and treatment records. Patient goals were not always specific, measureable and achievable.
  • Staff did not always help patients to live healthier lives. The hospital site was not smoke-free as patients could still smoke in the garden area. This was not in line with best practice.

18 and 21 September 2022

During an inspection looking at part of the service

We undertook an out of hours, focused inspection of this service looking only at the safe and well led key questions. The inspection was undertaken following information of concern we received about staffing levels and incidents of violence and aggression on the unit requiring intervention from the police.

Following this inspection, we issued the provider with a s29 Warning notice because of the serious concerns we had about staff not carrying out the required physical health monitoring of a patient after rapid tranquilisation was administered on multiple occasions. The service did not report all incidents of physical restraint of patients and where it did, records lacked sufficient detail. Staff carried out intermittent observations at regular and predictable intervals. There was a risk that the patients would know when observations would take place and plan their actions around this. Staff did not always respond promptly to a deterioration in a patient's physical health. Senior managers did not establish effective systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients. We asked the service to take immediate action to address these issues.

We did not rate the service at this inspection as we have not previously inspected the service and we only inspected parts of two key questions.

We found that:

  • We were not assured that staff only restrained patients when de-escalation techniques failed. This was because staff did not report all incidents of physical restraint. Where staff had reported an incident of physical restraint this was not recorded in sufficient detail and in line with the requirements of the Mental Health Units (Use of Force) Act 2018.
  • Staff did not always record a patient's physical health observations post rapid tranquilisation as per the provider's policy. Patients receiving rapid tranquilisation are at risk of seizures, airway obstruction, excessive sedation and cardiac arrest.
  • Staff did not always respond promptly to a deterioration in a patient's physical health or record why no action had been taken in response to elevated results of checks of their vital signs. There was a risk that serious physical health concerns would be missed.
  • Whilst staff followed the procedures to minimise risks to patients through regular therapeutic observations. Staff did not carry out intermittent level observations on patients at irregular and unpredictable times. There was a risk that the patients would know when observations were likely to take place and they could plan their actions around this.
  • Our findings demonstrated that governance processes did not operate effectively at service level and that performance and risk were not managed well. Senior managers had not established effective systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients.
  • The service was not able to analyse the frequency that rapid tranquilisation was administered to patients or analyse the frequency that physical restraint was used on patients as not all incidents were recorded, or records of such incidents lacked the required detail.
  • Patient care and treatment records were not comprehensive, and they were not easy for staff to access. There was no clear format used in patient care and treatment records to ensure staff could consistently and readily access pertinent patient information.

However:

  • The service had enough nursing and support staff to keep patients safe. Although the unit had a high number of vacancies, the service had enough staff on each shift to support patients safely.
  • The ward was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff checked, maintained, and cleaned equipment.
  • Patients said staff treated them well and behaved kindly. All patients said that staff were respectful and went above and beyond to support them. Patients said staff listened to them and treated them with dignity and respect.