Kneesworth House

We rated Kneesworth House as requires improvement because:

• The hospital did not provide consistently safe care. Emergency equipment and physical health monitoring equipment were not always present, appropriately maintained and easily accessible. The hospital did not consistently manage medicines safely. Staff did not consistently monitor the side effects of medicines or complete care plans for monitoring patients prescribed clozapine. 
• Patient bedrooms were not en-suite and patients had to share toilets, showers and bathroom facilities. Ward layouts were not always helpful in promoting personalised care planning for patients. The environment on the rehabilitation wards was poor. On Nightingale ward, staff secluded patients in a decommissioned seclusion room which contained potential safety hazards for patients.
• The acute ward, psychiatric intensive care unit and some rehabilitation wards some rehabilitation wards placed blanket restrictions on patients without assessing and documenting individual risk. These included not having access to keys and mobile phone chargers and restrictions to going outside.
• Managers and staff did not complete all episodes of seclusion in line with Mental Health Act Code of Practice on rehabilitation and forensic wards and did not complete all seclusion paperwork in line with Mental Health Act Code of Practice.
• Managers provided training data during the inspection. This showed that mandatory training on the rehabilitation wards, was below 75% in some key areas, such as fire safety, managing challenging behaviour, rapid tranquilisation, safeguarding children and adults and clinical risk assessments. Staff on the rehabilitation wards did not have access to additional rehabilitation-focused training. Not all staff were up to date with Mental Health Act and Mental Capacity Act training. Managers had not ensured action was taken to address this.

• The clinical records system was slow. Staff could not always locate records when they needed to. In the rehabilitation services, meeting minutes from lessons learned discussions were sparse and poorly recorded. Staff across all wards were unable to give examples of recent lessons learned. Governance systems did not always ensure that essential learning and information passed between the hospital’s senior management team and the nursing team.
• In the rehabilitation service, staff did not fully assess the physical health needs of patients on admission and did not routinely monitor their health or identify when their condition was deteriorating, including the monitoring of patients on Clozapine.
• Care plans on the forensic wards did not reflect the patient voice. Community meetings in the forensic service did not document outcomes of concerns raised by patients.

However:

• The service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm. The provider had addressed the issues found at the focused inspection in June 2019. The environments on Wimpole ward and the forensic/secure wards had improved and staffing numbers had increased on the forensic/secure wards.
• Staff assessed and managed risk on admission, and reviewed this regularly, including after incidents. Staff followed best practice in anticipating, de-escalating and managing behaviours that challenged and used restraint and seclusion only after attempts at de-escalation had failed. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• On the acute ward and psychiatric intensive care unit, the service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications patients’ physical health on these wards.
• Staff assessed the physical and mental health of all patients on admission. They developed care plans, which they reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected the assessed needs, were holistic and recovery-oriented. Care plans in the rehabilitation and acute services were personalised.
• Staff provided a range of care and treatment interventions suitable for the patient group and consistent with national guidance. Ward teams included or had access to the full range of specialists required to meet the needs of patients. Staff from different disciplines worked together as a team and held daily multidisciplinary meetings to benefit patients, attended by members of the senior management team, doctors and nursing staff.
• Managers made sure staff had a range of skills needed to provide high quality care. They provided an induction programme for new staff, supported staff with appraisals and supervision, identified training needs and gave staff the time and opportunity to develop their skills and knowledge.
• Most staff treated patients with compassion and kindness and respected patients’ privacy and dignity. Staff gave patients help, emotional support and advice when they needed it. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
• Staff involved patients in care planning and risk assessments. They had a good understanding of patients’ needs, supported them to understand and manage their treatment and ensured they had easy access to independent advocates. Staff informed and involved families and carers appropriately. Staff invited carers to multidisciplinary meetings and monthly ward reviews.
• Managers were visible in the service and approachable for patients and staff. Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. Staff felt able to raise concerns without fear of retribution.

We did not rate forensic/secure wards or psychiatric intensive care units at this focused inspection. We carried out this inspection to look at what improvements the provider had made after the concerns raised by the focused inspection on 23-25 June 2019, after which the CQC imposed urgent conditions on the provider. This inspection focused solely on the progress made against the conditions imposed by the Care Quality Commission across two core services. The report reflects what we found in the three wards we inspected. These were:

• Ermine ward, a 19-bed medium secure service for men with a mental illness
• Orwell ward, a 18-bed low secure service for men with a mental illness
• Wimpole ward, a 12-bed psychiatric intensive care unit for women with a mental illness

We found the following issues that the provider needs to improve:

• Managers had not transferred the learning from problems identified on the PICU to the rest of the hospital site. There were significant environmental issues on Ermine and Orwell wards, including dirty toilets, damage to the environment and a dirty kitchen area.
• The service had not ensured they had met all the conditions imposed by the CQC. Staff in the forensic/secure wards had not reviewed all patients’ risk assessments weekly as required and there had been considerable delays in completing some of the actions identified in their own action plan.
• In the forensic service, staff undertook constant and intermittent observations for more than two hours without a break, which was not in line with their own policy and best practice. Managers had not maintained oversight of this.
• Staff on the PICU did not always categorise the severity of incidents appropriately on the provider’s electronic incident recording system. Staff had classified some incidents of self-harming behaviour, including head banging, tying ligatures and assaults against staff, as having no harm or impact.
• Managers had not provided clarity about how staffing levels on the PICU should increase in response to patient numbers.
• The Priory’s mandatory ligature risk audit document did not allow staff to specify the nature of the risk effectively.

However, we found the following areas of good practice:

• The service had addressed the environmental issues on the PICU and had systems in place to ensure the ward remained clean and safe.
• Senior managers and ward managers had ensured staff on Wimpole ward had PICU specific training, including risk assessment and risk management, and were adequately prepared to work with patients within the service.
• Senior managers had increased staffing levels on Ermine and Orwell wards to ensure there were enough staff to maintain the safety of patients and facilitate patient leave consistently.
• Ward managers had ensured up-to-date ligature risk assessments were easily available to staff.

We did not rate forensic/secure wards or psychiatric intensive care units (PICU) at this focused inspection.

We found the following issues that the provider needs to improve:

• Wimpole Ward, the psychiatric intensive care unit (PICU), was unsafe. Staff reported high levels of aggression between patients and on staff. Some incidents involved several patients joining together to attack their peers. Managers had failed to provide staff with appropriate guidance on how to deal with these incidents or to learn lessons from them. Managers had not ensured staff working on the PICU had specific training to equip them for this and so were not adequately prepared to work with the specific patient group.
• Staff did not effectively manage patient risk. Staff had failed to identify individual patient risks or strategies to manage the risks on Orwell Ward or on Wimpole ward (the PICU). Staff on the PICU had not fully completed risk formulation for patients and staff had not updated risk assessments after incidents.
• Managers had not described or identified potential ligature points in the wards’ ligature risk audits or how staff should mitigate the risk. Staff did not have access to the most up-to-date printed ligature risk audits.
• The PICU was dirty and poorly maintained. Sink wastes needed replacing in toilets and bathrooms and a toilet door was missing. The kitchen and dining room areas had loose and engrained dirt in the floors, under tables and in drawers.
• Managers had not ensured there were enough staff to maintain the safety of patients and facilitate patient leave consistently. This was more evident on wards designed over two floors.
• Seclusion practices, including the recording of seclusion and the storage of records were not in line with the requirements of the Mental Health Act Code of Practice.
• Staff kept food at high temperatures in the kitchen on Wimpole ward which could pose a risk to patients.

However, we found the following areas of good practice:

• Staff offered practical and emotional support where needed. Seven of the 12 patients we spoke with told us staff were understanding, helpful and polite and cared about their wellbeing.

We did not rate psychiatric intensive care units (PICU) at this focused inspection.

We found the following issues that the provider needs to improve:

• While risk assessments had improved, staff did not manage patient risk consistently. Staff did not always update risk assessments after incidents. Managers were not assured that patients’ risks were always managed safely and effectively.
• Managers had not ensured staff had PICU specific training and were adequately prepared to work with patients within the service.
• Managers had not described or identified all potential ligature points in the wards’ ligature risk audits or how staff should mitigate the risk. Staff did not have access to the most up-to-date printed ligature risk audits.
• The provider had not addressed all environmental concerns in their action plan and some actions were overdue. Sink wastes needed replacing in toilets, bathrooms and bedrooms. The kitchen had loose and ingrained dirt in the floor and under the fridge.
• The chilled food cabinet was not working correctly and recording high temperatures. Staff had not checked the temperature of this equipment.

However, we found the following areas of good practice:

• The ward was visibly cleaner than at the last inspection visit.
• Risk assessments on the PICU were of a higher quality and contained more detail than at the last inspection.
• Managers had overseen some improvements to the PICU’s environment. We noted that the ward was cleaner, staff had replaced the toilet door and put up signs for toilets and bathrooms and had ordered new floors and sink wastes.

We rated Kneesworth House as inadequate because:

• We had serious concerns about the forensic service, which consisted of Clopton, Ermine, Icknield and Orwell wards.

• The provider had not addressed all the breaches identified at the last inspection. When staff secluded patients, they did not do or record this in line with the provider’s policy and the Mental Health Act Code of Practice. The provider had not prevented contraband items from entering some of the ward environments and had not resolved the ligature risks in the seclusion rooms. The provider had not fully addressed issues in relation to staff approaches towards patients.

• The provider had not kept patients safe from improper treatment and some staff were uncaring and disrespectful. Two patients told us some staff on Icknield ward used a key to prod their feet if they did not get up in the morning. Some patients altered their sleeping position or wore trainers in bed to prevent this happening. Seven patients we spoke with commented that a few staff were rude, unfriendly, did not listen to them or antagonised patients.

• Staff did not always complete risk assessments in a timely manner and did not manage patient risk robustly. Staff did not routinely update risk assessments after incidents. The provider did not have a consistent approach to physical health checks in line with guidance, including patients on high dose antipsychotics.

• Staff sometimes had to cancel patient leave and activities. Staff we spoke with told us that if there was an incident on the forensic wards, this could adversely affect plans for activities or leave. Four patients and one carer also told us there was insufficient staff to enable patients to take planned leave as planned and that staff regularly cancelled patient leave. On rehabilitation wards, six patients we spoke with told us that their regular permanent and bank staff were often moved to cover gaps in staffing on other wards, leading to a high use of agency staff.

• Staff did not consistently store, record or administer medicines in line with guidance. On forensic wards, staff did not always administer medication safely. Staff left syringes in pots of water with patient initials written on kitchen paper underneath. Staff had not recorded information about allergies on individual care records. Staff identified allergies to medicines on prescription charts, but these did not include full details of food allergies. On Clopton and Icknield wards, records did not contain a review for as-required medication in the previous 14 days. Staff audits did not ensure these issues were addressed.

• The clinic room on Clopton ward was dirty and disorganised. The clinic room on Orwell was disorganised and the medicine cupboard on Icknield ward was broken. Some ward areas were dirty, and many areas were in need of repair and redecoration. This included stained and dirty toilets and unpleasant odours. Furniture was ripped and the system for ensuring maintenance jobs were completed was ineffective. The system to highlight, action and monitor maintenance issues across the wards was not robust.

• Staff did not consistently involve patients in care plans and risk assessments in the forensic service. Patient records did not document how patients were involved in care planning or risk assessments.

• Managers had not ensured that there were effective processes to inform them of poor practices in different parts of the service and could not therefore take immediate steps to address them.

• The provider had not addressed the challenges posed by the wards which were on two levels. In the forensic service, staffing levels were not sufficient to ensure that patients had access to the whole ward. Staff used restrictive practices to manage the ward environments on Ermine, Icknield and Orwell wards. Staff confined patients to upstairs or downstairs areas at certain times. On Icknield ward, patients had to be downstairs by 8.30am and in bed by 10.30pm.

• Electronic recording systems were slow, and staff experienced difficulties in accessing information quickly.

However:

• We did not have similar concerns about the acute ward and rehabilitation wards.

• The acute and rehabilitation services had sufficient nursing staff, who knew the patients and received basic training to maintain safe staffing levels. There were sufficient medical staff, including out-of-hours cover across the hospital.

• The service provided mandatory training in key skills to all staff and made sure everyone completed it. The provider supported staff with induction, appraisals, supervision and opportunities to update and further develop their skills. Managers monitored the performance of the team to ensure staff received appraisals, supervision and training.

• Staff completed comprehensive mental health assessments and assessed most patients’ physical health fully on admission with a full medical assessment. Staff ensured that most patients had good access to physical healthcare and supported patients to live healthier lives, particularly on Bourn ward and in the rehabilitation wards.

• Staff held regular and effective multidisciplinary meetings. In the acute and rehabilitation services, staff treated patients with respect and put them at the heart of the discussion. They ensured that patients had access to independent advocates. Across the hospital, staff involved patients in their care through ward rounds and other multidisciplinary meetings.

• The rehabilitation and acute wards used systems and processes to safely prescribe, administer, record and store medicines in line with national guidance.

• The provider had emphasised the use of de-escalation in managing challenging behaviour. As a result, staff use of restraint had reduced since the last inspection.

• Staff provided a range of care and treatment interventions suitable for the patient group. This included medication, psychological therapies, ward activities and employment opportunities, such as the educational and vocational skill centre, which included a patient-run café.

• Staff informed and involved families and carers appropriately and enabled them to give feedback on the service they received. Carers we spoke with felt their relatives were safe and well cared for.

• Staff helped patients with communication, advocacy and cultural and spiritual support.

• In the acute and rehabilitation services, staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.

• The service treated concerns and complaints seriously and investigated them promptly. Lessons learnt were shared with the whole team and the wider service.