Priory Hospital Norwich

Staff had failed to ensure that patients were restrained using appropriate techniques. Four patients we spoke with told us that they had been harmed whilst being restrained by staff using more than minimal force.

Although the service had enough nursing and support staff to keep patient’s safe we found out of four staff on shift two to three staff on shift that were blocked booked agency staff. Patients had their escorted leave or activities postponed and rescheduled when the ward was short of staff or if staff were required to carry out enhanced observations of patients.

Ward managers determined the level of staffing numbers on the ward but did not book staff to work on the ward. The person responsible for booking staff was an administrator and not a clinical member of staff or someone in a management position. The administrator was not qualified to determine what skills and competencies staff should have in order to appropriately and safely meet the needs of individual patients, thereby exposing patients to the risk of harm.

Staff had failed to carry out all nursing observations in line with the patients care plan to maintain their safety. We were concerned that on some occasions staff were carrying out observations longer than what the hospital policy stipulates. The lack of observations or length of time staff carried out observations could have potentially impacted on patient safety.

Staff did not always administer medication in accordance with the patients’ prescribed medication. We found on one occasion that staff had administered eight milligrams of diazepam in a 24-hour period when the patient had only been prescribed six milligrams of diazepam in a 24-hour period.

Three of the patients we spoke with reported that they could not get access to staff as staff were always busy and that they had not been involved in their treatment plans and had not seen their care plans. Two patients reported that day staff were respectful and caring but night staff were rude and had at times been very forceful and aggressive.

Managers failed to provide a consistent and stable leadership team over a prolonged period of time. At the time of the inspection, a interim hospital director had been appointed for three months as the provider had not been able to recruit a permanent member of staff into this position. We found a lack of leadership due to this there was no clarity on what manager roles were within the service.

Governance meetings were often cancelled and did not contain accurate up to date information for a comprehensive meeting to take place and a robust plan of actions to be set to improve the service. We viewed the hospital risk register. The register was not up to date and did not reflect current issues.

Managers did not investigate incidents thoroughly. The services system was for incidents to be reviewed and closed by the Director of Clinical Services . Of the 14 records we looked at, only two had been reviewed and closed by the Director of Clinical Services, despite the incidents suggesting that patients could be exposed to the risk of harm.

There was no clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Managers did not ensure that staff had access to regular clinical supervision. We reviewed six clinical supervision records and found no evidence that showed staff’s competence to care for the patients on Redwood 1 ward was being assessed. The records also did not reflect that managers have gained assurances that staff were being appropriately supervised and their clinical competencies being monitored to ensure they were protecting patients from harm or exposure to the risk of harm.

Managers did not deal with poor staff performance when needed. Managers were fearful that if they challenged staff’s performance then staff would put in a grievance against them, therefore they took no action. Managers reported that the ward staff had an unhealthy culture and there were frictions within the team.

However,

Two patients told us that they had been involved in their care planning and understood their treatment plans. Additionally, three patients we spoke with reported that staff responded well to them when they were struggling and that they tried to support them.

One family we met during the inspection said they felt involved in their family members care and that staff were friendly and helpful. The had regular contact with the doctor and had been involved in the planning of care for their family member.

Staff completed and regularly updated thorough risk assessments of all wards areas and removed or reduced any risks they identified. Ward areas were clean, well maintained, well furnished and fit for purpose. Staff made sure cleaning records were up-to-date and the premises were visibly clean. Staff followed infection control policy, including handwashing.

Staff completed risk assessments for each patient on admission and reviewed this regularly, including after any incident. Staff knew the individual risks for each patient. When patients were admitted to the ward the doctors carried out a comprehensive assessment of the patients mental and physical health.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Patients records showed that staff were reporting safeguarding incidents when necessary.

Four staff we spoke with felt valued, respected and supported by ward staff, including the ward manager.

The Care Quality Commission carried out an urgent, focussed and unannounced inspection of the child and adolescent inpatient wards at Ellingham Hospital on 4,5 and 10 September 2019.

The Care Quality Commission has a duty under Section 3 of the HSCA to consider the immediate safety and welfare of the young people at the hospital.

We found significant and immediate concerns that required immediate action. We worked closely with the Norfolk and Young People Clinical Commissioning Group, Norfolk Local Authority, NHS England and the Priory Group senior management team to ensure that immediate concerns for the health and wellbeing of the young people were acted on. We began enforcement proceedings against Ellingham Hospital to require closure of both child and adolescent mental health wards.

Full information about our regulatory response to the concerns we have described will be added to a final version of this report, which we will publish in due course.

We rated the child and adolescent mental health wards at Ellingham Hospital as inadequate because:

• Senior managers failed to provide a consistent and stable leadership team, including a permanent registered manager since June 2019. During the inspection, staff told us that they did not always feel contained or empowered. We observed very busy staff who lacked direction and told us they were not always aware of their roles and responsibilities. During the inspection, we had difficulties getting the information that we requested as it was unclear which member of staff was responsible.

• The provider had not ensured patient safety was sufficiently prioritised. In the week before the inspection there was a significant patient against patient physical assault on Woodlands ward. Staff failed to provide adequate observation of the patients which allowed the attack to continue over a sustained period.

• Staff had not observed patients in the communal areas in line with the provider’s policy and failed to correctly complete patient observation records. Staff recordings of patient activity did not correlate with CCTV footage. We had serious concerns that staff had failed to record times correctly or had falsified observation records. This was raised as a safeguarding concern by the provider following our inspection.

• Staff failed to report all incidents that they had observed. We found at least two occasions where CCTV was reviewed and identified that staff had observed incidents and not reported them. This meant that there was a risk that patients had suffered harm and no immediate action had been taken to reduce the risk and protect patients from further harm.

• Senior staff did not have an effective process in place to review and learn from incidents. Since June 2019 we found there had been a high number of incidents. Staff on Cherry Oak ward recorded 133 incidents in July 2019 whilst there were four patients on the ward. On Woodlands ward for the same period there were 50 incidents. We were not assured of the accuracy of recording due to the points above.

• Staff use of restraint, and methods of restraint, were unsafe. Staff used restraint that was not proportionate and had failed to use least restrictive interventions, for example verbal de-escalation strategies, to manage risk incidents. CCTV footage showed staff using unapproved techniques and acting aggressively towards patients which compromised the safety of the patients. Agency staff used different methods to restrain patients than Priory-trained staff. This meant that restraints may not have been safely undertaken.

• Staff used restraint significantly more often, particularly on Cherry Oak ward. Last year, during a six-month period between 1 April 2018 and 30 September 2018 there was a total of 194 restraints carried out on Cherry Oak and Woodlands. In July 2019 there had been nearly the same amount in one month with staff reporting 147 incidents where restraint had been used.

• In the three months prior to the inspection, significant concerns had been raised to the Care Quality Commission by safeguarding authorities and other external stakeholders regarding the safety and welfare of young people at the hospital, particularly in relation to the high number of incidents, use of restraint and staff pre-employment checks. Safeguarding authorities had also raised concerns about the poor quality of safeguarding referrals they had received which had led to delays in triaging and investigation of incidents.

• Staff had not followed care plans for a patient who was being nursed in long-term segregation. During the inspection, we viewed CCTV footage which showed the patient in a communal area, to which they should not have had access due to the risk they posed. The nursing daily notes recorded that they were on grounds leave at that time.

• Managers did not have robust systems in place to ensure that staff pre-employment checks had been carried out and that staff were appropriately cleared to work within the hospital. We found that a member of staff was able to work whilst under investigation and, earlier in the year, another member of staff was able to return to work whilst the investigation into their conduct was ongoing. These incidents raised concerns that managers had not put effective measures in place following the first incident, allowing the second incident to take place. In addition to this, managers did not have effective systems to ensure they were aware of any issues declared on agency staff’s disclosure and barring service check. This resulted in a member of staff working there who had not been effectively risk assessed.

• The provider did not have adequate levels of staffing to work on the wards and to provide an effective multidisciplinary service. We were concerned that improvements in staffing observed during our last inspection in June 2019 had not been maintained and the ability of the hospital to employ and retain enough, suitably qualified and skilled staff had deteriorated. Our concerns were exacerbated by significant numbers of staff not arriving on site to work or cancelling shifts at the last minute. Key members of the multidisciplinary team had resigned, including the medical director, the newly appointed social worker, an occupational therapist and a play therapist.

• Staff had not sustained recent improvements in incident reporting. Staff failed to record all incidents on the provider incident reporting system and had not updated patients’ risk assessments after incidents had taken place. Staff had not added 22 paper incident records dating back from 18 July 2019 on Cherry Oak ward to the electronic incident reporting system. Managers had not reviewed a significant number of incidents on the reporting system. We were concerned that managers did not have effective oversight to ensure this work was completed or did not provide effective learning to take place to minimise the risk of repeated incidents. This resulted in staff not having robust risk assessments in place in order to safely manage the risk posed by patients to themselves or others.

• During July and August 2019, supervision rates for staff dropped to 33% for nursing staff. During this time, we noted an increased acuity on the wards and staff would have particularly needed support at this time. The quality of supervision records we did review demonstrated emphasis on conduct issues and lacked evidence of discussion of wellbeing or clinical discussion to improve practice. We were concerned that, due to the lack of supervision, staff’s stress levels had increased and promoted a culture for poor practice to develop.

This was an unannounced, focussed inspection. We did not rate this service at this inspection.

We found areas of improvement since the last inspection:

• Staffing had improved. The provider had created new posts and successfully recruited healthcare workers and a social worker into permanent positions.
• Staff morale had improved on Redwood and Woodlands wards and staff we spoke with all told us they were able to take their breaks, had more time to complete paperwork and activities and section 17 leave was rarely cancelled. However, staff morale was lower on Cherry Oak ward where staff were continually carrying out high intensity observations and there was an increased number of incidents against staff. Clinical governance meetings from June 2019 noted that staff on Cherry Oak ward were feeling ‘very beaten down’
• Managers had ensured that incident reporting had improved since the last inspection. Staff told us they were now expected to report incidents onto the electronic system immediately after an incident, wherever possible.
• Managers had improved oversight of the recording of serious incidents and there was improved identification of lessons learnt and sharing with staff. Governance meetings were taking place regularly, as planned.
• Staff knew about any risks to each patient and acted to prevent or reduce risks. We looked at observation sheets from the previous two weeks and all of them identified the patient risk and level of risk. This ensured that staff carrying out observations were aware of the reason for the observation level.
• Locum doctors, who did not have specialist training in psychiatry, had received additional supervision and training from their agency in the mental health act. They also had the opportunity to shadow speciality doctors and to observe ward rounds, which had increased their confidence and skills.
• Staff had access to support for their own physical and emotional health needs through an occupational health service. Reflective practise sessions, facilitated by psychology staff, were available for staff as a confidential place to explore feelings and gain support.

We found the following outstanding areas requiring improvement:

• The hospital continued to employ a high number of bank and agency staff and continued to find it challenging to recruit registered nurses. On Cherry Oak and Woodlands wards, the provider accepted agency staff with no specialist training in working with children. 
• Staff were not consistently following the hospital observation policy which could have an impact on patient safety.
• Staff were not ensuring that body maps were being completed fully, or transferred online if completed on paper, after every incident.
• We found inconsistencies in agendas and action planning around lessons learnt in meeting agendas and minutes. For example, on Redwood ward there was an agenda item called ‘ward improvement plan’ but no actions identified. Staff discussed lessons learnt under an agenda item called serious incidents in clinical governance meetings. Staff discussed incidents and lessons learnt during wellbeing centre minutes under a number of different agenda items. This made it more difficult to have a clear picture how actions from lessons learnt were identified and recorded.
• On Cherry Oak ward, we found three opened bottles of over the counter medicine, with a limited stock life. They had been opened, but not labelled with the date of opening. Staff could not be assured that these medicines would be effective or safe for patient use.

The Care Quality Commission carried out a comprehensive inspection of Ellingham Hospital on 8 and 9 January 2019

We issued a warning notice against Regulation 18 Staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Enforcement actions we told the provider to address are found at the end of the report.

During inspection we found that:

• We were concerned that the hospital continued to admit patients without assurance of being able to provide appropriate numbers of staff. Staff shortages, particularly for qualified staff, and high usage of bank and agency staff had an impact on both staff and patients. Staff regularly did not have time to take breaks, engage in activities, support new staff or fully complete paperwork. The provider did not provide sufficient staff to ensure patients accessed escorted leave in accordance with what had been agreed with them. Staff and patients told us that section 17 leave was often cancelled or delayed for patients requesting to leave the hospital. This was supported by section 17 paperwork.

• We were not assured that the enhanced observations were carried out safely. The provider policy for observations and engagement said that staff must not be continuously on 1:1 observations for more than two hours. Staff said that this was not always possible as there was often a high level of patients requiring observations. This included multiple staff observations where a patient required more than one staff with them at all times. On Redwood ward we saw that one support worker was tasked with supporting 14 patients on intermittent observations. We reviewed 13 observation records on Redwood ward. Of these 12 did not identify the individual patient risk. This meant that staff carrying out observations may not be aware of the reason for the observation level. However, the records were signed as complete.
• We were not satisfied that all serious incidents were being reported and reviewed by managers regularly. We found paper incident forms not uploaded on the electronic system in a timely manner on Cherry Oak Ward. We could not see rigorous identification and sharing of lessons learnt across all three wards.