Updated 7 January 2020
We rated St Andrew’s Healthcare overall as requiring improvement because we identified concerns in both the safe and well-led domains.
We rated the safe domain as requires improvement because we found the following:
- Environmental concerns including, actions from ligature audits were not completed in the Essex location. There were blind spots in some seclusion rooms and bedrooms.
- Medicines in the Birmingham hospital were not stored and disposed of safely.
- Care and treatment records were incomplete.
- Staffing Concerns including, a high use of bureau (bank and agency) staff. Night time cover on wards was a concern as staff were frequently moved from allocated wards to address shortfalls. There was only one doctor providing waking cover with a second doctor on call to the Northampton site between 11pm and 8am.
- We had concerns with the assessing and management of risk. We were concerned with the number of prone restraints being used in the CAMHS wards. Risk assessments and care plans around the use of prone restraint were not always in place.
- We also identified concerns with seclusion practices including poor recording and reviewing. We also saw that seclusion rooms were used for “time out”.
We rated the well-led domain as requires improvement because we found the following:
- The governance systems were not effective as there were variations in quality of service between hospital locations and between services in the same hospital or core service area. Even though we found that the board assurance framework and charity wide risk register, had identified many of the risks during our inspection.
- In some services staff morale was low. Staff working on the CAMHS wards told us they felt underappreciated by those senior managers and often felt not listened to as the provider was focused on other services areas. Staff from the learning disability wards told us they found it difficult working with high numbers of bank and agency staff in challenging environments.
- Some managers were managing more than one service. This was affecting their availability and effectiveness.
In the core services inspected we saw evidence of good practice. This was being delivered by caring and professional staff who were working collaboratively. However this was not the case in the learning disability service or the child and adolescent learning disability wards. Where we found that;
- Information was not produced in an accessible format for people.
- The staff we spoke with did not have a good knowledge of the safeguarding policy or procedures.
- There were issues with the use of and recording of seclusion. This included using seclusion facilities for “time out”.
- Notifications of incidents that required reporting to the CQC had not been made.
- There was a high use of bureau (bank and agency) staff which meant that staff did not always know the patients. The handovers that we observed were not comprehensive.
- We saw the use of a generic, restrictive risk safety system rather than individual risk assessments based on patient needs. These plans were often not discussed with or explained to the patient in a way that they understand. We were concerned that not all care and treatment was patient centred and relevant to the patient group.
- Managers and staff had a very limited understanding of children’s rights in the CAMHS services which meant care was not always planned in accordance with children’s rights.
The board, executive team and senior managers had recently undergone changes in key roles including a new chairman, chief executive and chief finance officer. People who use the services, staff and external stakeholders told us of new initiatives and plans to develop the service.
Before and during our inspection, people told us that most staff treated them with kindness, dignity and respect.
The provider managed risks and identified and investigated safeguarding concerns. Staff were aware of their role to identify and report all concerns and risks. However in the Essex service actions identified in the ligature risk assessment had not been completed on Audley ward. Care and treatment records were incomplete for one patient who had long term physical healthcare needs.
We visited all of the wards where detained patients were being treated. In the majority of the care records, which related to the detention, care and treatment of detained patients, the Mental Health Act (MHA) and the code of practice had been followed.
The provider was providing evidence based treatments in line with best practice guidance. Patients were being supported to make choices and gave informed consent where possible.
The provider was using outcome measures to judge the effectiveness of the treatment provided.
The governance processes were not fully supported by robust quality assurance systems. Many of these systems were new and had not always identified poorly performing services in a timely manner. This meant that although the provider understood its broad areas of risk it did not always identify all of the areas of concern early enough.
St Andrew’s Healthcare was providing a caring service for people across all locations. We saw throughout the inspection staff treating people with kindness, dignity and compassion. The feedback received from people who used services and their visitors was generally positive about their experiences of the care and treatment provided by the provider. However there were concerns identified on the learning disability wards. We were told that patients’ and carers’ were not involved in the planning of care. The care plans were not being produced in a person centred way and these were not available in an accessible format to assist patients to understand them.
Staff worked well together to meet people’s needs and that they were able to respond to individual needs and preferences.
The provider was in a period of change. The governance system for executives and non-executives was changing from a charity to a health provider and people were being appointed with health experience to effectively offer challenge. Lines of communication from the board and senior managers to frontline services were seen as a priority and people told us that the new chief executive had more presence in the clinical areas. Staff felt well supported by their immediate line managers. However the organisations vision and values were not fully embedded across the provider.
The main challenge for the provider was to ensure that governance processes were supported by quality assurance systems. This has meant that in each domain there are areas of very positive work but also areas where improvements are required.
There were variations in the quality of service provided between locations and services in the same locations or core service area. As a consequence there are a number of compliance actions relating to different services and it is our view that the provider needs to take steps to improve the quality and safety of their services. We will be working with them to agree an action plan to help improve the standards of care and treatment.