Sturdee Community Hospital

We rated Sturdee Community Hospital as requires improvement because:

• Managers had not ensured that the ligature audit was complete. There was no ligature audit for Aylestone unit or Foxton ward. Ligature points had been identified on Rutland ward including the blinds in the gym and sliding door in the corridor, but no action had been taken to reduce these specific risks. Managers had not identified blind spots throughout the service.

• Staff were not following the “to take out” (TTO) medicines policy. Staff recorded the medicines fridge as above eight degrees on 28 occasions in a two-month period.

• Doctors had not ensured that medication charts were written in accordance with guidance. We found one medication chart did not refer to the fact that Olanzapine and Lorazepam, prescribed for the same person, should not be administered within one hour of each other.

• Staff administered insulin to a patient from the medication trolley that was out of date.

• The hospital did not have an effective system of oversight for the delivery of its Mental Health Act administration functions. The hospital did not have a current or robust policy in place to cover the range of Mental Health Act administrator’s obligations. Managers had not provided the new mental health administrator with sufficient training, guidance and mentoring.

• Managers did not ensure completion of quarterly external audits of all Mental Health Act paperwork.

• Incident recording was variable. While staff reported incidents and notified to CQC, seven out of twenty records checked did not include what actions managers had taken, or what lessons they had learned.

• The inspection team considered quarterly visits by an external pharmacist was not adequate. Visits that were more frequent may have picked up the issues found during the inspection.

• Staff had not updated patients individual occupational therapy activity plans to reflect their current needs. Individual activity plans did not detail how the patient would achieve their identified goals.

However:-

• Wards were visibly clean, well maintained and had good quality furnishings. The infection control policy was in date. Cleaning records were available. All staff carried personal alarms and ligature cutters.

• Staffing levels at the hospital were good. The hospital had their full establishment of nurses and a multi-disciplinary team to meet the needs of their patients, and recruitment drives had been successful.

• Ninety-four percent of staff had attended mandatory training.

• Staff carried out full physical healthcare examinations as required. Staff completed separate and comprehensive physical healthcare records for each patient. Staff addressed specific issues such as pressure sores, and signs and symptoms of potential sepsis.

• Communication systems in the hospital were effective. Staff, including support staff, catering and maintenance staff attended a range of in house meetings including daily briefings, community meetings, and integrated governance meetings. This ensured that all staff working at the hospital were familiar with the patients and their current needs. All staff felt informed about the wider issues affecting the hospital.

• Patients and staff planned, facilitated and attended the weekly interactive academic teaching sessions on a Thursday morning.

• There was a clear admission and discharge policy and procedure, overseen by the consultant psychiatrist in discussion with the multi-disciplinary team.

• Staff understood the provider’s vision and values based on growth, recovery, ownership, warmth, and time and healing. A philosophy of positive risk taking and least restrictive practice underpinned the vision and values.

• Managers made significant changes to policy and practice following feedback from previous inspections, complaints and incidents.

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

• Doctors prescribed medication on more than one medication chart. We found that the same types of medication had been prescribed on both charts. If staff had administered the medication in the same 24 hours period it would have resulted in an overdose for the patient.
• Staff recorded the monitoring of patients physical health in four separate documents. However, staff did not ensure that all four documents were fully completed specifically the National Early Warning Score form. Due to the duplicated records we found it difficult to ascertain baseline observations for patients and if staff had fully addressed all physical health concerns.
• Staff did not seek medical intervention after monitoring a patient’s physical health and found that the patients’ blood sugar was outside of the normal limits.
• Whilst managers had a clear oversight of incidents that had taken place within the hospital they did not have a robust system in place to ensure that incident forms were fully completed. We found incident forms were not completed fully or reviewed by a senior member of staff. In addition we could not be assured that incidents were recorded within patients care notes or discussed in ward rounds as ward round summaries were missing from patients’ case records.
• Following a serious incident, managers had put measures in place to count cutlery. Whilst staff were following this new process, we found that the records showed a spoon had been missing for over five days. When we spoke with managers they were aware of this but no action had been taken to address it.
• Senior managers did not have access to the services ligature audit during the inspection.
• Managers had developed a red, amber green (RAG) rating system to assess patient’s risk. However, there was no guidance or procedures in place for staff to use the system.
• Managers did not have a robust system to ensure that patients detained under the Mental Health Act had their rights explained to them and that the paperwork remained in order and up to date.
• Mental Health Act papers were not examined by a suitable trained member of staff. The most up to date section 132 had not been filled correctly. Staff did not have immediate access to detention paperwork. Managers had partially addressed the concerns highlighted in regards to the two unlawful detentions. However, we found that the action plan was not robust and did not fully address the concerns.
• The management of incident reporting was unclear. Managers could not fully explain why they continued to use a process that duplicated incidents forms which we found to be incomplete. Managers did not have processes in place to ensure that all incidents were fully recorded within the patient case notes.
• There was no alert in place at the beginning of the patient’s case records to inform staff that the patient had physical healthcare issues that needed to be closely monitored. Whilst case records held this information we found it difficult to locate it quickly.
• Whilst weekly multi-disciplinary meetings took place to discuss patient care and treatment this was not always recorded within the patients case notes.
• Staff reviewed care plans on a monthly basis and recorded the review on a separate document. However, it was not clear that the patients had been involved in the reviews.
• Policies and procedures were in place for staff to follow and were available online. However, the manager had not kept the paper copies of polices in date. This increased the risk of staff not adhering to the most up to date policies.
• Managers did not have a robust recording system in place for monitoring patient’s physical health. Although staff had comprehensive discussions about the physical health needs of the patients the paperwork was duplicated and incomplete.
• Managers had formulated an action plan to address issues that were identified from the last CQC inspection in November 2016. We reviewed this during the inspection. We found that although some actions were highlighted as achieved this was not the case.

However:

• Since the last inspection carried out in November 2016 managers had adapted rooms on a closed ward so that patients had space to have one to one time in a private, quiet area of the hospital.
• Throughout the inspection we observed positive team working and mutual support for staff. Staff commented that they felt supported by all members of the team from the clinical staff to housekeeping.
• Patients we spoke with told us that staff were supportive with their mental health issues and any physical health issues. They felt that staff understood their individual needs.
• Multidisciplinary handovers and briefing meetings between shifts were effective. The notes taken in handover were comprehensive, and showed that staff had discussed staffing levels, the physical health care needs of patients and specific nursing duties that needed to carried out during the shift.
• 80% of staff had received regular in line with the services policy of four supervision sessions per year. In addition to this the managers provided supervision to regular bank staff that worked at the hospital.
• Managers carried out investigations into serious incidents and highlighted areas of practice that need to be improved.

We rated Sturdee Community Hospital as Good because:

• Patients said they felt involved with the day-to-day running of the hospital and when planning their care needs.

• We observed staff interacting with patients in a positive way, there were a variety of activities available seven days a week. Staff said there had been a lot of positive change over the last 9-12 months.

• Staff and patients jointly facilitated a weekly program of interactive academic education sessions, these sessions contributed to staffs continuing professional development and patients’ knowledge and skills portfolios.

• Staff used Health of the Nation Outcome Scales (HoNOS) and the recovery star to assess and record severity and outcomes for all patients. Staff carried out a range of audits and we saw how managers had made improvements.

• The hospital had a policy and procedure for carrying out observations. Staff kept up to date records of observations carried out. Staff and patients used and understood the personalised red, amber, green (RAG) rating to manage identified risks.

• Patients told us the variety and quality of food was good, and staff understood their needs. There was a range of activities available seven days a week and they were able to personalise their rooms and bed space.

• Senior managers held two daily morning meetings to discuss patient’s needs, any concerns, or complaints and to address issues promptly. This ensured that all staff could attend the meeting.

• Ninety two percent of staff had attended mandatory training, 100% of clinical staff had completed medication management training, and 84% of staff had completed safeguarding adults and children level one.

However:

• Whilst the ligature audit included all ligature points, it did not give sufficient detail about how ward staff should manage the identified ligatures.

• Healthcare support workers we spoke with did not fully understand the purpose of their supervision.

• At the time of the inspection, the provider had not updated their statement of purpose to reflect their current service model. They informed us they were finalising this document and subsequently submitted it within ten days of the inspection.

• There was no protected nurse time during routine medication administration.

We rated this hospital as inadequate because:

• Although the staff had completed a ligature risk assessment, they had not taken action or developed a strategy to mitigate any risks.

• The hospital placed blanket restrictions on patients rather than assessing individual needs. For example, patients could not have a key to their room, they all had to use plastic beakers for hot drinks, and all visits had to be authorised by the multidisciplinary team (MDT), including adult family members.

• The hospital used high levels of agency staff meaning patients did not always know staff working on the wards.

• Rates of staff training were low for bank staff, meaning the service did not have adequately or appropriately trained staff on shift at all times.

• Patients’ care records did not include patients or staff comments where patients disagreed with aspects of their care plan.

• Staff could not provide us with a copy of their induction pack when asked. The hospital did not provide temporary staff with written guidance on the local health, safety and security procedures for the ward when they arrived on shift.

• The managers of the hospital did not recruit staff in line with the hospital policy. They did not carry out pre-employment checks thoroughly to make sure the staff were suited to work with the patient group.

• The hospital did not have effective discharge planning so could not ensure patients had safe and coordinated care when they were discharged.

• We found adjustments for people requiring disabled access were poor. The gym, new visitors /family room, and adapted kitchen were accessed via a steep staircase. There was no lift available.

• Patients had limited access to a full range of rooms and equipment to support care and treatment.

• Rutland ward did not have any quiet areas, where patients could meet visitors in private.

• Staff could not describe the vision and values of the organisation and they could not tell us who the senior managers of the service were.

• Senior managers failed to assess health and safety risks to the premises which impacted on the safety and wellbeing of patients.

• There was a lack of openness and transparency between the provider and the hospital director which resulted in the identification of risk, issues and concerns being discouraged.

• The hospital director had no administration support.

• Staff expressed concern about bullying and were reluctant to report concerns about the service to managers.

• The hospital director was appointed seven months before, but the hospital still did not have a registered manager.

However:

• Medical records and medicine management systems were good.

• Rutland ward and Aylestone unit areas were clean and well maintained.

• A full range of mental health disciplines and workers provided input to the ward.

• Patients’ had good access to physical healthcare, including access to specialists when needed.

• Care records were up to date and comprehensive, apart from including patient’s views.

• We observed effective staff handovers.

• There were effective working relationships with teams outside the organisation including joint risk meetings.

• Patients knew where and how to access advocacy services.

• Staff and patients interacted positively and we saw evidence that staff had an understanding of individual patients’ needs and preferences.

• Staff appeared interested and engaged in providing good quality care to patients.

• Most patients were involved in planning their care. Patients could attend the ward rounds fortnightly. Staff identified special occasions, such as patients’ birthdays. Patients and staff would celebrate and kitchen staff made fresh cakes.

• Kitchen staff prepared fresh meals that were good quality. Staff prepared fresh fruit for patients that was available in communal areas.

• Staff supported patients to purchase their own food. This was stored in the kitchen with appropriate individual labels.

• Ward staff worked well as a team and offered support to each other.

• The hospital director arranged for staff annual appraisals and supervision. Ninety five per cent of staff received three monthly clinical supervision.