Archived: Garrow House

Updated 16 July 2018

Garrow House is a 12 bedded specialist tier four personality disorder inpatient service that admits female patients from the Yorkshire and Humber region. Garrow House is run by Northern Pathways Limited; a partnership between the Turning Point Group and the Retreat hospital, York.

Garrow House has been registered with the Care Quality Commission since 13 December 2010 and is registered to carry out two regulated activities:

• assessment or medical treatment for persons detained under the Mental Health Act 1983
• treatment of disease, disorder, or injury.

The hospital had a registered manager and a controlled drug accountable officer in place at the time of inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. The registered manager has a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations regarding how the service operates. An accountable officer is a senior person within the organisation with the responsibility of monitoring the management of controlled drugs to prevent mishandling or misuse as required by law.

At the time of inspection the hospital was providing care and treatment for 11 patients.

The Care Quality Commission has inspected Garrow House on six previous occasions. The last comprehensive inspection (where we inspected the five domains of safe, effective, caring, responsive and well led) took place in January 2016. We rated the service good overall and issued one requirement notice for safe under Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Safe care and treatment. This was because:

• staff did not ensure that all equipment used for providing care and treatment was safe for use
• staff did not follow policies and procedures for the safe management of medication.

We rated effective, caring, responsive and well led as good and safe as requires improvement.

We also carried out two follow up inspections in November 2016 and June 2017 to see if improvements had been made.

At the November 2016 inspection, we found that the provider had not made all the required improvements identified within the requirement notices from the January 2016 inspection.

Following the inspection in November 2016, we issued the registered manager with a warning notice under Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Good Governance. This was because we found continued issues with staff compliance with hospital policies and procedures related to medicines management. We identified the following issues:

• The hospital did not have effective systems or processes to ensure that all staff complied with the hospital’s medicines management policies and procedures.
• The hospital did not monitor and improve the quality and safety of the services sufficiently to ensure that medicines practices were safe for patients.
• The hospital did not adequately assess, monitor, and mitigate the risks relating to patients health, safety, and welfare. This included patients who received medication for rapid tranquillisation, anti-psychotic medication, and patients who administered their own medication.
• The hospital did not maintain accurate, complete, and contemporaneous records for patients who were prescribed medication.

At our focused inspection in November 2016 we did not fully inspect the safe and the well-led domain. However, our findings from the November 2016 changed the overall rating from good to not sufficient evidence to rate.

In June 2017 we carried out a focused inspection confirm if the provider had made all of the necessary improvements identified in the warning notice issued at the November 2016 inspection. We saw that although some improvements had been made, there were still issues with medicines management in the service. We issued a requirement notice under regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Good Governance because:

• The provider did not maintain accurate, complete and contemporaneous records in respect of each service user and of decisions taken in relation to the care and treatment provided.
• The provider had not kept a record of the initial risk assessment carried out at the multidisciplinary meeting regarding self-administration of medicines. Following the administration of rapid tranquilisation staff had not recorded the level of consciousness for patients, in particular when the patient had refused to have their observations taken.

During this inspection we saw that the provider had taken action to address the issues identified in the previous inspections.

Updated 16 July 2018

We rated Garrow House as good because:

• Garrow House had a strong, visible person centred culture and staff offered care that was kind. Women using the service were truly respected and valued as individuals and empowered as partners in their care.
• The service had a full range of rooms and equipment to support treatment and care. It was welcoming, clean and had pleasant furnishings. Equipment was checked regularly and well maintained. Although there were blind spots on the ward the service had clear, well communicated protocols that staff followed to lessen risk.
• The service used a recognised staffing tool to calculate staff numbers and skill mix. The service adjusted staffing levels to take account of case mix and ensured that service users could take leave and have access to an extensive range of activities seven days a week.
• The service had a proactive approach to anticipating and managing risks to women that used the service. Risks were clearly communicated and considered prior to, throughout and following admission. Risk management was integral to the service users’ care and treatment.
• The service cared and treated the service user’s physical and mental health needs and most care plans and risk assessment were completed collaboratively with service users and staff.
• The service had a thorough incident monitoring program and staff met regularly to discuss feedback. Staff visibly understood their responsibilities and acted accordingly.
• Staff induction included a range of training that helped them to understand the service users’ needs. Staff were encouraged and supported to develop professionally and acquire new skills. Staff had regular access to supervision, team meetings and reflective practice sessions.
• Staff understood and applied the principles of the Mental Health Act, the Mental Health Act Code of Practice and the Mental Capacity Act. Staff knew who to contact for additional advice and support. Staff could clearly explain their understanding of seclusion in line with the Mental Health Code of Practice definition and it was recorded and completed in accordance with the code.
• All of the service users described staff as caring, supportive, respectful and interested in their wellbeing. The women told us that the service promoted independence. Staff were fully committed to working in partnership with the women and we saw this happening in all aspects of their care. Feedback from people who used the service, those who were close to them and stakeholders was continually positive about the way staff treated the service users.
• Garrow House had a clear admissions process that informed and orientated the women to the ward and the service. Women had multiple ways to feedback about the service and the service fully encouraged and supported the women to do so. The service implemented changes based on service user feedback.
• All patients and staff knew the senior managers at Garrow House and described them as available and approachable. They said they were able to speak up without fear of victimisation, felt fully supported and that managers listened.
• Staff morale on the unit was high. There was strong collaboration and support across all functions and a common focus on improving quality of care and people’s experiences. Staff worked as an effective multidisciplinary team that focused on the recovery of the service users. There were no barriers between any of the disciplines and staff respected each other’s contribution.
• Garrow House had good systems in place to run the service effectively. Governance and performance management arrangements were proactively reviewed.

However;

• Some Mental Health Act and ‘use as required’ medications care plans were generic and had not been updated to reflect the individual service users’ needs. The service had not completed a risk assessment to determine the emergency medicines stock held in line with best practice guidance and daily checks had not identified defibrillation pads that had recently gone out of date.
• Medicines reconciliation was completed for all new admissions by the pharmacy service but this was not recorded in the care notes due to the pharmacy team not having authorised access to the provider’s system.
• The service’s environmental ligature assessment did not include the garden and outside environment where there were ligature risks.
• Informal patients’ fob access did not include the front door so women in the service had to ask staff to leave the ward.
• There was limited evidence of discharge planning visibly recorded on the electronic records system and care plans did not reference section 117 aftercare.
• There was no process to review patterns and trends over time for informal concerns and the complaints policy did not provide clear timelines for investigation or time points to feedback to the complainant for formal complaints.
• Staff were unclear who the Freedom to Speak Up Guardian was within the Turning Point organisation.

Updated 23 February 2017

Updated 16 July 2018