The Care Quality Commission
  • Mental Health
  • Independent mental health service

The Copse

Overall: Requires improvement read more about inspection ratings

Beechmount Close, Oldmixon, Weston Super Mare, Somerset, BS24 9EX (01934) 818070

Provided and run by:
Elysium Healthcare Limited

Important: The provider of this service changed. See old profile

All Inspections

21, 22, 23 March 2022

During a routine inspection

Our rating of this location stayed the same. We rated it as requires improvement because:

  • Staff did not always feel safe on the wards and did not always adhere to policies and risk management plans to keep themselves and others safe. Staff felt there weren’t enough staff to respond and provide support in an emergency. Managers had not ensured the environment was safe and that staff were aware of interventions to mitigate identified risks. Staff did not manage medicines safely and there were repeated medicine incidents.
  • The service’s reducing restrictive practice programme was only partially embedded. Managers did not fully assess the negative impact of restrictive practice on patients and take steps to reduce this as far as possible. Patients told us they could not access the garden except at allocated smoking times.
  • Staff did not always understand the individual needs of patients or support them to manage their own care and treatment. Staff did not always respect patients’ privacy and dignity. Patients told us that not all staff treated them with kindness and respect.
  • Staff had not received specialised training required to meet the rehabilitation and recovery needs of patients. They were not working within the specified model of recovery and utilising best practice assessment and outcome tools routinely. Staff did not develop recovery oriented and person-centred care plans in response to assessments that were completed. The service did not have an occupational therapist in post and during the coronavirus pandemic the range of treatments, activities and therapies on offer had significantly reduced.
  • Patients had limited opportunities to engage with the wider community. Carers and families did not feel involved in patient care and felt that communication from the service was poor. Staff did not develop comprehensive discharge plans and it was therefore unclear how staff were working with patients towards meaningful recovery and discharge into the community.
  • Managers did not have a clear understanding of the expected length of stay for patients. There was a lack of governance processes in place to monitor how clinically effective the hospital was.

However:

  • There had been significant improvements in the individual risk assessment and management of patients since our previous inspection in 2021. Patients had positive behavioural support plans in place, and assessment and management of risk was more comprehensively discussed at multidisciplinary reviews. Staff recognised incidents and reported them appropriately. Staff followed safeguarding processes, took action to protect patients from abuse, and worked well with other agencies to do so.
  • Managers had ensured that mandatory training compliance had improved. Although there were vacancies within the staff team, the number of shifts that did not meet planned staff requirements had reduced in the previous three months.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff felt confident to raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards patients.
  • The occupational therapy assistants were proactively working to increase engagement with the wider community and organising activities within the community. Over the previous month activities in the community had been restarted and some patients were engaging in internal employment and volunteer opportunities.
  • There was a new leadership team who had a clear plan in place for the site and had started to make progress. Although new processes had not had time to be embedded as yet, the new hospital director was aware of the risk areas and performance issues facing the service. They had reviewed the site improvement plan and had developed this in response to the identified areas for improvement, and progress with this was already evident. Staff said there had been a positive shift in culture.

10-11 August 2021, 17 August 2021, 29 September 2021, 12 October 2021

During an inspection looking at part of the service

The Copse is a long stay, high dependency rehabilitation hospital that admits patients over the age of 18 with enduring mental health issues from acute inpatient services, to help them transition to living better lives in the community or in supported community placements.

The service was last inspected in July 2019 to follow up specific concerns in response to the previous comprehensive inspection in 2018 that highlighted a failure to comply with a number of the Health and Social Care Act Regulations (HSCA). We inspected the safe and well led key questions and found the provider had addressed all previously raised concerns and we rated the service good in all domains and overall.

We expect providers that deliver care and treatment to people within a long stay/rehabilitation service to be able to demonstrate how they meet the needs of patients in line with current guidance and best practice. We expect long stay/rehabilitation services to provide safe care and treatment that is recovery focused, promotes independence and treats people who use the service with dignity and respect.

We carried out an unannounced, focused inspection of The Copse following concerns identified during engagement with the service. Other information of concern received via complaints, whistleblowing’s and our ‘share your experience’ website option also informed our decision making. Concerns related to safe management of medications, incidents and issues relating to staffing.

We began our inspection on 10 August 2021. On 17 August, we returned to gather more information. However, on arrival on site, we made the decision to leave and allow the service to implement their management of suspected or confirmed Covid-19 outbreak effectively as required.

As we were unable to gather the information we required, the inspection activity was paused until a time where we were able to return and complete our inspection activities.

During the paused period, the provider updated us of changes they were making to the service and resources that were being implemented as a result of feedback we gave during our initial visit.

On 29 September, we carried out further reviews of care records via remote access at an alternative Elysium site. This was due to The Copse following Covid-19 outbreak protocols, which meant we couldn’t go on site.

We returned to The Copse for our final visit on 12 October. During our visit, we further reviewed documentation that could only be conducted on-site.

Our rating of this location went down. We rated it as requires improvement because:

  • The service did not always provide safe care. During our inspection we found there were times when there was not enough staff on the wards to meet the needs of the patients. Wards were not always left with enough staff to meet the needs of the patients when responding to emergency calls for assistance. Staff were not always able to take breaks due to lack of sufficient cover available for them to leave the wards.
  • The ward environments were not always safe. The wards had blind spots that were partly mitigated by convex ceiling mirrors. However, there were not enough staff on the ward that were able to monitor patients and view blind spots via the mirrors.
  • Staff and patients told us there was an over reliance on bank and agency staff which meant there were times when patients were not familiar with the staff providing their care. We were told by staff that occasionally agency staff did not turn up when they were expected to, which contributed to the service being short staffed.
  • There was not always enough registered nursing staff available. During our initial visit, we saw there was only one registered nurse on duty that night. We reviewed previous night staff allocations and saw that there had been other recent occasions where only one registered nurse worked the night shift. The nurse was responsible for all medication administration across the four wards during the shift. We found eight occasions over the previous three months that the registered nurse administered controlled medication outside of company policy, without supervision and a signature from a second registered nurse. These administration errors coincided with times that only one registered nurse was on site. During these shifts, the registered nurse could not have a break for the whole shift or comfort breaks without leaving the wards without a qualified member of staff. Staff told us this was not an isolated occurrence.
  • Staff did not implement robust systems and processes to safely administer and manage medicines. Medicine management audits were not always acted on in a timely manner by staff. Staff did not consistently follow national guidance and company policy to ensure correct administration of medication. Clinical staff did not ensure that patients who received high dose antipsychotics (cumulative or single doses of antipsychotics above British National Formulary recommendations) had care plans in place, and that the effectiveness and appropriateness of this medication was regularly reviewed.
  • Staff did not assess or manage risk well. We reviewed care records and found that identified risks were not recorded properly and with appropriate management plans, which meant known risks and concerning behaviours were not safely mitigated. We saw no evidence of decision-making processes to substantiate the appropriateness of decisions being made. Disproportionate restrictions were placed on a patient that did not aid their recovery or promote wellbeing. The impact of this meant patients were at a risk of harm to themselves and others. Not all staff knew the location of emergency equipment. During our initial visit, a staff member was unable to identify where the emergency grab bag and defibrillator were kept.
  • Reporting of incidents was not consistent. Staff did not report all incidents in a timely manner and had not reported some incidents to external agencies as required. The escalation of incident reporting allows providers to reflect and learn, this learning could then be shared across the organisation to improve safety, practice and outcomes for people who use the service.
  • The service was not well led, leaders did not display clear oversight of the service. Staff we spoke to told us they were unsure of who held certain areas of responsibility. Monthly clinical governance meetings minutes lacked action plans to address all identified concerns.

However:

  • The service made some improvements to documentation around risks and risk management plans following our initial inspection visit. Minutes of multi-disciplinary team meeting (MDT) were more detailed and included discussions around risks and included some rationale to decisions made.
  • Further review of care plans following the initial visit showed that improvements had been made in response to the issues we had raised. Improvements included accurate identification of risks and management plans appropriate to meet the needs of the patient. Physical health needs, medication and food/fluid intake were comprehensively documented, personalised and up-to-date plans in place. Inappropriate restrictions that were previously placed on the patient were lifted and the rationale for other interventions were well documented.
  • A further visit in October showed improvements had been made following a review by leaders within the service. The clinic room was clean, tidy and equipment stored appropriately.
  • The service had restructured the ward arrangements following feedback on the initial visit. They had employed an additional ward manager to provide more leadership capacity with the staff teams. Leadership structure and accountability was better established.
  • Seven healthcare workers, two staff nurses and a deputy ward manager vacancy had been filled to reduce the number of bank and agency staff used following the inspection visits.

10 July 2019

During an inspection looking at part of the service

We undertook an unannounced, focused inspection of The Copse following concerns identified at our last inspection in November 2018. During that inspection, we found the provider was not fully meeting the required standards of care in Regulations 12 (safe care and treatment) and 17 (good governance) of the Health and Social Care Act (Regulated Activities) Regulations 2014. The service were not completing physical health checks following medication, and did not have reliable systems in place for safeguarding, completion of mental capacity assessments and incident reporting and follow up.

During this focused inspection we inspected the safe and well led key questions only to see if the service had made the required improvements. The service was rated as requires improvement in these key questions following the previous inspection. The service was rated as good in the effective, caring and responsive key questions. These areas were not inspected at this time and so the previous ratings for these areas remain.

During our inspection we found that all the required improvements had been made.

Our rating of this service improved. We rated it as good because:

  • We were satisfied that the service had made improvements following the previous inspection, because systems were in place to ensure staff were carrying out physical health checks of patients on clozapine medication and after rapid tranquilisation.
  • Improvements had been made to ensure systems were in place to ensure that safeguarding concerns and incidents were reported and followed up appropriately. Staff were also completing and recording mental capacity assessments. Systems were in place to ensure this was done.
  • The service provided safe care. The ward environments were safe and clean. The wards had enough staff. Staff assessed and managed risks to patients and themselves well. They achieved the right balance between maintaining safety and providing the least restrictive environment possible in order to facilitate patients’ recovery. They managed medicines safely and followed good practice with respect to safeguarding.
  • Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The service worked to a recognised model of mental health rehabilitation. It was well led, and the governance processes ensured that ward procedures ran smoothly.
  • Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff felt respected, supported and valued. They felt able to raise concerns without fear of retribution.

14 - 15 November 2018

During a routine inspection

We rated The Copse as requires improvement because:

  • Staff did not always carry out or document that they had carried out physical health checks for patients. They had not checked a patient for signs of over sedation, after administering rapid tranquilisation medicine to reduce their aggression; over sedation can lead to breathing complications and potentially suffocation. We found mistakes had been made with the administration of clozapine (a medicine with potentially serious cardiac effects. Despite clear documentation to tell staff not to administer a full dose of clozapine (national guidance is to build up to the full dose) staff had administered the full dose straight off. Staff had not recognised that this should have been reported as an incident. Once we highlighted this to staff, they reported it as an incident. Patients on this medicine were not checked regularly for any signs of side effects.
  • The systems in place did not ensure that allegations of abuse were raised in a timely manner to the appropriate bodies. Staff had received training on how to identify and raise concerns, but they left this task to a single member of staff. There were poor cover procedures or protocols for when this staff member was on leave or sick. We saw that this meant two alerts had not been made to the local authority, and staff had not notified CQC of the allegations of abuse as is required. We raised this and staff made the alerts retrospectively. Delays in raising safeguarding alerts potentially puts patients at risk of further abuse.
  • Processes to ensure that learning from incidents was recorded did not always work. Staff discussed changes in patients’ risks, and incidents that took place, but did not always document this appropriately or update risk assessments following incidents.
  • The process that staff followed when assessing a patient’s capacity to make decisions about their care did not ensure these assessments were always completed or available to relevant staff. We saw incidents where staff had acted against patients’ wishes without assessing their capacity to make that decision. When staff did carry out best interest assessments they stored this on a staff member’s individual computer drive, rather than in the care records. This meant that staff could not always access the documentation they needed.

However:

  • Staff had started to implement a new recovery model based on the Recovery Star to help guide patients through their recovery and reach their individual goals.
  • Patients said they felt staff were caring and supportive and involved them in their care planning and care decisions.
  • A new hospital director had taken up post six months before this inspection, which staff saw as a positive. They felt the new director was approachable, supportive and willing to listen and act on any concerns their concerns. This had helped develop a culture of respect and pride in working at the hospital.
  • The admission and discharge process at the hospital allowed patients to be discharged when they were ready (if there was an appropriate placement for them to go to).
  • There were facilities to ensure that people with disabilities could receive care at the hospital, and the service could provide meals to meet patients dietary, cultural and spiritual needs.