19, 20, 21 and 25 July 2023
During a routine inspection
The Chief Inspector of Hospitals is placing St Mathews Broomhill Hospital into special measures. Services placed in special measures will be inspected again within six months. If sufficient improvements have not been made such that there remains a rating of inadequate overall or for any key question or core service, we will act in line with our enforcement procedures to begin the process of preventing the operator from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.
Our rating of this location went down. We rated it as inadequate because:
- The provider had not ensured they had effective governance structures and processes to provide oversight and assurance of all aspects of service delivery to be able to identify and improve practice in a timely manner and sustain that improvement. Examples included patients’ identifiable information was not always kept securely. There was no effective monitoring to ensure patients received debriefs after incidents of violence or aggression from other patients. Such incidents were not recorded in a timely manner to allow for effective monitoring. There was little oversight to ensure that all patients received a comprehensive assessment and treatment plan in a timely manner, managers had not realised that some care planning information was cut and pasted between records, leading to recording errors. Managers were not monitoring the quality of the food served on the wards. Managers were not effectively monitoring the mandatory training compliance for all staff. A lack of governance oversight regarding mandatory training and sustainable action plans had been cited in previous inspection reports and enforcement action we had taken. This related to all wards in the hospital wide issue.
- The provider did not provide an environment which was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff could not observe patients in all parts of the hospital and there were reports of staff sleeping while on observation duties. We saw multiple blind spots throughout the wards in the long stay rehabilitation, which were not mitigated by mirrors or individual risk assessments. Numerous ligature points were identified on the ligature risk assessment, however the mitigation identified did not address the identified risk. This was reported on in previous inspection reports.
- Staff failed to ensure that all corridors were kept clear of hazards to enable safe exit from ward areas in the case of emergency and that patients had access to call alarms.
- The provider had failed to address maintenance issues and repairs in a timely way, leaving areas of risk for some patients. Staff had not ensured that all necessary repair works to improve the quality of the environment were completed within reasonable timescales and that high-risk requests were resolved on the same day. Not all ward areas were clean, and some wards had ripped, dirty, or broken furniture and fittings.
- Staff had not fully risk assessed all patient activities on the ward including potential risks relating to other patients. We saw electrical equipment placed on the floor in patient areas and staff had not fully risk assessed this issue. We found plastic bags in a drawer on one ward.
- Staff were not adhering to the hospital’s policy and procedure when bed rails were used.
- The service did not work to a recognised model of mental health rehabilitation, to meet patients’ needs. Staff were not routinely offering patients regular access to activities that promoted rehabilitation such as employment and education opportunities. This had been cited in previous inspection reports.
- Staff did not always adhere to the hospital’s infection prevention and control policy. Examples include food hygiene and storage of food. Lack of cleaning in areas where patients ate their food. Bedrooms that had not been cleaned before admission. Staff who were not bare below the elbows and wearing jewellery. Staff did not ensure that the traps used to manage the current mouse infestation on Manor ward were not placed in patient areas.
- Staff had not always followed best practice after administration of rapid tranquillisation regarding the monitoring and recording of physical observations. This had been cited in previous reports.
- Staff did not always ensure that patient medication was prescribed within British National Formulary limits and where this was needed, they were not recording a clear rationale for doing so and there was no evidence that second opinion was always sought. Staff had not ensured that all patients could give consent to treatment by medication.
- Staff had not always followed National Institute for Health and Care Excellence guidelines when undertaking enhanced patient observations. This was an area of concern in February and September 2020. Staff had not always used the correct techniques when restraining patients. Staff did not always have access to de-escalation facilities.
- Staff had not always routinely checked cleaned or calibrated medical equipment. Staff had not regularly checked the emergency grab bags and defibrillators, and emergency equipment was accessible in a timely manner.
- Staff had not always ensured that patients were protected from harm and safeguarded. Incidents included patient on patient assaults, sexual vulnerability and staff not managing known allergies. Managers had not managed the numbers of assaults and altercations between patients. Patients told us they did not always feel safe on the wards or received debriefs from staff following any incidents. Adequate safeguarding of patients was an area of concern in February 2021.
- Staff did not always treat patients with compassion and kindness, dignity, and respect. Staff did not always respect their privacy and dignity and did not always understand the individual needs of patients. We heard of several occasions when staff had been speaking to one another in front of the patients, in a language other than English. Staff did always knock on bedroom doors before entering. Staff who had made hurtful, racist, and derogatory remarks to patients. Dignity and respect issues been cited in previous inspection reports and enforcement activity.
- There were limited rooms for use as quiet areas on some wards. Wards had limited space for patients to meet visitors in private.
- Staff had not always made sure that patients were fully involved in the development and ongoing monitoring of their care plans, some patients told us they did not have copies of their care plans and there was no evidence in the care plan records that copies were routinely given to patients.
However:
- The ward teams included or had access to, the full range of specialists needed to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary team. This was an improvement on previous inspection findings.
- Staff had developed care plans informed by a comprehensive assessment. This was an improvement on previous inspection findings.
- Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.