CQC criticises seclusion at adolescent mental health service

St Andrews’s Healthcare Adolescent Service in Northamptonshire has been rated “inadequate” and placed in special measures by the Care Quality Commission, after an inspection found the safety of care had “deteriorated”.

“In some important respects, the safety of care has deteriorated” 

Paul Lelliott

The service at FitzRoy House, which cares for up to 100 young people with mental health conditions, autism and learning difficulties, will be closed if it does not improve by the time it is re-inspected within six months.

Inspectors were “particularly concerned” with how the service responded to patients whose behaviour staff found challenging, such as seclusion and long-term segregation, despite having raised the issue 12 times with the provider following previous inspections of hospitals it manages.

In its report, the CQC found that staff had not taken reviews or completed care plans for seclusion or long-term segregation and, in three instances, staff had secluded patients for longer than necessary.

Out of 21 reviews of episodes of seclusion, the CQC found medical reviews had not been carried out within the first hour of seclusion in six episodes and that nursing reviews had not taken place in all instances.

In the seclusion rooms, the health watchdog found the physical environment was “not always safe”, noting sharp edges on door frames, blind spots in the rooms and pieces of exposed sharp metal.

“If urgent improvements are not made to ensure people are safe, we will take action to prevent the provider from operating this service”

Paul Lelliott

Inspectors also noted discrepancies between written incident reports, staff recollection of incidents and images of those incidents captured on CCTV.

In addition, the CQC flagged that “staff did not always treat patients with dignity, compassion or respect”.

Observation records for nine episodes of seclusion detailed 28 entries describing a patient sitting or lying on the floor, the report noted, whilst highlighting the lack of bed, pillow, mattresses or blankets in seclusion rooms.

“It was the inspection teams view that this practice was uncaring, undignified and disrespectful,” the report stated.

On one occasion, inspectors found staff did not ensure female staff supported a female patient when changing clothes. The CQC said this “did not protect the patient’s privacy and dignity”.

Another area of concern was staff shortages in which the report identified instances of this impacting young people getting leave and attending activities.

The CQC said the service had “failed to ensure that shifts were fully staff”, adding it relied heavily on agency and bank staff in an attempt to make up the numbers.

Care Quality Commission

Dr Paul Lelliott

Paul Lelliott

Following the inspection, CQC’s deputy chief inspector of hospitals and lead for mental health, Dr Paul Lelliott, said: “This is the third time that we have inspected St Andrew’s Healthcare Adolescents Service in the past two years.

“Over that time, the service has failed to address some of the concerns we have raised. In some important respects, the safety of care has deteriorated,” he added.

Dr Lelliott also said: “We have told St Andrew’s Healthcare that it must take immediate action to address the problems we identified.

“We will continue to monitor the service closely and if urgent improvements are not made to ensure people are safe, we will take action to prevent the provider from operating this service,” he said.

The service has been told it must make a number of improvements before the next review, including:

  • The provider must ensure staff treat patients with kindness, respect and dignity. They must ensure patients’ comfort when using seclusion rooms as required by the Mental Health Act Code of Practice and ensure their privacy and dignity is upheld at all times
  • The provider must ensure that staff follow the Mental Health Act Code of Practice in relation to seclusion, long term segregation and blanket restrictions
  • The provider must ensure safety concerns are identified and addressed in a timely manner and that staff follow procedures in relation to checking cutlery, food hygiene and the checking of emergency bags and medical equipment
  • The provider must ensure sufficient staff of the right experience to deliver patient care and facilitate access to leave and other activities
  • The provider must ensure that leadership and governance arrangements support the delivery of high quality, person-centred care, operate effectively and address risk issues

The inspection took place in March and April 2019 and, as well as being rated inadequate overall, it is rated the same for whether the service is safe, caring and well-led. It was rated good for whether it is effective and responsive.

The most recent inspection followed a focussed inspection between October 2018 and January 2019, in which the service was told it must make improvements to how it manages patients who required long-term segregation.

In May 2017, the CQC rated the service as “requires improvement” overall, following a comprehensive inspection.

“We need a bigger rethink of our seclusion and long-term segregation process”

Katie Fisher

Responding to the latest rating, Katie Fisher, chief executive at St Andrew’s Healthcare, said: “We deeply regret that we have fallen below the standards we aim to uphold, and those expected by the CQC.

“With particular reference to process surrounding seclusion and long-term segregation, we accept that we should have done better by our patients,” she said. “We need a bigger rethink of our seclusion and long-term segregation process, so have begun a charity-wide review.

“This will ensure that, when safety concerns make it necessary to seclude or segregate a patient, the facilities provided and monitoring undertaken are consistently safe and robust,” she added.

Ms Fisher highlighted that the service was currently seeking independent advice from another CAMHS provider, whose services are rated outstanding by the CQC, to help it improve.

The service is also appointing a new improvement director, she noted, who will work across the organisation to “implement consistent changes that will benefit our patients”.

“The improvement director will oversee implementation of our seclusion and long-term segregation review,” said Ms Fisher.

“We are confident that when the CQC returns to inspect the St Andrew’s Healthcare Child and Adolescent Mental Health Service in the next six months, they will see significant improvement that will be reflected in an improved rating,” she said.