NHS learning disability service closed to admissions after CQC condemns quality of care

Inspectors uncover poor-quality care and staffing failings at Slade House, which is run by Southern Health NHS Foundation Trust

Inspection report
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An NHS learning disability service has been closed to new admissions after being condemned by the Care Quality Commission for delivering poor-quality care.

The Care Quality Commission (CQC) failed Slade House in Oxford on 10 standards it inspected the service against in an inspection in September and issued provider Southern Health NHS Foundation Trust with six warning notices to improve by next month.

The trust has closed the service – which includes two assessment and treatment units – to new admissions pending an internal investigation and urgent action to improve the quality of services, staffing and the environment.

The CQC’s report in particular condemned the service’s short-term assessment and treatment team unit (Statt), which it said “appeared to be an impoverished environment with little therapeutic intervention or meaningful activities to do”.

Patient felt unsafe

Of three patients whom inspectors spoke to, one said they “hated” being on the unit. Another, a female patient, said they felt “unsafe” because of a male patient who inspectors said was “allowed to roam unchallenged” through the female part of the unit despite staff saying he had the potential to be aggressive.

The same female patient decided to leave but, despite being there voluntarily, faced a “considerable delay” in doing so, undermining her right to consent to treatment. A relative told inspectors that their son, also a voluntary patient, had frequently requested to leave but had been told he would have to attend specific workshops to do so, which the CQC said amounted to an “illegal deprivation of liberty”.

Patients also reported having nothing to do and being bored. Inspectors observed that nurses stayed in the staff room during most of the day and rarely interacted therapeutically with patients.

Staff ‘insufficiently supported’

Staff attributed this to the volume of non-clinical, administrative work that they had to do, which they were not given additional time to complete. When they raised this in supervision, they were told to prioritise their work, inspectors found. The CQC was also told that staff felt “insufficiently supported” and “overly challenged” by one senior nurse and trust senior managers.

The inspection also uncovered significant training gaps with one-third of nurses not having had basic life support training in the past year and a similar proportion of all staff not having undergone adult safeguarding training during that time.

The service’s management were also slammed for poor quality monitoring, including for not acting on concerns they themselves had identified, including ligature risks and inadequate cleaning of the premises.

While some families said they had had good experiences of Statt and Slade House’s other unit – John Sharich House, a longer-term assessment and treatment unit – others said they had not been involved in care planning and felt unwelcome at the unit.

Patient death

The inspection report also said that a patient with epilepsy had died in the bath earlier in the year at Statt and, as a result, patients with the condition were now routinely observed discreetly while in the bath.

While inspectors found a more therapeutic care regime at John Sharich House they found that the unit’s defibrillator had no battery in it, meaning it could not be used if someone had a cardiac arrest.

The trust has been given until 17 December to respond to the CQC on how it was tackling the failings. Southern Health has launched an internal investigation into the failings and why they did not come to light sooner, and brought in a “turnaround team” from the rest of the trust to improve care. The team were reviewing internal processes and providing the “leadership and knowledge required to ensure best practice is shared”, said trust chief executive Katrina Percy.

“We have taken the findings extremely seriously,” she added. “The units are now both closed to new admissions and will remain so until we can provide assurance that we are able to deliver the best possible care to our patients.”

Remaining patients preparing for discharge

The trust said that one patient was left at Statt, whom staff were making arrangements to discharge. Five patients were left at John Sharich and staff were working with commissioners to make arrangements to discharge those who could safely move back to the community or closer to their homes.

Percy added that the trust had already addressed issues about the safety of the environment at Slade House, including by replacing sub-standard equipment, and put an action plan into place to address other failings.

While the CQC referred its findings to Oxfordshire Council’s adult safeguarding service, Southern Health said the local authority had been assured that the turnaround team was making a difference and clients currently in Statt were safe.

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