Failings uncovered in another service run by NHS trust slammed for preventable death of learning disabled man

Management and care failings have been uncovered at a learning disability care home run by the NHS trust responsible for the unit where an 18-year-old man died preventably.

The Care Quality Commission is taking enforcement action against Southern Health NHS Foundation Trust after an inspection of the 4 Piggy Lane home in Bicester, Oxfordshire, found significant failings in quality monitoring.

The regulator also found the trust not to be meeting four of the other five standards Piggy Lane was inspected against, on safeguarding, the quality of care, the level of staffing and record keeping.

The inspection report comes days after an inquiry found that the death of Connor Sparrowhawk in the short-term assessment and treatment team unit (Statt) at the trust’s Slade House service in Oxford last July was preventable. In an inspection following Connor’s death, the CQC failed Slade House on all ten of the standards it was rated against and issued six warning notices requiring it to improve.

At Piggy Lane, a five-bed home for people with learning and physical disabilities located across two bungalows, inspectors identified a lack of staff, widespread staffing concerns about the quality of management and “multiple areas of substantial concern regarding the lack of quality monitoring”.

A lack of staffing had resulted in one staff member working 11 out of 14 shifts, inspectors found. Staff reported being over-stretched but, while managers and trust senior managers were aware, staff told inspectors that nothing had been done to resolve the issue. Staff worked up to 14-hour shifts, though a Southern Health senior manager justified this to inspectors on the grounds that staff took breaks during their shifts.

‘An unfair organisation that threatens us’

They described working for “an unfair organisation that threatens us”; more than one member of staff told inspectors of a senior Southern Health manager threatening to close the service if staff didn’t “pull themselves together”. While staff said they wanted to deliver better care for residents, they felt actively prevented from doing so by being asked to undertake clinical tasks.

Staff reported high rates of sickness and agency staff usage and told inspectors that some agency staff lacked the skills to deliver appropriate care. The manager acknowledged these issues to inspectors and admitted agency staff were not aware of Southern Health policies and procedures, meaning they would not necessarily know how to deal with an incident in line with local guidance. Staff also reported that residents became unsettled and anxious when new staff were in the building, and that while management were aware of this, they had done nothing about it.

There was just one member of care staff employed overnight in one bungalow, meaning that residents who needed the help of two staff members for personal care could not receive this.

Southern Health’s recruitment policy was also implicated in the staffing problems. The manager told inspectors that staff were recruited centrally and then allocated to a service they may not have seen before starting work. She said on one occasion, a person left Piggy Lane after one day because it was not as they expected.

Enforcement action

The failure of managers to act on staff concerns contributed to the CQC’s decision to take enforcement action, requiring the trust to improve its assessment and monitoring of the quality of the service. In addition, it found a lack of robust procedures for medication management and clinical care checks, and evidence of a failure to learn lessons from incidents and investigations.

The CQC has required Southern Health to report on the action it will take to improve the service by 11 March.

Phil Aubrey-Harris, the trust’s director of social care, said it found the outcome of the CQC inspection to be “unacceptable”. “We deeply regret that the quality of our social care service was not of the high standard our service users and their families should expect,” he said. “We accept all of the report’s findings and have taken immediate action to address the problems highlighted by the CQC.”

Pressure on trust

The inspection report adds to the pressure on Southern Health, following the independent investigation into death of Connor Sparrowhawk, who was found dead in a bath at the Statt unit in Slade House following an epileptic seizure.

The investigation found that had a safe observation process been in place for when Connor was in the bath, he would not have died. The report also identified a lack of clinical leadership at the unit, which operated a team-based approach in which no one individual held responsibility for ensuring Connor’s care was appropriate.

Following the CQC’s damning inspection report on Slade House, published last November, the Statt and John Sharich House, a longer-term assessment and treatment unit on the same site, were closed to new admissions. The Statt was closed completely after remaining patients were moved out, a situation that remains true today.

The trust has also faced a storm of criticism on Twitter from social care practitioners and commentators for its response to Connor’s death and a perceived failure to take responsibility for it following the independent investigation.