A mental health provider failed to adequately support frontline staff at a service that saw a “significant increase” in incidents on wards, including cases of violence towards staff, the Care Quality Commission has found.
A CQC inspection report published in late December showed that inspectors failed the Ivydene care facility against all five standards of care it was assessed against at an inspection in October 2013. Care standards the service failed to meet included ‘supporting workers’ and ‘monitoring the quality of service provision’.
The service, run by independent provider Choice Lifestyles, provides low secure care to up to 30 women who have been detained under the Mental Health Act. A Choice Lifestyles spokesperson said the service has been reinspected by CQC “very recently” and said “considerable progress” had been made in addressing the issues identified at last October’s inspection.
At the October inspection, incident logs showed that two wards had seen a “significant increase” in incidents, including violence and aggression towards staff, in the months leading up to the inspection. The CQC said the rise showed that patients on both wards “experienced a less safe environment”. Inspectors found no evidence that learning from serious incidents had been cascaded to frontline staff.
“The absence of formal supervision and debriefing for staff further exacerbated the risk of staff not knowing why an incident occurred and more importantly, did not demonstrate that the provider was taking account of staff competency to manage incidents with a view to improving their performance for the safety of patients,” the CQC report found.
Staff at the service told CQC inspectors that supervision arrangements were “dire” and said there were either no or delayed “debriefing” sessions following serious incidents. Morale had also been damaged by frequent changes in senior management and senior clinical roles with “permanent staff struggling with the inconsistent staff team”, staff claimed.
Despite some reduction in the use of temporary staff, inspectors found that the service still made “significant use of agency staff” to cover vacant qualified nursing posts and unpaid leave. The use of agency staff had resulted in medication errors and impacted patient continuity of care, inspectors found. Patients said that staff shortages meant they could not always access activity sessions and the leave they were entitled to under section 17 of the Mental Health Act.
“Our findings were that the turnover of clinical and medical staff as well as senior managers had had a significant impact on service delivery,” the CQC report found.
Inspectors also found “serious concerns” about medication management and delays in patients having their physical health needs met.
A spokesperson for Choice Lifestyles said: “This report refers to an inspection which took place in October. The service was re-inspected very recently and considerable progress has been made in addressing the matters raised, and this has been acknowledged by the CQC.
“We are working towards addressing the few minor concerns that remain and expect to achieve full compliance very soon”.