Failing NHS learning disability unit passes first inspection test but remains closed to patients

Commissioner refuses to commit to using Slade House unit again, after regulator lifts half of six warning notices

An NHS learning disabilities service that stopped admitting new patients after a damning inspection has passed the first of several re-inspections.

However, commissioners have refused to rule out not using one of the service’s two assessment and treatment units again.

Slade House in Oxford failed all 10 the standards assessed at a Care Quality Commission inspection last September. It was issued with six enforcement notices for serious breaches and four more areas for further action.

The original inspection found significant problems at Slade House’s short-term treatment and assessment team (Statt) unit, including “little therapeutic intervention”, a building that was not clean or safe enough and poor record keeping. A patient also told inspectors that she felt “unsafe” at the unit, run by Southern Health NHS Foundation Trust.

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. An internal inquiry into the death of the patient, Connor Sparrowhawk, has just reported but the details are being kept confidential.

Though services were better at the eight-bed John Sharich Unit on the site, both stopped admitting new patients following the inspection and the trust launched an internal investigation.

Criticisms of Slade House in the CQC’s original inspection report in included:

  • A short-term assessment and treatment team (Statt) unit patient said he “hated” being there, another left the unit because she felt threatened by a male patient; Some relatives had good experiences of the two units but others felt unwelcome;
  • Emergency oxygen was out of date and a defibrillator in John Sharich House did not have a battery;
  • Some areas were “substantially unclean”;
  • A parent of a voluntary patient said he was told he could not leave until he attended workshops that he did not want to go to. The report said he was “illegally deprived of his liberty”;
  • Nurses said they could not deliver the care they wanted because of the volume of non-clinical tasks.

The re-inspection, which took place in December, only examined the units’ performance on the three “environmental standards” that it received warning notices on: cleanliness and infection control, the safety of premises and safety of equipment. It was found to be meeting all three standards on re-inspection.

The re-inspection did not cover the other three areas where warning notices were issued – the quality of care, record keeping and the monitoring of the quality of the service.

There are currently no patients in the Statt unit and five in John Sharich House.

A CQC spokesperson said inspectors would return unannounced to inspect the remaining areas where the service was failing.

“We’ve told the trust that if they decide to re-admit patients before we’ve been back again they need to tell us and provide evidence of how they are assured they are compliant with the standards,” she added.

A trust spokesperson said neither unit would admit new patients until it was re-inspected by the CQC against the remaining three areas. Of the Statt unit, he said: “We are working closely with commissioners and the CQC to ensure the unit is re-opened at an appropriate time and for a purpose which best meets the needs of the local population. Together, we must make sure the unit meets the same high standards as our other services and further work is needed before timescales for re-opening can be determined.”

He said the trust was “on schedule” with its action plan to address the additional problems where the CQC had said action was required but had stopped short of issuing an enforcement notice.

A spokesperson for Oxfordshire County Council, which previously commissioned beds at the Statt and has people placed at John Sharich House, said it was continuing to scrutinise the service to ensure care was “of the required standard”.

He said the council “will want to make use of the facility [John Sharich House] again” but that “no decision has been taken about [the Statt’s] future use”.  He said: “There are regular review meetings between the council, Oxfordshire Clinical Commissioning Group and Southern Health regarding Slade House and at this stage there is not a solid timeframe for possibly using the Statt there again.”

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2 Responses to Failing NHS learning disability unit passes first inspection test but remains closed to patients

  1. Sara Ryan January 27, 2014 at 1:52 pm #

    In the last six or so months, I’ve been pitched into a steep learning curve around the provision of learning disability support, budgets, commissioning and regulatory services. Our son, LB, died unexpectedly at an assessment and treatment unit (ATU) called STATT, in July 2013. He was 18 years and fighting fit, other than a diagnosis of epilepsy. He was also diagnosed with autism, learning disability and Klinefelter syndrome. The inquest has yet to happen but an internally commissioned, independent investigation has been conducted.

    The Trust who ran the ATU initially reported LB’s death as probably natural causes a few weeks after his death. Eight or nine weeks later, an unannounced CQC inspection of the unit, and a second setting on the same site, found serious failings. A safeguarding alert was issued and the inspection was widely reported in various media, including Community Care.

    The unit, which had flagged concerns attached to it for the past couple of years, closed to new patients and those still resident were re-located. The unit is currently closed.

    Obviously, as the parents of a young man who died there, we are deeply interested, involved and intertwined with any reporting around STATT and ongoing events. We weren’t informed by the Trust that the unit had closed. We found out through ‘word on the street’, twitter and other roundabout ways. I nearly wandered round there at one point, to see for myself if there was a closed sign on the door.

    Unsatisfactory times. Anyway, to cut a long ramble short, I was pretty irritated to read a short report in the local paper that said that there were signs of improvement at STATT. I was even more disappointed to read a similar report in Community Care. Careless reporting in a local rag is one thing. A non critical and pointless report in a leading journal is a different issue. The report states that three of the six warning notices imposed on STATT had been lifted, following a re-inspection in December. These three notices covered the environmental standards; cleanliness and infection control, the safety of the premises and safety of equipment. The headline says “Signs of improvement at NHS learning disability unit failed by CQC”.

    Why is this poor reporting? A representative from Community Care defended the article on twitter, stating that given the journal had covered the initial, critical inspection findings, they should also cover any ensuing improvements. Yes. I agree. But these improvements should be placed within a broader context. The article should refer to the full background of the ‘story’ and state that a young man died in the unit in the summer. This is of huge relevance to subsequent events at STATT, within the Trust and the broader post-Winterbourne developments. To pluck out these three improvements and to badge them with this headline is a partial, uncritical interpretation.

    Given how far there is to go in trying to improve the way in which learning disabled people are understood, perceived and supported in current services, this careless, quick, dirty and disengaged reporting, is unacceptable. Better to say nothing really.

    • mithran samuel
      mithran samuel January 27, 2014 at 8:31 pm #

      Thanks Sara. In the light of your feedback we’ve amended the headline and standfirst of the article. Thanks again.