An NHS trust has been ordered to improve by regulators after a third damning report into its learning disability services in Oxfordshire in five months.
A Care Quality Commission report found that part of Southern Health NHS Foundation Trust’s Evenlode unit in Oxford was unsafe after an incident in which a man was found unconscious with a ligature around his neck. The trust was also found not to have taken action to prevent such incidents happening again.
And following the report, the CQC’s fellow regulator, Monitor, which is investigating the trust, said it must urgently improve its governance and the quality of care in its services.
Monitor launched its investigation in December, a month after a highly critical CQC report into Southern Health’s Slade House facility in Oxford, where 18-year-old Connor Sparrowhawk, who had epilepsy, drowned in the bath last July. A separate report into his death said it was preventable. Last month the CQC also reported failings at the trust’s 4 Piggy Lane home in Bicester.
Man found unconcsious
Yesterday’s CQC report into the Evenlode facility, which is a medium-secure learning disabilities unit, said part of the building was unsafe after a man was found unconscious and having a seizure with a ligature around his neck in a seclusion room. The report said the design of the door, which had an observation panel in it, meant staff did not immediately see what had happened. Additionally the bathroom in the suite was locked because it did not have anti-ligature taps, so the person in the room would have to use a disposable toilet that could be seen by staff.
It also found that there had been a lack of timely action to prevent such incidents happening again, including from senior managers at Southern Health.
Southern Health rents the building from Oxford Health NHS Trust under a private finance initiative agreement, and the report said it had not followed up the problem with the building “with the host authority in a timely manner”.
Inspectors were “surprised” that the incident had not been reported to Oxfordshire County Council’s safeguarding service – it was subsequently reported on the second day of the inspection – although it had been recorded in an internal reporting system.
Opportunity lost to improve practice
“This means that a significant incident had not afforded the opportunity to review internal practice,” said the CQC report.
Unit staff told inspectors there was excellent local leadership and management but there was a “a ‘lack of engagement’ between the provider (Southern Health) and staff at unit level”. They also said that there was a culture of “listen but do nothing constructive” from the trust, the report added.
“The unit manager had tried to minimise the risks [in the seclusion room] but had not been wholly successful,” said the report. “The provider may wish to note that Southern Health NHS Foundation Trust were aware of these ongoing challenges but no senior intervention had resulted in the actions required to keep people completely safe.”
The CQC issued the trust with a warning notice to improve the safety and suitability of its premises by 30 April. It also found the service non-compliant with the standard on assessing and monitoring the quality of services because of the the lack of action to prevent risks to people in the seclusion room. It must report back to the CQC by 13 May on how it is improving its monitoring. However, the regulator found the service was compliant with four of the five other standards inspected against.
Much appropriate care
Inspectors said: “We saw many warm positive interactions between staff and much appropriate support and care delivered, even under challenging circumstances. We heard that people “liked” the staff and the senior manager of the unit, and this was clearly reflected in the mutual regard we observed.
Southern Health’s divisional director for learning disability, Lesley Munro, said: “We take the CQC findings very seriously and the necessary building works to ensure the unit is fully compliant are due to be completed imminently.”
Meanwhile, Monitor said today that the trust had “failed to act quickly enough to improve services in Oxfordshire and must get the right processes in place to ensure action is taken to fix problems quickly”.
Monitor and Southern Health agreed the trust would implement the actions required by the CQC inspections, improve its quality and board governance and implement its improvement plan for its learning disability services.
Monthly checks introduced
A spokesperson for Monitor said the CQC would monitor how its recommendations had been implemented and a local oversight group – which includes Monitor, the trust, NHS England, NHS Oxfordshire and service commissioners – would do monthly checks that the trust was implementing the changes it had agreed to make until they were completed. He said the trust must implement the CQC recommendations by the dates specified in the regulator’s reports.
Katrina Percy, chief executive of Southern Health said: “Over the coming weeks our focus will be on ensuring we make the improvements needed, to reassure both Monitor and our patients and their families about the quality of care we provide across all of our services day in, day out.”
Three of the CQC’s warning notices on Slade House were lifted following an inspection last December, but they related to environmental standards, not patient care. The service stopped admitting new patients following the inspection and one part of it – the short-term assessment and treatment team unit – remains closed altogether.
The family of Connor Sparrowhawk have launched a campaign to improve care for people with learning disabilities. The aims of the 107 Days of Action campaign include bringing a corporate manslaughter prosecution against the trust; an automatic, independent investigation of every unexpected death in a locked unit; improvements in inspection and regulation; and an independent investigation into deaths initially deemed to be from “natural causes” in Southern Health learning disability and mental health provision over the past 10 years.