Regulator finds NHS disability facility still failing to meet standards

A learning and physical disability service censured by the Care Quality Commission three months ago is still failing in several areas, a new report form the inspectorate has found.

Southern Health NHS Foundation Trust’s service at 4 Piggy Lane in Oxfordshire failed in three of the five areas covered in the re-inspection in April, published this month, although the CQC did find improvements since its earlier inspection report published in March. Piggy Lane is one of three learning disability services in Oxfordshire run by Southern Health subject to highly critical inspection reports in the past year.

The CQC lifted a warning notice it had placed on the facility in March but said action was needed to improve against standards relating to the care and welfare of people using the service, record keeping and monitoring the quality of the service.
During the first inspection the CQC gave Southern Health a list of areas to improve, which the provider said it would complete by 30 March and it was re-inspected soon afterwards. The CQC said not all the actions, particularly in relation to the monitoring of quality, had been completed when the re-inspection took place.

While the service users whom the inspectors met said they felt safe, the report said guidelines in epilepsy and rescue support plans were not always being carried out because staff were not always aware of the most recent guidance provided. Similarly a system to ensure information about people’s needs was effectively exchanged between staff was not delegated when the manager was absent meaning that the safety of patients could not always be assured. It said some systems, such as ordering of a nutritional supplement for people fed by tube, were also too dependent on particular people being present. It also found problems with record keeping such as a notes being misfiled and care plans that were inaccurate or out of date.

However it also found people were protected from abuse and from the excessive use of restraint, and staffing numbers – a key problem identified in the first inspection report – were now adequate. Services users said they felt safe and cared for and the inspectors saw evidence that they were able to do activities of their choice.

Piggy Lane was the second of three Southern Health learning disabilities facility to receive a highly critical verdict from inspectors when it was originally inspected in January. In April regulator Monitor said Southern Health must urgently improve after the three damning verdicts. In one facility, the short term assessment and treatment team unit at Slade House, an 18-year-old with epilepsy, Connor Sparrowhawk, drowned after being left unsupervised in the bath, and in another facility, Evenlode, a man was found unconscious with a ligature around his neck.

A CQC spokesperson said: “The CQC will return in due course to ensure that improvements are sustained, and that further improvements required are made. In the meantime, inspectors will continue to monitor the service and could return unannounced at any time if new concerns are raised.”

A statement from Southern Health said: “Southern Health NHS Foundation Trust recognises that the outcomes of the recent CQC report at 4 Piggy Lane, Oxfordshire remain unacceptable. We are committed to providing a high quality service for the people we support and, following the CQC inspection, have put a robust action plan in place to ensure that we are compliant in all areas of our service. The CQC have acknowledged that, since our last inspection, there have been significant improvements in all areas that were found to be non-compliant and recognise that in some areas a longer timescale is needed to be able to evidence these improvements. These actions will continue to be reviewed and monitored by the CQC, our commissioners and ourselves to ensure that the service is meeting the required standards.”

The report comes amid speculation that Oxfordshire Council may not renew Southern Health’s contract to run learning disability services in the county when it expires at the end of next year. Both the council and the provider say no decision has been taken as yet.