People with learning disabilities and autistic people were “not always protected from abuse or poor care” by insufficiently skilled staff, amid a blame culture in a mental health trust’s inpatient services.
That was the damning verdict from the Care Quality Commission (CQC) this week as it downgraded Tees, Esk and Wear Valleys NHS Foundation Trust’s inpatient learning disability and autism services from ‘good’ to ‘inadequate’.
Its report followed an inspection in May and June, triggered by practitioners at the trust’s Lanchester Road hospital blowing the whistle on serious concerns over unsafe staffing levels that they said management had not acted upon.
The trust said it had taken action to improve services since the inspection.
The regulator concluded that there was a “blame culture” at Lanchester Road: “Staff… did not feel respected, supported and valued by managers. Staff had raised concerns about the safety across the wards to senior managers who had failed to appropriately respond to the serious concerns.”
The CQC said sickness levels of 15% and vacancies for 30 healthcare assistants and 10 nurses meant Lanchester Road “did not have sufficient, appropriately skilled staff to meet people’s needs and keep them safe”. Wards regularly fell below the required numbers of workers, with leaders having to fill in, and two people at the hospital were cared for full-time by an agency staff team.
Staff absences had been caused, in part, by injuries to 32 healthcare assistants during restraints, with some requiring hospital treatment, while three of the four patients had also been injured, a situation the CQC dubbed “unacceptable”.
Family members of two of the injured patients said they were concerned for their safety, and that they did not feel reassured or listened to by managers.
High levels of restraint and seclusion
The CQC found high levels of restraint, seclusion and segregation across Lanchester Road and the other setting inspected, Bankfields Court, where services were generally better.
All four Lanchester Road patients were in long-term segregation, as were six of the 10 people at Bankfields Court, with no clear plans for reducing the use of these interventions.
For six patients, staff imposed restrictions that were not proportionate to risk and had no clear rationale, while inspectors found limited evidence of staff learning from restrictive interventions.
Staff training was also inadequate, with learning disability and autism training not mandatory for non-registered staff. Also, a ward manager at Lanchester Road had been off for several months before the inspection meaning supervision rates were low.
While staff had received training in the Mental Health Act 1983 and Mental Capacity Act 2005, understanding of both pieces of legislation and their principles were variable. For example, staff did not always support patients to make decisions for themselves and sometimes took decisions for them without recording that they had assessed capacity.
The CQC also found that people had been in the hospital for too long – with one Banksfield Court patient having been there for 10 years, and one Lanchester Road patient for four years. This was because of a shortage of community placements, reflecting the nationwide challenges in supporting people with learning disabilities and autistic people to move out of inpatient services.
As well as rating the service overall as inadequate, the CQC issued the same rating for safety, effective and leadership, while giving the trust a requires improvement grade for caringness and responsiveness to need.
More positively, the CQC found that most people at Bankfields Court were supported positively and warmly by staff who knew their individual needs well, and were kind and compassionate.
Some took part in leisure activities of their choice on a regular basis, including going to the local leisure centre, garden centre and beach, or were supported to learn everyday self-care skills.
Meeting legal requirements
Following the inspection, the CQC said the trust needed to make improvements in four areas to bring services into line with its legal requirements. These were to ensure that:
- There are sufficient suitably qualified, competent, skilled and experienced staff, receiving appropriate training, supervision and support.
- Care and treatment are designed and delivered in a way that meets individual needs, including through reducing the routine use of medication to control behaviour.
- Effective governance systems are in place to keep people safe and meet individual needs.
- Restrictions on people’s freedoms are only in place when necessary and proportionate, with safeguards in place for all episodes of seclusion and segregation.
In response to the report, the trust’s care group director for children and young people and learning disabilities, Jennifer Illingworth, said: “Given the previous good ratings for this service, this is clearly disappointing. We are committed to improving the experience for patients in our care and we are delivering an urgent action plan that is already showing we are making improvements.
“We immediately commissioned an independent peer review [by Mersey Care NHS Foundation Trust] into the service after the inspection in May and acted swiftly on its recommendations.
“Going forward, we will continue to work with our partners on the future provision of learning disability and autism services to ensure that together we offer the right packages of care that meets the needs of patients and their families.”
Improvements included reduced use of restrictive interventions.
NHS head urges action on ‘toxic and closed cultures’
The CQC report into Tees, Esk and Wear Valleys followed calls from NHS England’s mental health director, Claire Murdoch, for trusts to tackle “toxic and closed cultures” in their services.
Murdoch’s letter, to leaders of mental health, learning disability and autism services, was triggered by a BBC Panorama investigation that exposed abuse at the Edenfield Centre, a hospital run by Greater Manchester Mental Health NHS Foundation Trust.