The Care Quality Commission carried out a comprehensive inspection of Ellingham Hospital on 8 and 9 January 2019

We issued a warning notice against Regulation 18 Staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Enforcement actions we told the provider to address are found at the end of the report.

During inspection we found that:

• We were concerned that the hospital continued to admit patients without assurance of being able to provide appropriate numbers of staff. Staff shortages, particularly for qualified staff, and high usage of bank and agency staff had an impact on both staff and patients. Staff regularly did not have time to take breaks, engage in activities, support new staff or fully complete paperwork. The provider did not provide sufficient staff to ensure patients accessed escorted leave in accordance with what had been agreed with them. Staff and patients told us that section 17 leave was often cancelled or delayed for patients requesting to leave the hospital. This was supported by section 17 paperwork.

• We were not assured that the enhanced observations were carried out safely. The provider policy for observations and engagement said that staff must not be continuously on 1:1 observations for more than two hours. Staff said that this was not always possible as there was often a high level of patients requiring observations. This included multiple staff observations where a patient required more than one staff with them at all times. On Redwood ward we saw that one support worker was tasked with supporting 14 patients on intermittent observations. We reviewed 13 observation records on Redwood ward. Of these 12 did not identify the individual patient risk. This meant that staff carrying out observations may not be aware of the reason for the observation level. However, the records were signed as complete.
• We were not satisfied that all serious incidents were being reported and reviewed by managers regularly. We found paper incident forms not uploaded on the electronic system in a timely manner on Cherry Oak Ward. We could not see rigorous identification and sharing of lessons learnt across all three wards.