We did not rate this service.

We carried out this inspection to monitor progress following the warning notice issued after the focused inspection in April 2018.

We found the provider had addressed most of the issues identified in that warning notice including:

• Safe and proper prescribing, administration and storage of medications. Managers had adequate oversight and governance structures to monitor the management of medicines within the service, including regular audits and action plans. Managers had increased their community pharmacist visits from quarterly to weekly, starting 09 August 2018. The pharmacist carried out external audits and scrutiny of the providers medication and prescribing practice, and provided advice, focussed staff training and consultation.
• Managers ensured staff recorded all incidents including medication errors, in line with their incident reporting policy.

However, we found the following areas the provider needs to improve:

• Whilst staff had improved the monitoring of controlled drugs we found occasional gaps in the controlled drugs record where staff had not recorded the previous or carried forward page numbers. The standard operating procedures for medicines management was not easily accessible, this was in electronic format only, and there was no computer access in the clinic. When we made the manager aware of this she told us she would arrange to have a paper copy made available in the clinic.
• Some emergency equipment was out of date and had not been removed or replaced. Staff had not identified that the fridge in the clinic room was too small for the stock stored in it, airflow was restricted. The providers instructions for recording the fridge temperature range were not clear. Staff were not recording the actions they had taken to rectify inaccuracies in the daily clinic checklists.

We found the following issues that the service provider needs to improve:

• The provider’s medicines management practice was unsafe in relation to the storage, dispensing and medicines reconciliation. Staff made numerous errors and omissions when handling controlled drugs. These practices did not follow the services local medicines policy or NICE guidance. Managers had not addressed the issues with medicines management identified at the inspections in May 2017 and December 2017.
• Managers had not reviewed or updated the internal systems for reporting incidents.
• The majority of the staff we spoke with reported they did not feel supported or listened to by hopsital management.

However:

• Staff completed the initial assessment of the patients’ risks at the pre admission assessment and the multidisciplinary team updated the risk assessment once the patient had been admitted to the service.
• Managers ensured they had the required amount of staff on the majority of shifts to meet the needs of the patients.
• Staff reported that morale was ok and that they felt supported by their colleagues.

We found the following issues that the service provider needs to improve:

• Doctors prescribed medication on more than one medication chart. We found that the same types of medication had been prescribed on both charts. If staff had administered the medication in the same 24 hours period it would have resulted in an overdose for the patient.
• Staff recorded the monitoring of patients physical health in four separate documents. However, staff did not ensure that all four documents were fully completed specifically the National Early Warning Score form. Due to the duplicated records we found it difficult to ascertain baseline observations for patients and if staff had fully addressed all physical health concerns.
• Staff did not seek medical intervention after monitoring a patient’s physical health and found that the patients’ blood sugar was outside of the normal limits.
• Whilst managers had a clear oversight of incidents that had taken place within the hospital they did not have a robust system in place to ensure that incident forms were fully completed. We found incident forms were not completed fully or reviewed by a senior member of staff. In addition we could not be assured that incidents were recorded within patients care notes or discussed in ward rounds as ward round summaries were missing from patients’ case records.
• Following a serious incident, managers had put measures in place to count cutlery. Whilst staff were following this new process, we found that the records showed a spoon had been missing for over five days. When we spoke with managers they were aware of this but no action had been taken to address it.
• Senior managers did not have access to the services ligature audit during the inspection.
• Managers had developed a red, amber green (RAG) rating system to assess patient’s risk. However, there was no guidance or procedures in place for staff to use the system.
• Managers did not have a robust system to ensure that patients detained under the Mental Health Act had their rights explained to them and that the paperwork remained in order and up to date.
• Mental Health Act papers were not examined by a suitable trained member of staff. The most up to date section 132 had not been filled correctly. Staff did not have immediate access to detention paperwork. Managers had partially addressed the concerns highlighted in regards to the two unlawful detentions. However, we found that the action plan was not robust and did not fully address the concerns.
• The management of incident reporting was unclear. Managers could not fully explain why they continued to use a process that duplicated incidents forms which we found to be incomplete. Managers did not have processes in place to ensure that all incidents were fully recorded within the patient case notes.
• There was no alert in place at the beginning of the patient’s case records to inform staff that the patient had physical healthcare issues that needed to be closely monitored. Whilst case records held this information we found it difficult to locate it quickly.
• Whilst weekly multi-disciplinary meetings took place to discuss patient care and treatment this was not always recorded within the patients case notes.
• Staff reviewed care plans on a monthly basis and recorded the review on a separate document. However, it was not clear that the patients had been involved in the reviews.
• Policies and procedures were in place for staff to follow and were available online. However, the manager had not kept the paper copies of polices in date. This increased the risk of staff not adhering to the most up to date policies.
• Managers did not have a robust recording system in place for monitoring patient’s physical health. Although staff had comprehensive discussions about the physical health needs of the patients the paperwork was duplicated and incomplete.
• Managers had formulated an action plan to address issues that were identified from the last CQC inspection in November 2016. We reviewed this during the inspection. We found that although some actions were highlighted as achieved this was not the case.

However:

• Since the last inspection carried out in November 2016 managers had adapted rooms on a closed ward so that patients had space to have one to one time in a private, quiet area of the hospital.
• Throughout the inspection we observed positive team working and mutual support for staff. Staff commented that they felt supported by all members of the team from the clinical staff to housekeeping.
• Patients we spoke with told us that staff were supportive with their mental health issues and any physical health issues. They felt that staff understood their individual needs.
• Multidisciplinary handovers and briefing meetings between shifts were effective. The notes taken in handover were comprehensive, and showed that staff had discussed staffing levels, the physical health care needs of patients and specific nursing duties that needed to carried out during the shift.
• 80% of staff had received regular in line with the services policy of four supervision sessions per year. In addition to this the managers provided supervision to regular bank staff that worked at the hospital.
• Managers carried out investigations into serious incidents and highlighted areas of practice that need to be improved.

The Care Quality Commission received information of concern from a whistleblower. We decided to bring forward the scheduled inspection of the service and used the information provided by the whistleblower in deciding which outcomes we inspected.

When we inspected Sturdee Community Hospital one person was using the service. We were not able to speak with the person using the service or observe their care as health care professionals who were supporting the person on the day of our visit were concerned about the person’s health and wellbeing. Staff we spoke with had a good understanding of the needs of the person using the service.

We looked at the records which recorded the care, treatment and support of the person. Records identified the care and treatment the person required and the health care professionals involved. We found records had been regularly reviewed to meet legal requirements and some records provided comprehensive information. We found gaps in some records which we discussed with the manager at the time of our inspection.

We found systems for the prescribing, storing and administration of medication to be robust. Registered nurses were responsible for the administration of medication.

Staff told us a number of systems were in place which provided them with support. Staff told us they were aware of their responsibility in raising concerns, including whistleblowing and safeguarding.

We spoke with three people using the services of Opreco House and asked them whether they were involved in decisions about their care and treatment. We also asked them about their individual care and treatment plans. People told us they were involved in all aspects of their care and treatment and that things were clearly explained to them. People’s comments included:-

“I’ve always been in control of the decision making process, if anything was unclear it was comprehensively explained to me.”

“I have signed my care and treatment plans; they are regularly reviewed with my involvement. I am aware of all my treatment options, which includes reviewing the medication I am prescribed. My treatment has been phased and gradual.”

Records and discussions with people using the service showed people were involved in all aspects planning and reviewing their care and treatment and that their consent was regularly assessed and sought.

People were encouraged and supported to access community services, which included community centres and higher education establishments as part of their care and treatment being their planning for the future.

People were made aware of the complaints system and had been given a copy of the services policy. People were given the opportunity to take part in monthly meetings to discuss general issues about the service they received, which included meals.

We rated Sturdee Community Hospital as requires improvement because:

• Managers had not ensured that the ligature audit was complete. There was no ligature audit for Aylestone unit or Foxton ward. Ligature points had been identified on Rutland ward including the blinds in the gym and sliding door in the corridor, but no action had been taken to reduce these specific risks. Managers had not identified blind spots throughout the service.

• Staff were not following the “to take out” (TTO) medicines policy. Staff recorded the medicines fridge as above eight degrees on 28 occasions in a two-month period.

• Doctors had not ensured that medication charts were written in accordance with guidance. We found one medication chart did not refer to the fact that Olanzapine and Lorazepam, prescribed for the same person, should not be administered within one hour of each other.

• Staff administered insulin to a patient from the medication trolley that was out of date.

• The hospital did not have an effective system of oversight for the delivery of its Mental Health Act administration functions. The hospital did not have a current or robust policy in place to cover the range of Mental Health Act administrator’s obligations. Managers had not provided the new mental health administrator with sufficient training, guidance and mentoring.

• Managers did not ensure completion of quarterly external audits of all Mental Health Act paperwork.

• Incident recording was variable. While staff reported incidents and notified to CQC, seven out of twenty records checked did not include what actions managers had taken, or what lessons they had learned.

• The inspection team considered quarterly visits by an external pharmacist was not adequate. Visits that were more frequent may have picked up the issues found during the inspection.

• Staff had not updated patients individual occupational therapy activity plans to reflect their current needs. Individual activity plans did not detail how the patient would achieve their identified goals.

However:-

• Wards were visibly clean, well maintained and had good quality furnishings. The infection control policy was in date. Cleaning records were available. All staff carried personal alarms and ligature cutters.

• Staffing levels at the hospital were good. The hospital had their full establishment of nurses and a multi-disciplinary team to meet the needs of their patients, and recruitment drives had been successful.

• Ninety-four percent of staff had attended mandatory training.

• Staff carried out full physical healthcare examinations as required. Staff completed separate and comprehensive physical healthcare records for each patient. Staff addressed specific issues such as pressure sores, and signs and symptoms of potential sepsis.

• Communication systems in the hospital were effective. Staff, including support staff, catering and maintenance staff attended a range of in house meetings including daily briefings, community meetings, and integrated governance meetings. This ensured that all staff working at the hospital were familiar with the patients and their current needs. All staff felt informed about the wider issues affecting the hospital.

• Patients and staff planned, facilitated and attended the weekly interactive academic teaching sessions on a Thursday morning.

• There was a clear admission and discharge policy and procedure, overseen by the consultant psychiatrist in discussion with the multi-disciplinary team.

• Staff understood the provider’s vision and values based on growth, recovery, ownership, warmth, and time and healing. A philosophy of positive risk taking and least restrictive practice underpinned the vision and values.

• Managers made significant changes to policy and practice following feedback from previous inspections, complaints and incidents.