The Care Quality Commission (CQC) has rated an Elstree rehabilitation service inadequate and placed it in special measures, after an inspection found shortfalls in ensuring patient safety.
The CQC inspected Cornerstone House, run by Vision MH Limited, in April after receiving a high number of reports relating to patients self-harming and requiring hospital treatment.
In response to the findings, the organisation said it had replaced its leadership and clinical management teams and implemented a comprehensive improvement plan.
The inspection found staff did not always treat patients with compassion and kindness or respect their privacy and dignity, and had not always involved patients and families when writing care plans.
The inspection also found staff did not have access to the risk register and were unaware of its contents.
However, inspectors noted the wards were clean, well equipped and fit for purpose and staff effectively followed infection control policy and Covid guidance.
The service, previously rated outstanding, has now been rated inadequate and has been placed in special measures.
Following the inspection, Vison MH Limited was told that it must make several improvements at Cornerstone House, including:
• Staff must treat patients with compassion and kindness.
• Remedial action must be taken to address the blind spots on the ward.
• Staff must respond to a patient’s physical healthcare needs in a timely way.
• Appropriate actions must be taken in response to identified patient risk and self-harm.
• All incidents must be reported in patient’s clinical records.
• Actions must be taken to address the ongoing high number of medication errors.
• All staff must be up to date with all aspects of their mandatory training, including Mental Capacity Act and Deprivation of Liberty (DoLs) and ligature awareness.
• Staff must undertake physical health observations for all patients following the administration of rapid tranquillisation, line with the provider’s policy.
Systems and processes not followed
Stuart Dunn, head of inspection for mental health and community services at the CQC, said: “When we inspected Cornerstone House, we were not assured all reasonable steps were being taken to protect people from avoidable harm.
“It was concerning that action wasn’t always taken to keep patients safe after self-harm incidents and access to items which could be used to self-harm were not always risk assessed.
“Systems and processes to safely administer medicines were not always followed which resulted in a high number of medication errors, which meant people weren’t being treated safely or effectively.
“There was also no system in place to manage patient concerns and some patients told us they felt it was ‘not worth making a complaint’ as managers did not respond or take action to prevent re-occurrence.“
Dunn noted there was a lack of oversight from the service’s leaders with managers not acting to appropriately address or review ongoing patient self-harm incidents, medication errors and patient risks.
“However, staff told us they felt respected, supported and valued and felt able to raise concerns without fear of retribution,” he continued.
“Leaders know where they must improve, and we will continue to monitor the service closely to ensure this happens. We won’t hesitate to take further action to protect people if we are not assured care is being delivered safely.”
New leadership and management
In response a spokesperson for Cornerstone House said: “We are extremely sorry that our care and quality standards have fallen below the high standards we expect and that we previously provided.
“We have implemented a very comprehensive improvement plan, working with the CQC on a weekly basis, and are doing everything we can to protect and support patients. This includes the management of all aspects of clinical risk to provide safe and effective care and support.
“The past 15 months have been extremely challenging because of the Covid pandemic, which put additional pressure on our colleagues to maintain high quality care. We have now changed the leadership and clinical management team at the hospital.
“The CQC inspection noted that the wards were clean and well maintained and that many patients and colleagues fed back very positive experiences at Cornerstone.
“There is a significant need for the kind of support we provide to vulnerable adults and which we will continue to provide at the high-quality level for which Cornerstone has historically been recognised.
“As part of this, we are investing substantially in all aspects of the environment at Cornerstone for patients and colleagues.”
The service faces a further inspection in six months as it is in special measures. The CQC added that if there is insufficient improvement, it will use its enforcement powers further to protect patients from the risk of harm and hold the service’s leaders to account.