Concerns over the care and treatment of young people at an independent mental health hospital in Hertfordshire have been highlighted in a report by the regulator.
An inspection of Potters Bar Clinic, which is run by Elysium Healthcare No 2 Ltd, was carried out in February by the Care Quality Commission (CQC) after concerns were raised surrounding the care and treatment of people detained on child and adolescent mental health service wards. This included the death of a young person.
The hospital provides services to people requiring mental health care, some of whom are detained under the Mental Health Act 1983 or Mental Capacity Act 2005.
The inspection found that managers did not ensure that safeguarding processes and procedures were followed by staff. ‘We found a number of occasions when staff had not reported incidents to external bodies as required. This included safeguarding concerns, and serious patient injury,’ the report said.
Many young people self-harmed when under constant observation, while five out of seven patients did not have an initial risk assessment completed within 48 hours of admission, which did not follow the provider’s policy.
The report said staff had not completed a risk assessment for several weeks and managers had not identified all potential ligature anchor points on ward risk assessments. It also said at times there were too few staff to meet all care needs of the patients.
Inspectors found 59 active care plans between seven patients. Forty-one out of 59 care plans had the same review date and were all written across six dates spanning over two weeks. ‘Care plans were not always personalised. Two care plans referred to the patient by their hospital number, and the wrong gender. Another care plan stated the wrong patient name,’ the report said.
CQC’s deputy chief inspector of hospitals (and lead for mental health), Dr Paul Lelliott, said: ‘We concluded that the leadership and governance of the service did not always support the delivery of high quality, person-centred care.
‘What we found at Potters Bar Clinic did not represent the care that people should expect to receive. The provider knows what it must do now. We will monitor the hospital closely and will return to check on progress.’
The inspection highlighted 21 areas it must improve on, including relatives and carers being kept informed of patient wellbeing regarding feedback after incidents; ensuring patient records are personalised and meet the needs of individuals; making sure ligature risk assessments are accurate; meeting safe staffing levels; and making sure employees have the appropriate training and knowledge.
When the hospital was inspected, in September 2017, it was rated as ‘good’. The CQC’s most recent inspection was a focused inspection and does not alter the hospital’s rating.
A spokesperson for Elysium Healthcare said: ‘The health and wellbeing of young people in our care is of the upmost importance to us.
‘Our Potters Bar service is young and still developing and, working in partnership with both the CQC and NHS England, we are making improvements to the way we evidence the care we deliver and to improve the overall quality of the service.
‘We continue to work with the CQC so that they can see the changes we have made and how these changes have been embedded in the care we provide.’