• Suffolk mental health facility put in special measures
  • Some interactions “demonstrated elements of abuse”, CQC finds
  • Hospital failed to ensure patients’ safety or dignity, report says
  • Priory Healthcare says it is “committed to delivering all required improvements as swiftly as possible”

The Care Quality Commission has rated a Suffolk mental health hospital ‘inadequate’ after finding some interactions between patients and staff ‘demonstrated elements of abuse’.

The watchdog accused St John’s House — run by Partnerships in Care, part of the Priory group — of failing to ensure its patients’ safety or dignity after carrying out an unannounced inspection in December.

The inspection of the 49-bed hospital, which specialises in care for adults living with learning disabilities and associated mental health issues, was undertaken in response to concerns regarding patient safety, incident management, staffing and the use of restraint.

The CQC, which also placed St John’s House in special measures, had previously rated the hospital as “good”, following an inspection in 2018.

A CQC statement said: “[The inspection] found that risks to patient safety, dignity and wellbeing were not always well managed, and that some interactions demonstrated elements of abuse.

“Staff had physically restrained patients, when they presented a danger to themselves and others, before other methods of de-escalation had been exhausted.

“Some instances of restraint were disproportionate and used unauthorised techniques, including when a patient was pushed to the floor. This compromised patient dignity, damaged staff morale and caused physical injuries.”

The CQC’s findings, published in a report today, follow years of problems with the area’s main NHS mental health provider — Norfolk and Suffolk Foundation Trust — which is in special measures for quality issues and rated “requires improvement”.

The BBC has also recently reported the trust’s incoming chief executive, Mason Fitzgerald, who is due to take up the post in April, has previously misleadingly stated he held a masters of law qualification. This prompted a review, which is ongoing.

The Priory Healthcare said it accepted the CQC’s findings and it was “committed to delivering all required improvements as swiftly as possible”.

A statement by the company said: “We do not accept this standard of care in our services and have taken immediate action to deliver improvements at St John’s House. Senior management is overseeing the implementation of a comprehensive action plan to address all issues identified in the report, and we have already seen significant improvements in training compliance, the physical environment, upholding patient dignity, incident reporting and care planning.

“We have completed the required actions for 18 of the 24 key areas identified in the report, and are on track to complete the remainder within the timeframe agreed with the CQC. The service is now fully compliant with the required infection prevention and control procedures and we are committed to delivering all required improvements as swiftly as possible. Patient safety remains our absolute priority.”

Staff caught sleeping while working on CCTV

Inspectors said areas used by patients at the facility, in Palgrave, near Diss, who had been secluded “had ligature risks and blind spots, compromising people at risk of self-harming”. This issue was compounded because observations were not always undertaken correctly, including at least five instances captured by closed-circuit television where staff were asleep while they should have been monitoring patients.

The CQC statement continued: “The service was short-staffed, heavily dependent on agency workers, and it lacked essential equipment — including for resuscitation. There were also significant gaps in mandatory staff training, and personal protective equipment to help prevent the spread of covid-19 was not always used appropriately.

“Although staff understood how to identify abuse, and managers held monthly safeguarding meetings, the service had not always notified CQC or the local authority when safeguarding concerns had occurred. This is a statutory obligation to prevent a closed culture developing.”

NHS England and NHS Improvement East of England said in a statement: “The CQC’s findings show an unacceptable level of care, and we are overseeing the Priory St John’s actions to ensure that rapid improvements are made to improve patient safety, care and experience.

“We know that Priory St John’s shares a commitment to improve and address the safety and care concerns raised.” 

The CQC identified the following areas which needed improvements:

  • Addressing environmental risks, including ligature points;
  • Adequately implementing infection prevention and control measures;
  • Ensuring staff have access to functional and checked resuscitation equipment;
  • Employing enough staff and ensuring they complete mandatory training;
  • Observing patients in line with care plans and policies;
  • Ensuring staff have necessary breaks;
  • Only using physical intervention as a last resort;
  • Providing regular access to outside space, lounge areas and activities for long-term segregated patients;
  • Completing records and care plans in line with policies, including completing segregation records in line with the Mental Health Act code of practice;
  • Comprehensively reporting all allegations of abuse to CQC, and thoroughly reviewing all safeguarding incidents to drive learning; and
  • Using governance processes to identify problems and drive improvement.