The Mundesley Hospital in Norfolk has been placed into the “special measures” regime for struggling healthcare providers, following Care Quality Commission inspection.
The visit was carried out at the recently refurbished independent mental health hospital in North Norfolk in September 2016 when a number of concerns were found.
“We found a number of serious problems when we inspected the services”
CQC inspectors concluded that the hospital needed to make a number of improvements to ensure it was consistently delivering care which was safe, effective, caring, responsive and well-led.
The hospital was judged as “inadequate” for being safe and well-led, “requires improvement” for being effective, but “good” for being caring and responsive.
The facility, which only opened under its present owners in February, provides private mental health care for up to 27 adults who require assessment and treatment in an inpatient setting.
The CQC highlighted a number of concerns and areas needing improvement, including ensuring all staff were up to date with mandatory training and that all qualified staff received immediate life support training.
In addition, incident forms must be completed in full and signed off by a senior manager, and restraint forms and rapid tranquillisation forms must be fully completed as necessary, said the CQC.
The provider must also ensure there are appropriate systems in place to learn from incidents and share that learning with all staff, said the regulator.
“We have moved on in the three months since the [CQC] visit”
Mundesley Hospital statement
The CQC added that the provider must complete an environmental risk assessment that addresses ligature and other risks, which should then be updated regularly and identified risks mitigated.
Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals and lead for mental health, said: “We found a number of serious problems when we inspected the services run by Mundesley Hospital and have subsequently placed the service into special measures.
“All of the care plans examined lacked detail, staff did not always ensure that patients were aware of their rights and not all staff had completed mandatory training required to do their jobs correctly and effectively,” he said.
“The hospital did not follow their policies and procedures regarding incident management,” he said. “For example, inspectors saw examples of serious incidents that had occurred, none of which had been reported to CQC.
“Individual patient freedom was restricted due to the layout of the building and the need for staff to have to escort patients,” he said. “The hospital had not reviewed their environmental ligature risk assessments since the hospital began admitting patients.
“We were concerned that the monitoring and recording of rapid tranquillisation was incomplete and nurses did not consistently monitor the physical health of patients who received this,” added Dr Lelliott.
Dr Paul Lelliott
In a response statement, the board of the hospital said: “We welcome the observations made by the regulator and also welcome the opportunity to learn from the experience of working closely with the inspection team.
“To open a new hospital and bring a new team together has been challenging for all, but everyone’s commitment to a weekly development programme, mandatory training and intensive governance processes has helped us to achieve this and we have moved on in the three months since the [CQC] visit,” it said.
“For instance, where some areas of care plans and incident reports were incomplete, they are now consistently correct,” said the statement.
“Such administrative errors have not affected the safety or care within the hospital but we completely accept that the documentation must be as high in quality as the kind and caring interactions we have with our patients and their families,” it noted.
The statement added: “We and our stakeholders are undoubtedly disappointed to read the report about us from three months ago. However, we are certain that the ongoing developments we have made already put us in a completely different place now and that the CQC will see this when they next visit.”
The hospital was built in 1899 as a tuberculosis sanatorium for wealthy patients. Made in pre-fabricated timber sections, it was the first large centre in England constructed specifically for open-air treatment of the disease.
It was transferred to the NHS in 1957, but became a private drug and alcohol rehabilitation unit during the 1990s. However, the unit closed in 2009 and was sold on to its present owners.