The Care Quality Commission has criticised the lack of nurse leadership and supervision at a mental health trust which left staff fearing for their own safety.
An investigation into mental healthcare for older people delivered by the Devon Partnership Trust found that some isolated units run by the trust had just two staff on duty at night, including one trained nurse, and staff said they felt unsafe and at risk.
Every ward manager, and most nurses we spoke to, said they either never had or rarely had formal supervision
In a report published last week, the CQC said: “We were told of many occasions of ward managers having to step in to plug staffing gaps and there was widespread nervousness about having only one trained nurse on duty per shift, which was common.”
On one occasion staff locked themselves into an office and called for emergency help.
The problems were among a catalogue of failings in nursing care at the trust.
The commission was asked to investigate after concerns were expressed about the Harbourne Centre at Totnes Community Hospital, run by the trust, following the death of six patients.
An internal review found a number of problems at the unit, and, on an unannounced visit to the centre, CQC inspectors found that one constant observation patient with dementia was being kept in a room stripped of all furniture except a mattress on the floor and an armchair for the nurse observer. Shortly afterwards the unit was closed.
The CQC’s report said care at the rest of the trust was not as bad as at the Harbourne Centre, but nursing leadership was inadequate, there were not enough modern matrons working in the trust, and there had been no director of nursing in post for 19 months.
As a result, individual units within the trust were left to operate in isolation, and there was little support for nurses who challenged practice.
The report said: “Every ward manager, and most nurses we spoke to, said they either never had or rarely had formal supervision.”
Director of nursing and practice at the trust, Alison Moores, who joined it last year, told Nursing Times supervision of band 5 and 6 nurses in the more isolated units had been “sporadic at best”.
She said supervision had been reorganised so that nursing staff knew who their supervisor was, and more senior staff had a reasonable number of people to supervise.
Supervision is now electronically recorded, and quarterly peer and executive walk rounds have been introduced.