Advising with empathy and experience

Mental health unit's safety risks 'not addressed', health regulator says.


A mental health unit was rated inadequate for the second time in four months after it failed to address patient safety risks.

St John's House in Palgrave, Suffolk, had been in special measures since a Care Quality Commission (CQC) inspection but, at a later inspection, the CQC found many issues "remained unchanged", including its response to incidents of self-harm.

Inspectors saw two incidents involving self-harm where staff "did not intervene in a timely manner", one of which resulted in a patient’s head injury.

The CQC said that the home near Diss, which cares for adults with learning disabilities and associated mental health issues, had a "lack of clear leadership", having had four temporary managers in post since July 2020 who had not investigated all serious incidents.

Staffing levels were unpredictable because St John's House had a continued reliance on agency staff without the right training, the CQC added.

On the second visit, CQC inspectors again found staff were asleep when they should have been observing patients, including all three members of staff assigned to one patient.

The inspection report said that care plans "appeared to have been copied and pasted" across patients and did not include all individual health conditions and needs.

CQC head of inspection for mental health and community services, Stuart Dunn, said: "Disappointingly, our latest inspection found the overall quality of care had not improved and many of the issues we previously raised remained unchanged."

The CQC told the Priory Group it must make several improvements, including employing enough staff with the correct training and ensuring staff know the location of emergency equipment, including ligature cutters and the defibrillator.

Last year, inspectors found a patient was pushed to the floor as staff used "disproportionate and unauthorised techniques.”

CCTV footage showed seven incidents including "a patient being dragged across the floor, a patient being pushed over and the seclusion room door trapping a patient's arm and making contact with a patient's head when closed.”

After the initial inspection, Priory Healthcare said it had taken "immediate action to deliver improvements.”

In a statement following the most recent inspection, Priory, which said it was committed to ensuring patients' needs were met, added that it was "taking decisive steps" to address the issues, including recruiting nursing staff, a consultant psychologist, a new medical director and a hospital director.

It added it was working with commissioners and families to relocate patients to more appropriate settings.