‘Shocking state of affairs’ found at Oxford care unit for people with disabilities

Oxford Mail: John Sharich House John Sharich House

AN OXFORD care facility for people with serious learning disabilities was told to stop taking admissions following a damning inspection.

The Care Quality Commission (CQC) has raised concerns about Slade House, in Horspath Driftway, Headington, about nurses not interacting with staff, equipment that did not work and medicines not being safely administered.

A report by the group said that the building was not suitably safe, quality monitoring was inadequate and the facility was not clean enough. One person told an inspector they felt unsafe and uncared for, while another said they hated it there.

And staff complained of not having enough time to do their job.

Oxford East MP Andrew Smith said: “This report has uncovered a truly shocking state of affairs, with basic failings in every aspect of service examined by the inspectors. It is awful to think of patients being exposed to these risks in care and welfare, cleanliness and infection control, safety, quality of service, records, and much else.

“The public will rightly expect Southern Health Foundation Trust to put its house in order as a matter of urgency, bringing every area up to standard, and taking disciplinary action against the managers responsible. I am seeking a meeting with the chief executive of the trust to get assurances that every action is being taken to put things right.”

Southern Health NHS Foundation Trust run the site since November last year, having taken over from the Oxfordshire Learning Disability NHS Trust, also known as the Ridgeway Partnership.

It also runs the Evenlode medium secure unit in Littlemore.

Oxford Mail:

  • Katrina Percy, the chief executive of Southern Health NHS Foundation Trust

Bosses at Southern Health NHS Foundation Trust – which provides community health, specialist mental health and learning disability services in Hampshire, Dorset, Wiltshire, Oxfordshire and Buckinghamshire – said it was taking the report seriously.

Chief executive Katrina Percy – who was paid £175,000 to £180,000 in the last financial year, but whose salary for this year officials would not reveal – said she was “concerned the points raised in the report did not come to light sooner”.

Mrs Percy said the trust had “launched our own internal investigation” to understand the reasons for the failings.

The report will be made public.

She said: “We were most concerned to learn of the issues brought to light by the CQC.”

In the report, staff complained of not having time to care for patients, while the inspector for the CQC recorded concerns about patient safety and cleanliness.

The trust stopped new admissions for two units – for up to 15 adults – after a routine visit by the CQC.

The body visited the house’s two units, the Short Term Assessment and Treatment Team unit (STATT) and John Sharich House.

Eight patients were staying at the site at the time of the inspection.

During the two-day visit, the inspector said “nursing staff stayed in the staff room most of the time” to use computers and the phone.

The inspector said of STATT: “We saw very few social or therapeutic nursing interactions with people who stayed there.”

The unit “appeared process-led rather than patient focused,” with one nurse saying they were “unable to build therapeutic relationships they knew should be in place”.

Staff said they were asked to carry out audits without extra time and were told by managers to “prioritise their work”.

It found: “They wanted to spend more time with patients and constantly felt that they were unhappy about this.”

Oxford Mail:

  • The Short Term Assessment and Treatment Team unit

One patient told the inspector: “I don’t feel safe here. No one asks me what I want or, if they do, they ignore what I tell them. I have told them I want to go home.”

Southern Health NHS Foundation Trust must now report back to the CQC by December 17.

Five senior staff were brought in following the September inspection “to provide the leadership and knowledge required”, said Mrs Percy.

An action plan includes training, more patient information, a review of nursing plans, a new cleaning contractor and visits by senior staff. The units have a total of six patients.

Mrs Percy said admissions closed on September 24 “and will remain so until we can provide assurance that we are able to deliver the best possible care to our patients”.

Concerns from the CQC about equipment such emergency oxygen being “significantly out of date” – had been put right, she said.

The service is paid for by both Oxfordshire County Council and the NHS’s Oxfordshire Clinical Commissioning Group.

A joint statement from the organisations said both are seeking “to ensure that high-quality care is delivered at the unit”.

Key findings in the report

  • Respecting and involving people who use services. Finding: action needed. Privacy, dignity and independence was “not always respected” and “views and experiences were not taken into account”.
  • Consent to care and treatment. Finding: action needed. Staff did “not always act in accordance with people's wishes and consent”.
  • Care and welfare of people who use services. Finding: Enforcement action taken. Concerns about interaction with staff meant care was “not consistently planned and delivered”.
  • Safeguarding service users from abuse. Finding: action needed. Staff had “not taken reasonable steps to identify the possibility of abuse”.
  • Cleanliness and infection control. Finding: enforcement action taken. Guidance had “not been followed” and the environment was “not suitably clean”.
  • Management of medicines. Finding: action needed. Appropriate arrangements not in place, such as over-storage and checking expiry of drugs.
  • Safety and suitability of premises. Finding: enforcement action taken. Concerns included being able to fully open two windows and a lack of fire signs, meaning patients were “not protected against the risks”.
  • Safety, availability and suitability of equipment. Finding: enforcement action taken. The CQC’s concerns included a defibrillator with no battery and an oxygen cylinder which expired in June 2012.
  • Assessing and monitoring the quality of service provision. Finding: enforcement action taken. No “effective system to regularly assess and monitor the quality of service”.
  • Records. Finding: enforcement action taken. “Accurate and appropriate records were not maintained.”

Read the full report: CQC slade House final report.pdf

Comments (2)

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7:40am Fri 29 Nov 13

Oxfordme says...

This is a shocking report and brings shame n the NHS in Oxford. As you reported in this newspaper at the time, a young man left alone drowned in the bath while in the care of this so called ''care" unit back in July. Now we see a report where staff have been shown to have been in the staff room most of the time and not with the patients - even though the staff actually outnumber the patients most of the time!
What is astounding though is that the Trust waited until the CQC inspection in September to do anything about this unit and the patently obvious lack of care. Quite simply, three months went by from a death in early July to an external inspection in late September. Where are the Trust generated safeguards when something goes wrong? Why did it take the arrival of the CQC to get some action? Why had the trust not done something in the meantime? These questions should be posed to the Trust and answers demanded. Presumably patients were still arriving in the period between July and September. Would you have liked your relative to be under this kind of "care"regime?
This is a shocking report and brings shame n the NHS in Oxford. As you reported in this newspaper at the time, a young man left alone drowned in the bath while in the care of this so called ''care" unit back in July. Now we see a report where staff have been shown to have been in the staff room most of the time and not with the patients - even though the staff actually outnumber the patients most of the time! What is astounding though is that the Trust waited until the CQC inspection in September to do anything about this unit and the patently obvious lack of care. Quite simply, three months went by from a death in early July to an external inspection in late September. Where are the Trust generated safeguards when something goes wrong? Why did it take the arrival of the CQC to get some action? Why had the trust not done something in the meantime? These questions should be posed to the Trust and answers demanded. Presumably patients were still arriving in the period between July and September. Would you have liked your relative to be under this kind of "care"regime? Oxfordme

1:34pm Thu 12 Dec 13

Be fair Be honest says...

Funny how somethings can be reported from a totally one sided point of view unfortunately ( for the moment ) the full truth of how things really are and how they have been managed can not be written, but it will. There are many professionals within and at the head of this organisation who have many many years of unblemished service to the NHS and now for all their efforts and dedication are looking at being made escape goats due to the failing of the trust in question ie Southern Health. There are a lot of factors which haven't been reported on that have bought about the event but again due to reporting this without the full facts the media has totally let the people down how look after the people society wold rather not deal with and they do it with care compassion. I find it totally despicable the media jump on the band wagon and report without all the facts from the people concerned.
Funny how somethings can be reported from a totally one sided point of view unfortunately ( for the moment ) the full truth of how things really are and how they have been managed can not be written, but it will. There are many professionals within and at the head of this organisation who have many many years of unblemished service to the NHS and now for all their efforts and dedication are looking at being made escape goats due to the failing of the trust in question ie Southern Health. There are a lot of factors which haven't been reported on that have bought about the event but again due to reporting this without the full facts the media has totally let the people down how look after the people society wold rather not deal with and they do it with care compassion. I find it totally despicable the media jump on the band wagon and report without all the facts from the people concerned. Be fair Be honest

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