All inspections: Burton Park - Care Quality Commission

Date of assessment: 15 October to 1 November 2024. Burton Park is a 50-bedded hospital providing a neuro rehabilitation service. The service predominantly provides care and treatment for patients with acquired or traumatic brain injuries, including stroke. The service also offers continuing care for people who have progressive neurological conditions, such as Huntington’s disease and early onset dementia. The hospital has 3 separate units, however at the time of this assessment 2 of the units (Warwick and Dalby) were not in use. Warwick unit was being used for staff training but not was not open to patients. The Dalby unit had been de commissioned and was only used for storage. The Dalby unit required extensive maintenance work and refurbishment before being ready for patient use. At this assessment, only the unit known as Cleves was in use. There was a total of 12 patients at the hospital.

At our last assessment the service was rated 'requires improvement' overall. At this assessment, the provider demonstrated improvements had been made. The service is no longer rated as requires improvement overall or in any of the key questions. We assessed the service group (ASG) ‘’services for people with acquired brain injury". We also focussed on the breaches that gave rise to the previous ratings as required. We looked at all of the Quality Statements across all 5 Key Questions.

The service had made improvements and are no longer in breach of regulations. At this assessment we saw how staff and managers had worked hard to improve the quality of their care and to bring about required changes. The service had made the improvements required to improve their overall rating to ‘Good’.

Date of assessment: 15 October to 1 November 2024. Burton Park is a 50-bedded hospital providing a neuro rehabilitation service. The service predominantly provides care and treatment for patients with acquired or traumatic brain injuries, including stroke. The service also offers continuing care for people who have progressive neurological conditions, such as Huntington’s disease and early onset dementia. The hospital has 3 separate units, however at the time of this assessment 2 of the units (Warwick and Dalby) were not in use. Warwick unit was being used for staff training but not was not open to patients. The Dalby unit had been de commissioned and was only used for storage. The Dalby unit required extensive maintenance work and refurbishment before being ready for patient use. At this assessment, only the unit known as Cleves was in use. There was a total of 12 patients at the hospital.

At our last assessment the service was rated inadequate overall. At this assessment, the provider demonstrated improvements had been made. The service is no longer rated as inadequate overall or in any of the key questions. We assessed the service group (ASG) ‘long Stay or rehabilitation mental health wards for working age adults’. We also focussed on the breaches that gave rise to the previous ratings as required. We looked at all of the Quality Statements across all 5 Key Questions.

The service had made improvements and are no longer in breach of regulations. At this assessment we saw how staff and managers had worked hard to improve the quality of their care and to bring about required changes. The service had made the improvements required to improve their overall rating to ‘Good’.

Date of assessment: 15 October to 1 November 2024. Burton Park is a 50-bedded hospital providing a neuro rehabilitation service. The service predominantly provides care and treatment for patients with acquired or traumatic brain injuries, including stroke. The service also offers continuing care for people who have progressive neurological conditions, such as Huntington’s disease and early onset dementia. At this assessment, only the unit known as Cleves was in use. There was a total of 12 patients at the hospital.

We undertook an unannounced on-site assessment of 2 service groups (ASG’s) ‘long Stay or rehabilitation mental health wards for working age adults’ and services for people with an acquired brain injury. We also sought assurance from the provider through discussion with the senior leadership team and we reviewed evidence submitted. We looked at all of the Quality Statements across all 5 Key Questions. The assessment was focused on the patient pathway and the ward we visited was mixed with ‘rehabilitation’ and ‘acquired brain injury’ patients. Therefore, the 2 assessment service groups (ASGs) will produce identical reports.

Our rating of this service went down. We rated it as inadequate because:

Staff had failed to follow the Mental Health Act Code of Practice when caring for a patient in long term segregation. Staff had not recognised this as segregation despite the patient not being able to freely mix with other patients on the ward for five months.
Managers failed to ensure patients who received medicines covertly had a care plan in place detailing how staff complete this safely. Patients who received medicines through a percutaneous endoscopic gastrostomy (PEG) also had no detailed care plan in place instructing staff how to ensure medicines given by this route follows best practice guidance.
Staff had not consistently followed the Mental Capacity Act when assessing capacity to make specific decisions relating to medicines and the use of an electronic cigarette (vaporiser).
Staff could not locate all agency staff induction paperwork. We were not assured that this consistently took place. There was a lack of detail within agency staff profiles, particularly around mandatory training, what levels they had completed and when.
Due to the provider using a number of different care agencies to cover shifts, we were not assured that they had all received reducing restrictive interventions training in line with the providers own policy, and in line with national guidance.
The service had not had any regular psychology staff in post for at least 12 months despite some individual care plans listing psychological interventions and / or goals.
The provider used a high volume of agency staff to cover shifts. The majority of these were healthcare assistants. Agency healthcare assistants did not have access to patients’ electronic notes. They had to rely upon other staff inputting information on their behalf.
Staff did not always follow individual care plans relating to oral health and mouthcare, and cleaning and rotation of percutaneous endoscopic gastrostomy (PEG) sites.
Patients had not consistently received feedback following on from suggestions made or concerns raised during community meetings.

However:

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment.
Managers ensured staff had regular supervision and an annual appraisal of their work.
Staff actively involved patients, families and carers in care decisions when it was possible to do so, and appropriate consent had been sought.
Staff teams held regular team meetings which were recorded.
We saw some kind and caring interactions between staff and patients during inspection.
We spoke with some highly motivated and compassionate staff members.
We saw the wards had a variety of easy read documents.

Our rating of this location improved. We rated it as requires improvement because:

The service provided safe care. The ward environments had improved and were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice.
The ward teams included or had access to a range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, regular supervision and appraisals. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Most staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
There were new procedures in place for reporting incidents and learning from when things go wrong, staff were positive about the change and they knew about lessons learnt and changes to practice. Patient records were now kept securely and confidential.
All relevant staff had been involved in a review of patient observations and provided support. Staff told us about the refreshed vison and values across the service. Many staff told us they felt very proud to work at Burton Park; and the staff culture had improved across site. There was a clear change in the leadership within the service. Staff told us they valued the support and input from the registered manager, medical director and senior management team.

However:

The provider had staff vacancies with high use of bank and agency staff to cover. The provider had plans to reduce the number of beds that needed high observation levels with the new rehabilitation pathway model.
Whilst we noted an improvement in the cleanliness in the patient areas, we found that on Cleves ward non patient areas were not cleaned to the same standard. A staff kitchen and back stairs were visibly dirty. We reported this to managers during the inspection and they took action immediately. Some staff reported concerns about no cleaning support Monday to Friday after 3pm
Staff did not always follow safe administration and storage of medicines on Cleves and Warwick wards; however, we reported this to the manager who took immediate action.
On Warwick ward one risk assessment and one care plan out of 12 reviewed, were not regularly updated.
On Warwick ward one patient, who could not reposition themselves without support was observed alone in the same position for a long period.
Patients community meetings were not taking place regularly; and patients views not acted on. The provider told us they had plans to start in the new year. Some families and carers had concerns about the way patients were treated. Staff did not always respond appropriately to families and carers with support and information.
A staff member on Warwick ward was heard not speaking to a patient with dignity and respect.

On Warwick wards some bedrooms looked worn with marked floors, drab décor and looked bland and sterile. One patient’s bedroom door was unmarked, looked empty, no personalisation on bedroom door despite being at the service since 2019. The provider took immediate action to support the patient to personalise their bedroom.

This focused inspection was completed because we received information giving us concerns about the safety and quality of the care at Burton Park. At our last inspection we rated the provider overall as requires improvement.

This was a focused weekend inspection. Because of its limited scope, we did not rate each key question at this inspection. You can view previous ratings and reports on our website at www.cqc.org.uk.

Following the inspection CQC immediately issued an urgent enforcement section 31 letter of intent to address the identified areas of concerns. We issued three warning notices:

Regulation 12, (1) Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 17, (1) Good governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Regulation 18, (1) Staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

As a result of this inspection the rating for this core service has been changed to inadequate.

We are placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We found:

Staff did not always follow Covid-19 infection prevention and control principles. Whilst managers informed staff of the latest infection control prevention guidance at team meetings, they did not always follow this in practice.
Managers investigated serious incidents, but staff did not always know and implement the lessons learnt to improve patient safety.
Patients risk assessments were not regularly reviewed.
The provider did not maintain patient confidentiality, with patient identifiable information left unsecure in communal lounges
Managers failed to protect patients from abuse and improper treatment. In addition, managers failed to take actions as soon as they were alerted to suspected, alleged or actual abuse, or the risk of abuse.
Burton Park had a high use of bank and agency staff and staff vacancies. Managers failed to ensure that they had the required numbers of staffing for patient observations.
Patients were stopped from leaving the units during the pandemic for community leave to purchase essential items. This was not in keeping with the government guidelines at the time of the inspection.
Staff did not always treat patients with respect, dignity and kindness. Patients told us they felt some staff were rude. Some patients questioned whether there were enough therapeutic activities to aid their rehabilitation and recovery.
The culture across the three units was not positive. At the time of inspection, the culture was not one of fairness, openness, transparency, challenge and candour. Staff and patient feedback were inappropriately filtered or not responded to.
The leadership at the time of inspection was not robust. Staff told us they were not treated with respect and senior managers did not listen to their views. There was a disconnect between senior managers and staff across the three units.
Staff did not receive regular supervision with low compliance at 9% in February 2021.
The leadership team at Burton Park was not stable. The registered manager had resigned, and the clinical director was leaving, and a replacement not yet found. There had been a continued high turnover of senior leadership.
Managers failed to demonstrate that performance and risk were managed well. Governance processes did not work effectively at unit level.

However

All three units were generally well equipped, well-furnished and well maintained. Staff completed regular risk assessments of the care environment including a ligature risk assessment.
Staff followed best practice in anticipating, de-escalating and managing challenging behaviour. We saw staff on Cleves Lodge manage one patient’s challenging behaviour in a calm manner.
Mandatory training was compliant at 87%. Managers held a fortnightly safeguarding meeting which triangulated safeguarding referrals, incident data and actions.
Patients had a choice of food to meet dietary requirements. We observed mealtimes across the three units and saw a range of food prepared for tea including bread rolls, sandwiches and cakes.
Staff monitored and reviewed patient’s physical health care needs. Staff held weekly community meetings with patients. Patients engaged well with the process.
Around the service there were posters highlighting phone numbers that staff could call to report bullying and harassment and to whistle-blow. Across the provider there was a dedicated freedom to speak up guardian for the healthcare division.

We rated Burton Park as requires improvement because:

Staff did not follow the provider medicines management policy. We found three tubes of topical creams in the fridge on Warwick Lodge which staff had opened but had not labelled with the patient’s name.
Managers did not ensure there was adequate medical cover to prescribe essential medication. One patient had been admitted to the hospital when no medical cover was available. Therefore, essential medication had not been prescribed and the provider could not ensure the patient was safe.
Managers had not ensured all ligatures on Cleves Lodge had been included on the ligature risk assessment. We found ligature points in three bedrooms. Ligature points are places to which patient’s intent on self-harm might tie something to strangle themselves. Staff did not always adhere to the infection control policy regarding separating clinical waste from general laundry.
There were insufficient numbers of substantive staff which resulted in the provider using large numbers of temporary staff. The average vacancy rate for qualified staff across the hospital was 48% the vacancy rate for unqualified staff was 43%.

Staff did not follow the providers incident reporting policy. We found that one patient had not received their medication on five consecutive occasions. This was not reported at the time, we raised this with the ward manager who assured us that it would be reported immediately.

Managers did not ensure information to deliver care was available to all relevant staff. Temporary staff had read only access to the electronic patient record, which meant they could not update records.

Clinical documentation was not always reviewed and clearly recorded. Staff had not reviewed 10 out of 17 (59%) risk assessments inspected within the timescales set out in the providers policy. Staff did not always clearly demonstrate whether patients had received a copy of their care plan.

Practice did not promote the least restrictive environment. We found a blanket restriction in place at the time of inspection. The minutes of the hospital clinical governance meeting which stated that patients would not be allowed to drink caffeinated products from September 2018.
There was poor communication and governance structures in place. There was a lack of regular staff meetings taking place. Staff told us there had been no staff meetings for several months due to staff shortages, Staff were not aware of the governance structures in place to support best practice. We found a lack of regular community meetings and poor processes for sharing lessons learned.

However:

Clinic rooms were visibly clean and had enough space to prepare medications, physical health observations were undertaken in patient bedrooms. Physical health monitoring equipment had been calibrated and staff carried out weekly checks to ensure it was in good working order. Staff checked emergency resuscitation equipment on a daily basis and recorded this appropriately.

Patients had their own bedroom with an en suite shower room. Patients had personalised their room with pictures and soft furnishings and had access to lockable cupboards in which they could store valuable possessions. Patients were individually risk assessed for their suitability to have a key to their bedroom door.

The hospital had a range of rooms and equipment to support treatment and care. This included quiet rooms for family visits, activity rooms, therapy rooms and a gym. Patients had access to outside space. Patients could make phone calls in private in their bedroom using their mobile or the ward cordless phone.

The hospital kitchen provided a wide choice of meals for patients which included catering for specific dietary requirements. Healthy options were available and these were clearly displayed in dining rooms. Snacks and drinks were available 24 hours a day. Staff encouraged patients to make them for themselves wherever possible.
Staff treated patients with kindness, compassion and respect. We observed interactions between staff and patients during the inspection and saw that staff were responsive to patient's needs and were respectful. Staff treated patients with dignity and remained interested when engaging patients in meaningful activities. Staff interacted with patients at a level that was appropriate to individual needs.
We spoke with eight carers of people staying at Burton Park, six of which spoke highly of the care their relative received. Carers told us they were generally involved in their relative’s care planning reviews and received regular updates to any changes in their care plans, where the patient had consented to their information being shared.

We rated Burton Park as requires improvement because:

The ward layout meant that there were numerous ligature risks and blind spots on all three wards. There were comprehensive risk assessments to mitigate this but not all recommended actions had been carried out on the wards for example they had not fitted curved mirrors on the corridors.
When asked it took staff a considerable amount of time to look for ligature cutters on Warwick ward which were not in the place they were meant to be. In an emergency situation this could cause a potentially life threatening delay in staff getting to someone who had a ligature. A ligature is something such as rope or twine, tied around a part of the body, usually the neck in an attempt to self-harm or commit suicide.
The fridge temperature in Cleves ward clinic room was high at ten degrees Celsius, and we could not find a record of fridge temperatures on Warwick ward. We were not assured that medication was kept at the required temperatures.
Cleves ward was untidy and there was a smell of urine. We saw that a toilet on the ward was being used for storage.
For one patient’s record where rapid tranquilisation had been used there was no evidence that vital sign monitoring had been conducted.
There were issues with the labelling, storage and prescribing of medication on all three wards. Inhalers and topical creams had not been labelled correctly meaning that it would be easy for staff to give the wrong medication to the wrong patient and it would have been easy to pass on infection. Not all medication that was prescribed for mental health was recorded on the T3 forms for patients detained under the Mental Health Act (1983).
There were shortcomings with the environment particularly for bariatric patients who had restricted access to certain areas. Bariatric is the branch of medicine that deals with the causes, prevention, and treatment of obesity.
Carers had complained that the provider’s telephone system was not robust and it was difficult to get through to their relative.
The hospital did not provide a specific multi-faith space in a quiet location where people of differing beliefs were able to spend some time in contemplation or prayer.

However we found the following areas of good practice:

All care records were up to date, personalised, holistic with recovery orientated care plans and personal behavioural support plans.
The team provided National Institute for Health and Care Excellence recommended psychological therapies, they also used the Independent Neurorehabilitation Providers Alliance guidance, to provide the most up to date evidence based information.
Care records showed that patients received regular physical examinations and there was ongoing monitoring of physical health problems, including regular surgeries conducted at the hospital by the local GP and facilitating the support of patients to local hospitals when required.
Staff used a wide range of recognised rating scales to assess and record the severity and outcomes of neurological conditions. These included; the functional independence measure and functional assessment measure, the St Andrew’s Swansea neurobehavioural outcome scale, the supervision rating scale and the modified overt aggression scale.
Staff received monthly supervision from their line manager and a reflective group for clinical supervision was offered monthly. Staff training records showed staff were up to date with their annual appraisal.
We spoke with five patients during a focus group. All patients agreed that they were treated kindly by staff.
We spoke with six carers of people staying at Burton Park, they all spoke highly of the care their relative received.
Patients had an active involvement in their care planning and risk assessment.
Patients had access to independent advocacy services.
The provider had organised several family and carer events including a recent garden party. Carers told us that they were involved in their relative’s care programme approach reviews and received regular updates to any changes in their care plans where the patient had consented to their information being shared.
Patients were actively involved in the recruitment of new staff, sitting on interview panels and taking candidates on tour of the wards.
Managers ensured that staff were up to date with mandatory training.
Managers chaired monthly clinical governance operational group meetings and monthly senior management team meetings.
Shifts were covered by a sufficient number of staff with the correct grades and experience.
The ward managers had sufficient authority to do their job and administration support.
Staff we spoke with told us that staff morale was better as a result of changing to the new provider, and spoke of job satisfaction. We saw evidence of team working and mutual support.

Overall we rated Burton Park as requires improvement because:

the provider had not serviced the resuscitation equipment, such as the automated external defibrillator or suction machine, on a regular basis
the provider did not ensure that staff were well trained and supervised. Training records showed only 61% of staff received mandatory training as identified by the provider, staff supervision records showed that only 38% of staff had received supervision in September 2015 and only 53% of staff had received an appraisal since December 2014
staff had not attached the relevant Mental Health Act 1983 paperwork, for example, the certificate of consent to treatment (T2) or certificate of second opinion (T3) forms, to the patients’ medication charts
the provider’s computer system stated that five patients were being treated by staff under Deprivation of Liberty Safeguards (DoLS, part of the Mental Capacity Act 2005), when they were still awaiting assessment by the local authority
whilst some activities were available for patients’ specific needs, patients told us there was a limited amount of activities taking place

However:

the environment was clean and tidy, in a good state of repair, suitable for care and treatment, and risk assessed
single sex accommodation was provided, in line with Department of Health guidelines
staff assessed patients’ needs to develop personalised care and treatment plans, which the multi-disciplinary team discussed to work out they achieved the desired outcome for patients
staff appeared kind with caring and compassionate attitudes, and engaged with patients in a kind and respectful manner
governance committees and mechanisms were in place which supported the safe delivery of the service
the provider had strategic plans to develop the hospital and we saw evidence of progress in achieving the plans
patients’ views were gathered through “you said, we did” surveys. These results were analysed by the senior management and improvements were made

Burton Park

All Inspections

During an assessment of Services for people with acquired brain injury

During an assessment of Long stay or rehabilitation mental health wards for working age adults

During an assessment of the hospital overall

21 - 22 November 2023

During a routine inspection

7-8 December 2021

During a routine inspection

21 March 2021

During an inspection looking at part of the service

18 - 20 December 2018

During a routine inspection

30 May to 1 June 2017

During a routine inspection

21 and 22 October 2015

During a routine inspection