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St John's House mental health hospital, in Palgrave, shut down following damning CQC report

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A Suffolk mental health hospital has been shut down after a recent inspection brought to light a number of damning incidents of malpractice.

Inspectors found staff at St John's House, in Palgrave, were asleep on the job and failing to safeguard patients from self harm during a visit in December last year, and an inspection in July found there had not been sufficient improvements to these safeguarding concerns.

The 49-bed hospital, in Lion Road, was banned from admitting any new patients after last year's observations and given four months to clean up its act – but a further inspection in April this year determined that practices had not improved.

St John's House hospital was rated as 'inadequate' by the CQC following an inspection back in April. Picture: Google.
St John's House hospital was rated as 'inadequate' by the CQC following an inspection back in April. Picture: Google.

Providers Partnerships in Care has now closed the practice, after Care Quality Commission (CQC) officials carried out a focused inspection in July and found that insufficient progress had been made regarding patient safety, staffing, risk management and adherence to patient care and risk needs.

The providers are now working to find alternative care services for patients.

Stuart Dunn, head of inspection for mental health and community services at the CQC, said: “Our latest inspection of St John’s House found an unacceptable service where insufficient improvements had been made to protect patients from harm and abuse and the number of safety incidents remained high.

St John's House, in Palgrave near Diss, which has been shut down after a damning report by the CQC. Picture: Google
St John's House, in Palgrave near Diss, which has been shut down after a damning report by the CQC. Picture: Google

“Staff weren’t responding appropriately to patients who were self-harming, with one patient not being sent to hospital quickly enough after swallowing a foreign object, despite complaining of abdominal pain.

“We reviewed CCTV footage and found staff were sometimes asleep when they should have been observing patients to make sure they were safe.

“This was all the more concerning as we identified this as a concern during the previous two inspections of this service, demonstrating a lack of improvement to keep patients safe.

“Incidents of restraint remained high and not all staff had the right training to carry it out safely. In addition, staff were not following hospital policy when using soft handcuffs with patients during safety incidents."

Inspectors had also identified a reliance on agency workers who did not always know the service, or have the right training to support its patients.

According to the latest report, published today, the service had high numbers of incidents - with 271 in May, 236 in June and 282 in July, with the majority occurring on the Redgrave ward (a 16-bed medium secure female ward, with 11 patients), although this was a decrease in incidents compared to the previous inspection in April.

In April, the CQC said patients did not have regular individual time with a designated staff member, affecting the support they received to have timely access to external specialists.

The issue worsened because documentation, including for risk assessment, was not always comprehensive.

In addition to being rated inadequate overall, the service was rated inadequate for being safe, effective, caring and well-led. It was rated 'requires improvement' for being responsive to people’s needs.

Due to the serious level of concerns found in July, previous conditions the CQC placed on the provider remained in place, including restricting admissions to the hospital and further urgent conditions were imposed to prevent harm and to protect patients.

As a result of the damning report, Partnerships in Care, who are part of the Priory Group, took the decision to close the practice.

Mr Dunn added: “Services must inform CQC and other statutory bodies when they identify safeguarding concerns such as these to ensure patient safety. This service’s continued failure to refer all instances of abuse and thoroughly investigate concerns has put its patients at prolonged risk of harm.

“Following our inspection where additional enforcement action was taken, the provider made the decision to close this service.”

The hospital had 29 patients at the time of the inspection in July. It provided care for patients with learning disabilities and mental health problems.

A spokesman for the hospital said: “Following discussion with NHSEI, we notified the CQC on 23rd July 2021 that we had taken the decision to close St John’s House. This step has not been taken lightly but we consider that, given the wholly exceptional circumstances, it is the most appropriate course of action.

"Despite our best efforts and substantial investment, St John’s House continued to suffer from significant recruitment difficulties stemming from the nationwide shortage of specialist nursing staff for learning disability services. As such, it had become increasingly challenging to meet the needs of the people we look after and over the last 2 months we have worked diligently with all stakeholders to find appropriate alternative provision for service users. There are now only 2 service users remaining at the service and we expect alternative provision to be found for them later this month.

"We fully support the transforming care initiative, which enables more people with a learning disability to live in the community with the right support and close to home. In line with this approach, we will continue to work with NHSEI to change the way we deliver our learning disability services in order to provide the most appropriate form of care for the people we look after.”

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