Learning Disability Today
Supporting professionals working in learning disability and autism services

CQC closes Staffordshire inpatient unit after finding unsafe living conditions and patient abuse

The Care Quality Commission (CQC) has closed another inpatient unit, Eldertree Lodge in Staffordshire, after finding inadequate levels of safety and care, including evidence that some patients were subject to abuse.

Eldertree Lodge is a 41-bed mental health hospital for people with learning disabilities and autism, which was re-inspected by the CQC in May and June after receiving an “inadequate” rating in March.

During a two-week period from 27th February 2021 to 13th April 2021, the inspectors identified multiple incidents of inappropriate restraint, abuse and ill treatment of patients on a singular ward within the hospital.

As the report states: “We saw multiple examples where staff pulled or dragged a patient in an attempt to move them to the ward seclusion room. In another example, a staff member grabbed a patient from behind, again in an attempt to move them to the seclusion room.

“We saw two examples where staff slammed or forced doors shut on a patient without regard for the potential of their actions to injure the patient. All incidents demonstrated ill treatment or abuse and the use of inappropriate restrictive techniques by one or more of the staff members present.”

The inspectors also reported seeing staff members become visibly angry towards patients, and inappropriately secluding a patient on multiple occasions without clear reason to do so.

Staff were not properly trained

The report also found that staff “did not have the skills to develop and implement good positive behaviour support plans and did not follow best practice in anticipating, de-escalating and managing challenging behaviour.”

For example, staff did not always attempt to de-escalate prior to using restrictive techniques and did not always recognise the potential for their practice to harm patients.

The report states that on two occasions (between 6th May and 14th May) staff carried out restrictive practices that did not consider their environment, and inspectorates saw “risks from furniture and hard surfaces at proximity to the patient’s head”.

The report found that the provider’s timescale to ensure all staff were trained in the same restrictive techniques was not adequate to ensure patients were protected from a risk of harm at the earliest opportunity, with just 37% of agency staffed trained with the provider’s recognised restrictive technique by May 2021.

The CQC say that because the various failings had not been addressed by the provider, Coveberry Limited, they had no option but to close the facility.

Lack of incident reporting and inadequate protection from harm

Additionally, the report found that there was a severe lack of incident reporting and inaccurate record keeping, as the report states: “Of the incidents we reviewed between 27 February 2021 and 13 April 2021, despite multiple staff involved in the incidents or a witness to the incidents, none of the ill treatment or abuse was reported. Incident records relating to these incidents were not accurate.”

Some facilities were also found to be unclean and poorly maintained. Although improvements had been made since the March inspection, various ward areas continued to appear dirty, particularly ward baths and sinks.

Health hazards were also found across the wards, with sharp mirror edges exposed in one bathroom, out of date food in the fridge, and unlocked kitchen cupboards containing cleaning materials.

Other notable findings include:

  • Seclusion rooms did not allow two-way communication
  • The service did not have enough nursing and medical staff who knew the patients
  • Staff did not treat patients with compassion and kindness or respect patient’s privacy and dignity.
  • Not all staff understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • Leaders did not have a good understanding of the services they managed and were not always visible in the service and approachable for patients and staff.
  • Governance processes did not operate effectively at team level and performance and risk were not managed well.
  • Teams did not have access to the information they needed to provide safe and effective care and did not use that information to good effect.

“It is simply unacceptable that people with a learning disability and autistic people have again been failed by a system that should be protecting them”

In response to the report’s findings, BASW UK said that unsafe environments and the use of restraint, including limiting access to the outside world, should always be seen as a failure of the system and care.

“We are shocked that a number of Care Quality Commission (CQC) inspection summaries and reports have been published with inadequate ratings for health and social provision that provides care and support to autistic people and people with learning disabilities and call for urgent action,” they added. 

The learning disability charity Mencap are similarly urging the government to publish its long-awaited strategy around the Transforming Care programme.

Dan Scorer, Head of Policy at Mencap, said: “Families have repeatedly raised the alarm over the mistreatment and abuse?of their loved ones trapped in inpatient units. And despite the Government promising to get people out of these hospitals following the abuse uncovered at Winterbourne View a decade ago, there have been over 9,000 admissions since 2015 – equivalent to four a day. Behind these numbers are people whose human rights are at serious risk.

“We welcome the care regulator taking decisive action to safeguard people, stop abuse and close this failing unit, but it is simply unacceptable that people with a learning disability and autistic people have again been failed by a system that should be protecting them.

“The Government must treat this scandal with the urgency that’s needed and publish its long-awaited strategy?as soon as possible to drive the change that is so desperately needed. And the Government’s repeatedly delayed?social care reforms must come with significant funding?so people with a learning disability can get the support they need in their community – instead of being locked away in modern-day asylums.”

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