Springfield Review Response

Sutton 1  in 4 Network
Response to CQC review of Compliance Report on Springfield Hospital dated June 2011 
The report in our opinion is far more optimistic than service users actual experiences, indeed  the subjective experiences are truly represented in a report as to best practices by the Royal College of Psychiatrists and we are surprised that the CQC have not found more areas for concern. In particular, despite stating on page 4 that their unannounced visit comprised of 6 compliance inspectors, a compliance manager and a pharmacy inspector, it is apparent that no Nursing expert was present to give a view from that perspective. Perhaps a clarification could be made if this is not the case? If it is the case then surely this is a serious omission for a report on compliance which should be remedied for future visits?
The use by the CQC of adverbs and adjectives  such as ‘most’ and ‘generally’ qualifying their findings gives the wrong impression that all is well when in fact there are concerns. This is especially concerning when the area being described is one where the Royal College of Psychiatrists expect the standard to be met in order to comply with the law and not put patients at risk or be best practice (Type 1 and 2 standards.. see below). The terms are further eroded in effectiveness when one realises that only 50 patients / members of the public and 30 staff were interviewed over 2 days. This for a compliance team of 8 people works out at the rate of 5 people interviewed per day per team member, hardly a ringing endorsement for anecdotal based evidence. Despite this natural equitable viewpoint the CQC still have concerns with the Trust.
In addition, from a Sutton perspective, the report makes clear that Jasper / Crocus ward was one of the 10 wards visited on their unannounced visit but there is very little evidence of their findings as it relates to Jasper / Crocus ward.
Further, we do not understand why there are omissions in regard to Outcomes 3, 15, 18, 19, 20 or whether the last outcome truly is 21 or whether there are more after that. Clarification would be gratefully appreciated.
In compiling this report we were very conscience that criticism of the response being merely ‘sour grapes’ from the view point of service users was able to be objectively countered. In order to balance the response with evidence from non user sources we have referred to other documents with their professional opinions.  Note the standards for inpatients wards – working age adults, that hospitals and wards are recommended  to comply with to achieve Accreditation for Inpatient Mental Health Services (AIMS) 4th Edition January 2010 Pub No CRTU040 with the Royal College of Psychiatrists and the Department of Health guidelines called The Ten Essential Shared Capabilities,  a framework for the whole of the mental health workforce.  The NICE guidelines are also very applicable, although we have only seen draft guidelines at present so do not refer to them until they are officially published.
In the AIMS document the standards are categorised into types. Type 1 is when a failure to meet standard 1 would result in a significant threat to patient safety, rights or dignity and / or would breach the law.  Type 2 is when standards that an accredited ward would be expected to meet. Type 3 is a standard that an excellent ward should meet or standards that are not the direct responsibility of the ward.
The accreditation scheme has been in operation since 2003. The Royal College of Psychiatrists state it is most unusual that a hospital should not apply for the peer review process and accreditation, as accreditation shows a consistent level of professional standards across the whole range of mental health inpatient services. South West London and St George’s Mental Health NHS Trust – Springfield University Hospital has never
applied for the accreditation process.  This fact alone should be ringing alarm bells all over officialdom and we are questioning why it is not?
Part of the accreditation process involves key staff visiting accredited hospitals to learn the good practices that occur at the accredited hospital. Despite serial critical reports over many years and many management changes, Springfield have been incapable of learning the good practices and retaining those good practices. At present we feel that Springfield is a failed hospital, a drain on hard earned taxpayers resources and in many cases is the source risk for inpatients rather than the place of safety it is meant to be. We are close to having the opinion that Springfield Hospital should be having their licence to operate withdrawn and that the CQC should be placing a time limited action plan upon the Trust to solve the ingrained, institutional malaise that pervades the place. Drastic measures are needed, senior management should be in no doubt of that.
Page 6 : Respecting and Involving people
Although AIMS deals with adults, it is clear in para 6.1 Access to independent advocacy is a Type 1 standard and therefore in the report where it says  “there are no advocacy services available for children and young people” this is clearly illegal or puts patients at risk.
Page 6 : Activities
The report details here that activities are not available at weekends due to staff shortages.  AIMS para 38.1 states that these should “include evening and weekends activity” and is a Type 2 standard. AIMS para 2.1 & 2.3  states that wards should have agreed minimum staffing levels across all shifts, and mix factors to include staff needed for among others, “therapeutic engagement”.  Both paras 2.1. & 2.3 are Type 1 standards.
Page 7 : Consent to Treatment
It is gratifying that the CQC find that the majority of staff have little knowledge of the informally admitted patients, across the Trust, and of their right to leave locked wards whenever they chose. Given that Ms Judy Wilson publicly stated, at a Trust listening exercise in Sutton in 2011 into Trust Foundation status, that she abhorred the practice of coercing patients into hospital on the threat of sectioning them when there was no evidence to support a section and admitted the practice was widespread, it is concerning that the CQC finds that once in hospital, patient rights are further abused systematically and institutionally by the Trust and their staff.  As we have advised before, the management of the wards, the middle and senior  managers have systematically failed in their responsibilities. It is good the CQC has highlighted their concerns in this report, but we would urged further scrutiny.
The CQC should insist that figures for the balance of voluntary patients / sectioned patients should be available on the ward and over the Trust generally too. The rights of voluntary patients, and their ability to leave at will,  should be on open display on wards where this is appropriate. All staff should be aware of who are and who are not under a section. They should all know who their voluntary patients are. A failure to know this basic status should be a discipline offence as it suggests the risk of unlawful detention which is a possible criminal offence. Staff routinely deny voluntary patients their right to leave the ward. They treat all patients as they are under a section. Doctors and management allow this to happen. The CQC should urgently enquire with the Trust as to their robust plans to ensure this cannot occur.
Further, it is suspected that the coercion that is practiced is because of the additional paperwork and effort that is required by doctors and professionals at the point of diagnosis, treatment options and admissions. It is easier to admit a patient voluntarily rather than by a section. Also it has potential cost implications especially if a section 3 admission is made as then section 117 becomes a burden in due course and admission under a voluntary basis sidetracks this.  Not only is this practice unlawful, it is a serious breach of professional standards. The Trust collude in this, either with their full knowledge or by neglect by ensuring the consent to treatment is not investigated fully at the point of reception on the ward. This has to change and it is the Trust’s systems and professional, legal and moral standards that should ensure that change will occur.
It is our opinion that on reception, the patient, the patients friends and / or relatives who participated in the admission process should there be any, should be asked to sign that the admission was not coerced and is truly voluntary. Any suggestion to the contrary should be referred for investigation as a complaint against the doctor and professional concerned. The Trust is the final arbiter and carer for the patient and especially when entering a secure unit where freedom is restricted it is incumbent on the Trust to ensure that they are housing the patient legally and in accordance with all professional standards. The CQC should ensure robust plans are in place to ensure that they do. The personal experiences of hundreds of Sutton patients over many years can give testimony to these abhorrent practices.
AIMS  Type 1 standards apparently breached : para 9.1 admission protocol sharing; 9.4 agreed admission reasons between admission team and acute care team; 9.6 admitting nurse checking security of patient’s home and children / animals etc.; 11.2 unclear if there are written standards for the admission process; 12.5 & 12.6 detained and informal patients given rights, rights to advocacy and second opinions, rights to access interpreting services, professional roles and responsibilities and the complaints procedure explained and given.
Page 7 : Care Plans
The report outlines that Care Plans are rarely seen by patients let alone that copies have been given to the patient.
AIMS Type 2 standard : Patients should be offered copies of their care plan. Their carers too, if the patient agrees.  Para 13.7 & 13.8.
Page 8 : Safeguarding people from abuse
The report state that the “majority” of patients “felt safe”.  This is unacceptable. All patients should feel safe when they are admitted to a place of safety.
AIMS Type 1 standards: There are many and varied standards that the Trust may or may not be complying with.  They refer to NICE Guidelines also as well as other Department of Health Guidance and various Acts of Parliament. They advise that there is a Policy on patient safety, which one would never know about or know it exists as it is not generally available to the public. Similarly there should be Policies on restraint and rapid tranquilisation and mechanisms for documentation and monitoring of violence and aggression. In para 20.7 it states “any incident requiring rapid tranquilisation, physical intervention or seclusion is recorded contemporaneously..”. We know of only one method of contemporaneous recording and that is videoing. It is our view that in the interests of safety for the patient and staff that this is done.
Page 8 : Staffing Levels
It is concerning that the Trust have indicated that they are happy with the numbers of staff they employ. The report suggests that even staff are stating that “very few opportunities to interact with people using the service and to engage in their treatment other than on a superficial level” which suggests either under resource of staffing levels or perhaps just plain laziness.  It is our view that management failures are responsible for this in either case.
AIMS Type 1 Standards : Para 36.3 states Each patient is invited to meet with a member of staff for a one to one contact each waking shift and this is documented. Time should be set aside purposely for this.  Para 37.4 In patients  have access to specialist practitioners of psychological interventions for one half day (4 hours) per week per ward. Para 38.6 At least one staff member linked to the ward is delivering one basic, low intensity psychological intervention, and a Type 2 similarly states one staff member delivers one problem specific, high intensity psychological intervention. AIMS has many standards on engagement, counselling, access to primary nurses and one to one sessions.
Page 9 : Outcome 1 : People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run.
10 Essential Shared Capabilities : Espouses Working in Partnership; Respecting Diversity and Practicing Ethically.
Again it is gratifying that the CQC have picked up on the need for significant improvement on the issue of Care Plans. However, staff merely writing care plans and then giving copies out is barely sufficient.
It is our opinion that all staff should be conversant with the nature and specifics of each care plan. The patient’s primary nurse should be practicing the NICE Guidelines in respect to their patients on each working shift in respect to one to one face time in private. In between shifts the nurse in charge of the patient on that shift should also be interacting in a like way. Care plans are to be followed for treatment to be effective and non compliance with the care plan should be the exception and not the norm as it seems to be at present.
The CQC should ensure that robust plans are in place to ensure that not only are care plans written in consultation and the consent of the patient and the patient given a copy, they should ensure that processes for robust management supervision, which is in our opinion sadly lacking, is in place. It will become clear over time whether management are robustly supervising their staff in this regard as bad practices will either be eliminated or be easily shown to not exist by the ignorance of permanent staff.
When it comes to temporary or agency staff it is incumbent on ward managers and shift in charge Nurses to additionally know intimately the care plans of the patient allocations of the agency staff.  Blaming inadequacies on agency staff is a sad and outrageous indictment of the lack of supervision and management failures and is worse than the actual problem complained about.
We are not sure the CQC, in regard to privacy, will have merely moderate concerns when the facilities on Jasper ward for the safe guarding of property and privacy of patients sleeping facilities are examined. We would have thought the concerns would be greater.
AIMS Type 1 Standards : Para 36.3 states Each patient is invited to meet with a member of staff for a one to one contact each waking shift and this is documented. Time should be set aside purposely for this.  Para 37.4 In patients  have access to specialist practitioners of psychological interventions for one half day (4 hours) per week per ward. Para 38.6 At least one staff member linked to the ward is delivering one basic, low intensity psychological intervention, and a Type 2 similarly states one staff member delivers one problem specific, high intensity psychological intervention. AIMS has many standards on engagement, counselling, access to primary nurses and one to one sessions.
AIMS has much to say on Care plans and assessment of risks. Para 13.3 talks of immediate risk assessments. 13.4 about meeting with their primary care nurse. Importantly though it they also at para 13.9 state that all assessments are documented, signed and or validated in the case of electronic copies and dated by the assessing practitioner and all this should be done within 72 hours of admission, para 13.4.
They also look at the issues of Continuous Assessment and Reviews. Para 16.2 states that each patient should have a daily action plan. Para 15.5 states that ongoing assessment should involve the patient and his / her carer if consent is given.
AIMS advocate that Discharge Planning is instigated within 72 hours of admission and that the patient is actively involved in developing their discharge plans, para 17.1 & 17.3. A Type 1 standard goes on to discuss After care  plans at para 17.6
When one looks at the standards that should be happening the statement “other than on a superficial level” becomes an inexcusable justification for inaction and neglect. The CQC observation  on page 26 about staff in one activity was  “and those that were present remained standing and engaging very little with anyone..” is, unfortunately exactly what the opinion of service users in Sutton think of many of the staff.
Page 9 : Outcome 2 : Before people are given any examination, care, treatment or support, they should be asked if they agree to it.
10 Essential Shared Capabilities : Espouses Practicing Ethically; Promoting Recovery and Providing Service User Centred Care.
The comments made in relation to Consent above are no less relevant here too.
AIMS  The above mentioned standards are no less applicable here too.
Page 10 : Outcome 4 :  People should get safe and appropriate care that meets their needs and supports their rights.
10 Essential Shared Capabilities : Espouses Practicing Ethically; Promoting Recovery; Challenging Inequality and Providing Service User Centred Care
AIMS The above mentioned standards are no less applicable here too.
It is almost impossible to see how the Trust can be complying with the law when the CQC report findings of staff unable to access the computer systems because passwords had never been issued! The Data Protection Act requires that information is correct and current, just how this can be done when staff are unable to access the system is a scandal. Similarly how can records and inaccuracies be challenged if the care plans are unable to be printed by staff to be read by the patient?
Page 10 : Outcome 5 :  Food and drink should meet people’s individual dietary needs. 
The widespread practice of patients ordering takeaways  especially at weekends is confirmed from a user perspective. However, what the CQC has not picked up on is the practice of restricting the amount of cash patients are allowed to have possession of at any one time and then denying patient’s access to their retained property (money) as and when they require it for such purchases as indicated in the report. One of our members has incredibly given a patient the members own money, when staff would not allow a patient access to his money, in order to avoid a developing aggressive confrontation. Staff attitude and abuse of power being witnessed and more importantly not cared about being witnessed by all.
Page 10 : Outcome 6 : People should get safe and coordinated care when they move between different services.
We have to disagree with the CQC findings, certainly from a Sutton User perspective, that the Trust are complying with this essential standard.  The report states service users “.. receive safe and coordinated care and support from all the relevant health and social care professionals.”   It also states there is “.. clear evidence that medicines are being prescribed on an ‘as required’ (PRN basis) for minor ailments including headaches, colds and hay fever.”  Clear evidence from Sutton users that PRN medicine is not being administered as and when required is available to us. In fact if medicine is required at any other time other than the normal drug times then, more often than not, the professional standards are not being met. Omission to administer medicines both regular and on a PRN basis is as much a drug error as giving wrong doses.  NMC professional disciplinary drug errors are routinely made and management do not ensure disciplinary actions taken against those concerned.
CMHT care coordinators rarely visit as required especially in the week prior to discharge. Ward ‘leave’ is widely used to discharge patients at a whim and indeed because of pressure of new admissions. It is crisis management on beds and the least dangerous patient discharged for the crisis patient to be admitted.  The practice of allowing patients leave is dangerous and a practice that is widely used for the acute care team to continue to have access to the patient, but do not have the daily responsibility for the care and treatment of that patient. The discharge team at the CMHT will not have responsibility for the patient until discharged. This is most unsatisfactory and disaster is never far away. How does a referral process fit in with this system of allowing ‘leave’?
AIMS Type 1 standards    Para 5.22 NMC standards for the administration of medicines are adhered to. Para 17.12 The ward has a referral process for outpatient psychology, CMHT based or otherwise.
Page 10 : Outcome  7 : People should be protected from abuse and staff should respect their human rights. 
10 Essential Shared Capabilities : Espouses Respecting Diversity; Practicing Ethically; Challenging Inequality; Promoting Recovery; Providing Service User Centred Care and Promoting Safety and Positive Risk Taking.
Having requested under Freedom of Information Act the number and types of complaints made ward by ward, it is evident that recurring themes in regard to staff attitude, protection of property and personal safety are problematic for wards. Some wards are worse than others.  In our view the complaints handling procedures are designed to not end up in a paper form. It is so bad that the Trust having even admitted, in writing, to one of our members that a written complaint made directly to the ward manager had been lost and not registered.  The abuse and failures of management to address these problems over many years amounts to institutional neglect.
One of our members has even pointed out to the Trust how their access to medical notes was discriminatory across the whole of the Trust by the restrictive and difficult procedures that the Trust adopted making it too difficult for in patients and discharged patients to access their notes. Hopefully this has now been addressed but the point is made that human rights are not routinely protected by Trust systems.
AIMS  Many standards over many areas. However particular attention to paras 7.1; 7.2; 7.3 and 7.4 are relevant.  Clear policies and procedures, availability of information to patients and carers; staff training in this area and evidence of audit, action and feedback from complaints.
It is our view that complaints is a management tool that shows problematic areas and is under used as an instrument of change for the benefit of patient safety, staff awareness and training and discipline for errant members of staff.
Page 10 : Outcome  8 : People should be cared for in a clean environment and protected from the risk of infection. 
10 Essential Shared Capabilities : Espouses Practicing Ethically; Promoting Recovery; Providing Service User Centred Care and Promoting Safety and Positive Risk Taking.
We think that, from a Sutton perspective, that the Trust do a good job in this respect and substantially agree with the CQC on this aspect of the report.
One area on Jasper ward that is of concern to us is the lounge area. Patients have the habit of sleeping theire at night, sometime transferring blankets and pillows. The settees and chairs have over the years become ingrained with sweat and other bodily fluids. Staff on the ward do encourage the patients concerned to return to their bedrooms but with little effect.
There is a contradiction here, between hygiene and where the AIMS para 29.2, a Type 2 standard where patients should have access to a ‘day’ room at night for those patients that cannot sleep.
Jasper’s lounge is the main day room, although there is another one, but we question why management have allowed this practice to continue as new comers to the ward  including carers, family and friends cannot fail to notice the unhygienic nature of the lounge seating.
Page 11 : Outcome 9 : People should be given the medicines they need when they need them, and in a safe way.
10 Essential Shared Capabilities : Espouses Practicing Ethically; Promoting Recovery; and Providing Service User Centred Care
From a Sutton perspective it is concerning that the CQC has only minor concerns in regard to medicines and their safe dispensing on ward level.
On Jasper ward, Trust management have admitted, in writing, to one of our members, to medication training not being up to date and an urgent training process, still not completed at the time the CQC reported in June 2011. This admission merely reinforced anecdotal information we have from members some of whom are registered nurses and have personal experience of the ward.  If our information is typical across the Trust we would urge the CQC to ensure that a Nursing Expert is part of the team for compliance purposes for future visits to this particular Trust.
PRN is the term in  Latin “pro re nata”.  In medicine professionals mean it to mean ‘as and when required.’ It is accepted that it is as and when required by the patient themselves and not as and when staff require the patient to have it.
The CQC reports gives contradictory messages to the general understanding of the term PRN and a clarification is needed in our opinion. The reports states “People using services who are prescribed PRN medication should have individualized protocols in place which make it clear to staff when and how this type of medication is to be administered, and who authorises its use.”  Surely, any medication, in any hospital, is written up on the patient’s drug chart by the consultant and his/her team of doctors. No drug is authorised for any administration until this is done.  The protocol of administration is then also written up. This will be day time, night time, 4 hourly etc etc.  The category PRN or as and when required is surely a generic term which the doctor authorises the administrator to issue the medication as and when required generally by the patient.  It is accepted that staff in urgent and dangerous cases eg to sedate violent patients, that there may be a need for the staff to require the medication for and on behalf of the patient. A protocol should be in place for this and the lack of capacity surely would be a most important factor. This should be only done in exceptional circumstances and never routinely and a very high threshold of proof should be available in these cases. The Police routinely record prisoner reception, incidents and interviews. Mental hospitals should have at their disposal the ability to record staff actions in such cases for the safety of staff as well as patients, as there is no better record of an incident than a video of it. As most incidents are planned affairs and site security normally called for assistance, we see no practical reason for this not to occur. Issues of confidentiality are not relevant as the hospital at all times are in possession and control of the recording.  PRN is a term that gives suitable flexibility to solve a medical issue as it arises.  The professional is automatically authorised by the doctor on the drug chart, no further authorization should be necessary.
If it is not as and when required by the patient then it should never be written up as PRN. The CQC in qualifying what they believe PRN to mean in an individual case by case basis surely is over complicating a tried and tested system?  It is our opinion that this explanation may also have some root or basis in recent concerns expressed to the Trust where in their attempt to justify drug errors, they have also tried to rebrand the term PRN.  We urge the CQC to reevaluate what the term means in a medical and nursing context and clarify whether they actually mean to deny the patient their right to medication as and when the patient requires that medication as authorised by their treating doctor. We don’t believe the CQC meant this and urge they re-evaluate this part of their report.
Whilst on the subject of medication, the CQC should also be aware that medication being omitted or given at the wrong time is also a failure on drug protocols. Our members have concerns with this, especially as it relates to Jasper ward.
The Royal College of Psychiatrists  have Type 2 standards ie those that they expect the ward to meet:
Para 35.1 During the administration or supply of medicines to patients, privacy, dignity and confidentiality are ensured.   In respect of Jasper ward, but we suspect this is standard practice throughout the hospital, patients are designated at inflexible medication times are then made to queue outside the barn door of a room. This room is open for all to see and hear what is going on.  Disagreements as to medications between patient and staff are common place and the argument is played out in public. It is not uncommon for patient to refuse to take medication and the subsequent arguments  degenerate into a full scale insurrection, for which security have been needed to be called.  Forcible injections then takes place and these incidents again take place in the full view of the ward and  family and friends when the medication round takes place during visiting times.
Para 35.2 The choice of medication is made jointly by the patient and the responsible clinician based on an informed discussion of : the relative benefits of the medication; the side effects; alternatives; the patient’s physical, emotional and social needs; involving the patient’s advocate or carer where appropriate.  The user experiences of Sutton residents can best be described as mixed in the experiences of this particular standard. We suspect the user experience across the Trust is similar. Many service users describe how doctors, in responding to patients symptoms, tend to load new medication on top of previously tried medication but without removing the old one. It is accepted that many medications may be needed to counter different aspects of  problems presented, however we cannot escape from the conclusion that many doctors simply do not consider the effects of such loading and the patient can end up virtually comatose. This is not acceptable.  Many of the above standards as they relate to individual doctors  are met on individual basis’ but it is true to say they are only as good as the individual doctor the patient gets, and indeed pressure of work may intrude on the doctors standards too.
Routinely advocates and carers are  not involved in this aspect of chosing medication for the patient.
Para 35.3 The patient’s allocated nurse monitors the tolerability and side effects of medication on a daily basis.  As the interaction between allocated nurse and patient is almost invisible we cannot see how this standard could ever be met. It is widely held by our service users that nursing staff have no input into what the side effects of medication are. We cannot think of any occasion where nursing staff have influenced the prescribing or changing of medication for their patients.
Para 35.4  The responsible clinician and the primary nurse monitor the therapeutic response to medication on a weekly basis. Again the interactions between said professionals and the patient is minimal so this standard cannot be met either. Further it is standard practice, certainly on Jasper ward, for staff to do nothing for up to 4 weeks but passively watch patients without any medical changes to current medication regimes. This practice is ingrained to the degree that there is no differentiation between sectioned patients and those admitted there on a voluntary basis. How can there be monitoring of therapeutic responses to medication when there are no changes to that medication for weeks at a time?
Para 35.5 Patients have access to a pharmacist and / or pharmacy technician to discuss medications. This never happens at Springfield.  Often patients, who have been on medications for many years know their medications inside out. They will know what works and what does not work for them. This is an area that develops into confrontation and the obvious answer would be for the professionals to have an open discussion with the patient, but ingrained abuse of power, and superiority of attitude from professionals draws a line which the patient has no chance of crossing. This is not working jointly with the patient, it is a omnipotent power which is widely used and abused at Springfield. Similarly in para 35.5.1 discussion with carers never happen either.
Para 35.6 In preparation for discharge, the ward helps all patients to understand the functions, limitations and side effects of their medications and to self manage as far as possible. This never happens. The function seems to be to get the patient to where the doctors are satisfied and then discharge. This is, of course, unless ‘leave’ is necessary to treat an urgent admission, in which case the patient is asked to leave in favour of the new admission.  The patient is expected to merely cope with the medication regime that has been imposed with little or no input from the patient.
Page 11 : Outcome 10 : People should be cared for in a safe and accessible surroundings that support their health and welfare.
10 Essential Shared Capabilities : Espouses Working in Partnership; Respecting Diversity; Practicing Ethically; Challenging Inequality and Promoting Safety and Positive Risk Taking.
As the Trust have admitted to our members, in writing, as to failings in regard to disability access within the Trust buildings across the site and it is the experience of one of our wheelchair user members as to being unable to exit Jasper ward during an active fire alarm (not a drill) and following a complaint to the Trust over disabled access their Director of HR Mr Ian Fleming admitted to Disability access issues being problematic across the whole site.
At the time of the CQC visits in May 2011 the Trust did not have up to date action plans in place. These include not having complete personalised evacuation plans, ward on ward,  for all disabled patients.  This should, by the very nature of the hospital, include all patients as owing to the nature of their disabilities all would be at risk and in need of some or extensive input from nursing staff for any actual evacuation.
As a result of a complaint from one of our members raising this as an issue, Mr Fleming from early June 2011 is now undertaking an audit and he and his staff are in the process of considering this issue. Consequently we fail to see how the CQC can state the Trust is meeting this essential standard. The CQC surely must have had concerns with the very nature of the old and substandard buildings and facilities, which even the Trust acknowledge are not fit for purpose and are trying to have redevelopment plans approved and which they are having great difficulty in achieving.
Please can the CQC, in light of the above try and clarify and expand on this very important area as we believe the CQC have taken a very narrow view on their understanding of what “cared for in a safe and accessible surroundings that support their health and welfare” actually means.
AIMS  Para 22.2 a Type1 standard :  Internal design of the wards arranged to promote a safe environment by sight lines being unimpeded and blind spots dealt with.
Unfortunately, this is impossible with the current design of the infrasatructure of the buildings. The Trust have done as much as they can in this respect.
Page 11 : Outcome 11 : Safety, availability and suitability of equipment.
10 Essential Shared Capabilities : Espouses Working in Partnership; Practicing Ethically and Promoting Safety and Positive Risk Taking.
We have to accept that what the CQC are saying in regard to equipment is correct. We point out the legal and safety Type 1 standard at AIMS para 24.1 which states   A crash bag is available within three minutes. This equipment must include : an automatic external defibrillator; a bag valve mask; oxygen; cannulas; fluids; suction and first-line resuscitation medications.
The only comment we make here is that given the standard of training, the concerns we have with medication knowledge, the fact the Trust have admitted to having had concerns with up to date medication training which they have urgently addressed, the propensity to rely on agency staff, that staff have admitted they are short staffed often which restricts their ability to interact with patients, that the standard of knowledge and propensity to return to a malaise of neglect, that we have grave concerns that this essential standard is not being met. Hence we flag up this concern for the CQC to check when they next visit ensuring that a nursing perspective is used in the compliance process.
Page 11 : Outcome 12 : People should be cared for by staff that are properly qualified and able to do their job.
10 Essential Shared Capabilities : Espouses Working in Partnership; Respecting Diversity; Practicing Ethically; Challenging Inequality; Promoting Safety and Positive Risk Taking and Personal Development and Learning.
The Chief Executive, Ms Judy Wilson, has admitted publicly to our members that her Trust is historically staffed by people that she would not necessarily wish to employ and that the ability to dismiss substandard staff is very difficult.  The use of an inordinate number of agency staff in lieu of sickness rates beggars the question as to how the Trust have satisfied the CQC that their procedures are “sufficiently robust” ?   A close examination of the CQC wording shows that it is merely in regard to “recruitment.”  We would ask what the CQC have done to ensure the Trust’s sickness levels and spending on agency replacements are in tune with the aspirations of Outcome 12?
In addition, as it is our opinion that an excellent barometer as to staff suitability is the complaint rates over the Trust as a whole and by ward v ward as a bench mark for good governance and supervision and indeed as to the suitability of individual staff by the identification of patterns of complaints across wards and individuals, can the CQC explain what it has done to satisfy that the Trust have ‘robust procedures’ to identify and take action against errant managers and individuals?
It is the opinion of many of our members that many complaints as to staff attitude, nursing ability and lack of procedural probity never reach the light of day. The Trust has admitted, in writing, that managers have lost written letters of complaint from members of the public.  It appears to us that the systematic use by management of failure to record complaints made by patients and their relatives is very widespread indeed.  For a complaint about staff to reach an official level for investigation the complainant has to have a high level of tenacity.
Even when complaints do reach the heady heights for an investigation rarely does action against staff for justifiable complaints take place or if they do then the complainant never hears of the outcome as far as staff discipline is concerned.  A lax system is in place and it is our opinion that “services are (not) safe” and this is due to senior management’s inability to weed out incumbent staff from previous recruitment eras and managers shortcomings.  The CQC should satisfy itself that the complaints system is robust enough for the expulsion of substandard staff. It is our opinion that such a robust action plan should include a ‘Professional Standards and Discipline Unit’ independently run for and on behalf of the Trust, paid for by the Trust and able to report directly to the Board.  Decades of inadequate management, needs drastic measures.
AIMS  The Royal College of Psychiatrists AIMS accreditation scheme devote 5 pages to staffing issues. We do not propose to detail them at all. Many are Type 1 standards and many are Type 2. This gives an idea of how crucial staffing is in a Mental Health service. The very basis of excellent care is in the recruitment, retention, training and crucially the appraisal, supervision and support structures that are in place for the benefit of staff.  Following all that positive and supportive standards it is also equally important to have a robust complaints and discipline system to ensure that patient safety is maintained and public confidence in the service upheld. It is important that an open and transparent process is available for the public to see that their complaints are listened to and acted upon. This does not happen at present.
Page 11 : Outcome 13 : There should be enough members of staff to keep people safe and meet their health and welfare needs.
10 Essential Shared Capabilities : Espouses Working in Partnership; Respecting Diversity; Practicing Ethically; Challenging Inequality and Promoting Safety and Positive Risk Taking.
The CQC have highlighted that, “staffing levels on the more secure wards where people with more acute and complex mental health problems stay are not always sufficient to continually meet their health and welfare needs.” This is unacceptable and only proves what Sutton Service users have been saying all along.  So why does the Trust continually state that they are happy with the level of staffing they currently have?
AIMS Type 1 standards para 2.1 The ward has an agreed minimum staffing level across all shifts which is met.  Para 2.2 The agreed minimum staffing level included more than one qualified mental health nurse per shift.
Unfortunately night shifts, certainly on Jasper ward, have consistently broken this essential standard. Patients that ask for PRN medication in the middle of the night have consistently been asked to wait until the qualified nurse has returned from their break, thus indicating that there is not more than one qualified nurse on duty on the ward. This is unsafe.
Page 12 : Outcome 14 : Staff should be properly trained and supervised, and have the chance to develop and improve their skills.
10 Essential Shared Capabilities : Espouses Working in Partnership; Respecting Diversity; Practicing Ethically; Challenging Inequality; Promoting Safety and Positive Risk Taking and Personal Development and Learning.
Of all the Outcomes, this one, and Outcome 17,  for Sutton service users is probably the most inexplicable, certainly as far as it relates to their experiences on Jasper Ward.  We accept that the CQC is taking a broad view of the Trust and its procedures, however it does not seem equitable with the broad array of other standards, surveys, reports, and national tables available for comparison. Further it is not consistent with the views of 6 / 7 of the LINk’s that serve the areas that feed into the Trust’s catchment area. It does not equate with the concerns of all the local MP’s. It does not even equate with the public statements of the Trust’s own Chief Executive.
The above is not to suggest that all staff are incompetent, far from it, many staff are dedicated and skilled. Rather many of the Trust’s systems are let down by substandard staff and neither the good staff not the questionable staff are supported in a management structure that would sustain the degree of excellence that all would strive for.
AIMS  We have already indicated the 5 pages that AIMS allocate to staff. We do not propose to say any more.
Page 12 : Outcome 16 : The service should have the quality checking systems to manage risks and assure the health, welfare and safety of people who receive care.
10 Essential Shared Capabilities : Espouses Working in Partnership; Respecting Diversity; Practicing Ethically; Challenging Inequality; Making a Difference; Promoting Safety and Positive Risk Taking and Personal Development and Learning.
There is a great inconsistency in this aspect of the CQC report. In this section they state the Trust has, “suitably robust and logical systems in place to monitor the quality and safety of the care, treatment and support it provides the people using their services.”  However in Outcome 13 (on the same page 12 of their report) they also state, “we are concerned that staffing levels on the more secure wards where people with more acute and complex mental health problems stay are not always sufficient to continually meet their health and welfare needs.”  How can the Trust have robust systems in place to ensure and monitor these needs and not pick up on the fact that staffing levels on acute wards are putting the same patients at the risks they are monitoring to avoid! This is totally illogical.
Page 12 : Outcome 17 : People should have their complaints listened to and acted on properly.
The CQC should forgive Sutton Service Users for strenuously disagreeing with their opinion on this.
The CQC report above that staff have not been issued with passwords to enable them to access computers to ensure records are up to date and accurate. They report that staff were unable to print out care plans to ensure that patients can have copies to check and discuss and have the ability to correct mistakes. Apart from the fact that Sutton Service users have individual concerns, the CQC have expressed those concerns too above. How then can they then state the Trust is meeting this essential standard when they have already expressed concerns?
We would strenuously urge the CQC to insist that the Trust implement a full independent study that has access to past and present service users, their families and if need be carers and friends, to ensure that this statement accords with actual experience.  For the CQC to state people, “are confident that their concerns and complaints will be listened to and acted upon by staff,” is just not true, plain and simple.  If complaints were listened to and acted upon by staff, then there would be drastic changes and increased service user satisfaction. As the Trust continues to languish at the bottom of satisfaction surveys, including the Trust’s own generated surveys, we fail to see how the CQC can have any confidence in their own statement and opinion.
Just as it is right for the CQC to insist that their report should look at the Trust in a broad and fair way, it is equally true to say that the CQC cannot totally rely on statements made from a handful of service users, 50, (Page 5 line 2) who are still receiving treatment, are vulnerable to staff power, abuse and opinions, may feel intimidated by their situation and surroundings, may not have the knowledge to know any better and finally have the capacity to judge, compare or care about alternatives. On the contrary, it should be in the power of the CQC, and in the case of this Trust we would say that it is essential for the CQC for this Trust, to insist on an action plan to independently assess and verify a whole host of problematic areas, so future CQC reports have the confidence of Service Users, Carers, Family, Friends, the good staff and management.
Page 12 : Outcome 21 : People’s personal records, including medical records, should be kept safe and confidential
We do not have concerns in this area. In fact as some of the staff cannot even access the records we would say that confidentiality has been taken to a whole new level !!!!!
This reports falls far short on so many fronts, we have highlighted some of the main ones but not all.