Suffolk mental health unit's safety risks 'not addressed'

St John's House has room for 49 men and women with learning disabilities

A mental health unit has been rated inadequate for the second time in four months after it failed to address risks affecting patient safety.

St John's House in Palgrave, Suffolk, has been in special measures since a Care Quality Commission (CQC) inspection in December.

In April, the CQC found many issues "remained unchanged", including its response to incidents of self-harm.

Priory Healthcare said it was committed to ensuring patients' needs were met.

The independent hospital, near Diss, cares for adults with learning disabilities and associated mental health issues.

Inspectors saw two incidents involving self-harm where staff "did not intervene in a timely manner", one of which resulted in an injury to a patient's head.

It had a "lack of clear leadership", having had four temporary managers in post since July 2020, and managers had not investigated all serious incidents, the CQC said.

Staff asleep

Staffing levels were unpredictable because St John's House had a continued reliance on agency staff who did not have the right training, it added.

Inspectors again found staff were asleep when they should have been observing patients, including all three members of staff assigned to one patient.

Care plans "appeared to have been copied and pasted" across patients and did not include all health conditions and needs.

Stuart Dunn, CQC head of inspection for mental health and community services, said: "Disappointingly, our latest inspection found the overall quality of care had not improved and many of the issues we previously raised remained unchanged."

The CQC told the Priory Group it must make several improvements, including employing enough staff with the right training and ensuring staff know the location of emergency equipment, including ligature cutters and the defibrillator.

Last year, inspectors found a patient was pushed to the floor as staff used "disproportionate and unauthorised techniques".

CCTV footage showed seven incidents including "a patient being dragged across the floor... a patient being pushed over and the seclusion room door trapping a patient's arm and making contact with a patient's head when closed".

At the time, Priory Healthcare stated that it had made "immediate action to deliver improvements".

In a statement regarding its most recent inspection, it said it was "taking decisive steps" to address the issues, including recruiting nursing staff, a consultant psychologist, a new medical director and a hospital director.

It added it was working with commissioners and families to relocate patients to more appropriate settings "which may take several months due to a shortage of alternative placements".