The BBC has recently reported that Burton Park Hospital, in Melton Mowbray, which has failed every inspection since it opened in 2014, has now been rated as “inadequate” by the Care Quality Commission (CQC).
Burton Park Hospital
Burton Park Hospital is a 50-bedded, neuro-rehabilitation service. The hospital 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.
CQC findings
CQC inspectors visited the hospital in November 2023 and found a multitude of problems, which have now been highlighted in their report of 25 March 2024.
Some of the main concerns set out in the CQC’s report were as follows:
- Managers failed to ensure patients who received medicines covertly had a care plan in place detailing how staff were to complete this safely.
- Staff failed to follow the Mental Health Act Code of Practice when caring for a patient in long-term segregation.
- Staff could not locate all agency staff induction paperwork and there was no reassurance for inspectors that the inductions consistently took place.
- 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.
- Inspectors were not assured that agency staff had all received reducing restrictive interventions training in line with the hospital’s own policy and in line with national guidance.
- The hospital used a high volume of agency staff to cover shifts.
- Agency healthcare assistants did not have access to patients’ electronic notes and had to rely on other staff inputting information on their behalf.
- Staff did not follow individual care plans relating to oral health and mouthcare, and cleaning and rotation of PEG feeding sites.
Lack of restrictive interventions training led to risk of significant harm
In one case, a patient had been pinned to the floor for two minutes.
This is a form of restraint that should only be used in exceptional circumstances and for the shortest time possible.
The CQC inspectors found that neither of the staff members involved in this incident had received the appropriate training on restrictive interventions.
The inspection team ruled that this lack of training had placed “patients at significant risk of avoidable harm.”
Lack of staff
It was reported that between November 2022 and November 2023, the hospital had used temporary staff to cover a staggering 16,420 shifts.
Inspectors ruled that the hospital “did not have enough substantive nursing and support staff to keep patients safe.”
Furthermore, the CQC said that the reliance on temporary staff “increased the risk of people receiving inconsistent care as agency staff were not always familiar with patient’s care plans or routines.”
The hospital blamed the use of agency staff on recruitment difficulties in the local area and has said that it has recruited more permanent staff since the inspection.
Repeated failings
Perhaps most worryingly of all, inspectors said that Burton Park Hospital had repeated breaches of the Health and Social Care Act since it was registered with the CQC in 2014.
At every inspection since 2014, it has been rated either “requires improvement” or “inadequate”.
Inspectors were appalled to find there was little evidence of sustained improvement in the quality of the service.
Comment
Whilst reports of failings at any healthcare provider are always concerning, this hospital’s situation stands out significantly given that it has never managed to improve a CQC rating above “requiring improvement”.
This is totally unacceptable for a healthcare provider, particularly one providing care and treatment to some of the most vulnerable people in society, to continue to fail their patients and needlessly put safety at risk.
Patients with brain injuries, particularly when in hospital or dealing with an ongoing condition, often cannot comprehend or communicate what is happening to them, and the safeguarding of their wellbeing and safety must be the responsibility of those handling their care.
It is imperative that action is taken now to rectify the issues and it is clear that the hospital will rightly remain under close scrutiny for a while to come.
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Danielle Young is a Legal Director in our Medical Negligence team, which is ranked in Tier One by the independently researched publication, The Legal 500, and Commended in The Times Best Law Firms 2024.
If you have any questions about the subjects discussed in this article, please contact Danielle or another team member in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online enquiry form.