Poo stains found on ceiling of mental health ward rated ‘inadequate’ by inspectors

Two mental health wards at Clatterbridge Hospital have been rated ‘inadequate’ after stains ‘likely to be food or faeces’ were left on the ceiling for over a week.

The CQC carried out unnanounced inspections at Clatterbridge Hospital Psychiatric Service after concerns were raised, as well as the Mulberry ward in Macclesfield, between November 8 and 15 2022.

The inspection found that the quality of care was inadequate with leadership quality dropping from good to inadequate. Safety was also rated inadequate, however, Cheshire and Wirral Partnership NHS Foundation Trust’s rating overall remains good,

The trust has five acute mental health wards for working age adults and two psychiatric intensive care units wards across three locations, however, only Clatterbridge’s Lakefield and Brooklands wards and Macclesfield’s Mulberry wards were inspected.

Inspectors found that the seclusion room on the Brooklands ward was ‘not fully clean’ and a stain ‘most likely to be either food or faeces’ remained on the ceiling for over a week, despite being reported to the most senior nurse. Due to this, the CQC issued a warning notice and told the trust it must make significant improvements to any environment used to seclude patients by March 30.

However, the report did state, ‘There was no ward manager on Brooklands as the previous manager had resigned but the other ward managers were providing regular input and we did not identify any significant impact. The trust had put a supportive team and improvement plan around the Brooklands ward team.’

In Lakefield, carers said it was sometimes difficult to speak to other staff when phones wouldn’t be answered and there was no CCTV in communal areas to monitor patients.

The report did praise improvements made since a death at Lakefield in 2018. These included a member of staff being deployed at the entrances to bedroom corridors and improving visibility of patients.

The report said: “When the most serious untoward incidents occurred, managers shared lessons learned with the whole team and the wider service” and “there had been no further deaths by ligaturing or as a result of the compromised layout on Lakefield ward.”

The report said a serious incident in June 2022 in Brooklands is still under investigation but improvements had been put in place since.

Key findings

• Patients at Clatterbridge were treated with dignity and respect.
• The main ward areas were clean and maintained. In most instances the wards were designed to reduce the risks to patients, but there were no seclusion rooms at Macclesfield and the seclusion room on Brooklands ward in the Wirral was not fully clean.
• Most patients stated that staff cared for them well and were very friendly.
• The ceiling of the seclusion room on Brooklands ward was not fully clean. The CQC saw that the designated seclusion room had two small brown stains on the ceiling. They could not identify the substance causing the stains but it was most likely to be either food or faeces thrown by a patient. Inspectors highlighted the marks on the first day of inspections to the most senior nurse in charge and the housekeeper. When they returned a week later to carry on the inspection, the same stains were still there.

What has been said?

Tim Welch, chief executive, of Cheshire and Wirral Partnership NHS Foundation Trust said: “We fully accept the findings in the CQC report and acknowledge we have fallen short of the high standards we pride ourselves on.

“We sincerely apologise and are supporting those people affected and have taken immediate action in line with the targeted recommendations to improving environments, documentation and governance to enable our practices to be as safe as possible – specifically relating to seclusion.

“We are pleased the CQC observed “staff’s commitment to ensure patients receive good quality care”, recognising CWPs core values including care and compassion treating patients with “dignity, respect and kindness”.

“We are in regular contact with our regulators and partner organisations and will continue to update them on the actions we are taking as a result. If you, or someone you care for, have been affected please contact the CWP Patient Advice and Liaison Service on 0800 195 4462 (10am – 3pm) or via [email protected]. If you want to speak to somebody independent from the Trust, your local advocacy services are aware of the situation and are on standby to support you.

Cllr Yvonne Nolan, Chair of Wirral Council’s health and social care committee added: “ I am concerned to hear the outcome of the CQC inspection of psychiatric services at Clatterbridge Hospital. This provision serves some extremely vulnerable members of our community who need high quality, safe services.

“I am sure that Cheshire and Wirral Partnership will be acting quickly to make all necessary improvements to restore this facility to its previously high standards”