Healthcare Commission Triggers Action To Improve Safety Of Patients At Milton Park Hospital

Main Category: Public Health
Article Date: 22 Sep 2008 - 9:00 PDT

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The Healthcare Commission said that Milton Park Independent Hospital had made significant improvements to protect the safety of patients after inspections identified breaches of the regulations.

The Bedfordshire mental health hospital is run by Brookdale Healthcare Limited and specialises in assessment and treatment of adults with autistic spectrum disorders.

During May, the Commission made two unannounced visits to the hospital following an incident in April, in which a patient died while on authorised leave. It made further visits in June and August to check on progress with improvements.

The inspection team instructed an independent consultant forensic psychiatrist to review the care given to the patient who died. The psychiatrist found that the care given to the patient was appropriate and adequate.

The team also examined arrangements to grant leave, how risks are assessed, the hospital environment and staffing levels and training.

During its inspections on May 6, 22 and 23, the Commission identified a number of breaches of the Private and Voluntary Health Care (England) Regulations 2001. It issued two statutory notices to Brookdale Healthcare Limited, requiring it to undertake a range of measures at the hospital.

The follow-up visits on June 16 and August 22 showed that the hospital had addressed all the requirements of the notices.

In its assessments, the Commission worked with Bedfordshire Police, attended open public meetings, engaged with the local MP and residents in order to understand the broader issues at the hospital. The Commission said that the involvement and support of the local community was vital in providing effective and safe care at the hospital.

Nigel Ellis, Head of Investigations at the Healthcare Commission, said: "There has been a history of problems with the services at Milton Park Hospital and we have been working with them to get those problems sorted.

"Our recent inspections identified a number of issues at the hospital that could have compromised the safety of patients. I'm pleased that most of those have now been resolved.

"Staff at the hospital have been cooperative and helpful and this has contributed towards a positive outcome both for the hospital itself and for the patients. We will be monitoring the hospital closely and if we see standards slip back in any way, we won't hesitate to take further action, including enforcement action if appropriate."

The statutory notices, served on May 12 and June 6, required Brookdale Healthcare Limited to:

review policies and procedures for granting leave to people detained under the Mental Health Act 1983, including the assessment of patients before leave and proper recording of information about leave.

ensure that all staff have had appropriate training in granting leave and associated assessment processes; management of violence and aggression; observation practice; use of the automatic external defibrillator; and the assessment of risk.

- review policies to assess and manage risks.
- review environmental risks and consider different design of taps, door hinges and shower heads to reduce the number of ligature points.
- revise and update the medicines policy and include arrangements to store, use and dispose of unlicensed medicines and controlled drugs.
- ensure that the refrigerator where medicines are kept is properly maintained and within the proper temperature range.
- ensure that staff from Brookdale Healthcare Limited visit the hospital every six months and provide written reports to the Healthcare Commission, as per their statutory requirements.

The subsequent follow-on visits in June and August found the hospital had complied with the requirements of the statutory notices.

Inspectors found that assessment and recording of leave was appropriate, observation of patients was being recorded properly, a policy on seclusion was in place, the training programme for managing challenging behaviour had been entirely revised and policies on handling of medicines and on searching rooms had been updated.

The Commission said changes had also been made to the way that patients were assessed as to whether they presented a risk to themselves or others and actions had been taken to reduce environmental risks.

The Commission will continue to monitor the hospital closely to check that improvements are sustained.

Summary of regulatory action taken at Milton Park Independent Hospital (pdf 78kb) (opens new window)

More information on Milton Park Independent Hospital

Information on the Healthcare Commission

The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

Healthcare Commission