Manchester mental health inpatient service rated Inadequate

The Care Quality Commission has published the inspection report on Maryfield Court rating it Inadequate overall and placing it into special measures.

 CQC conducted an unannounced inspection of the service on 15 and 16 July 2019. The service is operated by ASC Healthcare Limited and was previously inspected in February 2019, rated Requires Improvement overall. The latest inspection was prompted by concerns identified at another service operated by the provider, The Breightmet Centre for Autism.

 The service was rated Inadequate for being safe and well-led, Requires Improvement for being effective and caring, and Good for responsive services.

 Maryfield Court is an independent mental health hospital providing care and support for adults of a working age. Inspectors found areas of the service, including bedrooms, were not safe or maintained to a good standard. Although the bedrooms concerned were not in use at the time of the inspection, 12 people had been receiving care in the weeks leading to the inspection. Some bedrooms showed signs of damp, furniture was damaged, fixings in a state of disrepair and one room’s door lock was faulty.

Bathroom floors in the bedrooms were reported as dirty and the walls were also marked and stained. Cleaning schedules had not been fully completed since March 2019, additional cleaning records lacked detail. Inspectors found the service’s quality audits had failed to fully identify risks, including a ligature point and the external perimeter fence being easily climbable. There had been 10 incidents of people leaving the service without authorisation since May 2019. Inspectors also found an oxygen cylinder was not being stored in line with national guidance an posed a significant risk to anyone visiting the hospital.

 People’s care records and risk assessments were not always reviewed or updated when an incident occurred, or measures considered on how to lessen any further risk. Inspectors also noted that incidents were being recorded but further consideration into taking appropriate action was not always being made. Whilst the leadership and management were experienced and understood the challenges the service faced, governance arrangements to support improvements were not robust or effective. Many of the environmental concerns identified at the inspection had been reported but went unactioned and quality checks had not identified or lessened risk.

 At the time of the inspection two people were being supported by the service and both said they were happy with the care being provided and felt safe. Both patients were transferred to alternate care arrangements or discharged shortly after the inspection. As a result of the concerns raised during the inspection the provider voluntarily stopped the admission of new patients to the service.

As well as putting the service into special measures, CQC issued two warning notices relating to premises and good governance following the inspection. A full history of CQC’s findings is available at:

Jenny Wilkes, Head of Mental Health Inspection, said:

“We returned to inspect this service because we had ongoing concerns about the provider’s ability to keep people safe, following our earlier findings at the hospital and the inspection of another of its services.

“We found the environment was unclean in many areas and several items of furniture and room fixings were in need of urgent repair and maintenance. The lack of attention to detail was concerning some issues went unnoticed or unreported, which risked people being exposed to avoidable harm.

“Whilst some of our findings were addressed following the inspection, we continue to have serious concerns about the provider’s ability to operate the service safely. We have placed this service into special measures and are keeping it under close review, alongside our partner agencies. We will return to inspect it again in due course.”