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Comprehensive management failure left vulnerable older mental health patients and staff on Rowan ward in Manchester...
Comprehensive management failure left vulnerable older mental health patients and staff on Rowan ward in Manchester isolated and in an environment that put the patients at risk, according to a report published by the Commission for Health Improvement today.

CHI's investigation followed allegations of physical and emotional abuse of patients by care staff at Rowan ward, which was a mental health unit for older people run by Manchester Mental Health & Social Care Trust. This is the third investigation by the health watchdog into the care of vulnerable older people, leading to concerns about standards of care for these people nationally.

Poor management by the trust and NHS organisations, including the former health authority, the former regional office and the city's primary care trusts, resulted in old fashioned and regimented nursing care. CHI found that Rowan ward had many of the known risk factors for abuse ??? poor institutionalised environment, low staffing levels, high use of bank and agency staff, little staff development, poor supervision, a lack of knowledge of incident reporting and a closed inward looking culture.

Acting chief executive of CHI, Jocelyn Cornwell, said: 'The care received by vulnerable older people on Rowan ward was unacceptable, but we are seriously concerned that circumstances surrounding this investigation are not unique.

'CHI has completed two previous investigations into the care of older people and has continual requests for investigations in this area. The same issues keep coming up and the NHS does not seem to be learning. The care of older people nationally is very concerning. NHS managers and commissioners should take a good look at this report and ensure recommendations are embedded in their own services. Organisations must learn to monitor closely what happens on older people's wards and open up wards to external visitors and patients' advocates.'

Staff and patient representatives told CHI Rowan ward had become a 'forgotten s ervice', after other trust services were relocated to another site in 2001. The relocation reduced support and maintenance services to Rowan ward and security was a major concern for staff, patients and carers.

The trust's model of nursing care in older people's services was old fashioned and its culture was not open and learning. For example, on Rowan ward patients' clothing was changed and hygiene needs addressed according to a routine rather than when the need arose. There were claims and counter claims of bullying and harassment on Rowan ward with senior staff claiming they were threatened with industrial action if modernisation was suggested and nursing assistants reporting that they were humiliated and bullied.

The trust's overall systems to improve care and safeguard patients are very poor. CHI found very little awareness across the trust of national policy to protect vulnerable adults or of monitoring of the implementation of the National Service Framework for Older People. The trust lacks a unified reporting system for incidents, which hampers analysis and learning from things that have gone wrong. The absence of central trust records of any accidents or incidents on Rowan ward between February 1999 and July 2002 may have contributed to a lack of awareness of problems in older people's services. Some serious injuries, including a scald and unexplained bruising, were not reported centrally. Neither were incidents of patients leaving the ward and putting themselves at risk. Also worrying are audits showing a number of problems with the prescribing and administration of medicine across the trust. For example, there is evidence that unqualified staff commonly gave medicine on adult and older people's wards.

Although the trust has made some improvements since the allegations were made last year, CHI has serious concerns about the extent of problems and the trust's capacity to resolve them. The issues on Rowan ward and in older age services are symptomatic of other potential problems in th e trust.

Dr Linda Patterson, CHI medical director said: 'The whole health community in Manchester has failed to ensure that vulnerable older people with mental health problems are safe and receive the care that they need. Patients and staff at Rowan ward were left isolated and in an environment that left them open to abuse. A severe lack of clinical leadership, supervision, monitoring of the quality of care and improvement mechanisms led to a culture in which staff felt bullied and patients' needs were neglected. Examples of unreported accidents and inappropriate training in the use of restraint techniques on Rowan ward were a direct result of this culture.'

The report makes recommendations for the trust, the strategic health authority and more widely across the NHS. Recommendations include:

  • the trust should actively improve patient health and safety, ensuring risk assessment at every level and a trust wide incident reporting system. The trust also needs to develop mechanisms to ensure professional staff demonstrate knowledge of, and practise, modern multidisciplinary evidence based care

  • an urgent need to strengthen management capacity and leadership at every level of the trust

  • the trust, the strategic health authority and commissioners, including the PCTs, need to agree how they will monitor the quality of patient care

  • Greater Manchester Strategic Health Authority must ensure the delivery of national standards relevant to older people with mental health problems

  • the Department of Health should review the complex accountability arrangements for the quality of care of older people's services and particularly in health and social care trusts

    Dr Patterson said: 'The trust has demonstrated some improvement since the allegations at Rowan ward emerged, but there is still a lot of work to be done. The trust must strengthen its leadership and management capacity. The board needs to take responsibility for ensuring quality of care and lines of accountability req uire definition and improvement. The strategic health authority must lead the health community in developing and delivering a strategy for older people's mental health services.'

    The full report is available hereor an executive summary here.

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