A controversial mental health crisis centre in Sheffield has been told by inspectors it must improve.
The facility, on Thornsett Road in Nether Edge, was visited unannounced by health watchdog the Care Quality Commission after a female patient suffered fatal injuries jumping from a window.
Inspectors raised concerns over unsafe fixtures and fittings, inadequate checks on ‘restrictors’ which stop windows from being fully opened, and failure to report the woman’s death to Sheffield Council.
The six-bed crisis house, operated by charity Rethink on behalf of Sheffield Health and Social Care NHS Foundation Trust, opened in April on the quiet suburban street, despite protests from local residents.
In July, a 31-year-old woman died after leaping from a third storey window. The CQC arrived days later.
In a report, inspectors said people received care that met their needs, with staff described as ‘very nice and helpful’ by patients.
But they wrote: “The provider had not taken all appropriate steps to provide care in an environment that was suitably designed and adequately maintained.”
Patients had stopped using bedrooms containing a certain type of window restrictor until the fittings were replaced, and checks were being made to make sure the restraints were locked and intact, but only when patients left.
Inspectors said: “No check was in place to assess that these restrictors remained intact during the course of people’s stay at the service.
“We also noted that wardrobes were not of a sturdy construction and not fitted to walls. This meant they could easily be pushed over or moved.”
Wardrobe hinges and rails, and automatic door shutters, posed a safety risk because they were not collapsible.
A review of records also indicated that a number of patients posed a risk to themselves, even though management said they did not accept referrals for such cases.
Bosses must now submit a plan setting out how standards will be met in future.
Paul Jenkins, head of Rethink, said: “It’s vital that after a serious and tragic incident such as the death of one of our residents, systems and procedures are properly looked into so everyone is ready to learn from the findings.
“We are pleased the CQC reported on its inspection so quickly. They were satisfied with our service and noted in particular how positive people staying at the house were about the care and support they had received.
“We have accepted all of these recommendations and are putting them in place as quickly as possible.”