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| Inspection Report | Wedgwood House | January 2014 www.cqc.org.uk 1

Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Wedgwood House

West Suffolk Hospital Site, Hardwick Lane, Bury St Edmunds, IP33 2QZ

Tel: 01284719700

Date of Inspection: 16 December 2013 Date of Publication: January 2014

We inspected the following standards as part of a routine inspection. This is what we found:

Respecting and involving people who use services

Met this standard

Care and welfare of people who use services Met this standard

Meeting nutritional needs Met this standard

Staffing Action needed

Records Action needed


Details about this location

Registered Provider Norfolk and Suffolk NHS Foundation Trust

Overview of the service

Wedgwood House is a self-contained unit in the grounds of West Suffolk Hospital. It provides care and treatment to adults and older people across three wards. Some people may be detained under the Mental Health Act 1983

Type of services Community based services for people with mental health needs

Hospital services for people with mental health needs, learning disabilities and problems with substance misuse

Regulated activities Assessment or medical treatment for persons detained under the Mental Health Act 1983

Treatment of disease, disorder or injury


Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page

Summary of this inspection:

Why we carried out this inspection 4

How we carried out this inspection 4

What people told us and what we found 4

What we have told the provider to do 5

More information about the provider 5

Our judgements for each standard inspected:

Respecting and involving people who use services 6

Care and welfare of people who use services 8

Meeting nutritional needs 10

Staffing 12

Records 14

Information primarily for the provider:

Action we have told the provider to take 16

About CQC Inspections 18

How we define our judgements 19

Glossary of terms we use in this report 21

Contact us 23


Summary of this inspection

Why we carried out this inspection

This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, carried out a visit on 16 December 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with staff, reviewed information given to us by the provider and were accompanied by a specialist advisor.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

What people told us and what we found

During our inspection we visited Northgate and Southgate wards that provided care and treatment to adults of working age. This inspection report does not include information about Abbeygate ward, a service for older people. We spoke with people using the servicewho told us that they were happy with the way they were looked after. They said that staff were respectful and caring.

Most people said that they felt well informed about the service. One person who had just been admitted to the ward told us, "I have had a welcome pack, and a copy of tomorrow's menu." Another person told us that "The share and social meetings are good. You get to say what you think about the place and how things are run."

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We examined a sample of the records kept about people's assessment, care and treatment and found that whilst they were of good quality, they werenot always accurate or fit for purpose. This placed people at risk of receiving unsafe or inappropriate care and treatment.

Arrangements to ensure the continuity of people's care and treatment were effective. However, there were not always enough qualified, skilled and experienced staff to meet people's needs.

People could choose from menus that offered varied and nutritious meals. Those who required support to eat and drink healthily received it.


You can see our judgements on the front page of this report.

What we have told the provider to do

We have asked the provider to send us a report by 31 January 2014, setting out the actionthey will take to meet the standards. We will check to make sure that this action is taken.

Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service(and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions.

There is a glossary at the back of this report which has definitions for words and phrases we use in the report.


Our judgements for each standard inspected

Respecting and involving people who use services Met this standard

People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run

Our judgement

The provider was meeting this standard.

People's privacy, dignity and independence were respected. People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

Reasons for our judgement

People expressed their views and were involved in making decisions about their care and treatment. We saw evidence that people's care and treatment was discussed and planned with them. Staff also noted when people declined to be involved. One person told us, "I have a treatment plan and it was explained to me." We saw that care plans and risk assessments were reviewed weekly or more frequently if required. People's family members and carers were invited to an evening 'clinic' twice weekly where they could discuss people's needs. We saw further evidence of relatives' involvement within people's records.

People who used the service understood the care and treatment choices available to them. They received an information pack on admission to the wards. This included information about what they should expect from the service, such as the items that they should not bring to the ward, searches, 'expectations whilst on the ward' and a daily timetable. Most people said that they felt well informed about the service. One person who had just been admitted to the ward told us, "I am waiting to see the doctor. In the mean time I have had a welcome pack, and a copy of tomorrow's menu." Conversely, another person said, "The problem I have is that I do not have things explained to me in the ways I can understand."

A range of written information displayed in communal areas informed people about how the service was delivered. For example, notices to remind people where they could use their mobile telephones, or smoke cigarettes. A notice on the treatment room door advisedpeople about the times they could attend to receive their medicines. Details of how people and their visitors could contact independent advocates were also displayed prominently. A wipe board and cards in people's bedrooms identified which staff were responsible for individual people's care. The board was updated as staff changed. This meant that people could check which staff member to relate to at that time.


People's privacy and dignity were protected. Closed circuit television was in place in all communal areas and people were made aware of this on their admission. We were impressed by the calm atmosphere on both wards, which were fully occupied. One person told us, "I am very comfortable as I have my own space and can relax when I wish." Another said, "Staff respect me as they always knock on my bedroom door." Bedrooms were arranged in gender-specific corridors with en suite toilets. Bedroom doors had privacy panels that allowed staff to check on people's welfare. We saw that these were kept closed unless checks were in progress. However, the provider may find it useful to note that these panels could not be adjusted by people from within their bedrooms, as required by national best practice guidance.

People were issued with swipe cards that allowed them access to their own bedrooms. They also had lockable bedside cabinets in which to store their personal belongings. However, we saw evidence that the arrangements for issuing swipe cards sometimes led to delays. This meant that people had to ask staff each time they wanted to access their bedrooms, which compromised their independence. Senior staff told us that in response tofeedback from a person who had used the service they were taking action to ensure that additional staff could issue swipe cards.

People's diversity, values and human rights were respected. Staff had access to translation services when required. They explained that there was a significant number of Polish and Portuguese people living in the local area and that interpreters were readily available. People and staff had access to a multi-faith chapel in the adjoining West Suffolk Hospital. Staff supported people to attend the chapel and people received spiritual supportfrom chaplaincy staff visits. However, staff expressed concerns about this service ceasing in March 2014. They explained that during a recent two-month period when the chaplaincyservice had temporarily ceased, they had found it difficult to meet people's spiritual needs. One person told us that their religious or cultural needs were not being met. We raised thiswith senior staff who agreed to follow this up.

People were asked for their feedback about the service and provided with opportunities to suggest improvements. A visitors' noticeboard included details of how to make suggestions for improvement, or complaints. The minutes of a weekly 'share and social' meeting showed that changes had been made in response to feedback from people. For example the supply of bird feeders in the courtyard and the creation of a relaxation compact disc were being considered in response to people's requests. Minutes of these meetings were displayed on noticeboards. People who used the service, their representatives and advocates attended a recently convened monthly Wedgwood Action Group meeting, chaired by a carer. Minutes showed that service-related issues were discussed, such as planned changes. Those attending were able to raise any concerns or comments they had.


Care and welfare of people who use services Met this standard

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement


Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.


People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. The care records we examined showed that people were treated by multi-disciplinary teams. We noted extensive records relating to people's medical histories, consent, care plans and risk assessments. The aims and objectives of people's treatment were clearly recorded. Other clinical records were informative and gavea clear picture of people's changing requirements and their progress towards discharge. Communication and co-operation between health professionals from different disciplines was evident, including support from the co-located acute hospital. Ward rounds took place on three days a week, when people's treatment, care and risks were reviewed. Staff managed this process proactively by planning ahead to ensure that people were afforded appropriate priority and that relevant records were available.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The risks associated with people's mental health and vulnerability were assessed and corresponding risk management plans were in place. Records showed that these plans were reviewed at minimum weekly during ward rounds. However they were often updated more frequently following events or changes. One person's risks had been reviewed almost daily in one week following an adverse incident. During a handover meeting we attended, staff discussed people's individual risks and how they could be managed. They identified one person, known to be at risk of domestic violence, who did not have a relevant management plan in place. However, it was clear from discussions that, in the absence of a management plan, the risks associated with thisperson had been proactively managed.

Wellbeing and therapeutic care plans were developed by the occupational therapist that set out the person's aims for recovery, what they needed to work on and what support theywanted from staff. For example, one person's plan stated, '…to talk to me, let me get things off my chest.' Most of the people we spoke with told us that they felt safe in the careof the hospital.

Planning was in place for people's discharge from the hospital and a discharge checklist was included in the hospital information booklet. For example, we saw one person had


been accompanied by staff to their home on the morning of our inspection in order to help determine their ability to manage household tasks. This person had also undertaken a 'preparation of hot drink assessment'. We saw people being visited by a professional to discuss their accommodation needs in order to facilitate their discharge. However, the provider may find it useful to note that some of the people we spoke with who were about to be discharged were unclear about what support to expect in the community. One personsaid, "I am of the view that I should be discharged as I feel better now and no one is tellingme the reason why I am not going home."

People could participate in a programme of activities, facilitated by an occupational therapist and activities staff. One person said us, "They (staff) don't force you to get involved." Another told us that there were "Lots of activities available, but not much at the weekend." Examples of activities included woodwork, mosaic and challenging anxiety sessions. Some activities were offered outside the hospital, such as joining a local art group. One person told us, "I requested to go out of the ward to go shopping and I was escorted by a member of staff and I was very pleased with this." Multi-function rooms provided leisure and social activities such as pool and films. An occupational kitchen enabled people to develop domestic skills and cook under staff supervision. Regular walksin the local community were organised for those people who were assessed as able to participate. Staff were encouraging people to enrol for the Recovery College programme, which is part of a national initiative to improve understanding of mental illness.

People's physical health was assessed and monitored. Initial assessments were completed and corresponding care plans developed for those people who had physical health needs. The provider may find it helpful to note that we found that some weekly records of people's physical health observations were incomplete. When we asked staff about this they told us that on occasions when the person was away on weekend leave, the observations were not completed. We also identified that one person who was prescribed medicine to thin their blood, had missed a routine screening test. However, staff had identified this and were taking action to address it.

People were offered support to promote healthy lifestyles. For example, they were offered support to stop smoking and achieve a healthy weight. They were also supported to use the hospital gym safely to increase or maintain their physical fitness. Where people's physical health needs required input from specialists this was arranged promptly, includingreferrals to a tissue viability nurse, podiatrist and physiotherapist. People were supported to access primary healthcare services such as dentistry or optometry when required.

There were arrangements in place to deal with foreseeable emergencies. Staff reported good access to medical support at all times. All staff received first aid and resuscitation training as part of their annual mandatory training programme and a resuscitation flowchartwas displayed for their reference. In a serious emergency they were supported promptly by staff from the neighbouring acute hospital. Resuscitation equipment was available on each ward, including oxygen and an automatic external defibrillator. Records showed that emergency bags and trolleys were checked in accordance with trust policy and this checking was monitored by senior staff.


Meeting nutritional needs Met this standard

Food and drink should meet people's individual dietary needs

Our judgement


People were protected from the risks of inadequate nutrition and dehydration.


The hospital information pack, given to people on admission, clearly set out the arrangements to ensure they received adequate food and drink. This included mealtimes, areas where food could be consumed and vending arrangements. Most of the people we spoke with commented positively about the food and drink they were offered. One said, "You get plenty of food. You don't die of hunger here." Another person told us there was "Not enough fish" on the menu. People said that catering staff were "…kind." Others madecomments including, "The meals are good and the portion sizes are pleasing"; "If you ask for extras this is always forthcoming"; " The meals are tasty most of the time."

People were provided with a choice of suitable and nutritious food and drink. All meals anddrinks were provided by an independent facilities company and all food was cooked on site. We observed meals and drinks being delivered to the wards and provided to people. Hot drinks were available from a trolley at set times throughout the day, up until 9.30pm. Jugs of cold drinks of their choice were provided in people's rooms and changed daily. Both wards were equipped with hot and cold drinks vending machines. However, the provider may find it helpful to note that during our inspection both machines were out of order. Staff and people told us that this was an ongoing problem and on Southgate ward the machine had been out of order since August 2013. We brought this to the attention of senior staff who told us that discussions with the facilities contractor were ongoing.

People's food and drink met their religious or cultural needs. People selected their meals each morning, for the following day, recording their choices on menu forms. The menus indicated clearly the meal choices that were suitable for people who required vegetarian ordiabetic diets. Arrangements were in place to provide meals for people who required special diets. For example, two people told us that they received Halal meals in line with their cultural needs. Menus contained sufficient choice and we saw that people could opt for a snack if they did not wish to eat a main meal.

Meals were served in small dining rooms within the wards and snacks could be eaten in some communal areas. Staff promoted the NHS 'protected mealtimes' policy to ensure that people could enjoy their meals uninterrupted. We noted that although wards accommodated 20 people, seating in the dining room was available for only 16. Staff told us that this was not usually a problem because people often went out for meals. However, this meant there was a risk that people may not have been able to join others at


mealtimes. We raised this with managers who agreed to take action to address it. People who were admitted outside catering hours were offered sandwiches or toast.

People were supported to be able to eat and drink sufficient amounts to meet their needs. People's nutritional needs were routinely assessed as part of their admission process. Staff were completing 'food diaries' for a number of people who had difficulty in maintaining adequate food and fluid intake. Records showed that those people found to have significant dietary needs were referred to a dietician. One person who had been admitted to the hospital three times over the preceding year had been assessed on each occasion. During their first admission they were assessed as being at high risk of malnutrition. We saw evidence that food and fluid charts were completed to monitor their intake, including the amounts of food and fluid they consumed. This person's weekly observation folder showed regular monitoring of their weight.

We saw good evidence that people were supported by therapy staff to improve their shopping and cooking skills. Action plans were in place to support skills development and thus promote healthy eating.


Staffing Action needed

There should be enough members of staff to keep people safe and meet their health and welfare needs

Our judgement

The provider was not meeting this standard.

There were not always enough qualified, skilled and experienced staff to meet people's needs.

We have judged that this has a minor impact on people who use the service, and have toldthe provider to take action. Please see the 'Action' section within this report.


The hospital had experienced a period when staff had found it difficult to provide an effective service due to staff vacancies and absence. Most of the staff we spoke with told us that this was being addressed and that teams were establishing and becoming more effective. However, there remained a significant reliance on agency staff. This posed a riskto the quality and continuity of the care people received. It also increased both clinical and safety risks for people and staff.

Senior staff told us that the rate of staff sickness absence at Wedgwood House was low and that they were actively recruiting to fill vacancies. Both of the wards we visited had vacancies, amounting to 17.5% of the total staff group. A member of staff from one ward was supporting the other ward where a member of staff was on unplanned sick leave. Senior staff told us that any staff absence was covered by agency staff, both NHS and independent. We could see from staff rotas for November and December 2013 that the majority of shifts were covered with an appropriate number of staff. We could also see thata number of agency staff worked shifts in Wedgwood House on a regular basis. This arrangement offered some continuity of care and support to people. One ward manager had been working closely with an independent agency to ensure that consistently appropriate staff cover was provided.

Incident data showed that staff routinely reported instances of low staffing levels to ensure that the trust was aware of the risk and impact. 24 reports of low staffing levels had been reported in the 11 months preceding our inspection. However, we were unable to determine the context surrounding these incidents. Ward staff were also required to staff the place of safety suite on a rota basis. Rotas showed that an additional staff member was rostered to provide effective cover at night. However, rotas also demonstrated that staffing was not always appropriately managed. For example, during October 2013 three out of the four senior clinical staff from one ward were on leave at the same time. This presented a risk to the ward team's clinical leadership during that period.

During our inspection we saw that staff were deployed so that they met people's needs


appropriately. A clear staff structure was displayed in corridors and we saw that staff had the capacity to observe people and complete required checks on their welfare, in line with care planning. Staff told us that they were required to ensure that people were offered one to one time with them each day. We heard them being reminded of this during a handover meeting. However, some people told us that they would like one to one time, but it was notalways offered. They told us that they believed that staff were too busy. One person told us, "I have spent time on two separate occasions speaking with staff on a one to one basisand I found the time invaluable." Other people made comments that included, "Not enoughone to one time with staff"; "They (staff) stay in their goldfish bowl of an office. Don't see enough of them"; "I wish they had more time for you. They are pretty busy with their paperwork." During our visits to the wards we found that staff were frequently occupied completing paperwork in the office. One senior member of staff expressed the view that there was sometimes insufficient staff on the ward to release nurses to spend more time with people on an individual basis. They said that this compromised their capacity to complete effective assessment and evaluation and to establish and maintain therapeutic relationships.

Arrangements were in place to ensure continuity of care and treatment from staff when shifts changed. We observed a staff handover meeting and saw that good quality accurateinformation was exchanged. The meeting took place away from the ward and information was provided in both written and verbal forms to optimise staff's understanding. It also provided the opportunity for staff to check that tasks had been completed and to ask for clarification about people's needs.

During our visit we spoke with three student nurses who were completing placements on the wards. They told us that they received good support from the ward staff and that they were deployed according to their experience and competence. On one ward four newly qualified staff nurses had been recruited. Whilst they were part of the core team they required significant supervision and structured mentoring and this presented a risk to staff providing support to the people in their care.

A team of therapy staff managed the provision of therapeutic and leisure activities within the hospital. This released care staff to undertake nursing and care duties. Therapy staff were rostered to work during the evening and at weekends to provide activities that met people's needs. However, people told us that the weekend activities did not always providefor their needs because fewer activities were offered. Several staff told us that low staffing levels sometimes meant that activities both on and off site had to be changed or cancelled.

We saw evidence that people's views about staffing arrangements had been taken into account. Minutes of the 'share and social' meeting showed that people had raised concerns about the absence of staff in the dining room at mealtimes. Subsequent minutes showed that this had been addressed.


Records Action needed

People's personal records, including medical records, should be accurate and kept safe and confidential

Our judgement

The provider was not meeting this standard.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained.

We have judged that this has a minor impact on people who use the service, and have toldthe provider to take action. Please see the 'Action' section within this report.


Records were kept securely and could be located promptly when needed. Staff maintainedrecords about people's assessment care and treatment in both electronic and paper formats. The electronic system was password protected and therefore accessible only to authorised staff. We saw that staff positioned monitors so that they could not be observed by unauthorised people. They also logged out of the system when they had finished using it. Paper records were stored in ward offices that were accessible only to staff. The doors to these offices were kept locked when not in use.

Some records, such as assessments were completed on the electronic 'EPEX' system andstaff could print off paper copies to refer to. Paper records were electronically scanned andstored on this system. However, staff told us that they had amassed a significant backlog of paper records that required scanning onto the electronic system. This meant that there was a risk that electronic records were incomplete and that staff did not have ready accessto current information about people.

The ward information booklet informed people about how information was shared with other people and of their right to confidentiality. People were asked to sign to give their consent to share their information with others. They were also informed about their rights to view their health records.

People's personal records including medical records were not always accurate and fit for purpose. We looked at a sample of people's records and found that they were not always complete. Evidence showed that staff always experienced delays in obtaining the records of people admitted from other areas of the trust. They told us that it could take up to a week to obtain people's records because they had to request this formally. We found that the records of some people who had been admitted during the week prior to our inspectionwere still incomplete. These arrangements meant that there was a risk that staff did not have access to complete or current information about people. There was therefore a risk that they may not have provided appropriate care and treatment. For example, staff told usthat they understood that one person had a history of significant risk about which they had


no written information.

We saw other examples of people's written records that did not contain full or accurate information. Some people had specific dietary needs in relation to their culture or medical conditions. We found that one person who was vegan and living with unstable diabetes didnot have a relevant care plan in place. This person's multidisciplinary information sheet, where specialist diets and dietary requirements were logged, only recorded their requirement for a vegan diet. A person who posed a risk of domestic violence did not havea care plan to manage this safely. Another person's records stated that they were detainedunder the Mental Health Act. Their detention had actually ceased during the week prior to our inspection. We brought this to the attention of staff and the record was amended in ourpresence.

Ward staff relied on other information about the people in their care. Wipe boards contained summary information about people, such as the section of the Mental Health Actunder which they were detained. This information was coded, or obscured from view to minimise the risk to people's confidentiality. We saw that the information was updated frequently. For example, one board contained details of the people recently admitted to theservice and the physical health assessments that they required. This information was updated as assessments were completed. We observed a handover meeting between different groups of staff. This was structured according to a 'SBAR' document that set out information about people's individual status (under the Mental Health Act), background, assessment and recommendations for their effective care. This information was delivered to staff consistently and updated during the meeting so that all staff received accurate and complete information.

Other records relevant to the management of the services were accurate and fit for purpose. During our inspection we looked at other records including incident reports, equipment checks and property management records. We found that whilst incidents wererecorded effectively, the records of the checks made on emergency equipment was less reliable. Staff were recording these checks inconsistently, on two separate documents within one file. This made it difficult to be certain that checks had been completed as required to ensure people's safety in the event of a medical emergency. The records madeof people's belongings that were kept securely in the patient property store room were not always completed by staff. A random selection of seven people's files showed two people's property had not been logged in accordance with the trust's policy. This posed a risk that people's property may have been mislaid, or may not have been returned to them appropriately.

This section is primarily information for the provider


Action we have told the provider to take

Compliance actions

The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activities Regulation

Assessment or medical treatment forpersons detained under the Mental Health Act 1983


Regulation 22 HSCA 2008 (Regulated Activities) Regulations2010

Staffing

How the regulation was not being met:

Regulation 22. In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.

Regulated activities Regulation

Assessment or medical treatment forpersons detained under the Mental Health Act 1983


Regulation 20 HSCA 2008 (Regulated Activities) Regulations2010

Records

How the regulation was not being met:

Regulation 20. (1) The registered person must ensure that service users are protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about themby means of the maintenance of—(a) an accurate record in respect of each service user which shall include appropriate information and documents in relation to the care and treatment provided to each service user; and

This section is primarily information for the provider


(b) such other records as are appropriate in relation to—(ii) the management of the regulated activity.

This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The provider's report should be sent to us by 31 January 2014.

CQC should be informed when compliance actions are complete.

We will check to make sure that action has been taken to meet the standards and will report on our judgements.


About CQC inspections

We are the regulator of health and social care in England.

All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.

The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "governmentstandards".

We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming.

There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times.

When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place.

We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it.

Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re-inspect a service if new concerns emerge about it before the next routine inspection.

In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers.

You can tell us about your experience of this provider on our website.


How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection.

We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action.We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement action taken

If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.


How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact.

Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.


Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17)

Consent to care and treatment - Outcome 2 (Regulation 18)

Care and welfare of people who use services - Outcome 4 (Regulation 9)

Meeting Nutritional Needs - Outcome 5 (Regulation 14)

Cooperating with other providers - Outcome 6 (Regulation 24)

Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)

Cleanliness and infection control - Outcome 8 (Regulation 12)

Management of medicines - Outcome 9 (Regulation 13)

Safety and suitability of premises - Outcome 10 (Regulation 15)

Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)

Requirements relating to workers - Outcome 12 (Regulation 21)

Staffing - Outcome 13 (Regulation 22)

Supporting Staff - Outcome 14 (Regulation 23)

Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)

Complaints - Outcome 17 (Regulation 19)

Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.


Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.


Contact us

Phone: 03000 616161

Email: [email protected]

Write to us at:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

Website: www.cqc.org.uk

Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with thetitle and date of publication of the document specified.

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