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This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospital Requires improvement –––

Medical care Requires improvement –––

Royal Devon and Exeter NHS Foundation Trust

MarMardondon NeurNeuroo-r-rehabilitehabilitationationCentrCentreeQuality Report

Barrack RoadExeterEX2 4UDTel: 01392402357Website: www.rdehospital.nhs.uk

Date of inspection visit: 3-6, 10 & 16 November 2015Date of publication: 09/02/2016

1 Mardon Neuro-rehabilitation Centre Quality Report 09/02/2016

Letter from the Chief Inspector of Hospitals

We inspected Royal Devon and Exeter NHS Foundation Trust as part of our programme of comprehensive inspections ofall NHS acute trusts. The trust was identified as a low risk trust according to our Intelligent Monitoring model. Thismodel looks at a wide range of data, including patient and staff surveys, hospital performance information and theviews of the public and local partner organisations.

Level 6 is the lowest level of risk which the trust had been rated since march 2014.

The inspection took place on 2 – 6 November 2015 and included Wonford Hospital and Mardon Neuro-RehabilitationCentre

We rated the trust as good overall and Mardon Neuro-Rehabiliation as requires improvement overall.

• The chief executive had been in post for 18 years at the time of the inspection. It appeared that the Chair and ChiefExecutive had a supportive relationship and worked well together. The board overall had the experience, capacityand capability to lead effectively.

• The trust culture is strongly focused on quality and safety with patients being the absolute priority. There wastangible evidence of the culture in trust policies and procedures. This was also a consistent theme in the feedbackfrom staff at all levels in the focus groups and drop in sessions held during the inspection.

• There was an incident review group which reports to the Clinical Governance Committee and reviews all incidentsthat are categorised as amber or red

• The trust had no never events since 2013. Never Events are serious, largely preventable patient safety incidents thatshould not occur if the available preventative measures have been implemented. NHS trusts are required to monitorthe occurrence of Never Events within the services they commission and publicly report them on an annual basis.

• The trust performed well on infection rates having had no incidents of MRSA blood stream infection since 2011.• Staffing in wards was reviewed on a regular basis with evidence of skill mix changes and additional posts being

created in some areas. Other areas were finding it hard to recruit with some reliance on bank or agency staff.• The overall trust target for mandatory training was 75% which had been achieved for topics such as safeguarding.

There were some topics which were above the target and some slightly under the target.• Staff reported communication was good in their local teams through use of ‘Comm cells’. These took place regularly

with discussions including training, complaints incidents and well as feedback of results of audits.• For the Mardon Neuro-rehabilitation centre there was a lack of strategy for the provision of a responsive service that

delivered care as close to home as possible services seven days a week.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure medicines are administered to patients safely in line with policy and take into account their rights.• Ensure medicines are disposed of and returned to pharmacy in accordance with the trust’s policies and standard

operating procedures.

In addition the trust should:

• Ensure there are sufficient therapy staff deployed in order for patients to receive consistent care and according totheir needs.

• Ensure incidents are investigated and records are available with a robust process for disseminating information to allstaff following incidents investigations.

• Ensure discharge planning processes are pro-active and well co- ordinated to reduce delayed transfers out of thecentre.

Summary of findings


• Ensure service strategies are clear and communicated effectively and development plans for the service areidentified.

• Identify a lead to develop the service and provide management support at operational level.• Review feedback from patient surveys and develop action plans to improve patient experience.

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Medicalcare

Requires improvement ––– We have rated The Mardon Neuro-rehabilitationCentre as requires improvement overall. Effective,caring and responsive were rated as good and safeand well led rated as requires improvement.Medicines were not always managed safely andaccording to best practice guidance to safeguardpatients. This included the covert administrationof medicines which were disguised in food.There were not always sufficient numbers oftherapists such as speech and language therapists toprovide care and support to patients to meet theirrehabilitation needs. Patients told us they receivedappropriate support from nursing staff. There wasgood multi-disciplinary working for the benefit ofpatients.Incidents were monitored and staff followedprocedures to report incidents and monitor patients’risks. There was inconsistency in the way thatinvestigations and learning from these werecascaded to staff at local level.The environment was clean and equipment was wellmaintained. Infection control procedures werefollowed to protect patients from risk of crossinfection. Staff had access to a variety of equipmentto enable and support patients’ independence.Regular equipment checks were completed andrecords were maintained to ensure they were safefor use.Staff had good understanding of action they wouldtake to safeguard patients in vulnerable situations.The Mental Capacity Act 2005 and Deprivation ofLiberty Safeguards and mental capacityassessments were completed and reviewed.Although this principle was not followed whenadministering covert medicines.Patients were assessed and care plans developed tomanage risks. There was no tool used to assessdeteriorating patients which could lead toinconsistency in their management. Records werestored securely and available to support patients’care

Summaryoffindings

Summary of findings


Staff provided care based on national guidance suchas National Institute for Clinical Excellence (NICE)guidelines and British Society of RehabilitationMedicine guidance.Staff received induction and other training and therewas a formal process in place for staff to follow tomeet requirements of the Duty of Candour. Patientsreceived compassionate care that respected theirprivacy and dignity. Patients and relatives said theyfelt involved in decision making about their care.There were effective governance arrangements thatlooked at incidents and risks. Staff felt supported bytheir managers and felt they worked for Mardoncentre and were not connected to the wider trust.The trust had confirmed there was a strategy forMardon. However this was not known at local leveland was not embedded within the unit; for theprovision of a responsive service that delivered careas close to home as possible seven days aweek. There was a lead for the service, staff said theywere not visible in the unit to develop the serviceand provide management support at operationallevel. They were and available by telephone andvisited infrequently.The trust routinely monitored case mix and outcomedata for the purpose of benchmarking and qualitymonitoring annually as part of a national audit.

Summaryoffindings

Summary of findings


MarMardondon NeurNeuroo-r-rehabilitehabilitationationCentrCentree

Detailed findings

Services we looked at

Mardon Neuro- Rehabilitation Centre

Medical care for rehabilitation


Contents

PageDetailed findings from this inspectionBackground to Mardon Neuro-rehabilitation Centre 7

Our inspection team 7

How we carried out this inspection 8

Facts and data about Mardon Neuro-rehabilitation Centre 8

Our ratings for this hospital 8

Action we have told the provider to take 25

Background to Mardon Neuro-rehabilitation Centre

The Mardon Neuro Rehabilitation Centre is run by theRoyal Devon & Exeter NHS Foundation Trust and is part ofthe medical directorate. The Centre has 12 beds andcares for sub-acute patients with a variety of neurologicalconditions. It provides care and services to adult patientsin Exeter, and East and Mid Devon and also to patientswho may be out of County as far as Cornwall.

There is clearly defined admission criteria to the unit suchas patients should have a primary neurological condition,be over 16 years of age and not in full time education.Referrals are received from the acute and communitymulti- disciplinary team (MDT) teams. GPs contacted theconsultant neurologist and all referrals are discussed aspart of the weekly MDT meetings.

The Mardon unit has dedicated beds where neurologypatients are admitted for assessment and diagnosis offunctional symptoms. These patients are admitted for aset period of four weeks for assessments.

There is a specialist multi-disciplinary team approach toassessments and treatment where the team workscohesively to provide a rehabilitation programme. Thisincludes joint working with other agencies in thecommunity with the aim of integrating the patients backinto the community. Mardon also provides facilities suchas sleep studies for monitoring brain activity as part ofassessment of epilepsy.

We undertook this inspection of Mardon NeuroRehabilitation Centre as part of our inspection of RoyalDevon and Exeter NHS Foundation Trust. We observedhow people were being cared for and reviewed sixpatients care records. We also spoke with 11 staffincluding doctors, nursing auxiliaries, domestic, nurses,therapists, psychologists and the maintenance/ driver forthe unit.

The report will reflect some of the data from the medicaldirectorate which Mardon is part of.

Our inspection team

Our inspection team was led by:

Chair: Professor Ted Baker, Deputy Chief Inspector.

Head of Hospital Inspections: Mary Cridge, Care qualityCommission

The full inspection team included CQC senior managers,analysts, inspectors and specialist advisors such as

doctors, nurses, allied healthcare professionals; ’expertsby experience’ and senior NHS managers also joined thisteam. The inspection team for Mardon Neurorehabilitation unit comprised of two CQC inspectors, anda specialist advisor who is a physiotherapist.

Detailed findings


How we carried out this inspection

To fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

We carried out the announced part of our inspectionbetween 3 – 6 November 2015. During the inspection wevisited a range of wards and departments across thetrust and spoke with over 300 clinical and non clinicalstaff and held focus groups to meet with groups of staffand managers. We observed how people were beingcared for, talked with carers and family members andreviewed patients’ records of their care and treatment.

Prior to the inspection we obtained feedback andoverviews of the trust performance from the New DevonClinical Commissioning Group and Monitor (theFoundation trust regulator).

We spoke with HealthWatch Devon who shared with usviews they had gathered from the public in the year priorto the inspection. In order to gain feedback from peopleand patients we held some listening events. One of theseevents was held at a venue in Exeter city centre and twoothers were held at Honiton and Tiverton Libraries. A totalof 50 people came to share their experience with us andwe used what they told us to help inform the inspection.We also received feedback that people provided via theCQC website.

Facts and data about Mardon Neuro-rehabilitation Centre

The Mardon Neuro centre was last inspected in August2012. We reviewed five essential standards during theinspection and Mardon unit was compliant with thestandards we inspected.

Our ratings for this hospital

Our ratings for this hospital are:

Safe Effective Caring Responsive Well-led Overall

Medical care Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Overall Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Notes

Detailed findings


Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceThe Mardon Neuro Rehabilitation Centre is run by theRoyal Devon & Exeter NHS Foundation Trust and is part ofthe Medical Services Division. The Centre has 12 beds andcares for sub-acute patients with a variety of neurologicalconditions. It provides care and services to adult patientsin Exeter, and East and Mid Devon and also to patientswho may be out of County as far as Cornwall.

The Centre does not provide care to patients who areunder 16 years. There was a clearly defined admissioncriteria to the unit such as patients should have a primaryneurological condition, be over 16 years of age and not infull time education. Referrals were received from theacute and community multi- disciplinary team (MDT)teams. GPs contacted the consultant neurologist and allreferrals were discussed as part of the weekly MDTmeetings. Mardon Neuro Rehabilitation Centre is part ofthe Medical Services Division. The team provides a multi-disciplinary approach to care from nurses, doctors andtherapists as part of rehabilitation service.

Summary of findingsWe have rated The Mardon Neuro Centre as requiringimprovement overall with effective, caring, responsiverated as good, and safe and well led as requiresimprovement.

Medicines were not always managed safely andaccording to best practice guidance to safeguardpatients. This included administration of covert such asmedicines which were disguised in food.

There were not always sufficient numbers of therapistssuch as speech and language therapists to provide careand support to patients to meet their rehabilitationneeds. Patients told us they received appropriatesupport from nursing staff. There was goodmulti-disciplinary working for the benefit of patients.

Incidents were monitored and staff followed proceduresto report incidents and monitor patients’ risks. Therewas inconsistency in the way that investigations andlearning from these were cascaded to staff at local level.

The environment was clean and equipment was wellmaintained. Infection control procedures were followedto protect patients from risk of cross infection. Staff hadaccess to a variety of equipment to enable and supportpatients’ independence. Regular equipment checkswere completed and records were maintained to ensurethey were safe for use.

Staff had good understanding of action they would taketo safeguard patients in vulnerable situations. The

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Mental Capacity Act 2005 and Deprivation of LibertySafeguards and mental capacity assessments werecompleted and reviewed. Although this principle wasnot followed when administering covert medicines.

Patients were assessed and care plans developed tomanage risks. There was no tool used to assessdeteriorating patients which could lead to inconsistencyin their management. Records were stored securely andavailable to support patients’ care

Staff provided care based on national guidance such asNational Institute for Clinical Excellence (NICE)guidelines and British Society of Rehabilitation Medicineguidance.

Staff received induction and other training and therewas a formal process in place for staff to follow to meetrequirements of the Duty of Candour. Patients receivedcompassionate care that respected their privacy anddignity. Patients and relatives said they felt involved indecision making about their care.

There were effective governance arrangements thatlooked at incidents and risks. Staff felt supported bytheir managers and felt they worked for Mardon centreand were not connected to the wider trust.

There was a lack of strategy for the provision of aresponsive service that delivered care as close to homeas possible seven days a week. Resources were not usedeffectively and there was no lead to develop the serviceand provide management support at operational level.

The Mardon centre monitored outcome data through anational data collection for the purpose ofbenchmarking.

Are medical care services safe?

Requires improvement –––

By safe, we mean that people are protected fromabuse and avoidable harm.

We have rated safe as requires improvement.

Medicines were not always managed safely andaccording to best practice guidance to safeguardpatients. This included administration and managementof covert medicines such as disguised in food. Wherepatients were administering their own medicines, staffdid not follow guidance and risks were not assessed tosafeguard patients.

The resuscitation box was not tamper evident which mayhave posed risks as these could be accessed by patientsor visitors at the service.

The Mardon centre was visibly clean and infection controlprocedures were in place to control and prevent thespread of infection to patients, such as the availability ofhand sanitizers in reception and other points. Processand procedures were followed to report incidents andmonitor risks. Staff were aware of their responsibilities inadhering to the duty of candour.

Staff had knowledge about safeguarding patients andactions they would need to take to protect patients invulnerable situations.

Incidents were reported and feedback was providedfollowing investigation as part of lesson learnt. Therewere mostly adequate nursing staff; although theregistered nurse cover in the afternoon had been reducedsince October. There were not always adequate therapystaff to consistently meet the needs of the patients.

Incidents

• There had been no incidents of “Never Events”associated with the unit, these are incidents determinedby the Department of Health (DH) as serious, largelypreventable patient safety incidents that should notoccur if the available preventative measures have beenimplemented.

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• Incidents and accidents were reported using a trustwide electronic system, all staff had access to this andunderstood the incidents that required reporting.

• There was a speciality governance meeting that sharedlearning from incidents, risks, complaints and concerns.Minutes from these meetings were circulated anddiscussed at staff meetings. Clinical teams attendedmortality and morbidity meetings that were held for themedical division. However staff knowledge andawareness of learning from both local and wider trustincidents was limited.

• For example, following an incident a staff member toldus a review of the resuscitation equipment was beinglooked into. However staff were unable to provideevidence and outcome of the investigation. There wasno root cause analysis available. No action plan hadbeen developed to ensure learning from the incidentwas shared and risk of reoccurrence minimised.

• Some staff were aware of the quarterly trust newslettersin which lessons learnt were shared from other services.However, not all staff were aware of learning sharedfrom other areas across the trust. Therapy staff told usthis was variable, although this had improved with thenew information sharing system.

• Staff used the “Comm cell” which is an internal systemcommunication board, which the staff used to discussvarious issues affecting standards of care such aschanges in patients’ conditions. Staff said this was apositive step in improving communication across theunit.

Duty of candour

• The Duty of Candour legislation which came into effectin November 2014 requires healthcare providers todisclose safety incidents which result in a level of harmclassified as death, severe, moderate or prolongedpsychological harm. These incidents must beinvestigated and reported to the patient, and any other‘relevant person’, within 10 days. Organisations have aduty to provide patients and their families withinformation and support when a reportable incidenthas, or may have occurred.

• Staff we spoke with had varied understanding of thislegislation of the Duty of Candour and they had notreceived training about this. However they all said theywere encouraged to report incidents.

• The trust’s internal electronic reporting system had afunction which meant the investigator had to considerduty of candour when any incident of moderate harmand above occurred.

• The trust told us any moderate or above incidenttriggered a set circulation list within the relevantdivision. The trust and the relevant governance managerwould follow through to ensure duty of candour hadbeen followed.

• The trust’s Incident Review Group also monitoredcompliance with the duty of candour. Between March2014 and the June 2015 there were 19 incidents forthe Medical Services Division which met the duty ofcandour criteria for investigation. The duty of candourwas initiated following a patient’s fall at the centre. Theinvestigation report was shared with the patient andtheir representative and included an apology.

Safety thermometer

• The trust collected safety thermometer data in relationto care provided to patients. The NHS safetythermometer is a monthly snapshot audit of theprevalence of avoidable harms including new pressureulcers, catheter-related urinary tract infections and falls.Safety thermometer information provides a means ofchecking performance and is used alongside othermeasures to direct improvement in patients’ care.

• Information about safety thermometer was collected atMardon; however this was not visible and staff were notaware of the findings. A senior member of staff told usthey were not aware that this information should beavailable to patients and others.

• Safety thermometer data showed there was a lowprevalence of pressure ulcers. There were two pressureulcers of grades two and three for September 2015.However, these were patients who had been admittedto the centre from other wards and another hospital.The trust also monitored catheter urinary tractinfections and catheters inserted over 28 days. At timesthe incidence of patients with a urinary catheter over 28days on the unit was high. This was due to patientshaving long term catheters due to their neurologicalcondition. In August 2015 Mardon had five cathetersover 28 days and one new urine tract infection.

Cleanliness, infection control and hygiene

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• The unit was visibly clean and infection controlprocedures were in place to control and prevent thespread of infection to patients

• The Department of Health publishes the Health andSocial Care Act 2008 Code of Practice on the Preventionand Control of Infections and Related Guidance. TheCode sets out the criteria against which the CQC willjudge a registered provider on how it complies with thecleanliness and infection control requirements.

• Policies and procedures had been developed for thecontrol and prevention of infection. These includedregular audits to assess their compliance and actionplans developed to manage shortfalls as required.

• Staff and visitors were able to easily access handsanitisers with these being available in reception andother points. We observed staff following hand hygieneprocedures such as washing their hands and usingsanitising gels in between patients in line with trustpolicy. The trust had set targets for hand hygienecompliance audits and rated 85% as amber and 90% asgreen. The Mardon Centre had achieved 95%compliance in the last four hand hygiene audits whichshowed compliance rate was good.

• The trust had reported no cases of Methicillin ResistantStaphylococcus Aureus (MRSA) blood steam infectionsince 2011, and no Clostridium Difficile (C .Diff) in thelast three years which related to Mardon unit.

• An environment daily cleaning checklist was completedto monitor and assess compliance with daily cleaningand this was adhered to.

• Patient Led Assessment of the Clinical Environment(PLACE) audit 2014/2015 showed the Mardon unit with ascore of 96% for cleanliness and 91% for theenvironment.

Environment and equipment

• Staff had access to emergency medicines in the event ofa cardiac arrest. However the resuscitation box was notmaintained securely in line with trust’s policy. The boxwas open and not tamper evident which posed risk ofunauthorised access to equipment and medicines orthat the required medicines may not be available whenrequired.

• The staff said the resuscitation equipment should bechecked weekly and we saw records that these checkswere maintained.

• A random check of syringes in the treatment roomshowed there were six blood taking syringes which had

expired in September 2015. This may have posed risksas these syringes may not be fit for purpose. We broughtthis to the attention of the nurse in charge and thesewere removed. Staff told us there was no system forchecking stock items.

• The Mardon unit was purpose built andaccommodation was provided in single rooms withadaptations which were appropriate and met the needsof patients.

• Patients were complimentary about theaccommodation provided and confirmed they had thenecessary equipment needed. A patient told us aboutan adapted frame they had started using which hadhelped their mobility.

• As the purpose of the unit was to provide arehabilitation service to meet individual needs therewas access to a variety of equipment, such as speciallyadapted wheelchairs, baths, beds and walking frames tosupport and maintain patients’ independence. Thisincluded specialised equipment which was accessibleand according to patients assessed needs. A patient wasprovided with an adapted frame which they told us hadbeen “very good” and had improved their mobility.

• A random check of equipment showed these had beenserviced regularly in line with the trust’s policy. Electricalequipment had portable appliance test (PAT) completedto ensure they were fit for use.

• The League of friends provided support to the centreand had recently purchased two wheelchairs and twobeds which benefitted the patients as they hadequipment to meet their needs.

Medicines

• Staff did not always manage medicines safely in linewith policy.

• We were concerned that staff were administering somemedicines covertly, disguising this in a patients drink.The trust medicines’ policy showed that the decision toadminister medicines covertly must involve amultidisciplinary team, including at least a doctor and anurse and, where possible, a pharmacist. Where covertmedicines is considered there are national guidelinesregarding administration of medicines as crushingmedicines may alter the way the tablet or capsuleworks. For example, when crushed the absorption of themedicine may be quicker than intended and lead toside effects. The decision to administer medicinescovertly and how best to achieve covert administration

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must be clearly recorded in the medical notes and thedecision must be regularly reviewed. There was noevidence that staff were following this or were takinginto account best practice consent and considering amental capacity assessment in line with the trust’spolicy. There was no evidence staff had considered theleast restrictive option and having due regards to thepatient’s basic rights and freedom (Human Right Act1998) when administering covert medicines. The trusthad confirmed there was no separate covertadministration procedure or guideline available toinform staff’s practice.

• Staff did not always follow the trust’s own proceduresfor medicines administration. The standard operatingprocedure (SOP) and assessment for covert medicineswhich was in a patient’s note were from DevonPartnership trust. This may differ from the current trust’sSOP as was not approved by the trust.

• The staff did not follow their procedures to ensuremedicines were disposed of and returned to pharmacyin accordance with the trust’s policies and standardoperating procedures. There was a large box ofmedicines which staff said had been there for over sixmonths and had not been returned to pharmacy.

• One patient had been administering their owncontrolled drug to manage pain effectively. A decision towithdraw the medicine was made followingpharmacist’s advice as the patient had become verydrowsy. During the time the patient had beenself-medicating there was no evidence of a riskassessment being undertaken to ensure the patient wasmanaging this safely.

• The Mardon centre had a first aid box which alsocontained two types of pain tablets. Records showedstaff were dispensing these tablets to other staffmembers and this posed a risk as the staff may have anadverse reaction to these medicines.

• We received conflicting reports about the storage of anemergency drug in the resuscitation box which mayhave caused delay in accessing this if required. This wasresolved on the second day of our inspection.

• Medicines were stored in dedicated refrigerators and therefrigerator temperature was monitored daily whichincluded the minimum and maximum temperature.Records we saw all showed the temperatures to be

checked and within the required range. This meant staffwere able to see when the refrigerator temperature waseither above or below the normal range and actioncould be taken as needed.

• Other medicines were stored in a cupboard in thestaffroom. The nurse in charge confirmed they were notable to monitor the temperature of the room wherethese medicines were stored. These included creams,ointments, liquid medicines and tablets. Medicines notstored according to the manufacturer’srecommendations could reduce the efficacy ofmedicines given to patients.

• Patients told us they were able to receive theirmedicines when they needed them and this includedpain control tablets.

• We viewed the controlled drug (CD) registers and foundthese to be appropriately completed, with weekly CDschecks and CDs were kept securely.

Records

• Records were seen to be stored securely and wereaccessible. We reviewed six medical, nursing notes andother associated records and found the quality andlegibility to be good.

• The unit used a combination of paper and electronicsystem for patients’ records. Access to electronic recordswas password protected which staff said was secure.

• Patients had a comprehensive pre-assessment whichwas recorded in the pre-assessment care pathwaydocument prior to patients moving into the service. Wesaw the records were completed appropriatelyincluding risk assessments and care plans were in place.These included detailed therapists input and goals.Medical records were up to date and provided detailedinformation on the patients care and treatment.

• Individual care plans were developed which includedregular reviews and mapping of rehabilitation progresswhich were discussed at clinical reviews.

• Detailed records were maintained at the weeklymulti-disciplinary team (MDT) meetings which includedassessments of risks, goal setting and action plans.

• Records contained information following reviews andassessments form other healthcare professionals toinform staff’s practices.

Safeguarding

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• Staff in the unit, including non-clinical staff, were awareof what constituted abuse and the actions they wouldtake and how to report issues to protect the safety ofpatients in vulnerable situations.

• Staff would report to the matron and some wereconfident to report higher up if they felt action had notbeen taken or needed to be taken promptly.

• Staff were aware of the trust whistle-blowing policy andwe were told they could find information on the trust’swebsite.

• There were safeguarding policies and guidelines for theprotection of vulnerable adults. Safeguarding adultstraining was part of the trust’s mandatory trainingprogramme. The current training data from the trustshowed 97% of staff had completed safeguarding adulttraining against the trust target of 100%.

Mandatory training

• Staff told us they undertook a three day mandatorytraining when they joined the trust. This included arange of topics such as fire safety, health and safety,basic life support, safeguarding, mental capacity,manual handling, infection control/ hand hygiene,conflict resolution, consent and information governancetraining.

• The data provided by the trust showed compliance withmandatory training varied across the service. Staff atMardon had achieved 100% compliance with equalityand diversity and infection control training. Howeverdata showed that the percentage of staff who hadcompleted training in conflict resolution was 55%, firetraining and infection control 90% and moving andhandling 83%.

• All staff with access to NHS patient information shouldundertake information governance (IG) training. Datafrom the trust showed 86% of staff had completed thistraining against a trust target of 100%.

• The Mardon unit did not have 24 hour medical coversuch as a doctor on site. Patients suffering a cardiacarrest, for example, would be reliant on nursing staff toprovide basic life support (BLS) until help arrives. Asenior nurse told us staff had completed BLS training,but the trust had not been able to provide a breakdownof data to confirm this. The lack of oversight on trainingmay impact on care and treatment as staff may not havethe skills and confidence to provide this level ofemergency care.

Assessing and responding to patient risk

• The Mardon unit was a low risk patient ward away fromthe acute hospital. This meant that staff would have tocall 999 in the event of an emergency and possiblytransfer a patient to the main site emergencydepartment. Staff were confident and said they followedtheir procedure in accessing emergency support ifneeded.

• Due to the nature of their condition at times there maybe patients on the unit who require mechanicalassistance with breathing such as Bilevel Positive AirwayPressure, (BiPAP). This is a form of treatment for patientssuffering from respiratory conditions where patients usea breathing mask at night to maintain their airway andare attached to a machine. We were concerned whetherstaff had the skills to manage these patients and weretold while staff did not have specific training in the useof BiPAP, the unit only accepts patients using thisequipment if they are able to manage it themselves.Support would be available to staff from Culmrespiratory ward in the event of a concern or therespiratory nurses would also visit.

• Staff did not use the early warning score (EWS) to assessa potentially deteriorating patient, which was due to theservice being a rehabilitation unit. Baselineobservations such as temperature, blood pressure weretaken when patients were admitted and this would berepeated if the patient became unwell. There was a riskthis may not be escalated in a timely way. Staff said theywould escalate to the medical team or could call 999and transfer the patient to the accident and emergencydepartment.

• Risk assessments were undertaken for individualpatients in relation to falls, malnutrition and pressureulcers. The trust used the Extra Pressure RiskAssessment tool (ESPRAT) for patients’ pressure risksassessments. Actions to mitigate the risks identifiedwere instigated such as provision of pressure relievingequipment.

• Patients were assessed for falls risks. Those who wereassessed as low risk of falls did not have a care plan.Staff said this was normal practice for the centre. Thetrust audit on falls showed that the centre was notmeeting the below 85% reduction in falls. Matron told uspatients were at higher risks of falls as the centre was arehabilitation unit. An assessment of patient’s fall riskswas undertaken and care plan developed for those

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deemed as high risks. Staff monitored patients as part oftheir intentional rounding, call bells were available andpatients were encouraged to ask for help whenmobilising.

• Occupational therapists undertook assessments ofpatients’ home environment, and identified risk ofpossible hazards where appropriate. We saw in onepatient’s records this had been carried out prior to theirdischarge.

Staffing

• Nursing staff numbers did not always meet the plannedrequirement and therapy staffing levels were not in linewith national standards.

• There are nationally defined minimum safe staffinglevels for inpatient care wards. These include SafeStaffing: A Guide to Care Contact Time (NHS England,November 2014) and Direct Care Measurements (NHSEngland, January 2015). Staffing at the centre wasreviewed every six months as part of the trustsestablishment reviews. They used the British Society ofRehabilitation Medicine (BSRM) standards forrehabilitation services mapped to the National ServiceFramework (NSF) as these were appropriate to the unit.

• Shifts were agreed in advance against the plannedregistered nurse to patient ratios required for each shift.Since October 2015, staff told us and we saw the dutyroster showed, there were occasions when there wasonly one registered nurse for part of the afternoon/evening shift. We received mixed views from the unitstaff regarding the recent levels of registerednursing staff for late shifts. Patients told us they mostlyreceived adequate nursing support. We noted twopatients had been identified as requiring 1:1 supportand this was provided to ensure the patients’ safety.

• The unit used the trust's bank staff to cover shortages,although they had problems getting staff from the maintrust to support them. Any shifts that could not beadequately staffed on the rota were escalated. Data forOctober 2015 showed eight shifts for specialing patientshad not been filled on request.

• The national guidance for therapists (Royal college ofPhysicians 2003) guidelines for managing patients withacquired brain injury, state there should be oneoccupational and physiotherapy plus support staff forfive beds. For the 12 beds on the unit the currentphysiotherapist staffing was 2.1 whole time equivalent(WTE). Occupational therapist was 1.88 WTE.

• Patients felt there was not always adequate therapystaff and this impacted on the level of occupational andphysiotherapy they received. A patient said they hadthree half hour sessions of physio in a week. Therapystaff confirmed staff shortage had impacted on the levelof therapy time patients received.

• Staff used the British Society of Rehabilitation Medicineguidelines in relation to the number of therapy staffneeded to provide effective care and support forpatients. Therapy staff undertook a review to show theimpact of Speech and language therapy (SLT) staffingpressures and clinical contacts at Mardon from Januaryto September 2015. This showed a marked decrease ofclinical contact with patients from 500 units in Januaryto 200 units in September 2015. A Band 5 staff memberwas funded for a year and this had terminated in March2015. The current Band 7 therapist worked three days aweek and also provided support to patients on theneurology ward at the trust. Staff told us this had animpact on patients with a reduction of time spent withpatients. Staff told us not all of the patients wereassessed on admission and a reduced speech andlanguage therapy input for patients. They were alsounable to undertake visits in the community for “vitallife skills”. At times therapists were also “pulled” tosupport the team on the acute wards at the trust whichhad an impact on patients receiving the required levelsof rehabilitation at Mardon.

• The number of vacancies across the Medical ServicesDivision was 28.23 WTE which included high levels ofAllied Health Professional’s (AHP) vacancies. Theshortage of therapists had been highlighted on thetrust’s risk register.

Medical staffing

• The Mardon unit was consultant led. The consultantNeurologist provided half a day cover per week. Theconsultant attended the unit once a week onWednesdays and took part in MDT meetings. Patientswere reviewed and included discharge planningmeetings with involvement of relatives as appropriate.However staff had access to registrars and theconsultant could be contacted for advice and support.

• Neurology registrars provided cover between 9-5 pmand visited the unit on Mondays, Wednesdays andFridays. Out of Hours was covered by Devon Doctors.

• Staff told us there were some issues with Registrar’scover when one of them was on leave which meant

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patients were not routinely reviewed. At these timesstaff contacted the on call trust’s team for urgent casesor accessed out of hours cover which could at timesimpact on patients’ care. This meant transferringpatients to the accident and emergency department,when the treatment could have been provided on site.

Major incident awareness and training

• Arrangements were in place to respond to emergenciesand major incidents and staff would follow the trust’scontingency plan. The unit accommodation wasprovided on the ground floor and exits were clearlysignposted.

Are medical care services effective?

Good –––

By effective, we mean that people’s care, treatmentand support achieves good outcomes,

Promotes a good quality of life and is based on thebest available evidence.

We rated effective as good.

Staff provided care to patients based on nationalguidance, such as National Institute for ClinicalExcellence (NICE) and the British Society RehabilitationMedicine standards and guidelines.

Patients’ pain was monitored and they received painrelief when they needed it.

Patients who were at risk of malnutrition or hadswallowing difficulties were supported by appropriatelytrained and competent staff. Assessments werecompleted by speech and language therapists and plansof care developed.

Patients’ consents were sought prior to care andtreatment. Staff were clear about their roles andresponsibilities regarding the Mental Capacity Act 2005and Deprivation of Liberty Safeguards. Multi- disciplinaryreviews were undertaken for patients who were underDoLS to ensure their rights were safeguarded.

Evidence-based care and treatment

• Patient needs were assessed and care and treatmentwas delivered in line with National Institute for Health

and Care Excellence (NICE) quality standards. Forexample, clinical staff followed guidance relating to fallsassessment and prevention, pressure ulcers andmalnutrition assessments.

• The British Society of Rehabilitation Medicine Standards(BSRM) for care of acute brain injury and rehabilitationof adults were used. These followed the nationalframework guidance and staff were aware of theseguidelines.

• Therapists used a patient centred approach in theassessment and therapy-focused goals with patientsand their family involved in the goal setting at all times.The Functional Independence Measure/FunctionalAssessment Measure (FIM/FAM) tool was used in theassessment of patients which looked at the physical andpsychosocial functions which were often the mainfactors limiting outcome in brain injury patients.

• Therapy staff used the Rivermead index tool to assesspatients’ functional mobility. This is a tool specificallydeveloped for patients who had neurological deficits.

Pain relief

• Patients told us they received pain control when theyrequired them. Patients’ pain was assessed and advicesought from a pain specialist from the trust as needed.

• We noted during there was a multi- disciplinaryapproach to pain assessment which included input fromthe clinical psychologist in achieving the best outcomefor patients.

• Patients who were prescribed pain control, includingcontrolled medicines, received them in a timely way.

Nutrition and hydration

• NICE guidelines were used as part of assessments whichincluded the Malnutrition Universal Screening Tool(MUST) to assess patients’ risk of malnutrition. This wasused during a patient’s initial assessment in line withthe NICE clinical guideline 32 ‘Nutrition support inadults: oral nutrition support, enteral tube feeding andparenteral nutrition’.

• Patients were complimentary about the meals andcomments included “very good food”. They said choiceswere available including alternative meals from themain menus. However some patients told us the varietyof the food could be improved as some patients werethere long term and meals could be more varied.

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• Patients had access to fluids and snacks in betweenmeals. Patients who were at risk of malnutrition wereassessed by dieticians and actions taken to meet theirnutritional needs.

• We observed patients received support with their mealsin a respectful way and were encouraged to eatindependently and supervised if needed.

• Speech and language therapists carried out thoroughassessments and used care plans to ensure patientscontinued to receive food and fluids safely. Adaptationssuch as “chin tuck” therapy were used to supportpatients who had difficulty swallowing and enablingthem to receive their diet and fluids safely.

• The Patient Led Assessments of the Care Environment(PLACE) 2015 scored the trust at 88% for quality of foodwhich was comparable to the England average.

Patient outcomes

• From December 2013 to November 2014; there were 5readmissions to Mardon Neuro-rehabilitation Centrefrom the 72 patients admitted. Low standardisedrelative risk of readmission was noted for the unit.

• Data from Hospital Episodes Statistics (HES) for Mardonshowed for 2014/15 the Median was 8.5, Mean 30.26 and44% have a LOS of 2 days or less.This meant that a largepercentage of patients stay for 1-2 days, but somestayed for much longer.

• The length of stay data was not reliable as each time apatient was transferred for treatment to the main trustthey were readmitted to the unit. This included if apatient went to the ward at the trust for treatment whichlasted a couple of hours such as for an infusion. In effecta patient who had been in the unit for over 25 days wasrecorded as being there for two days.

• Mardon took part in the UK specialist RehabilitationOutcomes Collaborative (UKROC) which was set up inSeptember 2008 through a Department of Healthinitiative to develop a national database for collatingcase episodes for inpatient rehabilitation. Participationhad been annually and showed the centre performanceagainst the national data for referral to assessment,referral to admission which were greater than theaverage of other units contributing to the collaborative.

Competent staff

• There was a trust induction programme for all new staffand those who had attended this programme felt it mettheir needs.

• The department did not have an educational facilitatorin place and the funding to recruit one was beingdiscussed.

• Staff told us they had regular annual appraisals;however the data provided by the trust demonstratedthat appraisal completion rate varied. Informationreceived from the trust showed nurse’s band 5-6 hadachieved 81.2% and nurses band 7-8a-c 75%. AlthoughMardon centre had some appraisal ratings displayed, asenior member of staff told us these were not accurateas they had not been updated.

• Staff undertook role specific training to maintain anddevelop their skills. Advanced practitioners included apain specialist to offer advice and support to patientsand nurses.

• Allied health professionals (AHP’s) held monthlymeetings where staff could discuss complex cases.

• Health care assistants had completed training inself-catheterisation to support patients. These staff hadtheir competency assessed to ensure the procedure wascarried out safely.

• Therapists received regular supervision and they saidthis was effective. Nursing staff told us they did not havesupervision and none of them were able to tell us abouttrust process to monitor and develop practices such asCare Matters, a forum where The Reflective Toolkit fornurses, midwives and allied health professionals wasdeveloped. Schwartz rounds which are open to all staffproviding an opportunity for reflection. Ward basedapproaches are supported by matrons beingsupervisory to shift (60%) enabling then to work withnursing staff and reflect in practice.

Multidisciplinary working

• Internal multi- disciplinary working (MDT) was wellestablished and formed an integral part of care in theMardon Centre.

• Patients’ records showed they were referred, assessedand reviewed by a multi-disciplinary team (MDT) such asphysiotherapist, dietitians, speech and languagetherapists, learning disability, and continence teams.

• Weekly multi-disciplinary team meetings were held on aWednesday. We attended part of the MDT meeting andobserved good interdisciplinary working which waspatient focused and plans were devised to

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ensure patients received effective care. The teamcomprised of therapists, physio and occupationaltherapists and speech and language therapists, nurses,psychologists and doctors.

• Pharmacy support had not been available for nearly ayear which staff said had been “difficult”. This hadimpacted on the way that medicines were managedsuch as staff were unsure about safe disposal ofmedicines. Since October pharmacy support had beenput in place and staff commented this was a muchneeded service.

• Records viewed identified family involvement asnecessary for effective discharge planning and referralto the community support teams.

• Physiotherapy and occupational therapy took leads inpatients’ discharge planning and liaised with thecommunity teams, and GPs to ensure continuity of carepost discharge.

• Patients had access to specialist nurses such as painand continence assessors.

• Access to a psychiatrist and referrals were made asappropriate.

• External multi- disciplinary working was also wellestablished with transfers between other trusts andspecialist care and treatment.

Seven-day services

• Patients received 24 hr nursing care and medicalsupport was available during the hours of 9-5pm fromthe trust. Out of hours medical assistance was providedby Devon doctors.

• Any emergency would require the patient to betransferred to the accident and emergency departmentat Wonford Hospital.

• There were no physiotherapy and occupational therapyservice at the weekends which some patients felt couldbe improved. Rehabilitation should be a 24-hourprocess, with agreed goals and activities.The nursingstaff supported patients in the continuation of theirrehabilitation goals when therapists are not on duty.Nursing said they provided some support to patientswith their exercise regimes at weekends. There was noplan to implement seven day therapists service in thefuture.

• The pharmacy department was open seven days aweek, but with limited hours on Saturday and Sunday.An on-call pharmacist was available to dispensemedicines and offer urgent advice over the weekends.

Access to information

• Staff told us they had good access to patient-relatedinformation and records whenever required. All staff hadaccess to patients’ care records to enable them toprovide care and support. The electronic patients’information document was available to the multi-disciplinary team which contained detailed informationrelating to patients’ action plan and goal setting.

• There was a patient transfer summary in patients’ notesfor those who were transferred within the hospital andthis ensured continuity in the patient’s care.

• Discharge was pre planned and discharge letters werefaxed to GPs on the same day to inform them of theirpatient’s medical condition and the treatment they hadreceived. Patients were also issued with a copy ondischarge.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff were aware of their roles and responsibilitiesregarding the Mental Capacity Act (2005) (MCA) andDeprivation of Liberty Safeguards (DoLS). Patients wereasked for their consent to care and treatment. Wherepatients lacked capacity to consent, the principles of theMental Capacity Act 2005 were followed to ensuredecisions were made in the best interests of patients.Two doctors were able to describe action they wouldtake if patients did not have capacity to consent such asbest interest decisions and involvement of relatives orfriends as appropriate.

• Records for a patient showed a detailed capacityassessment had been completed with a multi-disciplinary team approach. This included assessmentwith input from a psychologist and speech andlanguage team.

• There was one patient who was under a deprivation ofliberty safeguard (DoLS) at the time of our inspection.Staff had followed their process such as a referral wasmade to the local authority team for assessment. Arecent review of the DoLS application had beencompleted which meant staff were aware that DoLSwere time limited to safeguard patients.

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• Patients’ records showed mental capacity assessmentswere completed and this was also audited on a monthlybasis using their treatment escalation plan whichshowed they were compliant.

• We observed staff asking for patients’ consent whenproviding support and giving explanations in a clear andunhurried way.

• Patients told us clear explanations about their care andtherapy had been discussed with them and they feltinvolved in their care.

Are medical care services caring?

Good –––

By caring, we mean that staff involve and treatpatients with compassion, kindness, dignity andrespect.

We rated caring as good.

Staff provided compassionate care and ensured patientswere treated with dignity and respect when supportingthem. Patients were positive about the care andtreatment they were receiving.

The multi- disciplinary team were motivated and carewas patient focused. Patients and their relatives feltinvolved in the care and decision making and care wascentred on their individual needs.

Staff rated patient’s emotional needs highly and thesewere embedded in their care and treatment. Weobserved that staff were responsive to patients’ needs,and provided emotional support to patients in a calmand respectful way.

Compassionate care

• We spoke with seven patients and relatives during theinspection. All patients said that the multi-disciplinaryteam provided them with “very good” care and supportand a good and caring service.

• We found staff provided care with empathy,understanding and compassion. The staff and patientshad developed good relationships with patients andtheir relatives.

• Staff were passionate and committed about the careand treatment they provided and we observed positiveand caring interactions with patients.

• The NHS Friends and Family test results for Mardonshowed that 95% of patients would recommend thetrust as a place to receive care and treatment which wassimilar to the national average. However this result wasdated 2011 and we do not have any recent survey.

• We observed multiple examples where staffdemonstrated compassionate and kind behaviourtowards patients. Staff in multidisciplinary meetingsdemonstrated knowledge, skill and a caring attitudetowards patients during their discussions.

Understanding and involvement of patients andthose close to them

• All the patients we spoke with felt well informed andinvolved in the decision making regarding their care andtreatment. They were able to discuss their plan such asphysiotherapy and occupational therapy and found theteam was supportive. One patient reported that staffdiscuss what is going on with their exercises andanother patient reported that they see thephysiotherapist every day and were given a new framewhich has been beneficial.

• We observed sharing information to patients andfamilies in a way they could understand. Staff employeddifferent techniques to ensure effective communication.Staff recognised when patients required extra support tobe able to become involved in their treatment plans.

• Both patients and their relatives commented thatinformation was discussed in a manner theyunderstood. Patients told us the doctors had explainedtheir diagnosis and that they were aware of what washappening with their care. None of the patients wespoke with had any concerns with regard to the waythey had been spoken to, and all were complimentaryabout the way they were treated.

• Relatives told us they received support from the staffand were involved in the care of their relatives asappropriate.

Emotional support

• The MDT team also consisted of clinical psychologistswho provided treatment and support in the unit.Patients said they felt this was a valuable service andhad helped them in their recovery.

• Throughout our inspection we witnessed patients beingtreated with dignity and respect. We observed staffcommunicating with patients in a respectful way. Weobserved a staff member supporting a patient who

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became distressed as they were not able to makethemselves understood. The staff remained focused onthe patient and allowed them time until they workedout the patient wanted to go back to their room.

Are medical care services responsive?

Good –––

By responsive, we mean that services are organisedso that they meet people’s needs.

We rated responsive as good.

There were good examples of multi-disciplinary workingwhich was responsive to meet the needs of local people.Admission criteria were followed to ensure patients wereat the right place for their rehabilitation. Althoughdischarge planning was initiated early, this was notalways effective as patients remained longer at the centredue to lack of community places.

Support was available for patients working closely withother local teams to meet the needs of patients invulnerable circumstances.

Complaints were handled in line with the trust’s policy.The trust told us some complaints took some time torespond due to their complexity. Patients we spoke withfelt they would know how to complain if they needed to.Staff received feedback from complaints and these werediscussed at team meetings and were learnt from.

Service planning and delivery to meet the needs oflocal people

• The Mardon centre provided specialist care to patientswith facilities specially adapted to meet therehabilitation needs of patients following brain injury.

• Guidelines for implementation of the National serviceFramework (NSF) recommend that service providers andcommissioners should work together to increasecapacity in rehabilitation services, both in hospital andthe community which will help to relieve pressure onacute beds. Staff told us there were capacity issueswhich impacted on patients who were waiting for a bedat the service. There were two rooms which had been

completely refurbished which staff said had not beenused with no specific plan in place for when they wouldbe open for patients. The trust has since told us theywere working with commissioners to resolve this.

• There was a dedicated bed used for functionalassessment patients such as fatigue, lack of sleep andpsychological symptoms. These patients were admittedfor a set period of four weeks; however this was noteffectively achieved due to bed availability and long staypatients.

• Mardon centre carried out sleep studies three days aweek. This was currently suspended due to anequipment fault which impacted on the service forpatients. The staff could not tell us about when thiswould be reopened.

Access and flow

• There was a clearly defined admission criteria to theunit such as patients should have a primaryneurological condition, be over 16 years of age and notin full time education. Referrals were received from theacute and community MDT teams. GPs contacted theconsultant neurologist and all referrals were discussedas part of the weekly MDT meetings.

• Assessments were carried out within a week of referralin line with the centre’s standard operationalprocedures. The process was for the therapists to assesspatients within six days following referrals and this wasbeing met.

• Staff told us the bed occupancy at the Mardon centrewas above 90% for the majority of the times. It isgenerally accepted that at 85% level, bed occupancycan start to affect the quality of care provided topatients, and the orderly running of the hospital. Therewas no data available in relation to bed occupancy forMardon.

• We were told that the main cause of delays for dischargewere the complexity of patients’ needs and theprovision of community services. Some of theseincluded care home placements, to meet patients’on-going needs. The withdrawal of community bedshad impacted on patients’ discharge.

• Currently throughput to Mardon was very slow andpatients who would benefit from rehabilitationremained in acute beds. Staff told us some patientswere discharged home while they were waiting for arehabilitation bed. There were four patients who hadbeen at the centre for between nine months to a year.

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Staff told us this had a major impact on delivering arehabilitation service. This impacted their ability toadmit referrals from the neurology acute ward at thetrust.

Meeting people’s individual needs

• All the patients were provided with singleaccommodation which patients said met theirindividual needs. The centre had been designed andprovided excellent facilities for patients with limitedmobility. The corridors were spacious and patients hadlevel access and safe ground outside. There werespecific adaptations and designated physiotherapy andoccupational therapy rooms to meet the needs of thepatients

• A wide range of patient literature was displayed inclinical areas and included disease and procedurespecific literature, health advice and generalinformation relating to health and social care andservices available locally. Patient information leafletswere not displayed in languages other than English.However the trust had an interpretation and translationservice and face to face interpretation and translationwas available including Braille.

• Staff had access to the learning disability team whowere responsive and we saw assessment and plans ofcare had been developed.

• There was a chaplaincy service and details of prayerservices were displayed at the centre. Training wasavailable to staff in spiritual care and awareness trainingfor new auxiliaries, preceptorship and return to nursingcolleagues.

• The Trust was finalising a spiritual care policy to supportthis good practice for all patients and ensure that thehospital chaplaincy guidelines were followed.

Learning from complaints and concerns

• Complaints were handled in line with trust policy, andstaff showed us that patients were given information onhow to complain. Staff directed patients to ‘PatientAdvisory Liaison Service (PALS)’ if they were unable todeal with their concerns directly and advised them tomake a formal complaint.

• Patients expressed a high degree of satisfaction withtheir care and said they were able to raise any concerns.

• Literature and posters were displayed advising patientsand their supporters how they could raise a concern orcomplaint, formally or informally.

• Where patient experiences were identified as beingpoor, action was taken to improve their experiencessuch as investigations and learning from complaints. Asenior staff told us that any learning from complaintinvestigations was shared with the team at their “Commcell” meetings.

Are medical care services well-led?

Requires improvement –––

By well led, we mean that the leadership,management and governance of the organisationassure the delivery of high quality person-centredcare, supports learning and innovation, andpromotes an open and fair culture.

We rated well-led as requires improvement.

There was a trust's strategy, this was not known at locallevel and embedded for the provision of a responsiveservice that delivered care as close to home as possibleseven days a week.

Although patients and staff surveys were collected; therewas no evidence to show how this impacted in planningand developing services.

There was a governance structure to manage risk andquality. Staff felt supported by their managers. The staffreported there was no lead at the service in order to drivechanges and provide operational support. The trust hasconfirmed there was a clinical lead for Mardon who wasbased at the trust. Staff described management at locallevel as good and felt they were supported in their roles.Staff at the Mardon centre did not feel connected to thetrust as a whole.

Vision and strategy for this service

• The vision for the service was to see Mardon build on itscurrent position as an inpatient Neuro-rehabilitationService.

• A senior manager told us the trust had identified thepriorities for the service. The trust was planning toexpand the service and providing moreNeuro-rehabilitation beds at Mardon but also incommunity based settings including patient’s homeswhere appropriate. However the current facilities such

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as two fully refurbished rooms were under-utilised andthere were plans to reopen them. This had beenescalated to a system resilience group in order to movethis forward.

• The plan was to increase the consultantNeuro-rehabilitation cover and extend the service forspinal injured patients, Functional Neurology Patients,and for more acutely unwell patients to start therehabilitation process early and relieve the pressure onacute hospital beds. There was no firm date as to whenthis would happen.

• There was a plan to identify the opportunities for adedicated hydrotherapy facility at Mardon as part ofdeveloping the rehabilitation pathways for patients andwas yet to be agreed.

• All the above were aspirational. No firm action plan wasin the place in order to achieve these objectives.

• Staff were not able to able to tell us about the trust’sstrategic visions and values and felt disconnected fromthe wider trust. However they were passionate aboutproviding care and working at the unit.

Governance, risk management and qualitymeasurement

• There was a clear governance structure and process inplace, the neurology speciality governance groupmeetings took place on a bi-monthly basis, whichincluded morbidity and mortality (MM). Also reportingon finance and performance and quality issues withinthe division. They looked at serious incidents, cases ofhospitals acquired infection, compliance with handhygiene audits, care and quality performance indicators.

• We saw, from minutes following these meetings, wherea wide range of issues were covered including auditactivity and results, patient feedback, staff training andfinance.

• The Mardon centre monitored outcome data through anational data collection for the purpose ofbenchmarking against other rehabilitation services.

• Minutes of governance meeting from October 2015showed that Mardon service continuity plan was beingsubmitted to the divisional governance for sign offwhich was provided to us. Senior staff were not aware ofa continuity plan for the service.

• The service had a risk register that included all knownareas of risk identified for neurology. These risks were

documented and a record of the action being taken toreduce the level of risk was maintained. The risks werereviewed regularly in the clinical governance meetingsand appropriately escalated.

Leadership of service

• There was a wellestablished rehabilitation team andthe Mardon centre had a nurse manager who providedday-to-day leadership to the staff. Staff felt wellsupported by their manager and said this worked well atlocal level. Staff told us senior management from thetrust was not visible at the centre. They felt there was nolead to develop the service and provide managementsupport at operational level.

• Staff commented there was no one in a leadership roleto push changes. For example, underused resourcessuch as beds which were not commissioned. Staff saidthey had tried to get a working group together to reviewservices, but there was no support from seniormanagement at the trust to push this through.

• Staff felt there was a disconnect between the ‘centre’and they did not all consider themselves as part of thetrust. Although they felt valued by their immediatemanagers and peers and told us they really enjoyedworking at the centre with a strong focus on providingcompassionate care.

• Two staff commented the centre was not forwardthinking and averse to changes.

• Staff were aware of the whistle –blowing procedure andwere confident in using it. Staff were proud of themulti-disciplinary approach and team work at locallevel which they said was very good.

Culture within the service

• Staff spoke positively and passionately about the careand the service they provided. There was an openculture in raising patients’ safety concerns, and staffwere encouraged to report any identified risks.Comments included “we are here for the patients”

• Staff said they felt like valued team members. Theyprovided examples where they had been supported inacquiring new skills which benefitted patients.

• Staff felt proud to work for the Mardon centre. Staff,including student nurses, therapists, and doctors andhousekeeping staff spoke passionately about their workand of being part of the team.

Public engagement

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• The centre had developed good links with the League offriends who supported them in caring for the patients.The league of friends was involved and supported theunit and had recently purchased some equipment forpatients.

• There was a system in place to gather information frompatients and their relatives. These were discussed onthe “Comm cell” as “what you said” and “what we did,showing how staff had made changes in response tofeedback such as meals and activities.

• The patient satisfaction survey from January 2014- April2015 showed 62% of patients felt the rehabilitationprogramme was tailored to their needs. 68% of patientssaid the rehabilitation addressed their specific physicaldisability. Patients were less positive about other factorsof their care such as 57% felt progress reviews werehelpful and 56% were with doctors input. There was noaction plan developed to address the shortfallsidentified in the survey.

Staff engagement

• The 2014 NHS staff surveys showed 91% of staff felt thetrust provided opportunities for career progression. Thisindicated that 68% of staff felt they contributed toimprovement at work and 67% were confident to reportconcerns about unsafe clinical practice. Only 28%reported there was good communication betweensenior management and staff.11% said they hadsuffered discrimination at work and 20% reportedharassment and abuse from other staff. Staff were notaware if actions had been taken following the surveyresults. There was no specific survey data for Mardon.

• The trust had introduced ‘Comm cell’ to facilitatecommunication between the multi- disciplinary team.Staff used this for raising concerns around servicedelivery issues as well as feedback results of incidents.

Innovation, improvement and sustainability.

• There were plans for developing two private beds andthe resource from this would be used to develop theservice. This was currently under discussion and no firmdecision had been reached.

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Areas for improvement

Action the hospital MUST take to improve

• Ensure medicines are administered to patients safelyin line with policy and take into account their rights.

• Ensure medicines are disposed of and returned topharmacy in accordance with the trust’s policies andstandard operating procedures.

Action the hospital SHOULD take to improve

• Ensure there are sufficient therapy staff deployed inorder for patients to receive consistent care andaccording to their needs.

• Ensure incidents are investigated and records areavailable with a robust process for disseminatinginformation to all staff following incidentsinvestigations.

• Ensure discharge planning processes are pro-activeand well co-ordinated to reduce delayed transfersout of the centre.

• Ensure service strategies are clear andcommunicated effectively and development plansfor the service are identified.

• Identify a lead to develop the service and providemanagement support at operational level.

• Review feedback from patient surveys and developaction plans to improve patient experience.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Treatment of disease, disorder or injury Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Regulation 12 HSCA 2008 (Regulated Activities)Regulations 2014:

Safe care and treatment

How the regulation was not being met: People who useservices and others were not protected against the risksassociated with unsafe care or treatment because:

The management of covert medicines was not managedsafely and effectively. Patients’ rights were notrespected. Policies and procedures were not followed forthe safe management of medicines.

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


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