the woodhouse independent hospital - cqc

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Inadequate –––

Are services safe? Requires improvement –––

Are services effective? Inadequate –––

Are services caring? Requires improvement –––

Are services responsive? Requires improvement –––

Are services well-led? Inadequate –––

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

TheThe WoodHouseWoodHouseIndependentIndependent HospitHospitalalQuality Report

Lockwood Road,Cheadle,Staffordshire,ST10 4QUTel: 01539 755623Website: www.elysiumhealthcare.co.uk

Date of inspection visit: 18 – 20 June 2019Date of publication: 03/09/2019

1 The WoodHouse Independent Hospital Quality Report 03/09/2019

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

Summary of findings


Letter from the Chief Inspector of Hospitals

I am placing the service into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have beenmade such that there remains a rating of inadequate overall or for any key question or core service, we will take actionin line with our enforcement procedures to begin the process of preventing the provider from operating the service. Thiswill lead to cancelling their registration or to varying the terms of their registration within six months if they do notimprove. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Wherenecessary another inspection will be conducted within a further six months, and if there is not enough improvement wewill move to close the service by adopting our proposal to vary the provider’s registration to remove this location orcancel the provider’s registration.

We found that the service was not well led at ward level and there was a lack of resource at all levels of leadership. Thegovernance processes did not operate effectively at ward level meaning that performance and risk were not managedwell. Clinical and internal audit processes did not have a positive impact on quality governance. The hospital was notadequately staffed. Nearly 90% of the establishment ward staff posts were unqualified support workers and 40% ofposts for both nurses and support workers were vacant. The hospital relied heavily on agency staff that covered a highnumber of shifts. Some of the agency staff were new to the hospital and did not know the patients well. Managers didnot provide staff with the induction, training, supervision or appraisal that would have mitigated the staff’s lack ofqualifications and specialist skills required to provide high quality care to people with such complex needs.

Professor Ted Baker

Chief Inspector of Hospitals

Overall summary

We rated The Woodhouse Independent Hospital asinadequate because:

• The hospital was not adequately staffed. Nearly 90% ofthe establishment ward staff posts were unqualifiedsupport workers and 40% of posts for both nurses andsupport workers were vacant. As a result, unqualifiedagency staff covered a high number of shifts. Thisincluded most of the night shifts. Some of the agencystaff were new to the hospital and did not know thepatients. This meant that the care plans and positivebehaviour support plans developed by the specialiststaff were not always enacted by the ward-based staff– some of whom told us that they had not read theplans. Also, the staffing situation meant that aqualified nurse was not always present in communalareas of the ward, that staff were often unable to takerest breaks or regular breaks from enhanced

observations, that escorted leave was often cancelledfor patients on general observations and that patientsdid not have regular one-to-one time with their namednurse.

• Managers did not provide staff with the induction,training, supervision or appraisal that would havemitigated the staff’s lack of qualifications andspecialist skills required to provide high quality care topeople with such complex needs.

• The service was not well led at ward level and therewas a lack of resource at all levels of leadership. Thegovernance processes did not operate effectively atward level meaning that performance and risk werenot managed well. Clinical and internal auditprocesses did not have a positive impact on qualitygovernance. There was no structured inductionprogramme for agency staff. Staff were not supportedthrough appraisals and regular supervision to enable

Summary of findings


them to carry out the duties they were employed toperform. There were no regular team meetings for staffto discuss clinical concerns and learning as a teamwith managers.

• Staff did not always follow systems and processes tosafely store and manage medicines. Learning fromincidents was not discussed with staff. Managers didnot always debrief and support staff after seriousincidents.

• The ligature risk assessments lacked clear actions onhow the risk was managed. There was no emergencydrug (Adrenaline) available to treat anaphylaxis. Thechecks were not always reliable and valid.

• Staff did not monitor the physical health of patientsconsistently. Care plans did not always reflect theassessed needs of patients. They were not alwayspersonalised, holistic and recovery-oriented noralways updated in a timely manner. Staff did notparticipate in clinical audits, benchmarking andquality improvement initiatives.

• Staff did not always assess and record capacity toconsent clearly where patients might have impairedmental capacity. Staff did not know their identifiedlead for the Mental Capacity Act.

• There was no sensory room within the hospital tomeet the needs of patients who would benefit. Quietareas on some wards were not available to allow

patients an opportunity to avoid noise and disruption.Managers did not regularly review the mix of patientson the wards to ensure the environment wascomfortable for all patients.

• The provider had not carried out an autism friendlyassessment to ensure that the environment wassuitable for patients with autism. The service did notensure that the needs of patients with specificcommunication needs were met.

However:

• Staff understood how to safeguard patients fromabuse and the service worked well with other agenciesto do so. Staff had training on how to recognise andreport abuse, and they knew how to apply it.

• Staff regularly reviewed the effects of medications oneach patient’s physical health. They knew about andworked towards achieving the aims of the STOMPprogramme (stop over-medicating people withlearning disabilities).

• We observed staff treating patients with compassionand kindness. They respected patients’ privacy anddignity. The multidisciplinary team involved patients incare planning and risk assessment and actively soughttheir feedback on the quality of care provided.

• Staff planned and managed discharge well. Staffhelped patients with advocacy, cultural and spiritualsupport.

Summary of findings


Contents

PageSummary of this inspectionBackground to The WoodHouse Independent Hospital 7

Our inspection team 7

Why we carried out this inspection 8

How we carried out this inspection 8

What people who use the service say 8

The five questions we ask about services and what we found 9

Detailed findings from this inspectionMental Health Act responsibilities 14

Mental Capacity Act and Deprivation of Liberty Safeguards 14

Overview of ratings 14

Outstanding practice 33

Areas for improvement 33

Action we have told the provider to take 35

Summary of findings


The WoodHouse Independent Hospital

Services we looked atWards for people with learning disabilities or autism

Inadequate –––


Background to The WoodHouse Independent Hospital

The Woodhouse is an independent mental healthhospital provided by Elysium Healthcare (Acorn Care)Limited. It was provided by Lighthouse Healthcare until itwas acquired by Elysium Healthcare Limited in June2017. The Woodhouse provides a care pathway oflearning disabilities and autism services in a range ofsmall, bespoke units and cottages. The service specialisesin providing care for individuals with autism, forensichistories, including sexual offending, highly complex andbehaviours that challenge. The service is commissionedby clinical commissioning groups. It provides care for upto 39 male patients under 65 years old who have learningdisabilities or autism. The hospital is able to acceptpatients detained under the Mental Health Act, includingRestriction Orders and those supported by Deprivation ofLiberty Safeguards.

The Woodhouse hospital has eight units/wards locatedon a rural site in Cheadle, Staffordshire.

They are:

• Hawksmoor, eight beds, locked rehabilitation/assessment and treatment ward going underrefurbishment into self-contained flats;

• Lockwood, eight beds, rehabilitation ward;• Farm Cottage, three beds, rehabilitation house;• Woodhouse Cottage, three beds, rehabilitation house;• Moneystone, eight beds, autism complex/challenging

behaviour ward;• Whiston, four beds, autism complex/challenging

behaviour self-contained flats;• Highcroft, four beds, autism rehabilitation ward;• Kingsley, four beds, autism complex/challenging

behaviour self-contained flats.

The Woodhouse is registered to provide the followingregulated activities:

• Assessment or medical treatment for persons detainedunder the Mental Health Act 1983

• Treatment of disease, disorder or injury.

The hospital had a registered manager.

We last carried out a comprehensive inspection for thishospital in January 2017, we rated it as good overall. Werated safe as requires improvement and effective,responsive, caring and well-led as good. We issued thehospital with three requirement notices and these relatedto:

Regulation 12 HSCA (RA) Regulations 2014, Safe Careand Treatment

• When staff gave oral medication for the purposes ofrapid tranquillisation, they did not consistentlycomplete the necessary physical observations.

• There were gaps in checks of the emergency bag onMoneystone and Highcroft wards, and there were norecords confirming the cleaning of portable equipmenton Moneystone and Highcroft wards.

• The hospital did not have an active clinical lead role(for example, a named nurse) allocated to infectionprevention and control.

Regulation 17 HSCA (RA) Regulations 2014, GoodGovernance

• There were inconsistencies in the completion of formsused for recording observations of the patient inlong-term segregation.

Regulation 18 HSCA (RA) Regulations 2014, Staffing

• There were short periods when there was no qualifiednurse present on Moneystone ward.

• On Moneystone ward, there were occasions whenthere were not enough staff to meet patients’individual observation requirements adequately.

There was a follow up inspection carried out in November2017 to find out whether the hospital had madeimprovements required since our inspection in January2017. We found that improvements had been made andwe changed the rating of safe to good.

Our inspection team

Team leader: Raphael Chichera

Summaryofthisinspection

Summary of this inspection


The team that inspected the service comprised four CQCinspectors and a variety of specialists: one consultantpsychiatrist in learning disabilities, one nurse specialist inlearning disabilities, one speech and language therapistin learning disabilities and one expert by experience.

Why we carried out this inspection

We inspected this service as part of our ongoingcomprehensive mental health inspection programme. Webrought forward this inspection after we had received anumber of concerns about this service from staff, ourMental Health Act Reviewer, commissioners and families.

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?

Before the inspection visit, we reviewed information thatwe held about the location and asked a range of otherorganisations for information. This was an unannouncedinspection.

During the inspection visit, the inspection team:

• visited all eight units at the hospital, looked at thequality of the ward environment and observed howstaff were caring for patients;

• spoke with eight patients who were using the service;

• spoke with nine carers/family of patients who wereusing the service;

• spoke with the registered manager, nurse managerand the regional lead nurse;

• spoke with 46 other staff members; including doctors,nurses, occupational therapist, psychologist, speechand language therapist, domestics, mental health actadministrator and hotel services manager;

• spoke with one commissioner and attended one careand treatment review;

• spoke with an independent advocate;• attended and observed two multi-disciplinary team

meetings;• Looked at 22 care and treatment records of patients;• looked at 26 prescription cards;• carried out a specific check of the medication

management on all units; and• looked at a range of policies, procedures and other

documents relating to the running of the service

What people who use the service say

Patients told us staff were kind and treated them withrespect and dignity. They involved them in decisionsabout their care and treatment. Patients felt safe andcould raise their concerns with staff.

Patients told us that they had access to a GP anytime andspecialists for their physical health problems.

Patients told us that the hospital made frequent use ofagency staff who were not familiar with the wards. Theyalso reported that there were not have enough staff onduty at all time; and particularly weekends. Families andcarers told us that they had not been provided with theopportunity to give feedback on the service.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated safe as requires improvement because:

• The hospital was not adequately staffed. Forty percent of postsfor nurses and support workers were vacant. As a result, agencystaff covered a high number of shifts. This included most of thenight shifts. Three wards ran entirely on agency staff. Some ofthe agency staff were new to the hospital and did not know thepatients. This was something that patients were concernedabout. Those agency staff that had worked shifts at the hospitalfor some time were moved to work on different wards eachshift. This adversely affected continuity of care. The way thatstaffing was managed meant that a qualified nurse was notalways present in communal areas of the ward, that staff wereoften unable to take rest breaks or regular breaks fromenhanced observations, that escorted leave was oftencancelled for patients on general observations and thatpatients did not have regular one-to-one time with their namednurse.

• The service had not done all it could to minimise the use ofphysical restraint. Although the positive behaviour supportplans described actions that staff could take before resorting torestraint, some staff told us that they had not read the plansand other staff were new to the wards and did not know thepatients. Also, only senior managers understood andparticipated in the provider’s restrictive interventions reductionprogramme. They had not promoted awareness of theprogramme among ward staff to ensure that they understoodthe meaning of restrictive practice, its impact and how tominimise the use of restrictive interventions.

• Staff did not always mitigate the risks to patient safety posed bythe ward environment. The ligature risk assessments lackedclear actions on how the risk identified was to be managed.Lockwood ward had no ligature risk assessment available.Mangers did not share copies of the ligature risk assessmentswith staff.

• Staff did not always follow systems and processes to safelystore and manage medicines. Also, the resuscitationemergency bags to treat anaphylaxis did not contain the drug(Adrenaline) routinely used in the hospital to treat the potentialadverse reaction to injectable medicines. The checks tomonitor the emergency bags were not always reliable and valid.

Requires improvement –––




• Managers did not discuss learning derived for the investigationof incidents with staff. Managers and staff were not aware of theLearning from Deaths Mortality Review (LeDeR) Programme.Managers did not always offer staff debrief and support afterserious incidents.

However:

• Staff understood how to protect patients from abuse and theservice worked well with other agencies to do so. Staff hadtraining on how to recognise and report abuse, and they knewhow to apply it.

• All of the provider’s own staff had easy access to clinicalinformation and it was easy for them to maintain high qualityclinical records.

• Staff regularly reviewed the effects of medications on eachpatient’s physical health. They knew about and worked towardsachieving the aims of the STOMP programme (stopover-medicating people with learning disabilities).

• However:• Staff understood how to protect patients from abuse and the

service worked well with other agencies to do so. Staff hadtraining on how to recognise and report abuse, and they knewhow to apply it.

• All of the provider’s own staff had easy access to clinicalinformation and it was easy for them to maintain high qualityclinical records.

• Staff regularly reviewed the effects of medications on eachpatient’s physical health. They knew about and worked towardsachieving the aims of the STOMP programme (stopover-medicating people with learning disabilities).

Are services effective?We rated effective as inadequate because:

• A high proportion of staff working on the wards lacked the skills,training and experience to support the complex needs of, andprovide high quality care to, patients with learning disabilitiesor autism. A high proportion of ward staff were agency staff andmanagers had not provided them with the induction, trainingor clinical supervision that would mitigate their lack ofprofessional training. Also, they had not provided training orleadership development opportunities to ward managers.

• As a result of the staffing situation, ward staff were not alwaysaware of or following the care plans developed by the specialiststaff.





• Staff did not have time to fully familiarise themselves with careplans and positive behaviour support plans on wards to use theinformation in practice.

• Managers did not ensure that staff attended regular teammeetings on wards.

• Staff did not consistently monitor physical health. Recordsreviewed showed that 35% of patients had no hospital passportin place or it was not fully completed with the importantinformation required.

• Care plans did not always reflect the assessed needs and werenot always personalised, holistic and recovery-oriented and attimes not updated in a timely manner.

• Staff did not participate in clinical audits, benchmarking andquality improvement initiatives.

• Staff did not always assess and record capacity to consentclearly each time a patient needed to make an importantdecision where they might have impaired mental capacity.

• Staff did not know their identified lead for the Mental CapacityAct and were not sure where to get advice on Mental CapacityAct.

However:

• The specialist staff developed care plans that were appropriatefor the patient group and consistent with national guidance onbest practice. However, many of the front-line staff did not havethe skills to enact these plans.

• Staff assessed the physical and mental health of all patients onadmission, ensured that patients with known problems hadaccess to physical healthcare and supported patients to livehealthier lives.

• Staff used recognised rating scales to assess and record severityand outcomes.

• The service had good working relationships with staff fromservices that would provide aftercare following the patient’sdischarge and engaged with them early on in the patient’sadmission to plan discharge.

• Staff understood their roles and responsibilities under theMental Health Act 1983 and the Mental Health Act Code ofPractice and discharged these well. Managers made sure thatstaff could explain patients’ rights to them.

Are services caring?We rated caring as requires improvement because:

• Agency staff who were not familiar with the patients did nothave the knowledge or skills to use appropriate communication





methods to support patients to understand and manage theirown care, treatment or condition. This included findingeffective ways to communicate with patients withcommunication difficulties.

• Although regular staff understood and supported the individualneeds of patients, a significant proportion of ward staff wereunfamiliar with the patients and their care plans and thereforecould not support patients effectively to meet their needs.

• Families and carers were not provided with information orsignposted on how to access carer’s assessment.

However:

• Staff treated patients with compassion and kindness. Theyrespected patients’ privacy and dignity.

• The multidisciplinary team involved patients in care planningdiscussions and actively sought their feedback on the quality ofcare provided. They ensured that patients had easy access toindependent advocates.

• The service invited families and carers to attend care planningand multidisciplinary team discussions.

Are services responsive?We rated responsive as requires improvement because:

• The provider had not carried out an autism friendly assessmentto ensure that the environment was therapeutic for patientswith autism. The managers had not considered the possiblemix of sensory needs of patients living in the same ward.

• There was no sensory room across the hospital to meet theneeds of patients.

• There were no quiet areas on some wards. Staff did not reviewthe patient dynamics adequately and regularly to ensure theenvironment was comfortable for all patients.

• The service had made suitable adjustments for disabledpatients to access all the units except one of the cottages. Therewere no adjustments made for visitors to access the mainreception area.

• The service did not ensure that the needs of patients withspecific communication needs were met.

• There was no clear learning from complaints shared with staff.Staff did not receive feedback on the outcome of investigationsof complaints.

However:





• Staff planned and managed discharge well. They liaised wellwith services that would provide aftercare and were assertive inmanaging the discharge care pathway. Discharge was rarelydelayed for other than a clinical reason.

• Each patient had their own bedroom with an en-suitebathroom and could keep their personal belongings safe.

• The food was of a good quality and patients could make hotdrinks and snacks at any time.

• Staff helped patients with advocacy and cultural and spiritualsupport.

• When patients complained or raised concerns, they receivedfeedback.

Are services well-led?We rated well-led as inadequate because:

• The service was not well led at ward level and there was a lackof resources at all leadership levels.

• There was a disconnect between the senior leadership andwhat was happening at ward level.

• Our findings from the other key questions demonstrated thatgovernance processes did not operate effectively at ward leveland that performance and risk were not managed well.

• Clinical and internal audit processes did not function well anddid not have a positive impact on quality governance.

• There was no active strategy to consistently promote equalityand diversity in day to day work.

• Staff did not engage actively in local and national qualityimprovement activities.

However:

• The hospital director clearly understood most of the areas thatrequired improvement and had come up with an improvementaction plan to address these areas. There was lack of enoughleaders with knowledge and experience to give adequatesupport. The hospital director was visible in the service andapproachable for patients and staff.

• Staff knew and understood the provider’s vision and values andhow they were applied in the work of their team.

• Most staff felt respected, supported and valued. All staff feltable to raise concerns without fear of retribution.





Mental Health Act responsibilities

Staff received and kept up to date with training on theMental Health Act and the Mental Health Act Code ofPractice and could describe the Code of Practice guidingprinciples.

As of June 2019, 91% of the workforce in this hospital hadreceived training in the Mental Health Act. The providerstated that this training was mandatory for all clinicalstaff and was renewed yearly.

Staff had easy access to administrative support and legaladvice on implementation of the Mental Health Act andits Code of Practice. Staff knew their Mental Health Actadministrators.

The provider had relevant policies and procedures thatreflected the most recent guidance. Staff had easy accessto local Mental Health Act policies and procedures and tothe Code of Practice.

Patients had easy access to information aboutindependent mental health advocacy. Staff were aware ofhow to access and support patients to engage with theindependent mental health advocacy and patients wholacked capacity were automatically referred to theservice.

Staff explained to patients their rights under the MentalHealth Act in a way that they could understand, repeatedit as required and recorded that they had done it.Patients we spoke with confirmed that their rights underthe Mental Health Act had been explained to them.

Staff ensured that patients on constant observationswere able to take Section 17 leave (permission forpatients to leave hospital) when this was agreed with theResponsible Clinician and/or with the Ministry of Justice.However, those on general observations were not alwaysable to take section 17 leave due to lack of staff. Staffmade patients and their carers aware of the conditions ofleave and any risks and advised them on what to do inthe event of emergency.

Staff requested an opinion from a Second OpinionAppointed Doctor (SOAD) when they needed to. Consentto treatment and capacity forms were appropriatelycompleted and attached to the medication charts ofdetained patients.

Staff stored copies of patients' detention papers andassociated records (for example, Section 17 leave forms)correctly and so that they were available to all staff thatneeded access to them.

Care plans included information about after-care servicesavailable for those patients who qualified for it undersection 117 of the Mental Health Act.

The Mental Health Act Administrators completed auditsto ensure that the Mental Health Act was being appliedcorrectly and there was evidence of learning from thoseaudits. One patient had a section that lapsed and wasdiscovered that the section was not renewed at the timeit required to be renewed. This issue was highlighted aspart of an audit and resolved.

Mental Capacity Act and Deprivation of Liberty Safeguards

As of June 2019, 88.3% of staff had received training in theMental Capacity Act and Deprivation of LibertySafeguards. The provider stated that this training wasmandatory for all clinical staff and was renewed yearly.

Most of the staff had a good understanding of the MentalCapacity Act 2005, particularly the five statutoryprinciples.

The training compliance reported during this inspectionwas higher than 86% reported at the last inspection.

Regular staff understood the organisation’s policy on theMental Capacity Act 2005. The provider had a policy onthe Mental Capacity Act. Staff were aware of the policyand had access to it.

Staff were not sure where to get advice from within thehospital regarding the Mental Capacity Act andDeprivation of Liberty Safeguards. Staff did not know theiridentified lead for the Mental Capacity Act.

Detailed findings from this inspection


In some cases, staff gave patients all possible support tomake specific decisions for themselves before deciding apatient did not have the capacity to do so. The practicewas not consistent. There were cases when there weregood easy read and pictorial information made availableand in other cases they were none.

Staff did not always assess and record capacity toconsent clearly each time a patient needed to make animportant decision. This practice varied greatly within theservice, where it was done there were very goodexamples of assessments and recording. However, therewere a number of incidences where no assessments werecarried out or recorded around physical health needs andfinancial needs. We found cases where it was justrecorded lacked capacity without any records to indicatehow staff had arrived at that decision.

Where staff assessed and recorded patients as not havingcapacity, they made decisions in the best interest ofpatients and considered the patient’s wishes, feelings,culture and history. However, where the assessmentswhere not recorded we could not be assured thatpatient’s wishes, feelings, culture and history wereconsidered. The decisions in the best interest of patientsand what had been considered were not recorded inthose cases.

There were no Deprivations of Liberty Safeguardsapplications made in the last 12 months prior toinspection.

The service had no arrangements to monitor adherenceto the Mental Capacity Act. Staff did not audit theapplication of the Mental Capacity Act to make anychanges to improve where needed.

Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Wards for people withlearning disabilities orautism

Requiresimprovement Inadequate Requires

improvementRequires

improvement Inadequate Inadequate

Overall Requiresimprovement Inadequate Requires

improvementRequires

improvement Inadequate Inadequate

Detailed findings from this inspection


Safe Requires improvement –––

Effective Inadequate –––

Caring Requires improvement –––

Responsive Requires improvement –––

Well-led Inadequate –––

Are wards for people with learningdisabilities or autism safe?


Safe and clean environment

• Staff completed and regularly updated risk assessmentsof all ward areas and removed or reduced any risks theyidentified.

• Staff could observe patients in all parts of the wards inMoneystone and Whiston only. All other wards had blindspots. However, there were mirrors to mitigate any risks.

• The wards were all male and complied with guidance onsame sex accommodation.

• There were ligature risks on all wards within this service.The ligature risk assessments lacked clear actions onhow the risk identified from potential ligature anchorpoints was to be managed.

• Patients had been moved onto Lockwood ward withoutthe ligature risk assessment having been completedafter its refurbishment. Staff on the wards did not havecopies of the ligature risk assessments shared withthem. However, staff mitigated any risks throughindividual patient risk assessments and closeobservations.

• Staff had easy access to alarms and radios, but thewards had no built-in nurse call system. Staffindividually assessed patients to see the ones thatrequired a nurse call system and were provided withone if needed.

Maintenance, cleanliness and infection control

• All wards were clean and well furnished. However,Hawksmoor and Moneystone’s décor and fittings lookedworn out. All other wards were well maintained.

• Staff made sure cleaning records were up to date andthe premises were clean.

• Staff followed infection control policy, includinghandwashing. The hospital had one of the charge nurseas the identified lead for infection prevention andcontrol.

Clinic room and equipment

• The wards were fully equipped with accessibleresuscitation equipment that staff checked regularly.However, the emergency medicine (Adrenaline) was notavailable on all but one ward. Adrenaline is used to treatanaphylaxis, a possible adverse allergic reaction tomedicines and other possible triggering agents found inthe hospital. We noted that in Moneystone staffcontinued to sign that it was available on the checkingform when actually it was not available. This meant thatthe checks made by staff were not a true reflection ofwhat was held in the emergency bag. Adrenaline hadexpired and removed from the bags and only to bereplaced on 20/06/2019 when the inspection teamraised this. The only one on site in Lockwood hadexpired.

• Staff checked, maintained, and cleaned equipment.

Safe staffing

Nursing staff

• The hospital required a staffing establishment of 22.5whole time equivalent qualified nurses and 188 supportworkers. There were 9.5 whole time equivalent (42%)

Wardsforpeoplewithlearningdisabilitiesorautism

Wards for people with learningdisabilities or autism



nurse vacancies, and 76 whole time equivalent (40%)support workers vacancies. The vacancy rate hadincreased since we last inspected the service in January2017. At that time, the nurse vacancy rate was 30%.

• As a result of the vacancies, 2375 shifts were filled byagency staff in the three-month period from 01December 2018 to 28 February 2019. There were 153shifts covered by bank staff in the same period. A total of77 shifts had not been filled by bank or agency staff. Themain reason for use of agency staff was vacancies.

• Most of the night shifts were covered by agency staff. Wevisited the night shift on 19 June 2019 and found thatonly seven staff out of 40 (18%) staff on duty that nightwere permanent, and the other 33 (82%) were agency.Three wards ran entirely on agency staff. Some of theagency staff had worked regularly on the wards and hadsome experience of the hospital and familiarity with thepatients. Four of the staff were new to the wards andothers had only started working for the hospital within aweek of our visit. We found that these new agency staffdid not know the patients very well. Patients told usthere were always new agency staff that were notfamiliar with the wards. This lack of consistencyimpacted on the quality of care received by patients. Forexample, a nurse on her second shift at the hospital wasasked to attend a care treatment review meeting on 19June 2019 for a patient that she didn’t know.

• Some agency staff had worked at the hospital longenough to be familiar with the patients and systems.However, they were not used in a way that would putthat advantage to effect in developing therapeuticrelationships and building effective ward-based staffteams. We looked at the staff rotas for the last threemonths prior to inspection and found that regularagency staff were consistently moved around the wardson a daily basis. Agency staff told us they were alwaysmoved to work in different wards each time they wereon duty. This meant there was no consistency andcontinuity of care and patients did not have familiarstaff all the time. This had an impact on quality of careprovided to patients, for example, we found that careplans were not always followed.

• Managers did not accurately calculate and review thenumber and grade of nurses and support workers foreach shift to support the needs of both patients andstaff. The managers told us they did not use any tool tocalculate their staffing levels. Staff reported that theywere not able to take rest breaks at work or regular

breaks from enhanced observations. Staffing levels inMoneystone, Whiston, Kingsley, Hawksmoor, Lockwoodand Highcroft were not enough to give staff regularbreaks from observations as the amount of enhancedobservations required exceeded the number of staffassigned to the shift if all required breaks were given.

• The staffing situation had an adverse impact on patientcare. The qualified nurses spent most of their time in theoffice dealing with paperwork and on some occasionscovering two wards. Highcroft at times shared a nursewith Kingsley and Lockwood shared a nurse with thetwo cottages. This meant that a qualified nurse was notalways present in communal areas of the ward. Staffand patients confirmed this. Patients and staff told usthat the wards were very busy and there were notenough permanent nurses to have regular one-to-onemeetings with their patients. Also, there were difficultiesin facilitating escorted leave for those patients ongeneral observations as there were no staff available tosupport leave. This was not a problem for patients onenhanced observations.

• There was a lack of leadership at ward level. The wardsdid not have enough charge nurses to take leadership atward level to supervise and support the support workersto carry out their roles effectively. For example, somedocuments were not always completed, and teammeetings for nurses and support workers were nothappening. There was one nurse manager responsiblefor managing all wards. We were told two senior nursemanagers, who would take up these responsibilities,were on induction at the time our inspection and weredue to start the following week. The service had ahospital director and a nurse manager. A lead nurse andanother nurse manager that were due to start work afterthe inspection. They were in the process of recruitingmore charge nurses for each ward to be in charge of thewards and running shifts. We were told that where shiftscould not be filled as a result of sickness and absencethe managers would step in to cover the shifts. Theservice had high turnover rates. The staff turnover rateat the same period was 42.4%. The managers told usthat the turnover rate increased when the culture of thehospital changed with new management taking a newapproach to leadership of changes in working pattern,less restrictive practice and more empowering topatients.

• Levels of sickness were low. The sickness rate in the12-month period from June 2018 to May 2019 was 2.5%.





Medical staff

• The service had enough daytime and night time medicalcover and a doctor available to go to award quickly in anemergency. There was a doctor on site weekdays 9am to5pm. The hospital had an out-of-hours doctor on callsystem that ensured a doctor could get on site quickly ifneeded.

• Managers could call on locum doctors when theyneeded additional medical cover. There was one fulltime doctor and one locum doctor working three dayswhole time equivalent over five days to cover a vacancy.Managers made sure all locum doctors had a fullinduction and understood the service before starting.

• Staff had completed and kept up to date with theirmandatory training. The compliance for mandatory andstatutory training courses at June 2019 was 94%. Themandatory training programme was comprehensive,and managers monitored it and alerted staff when theyneeded to update their training.

Assessing and managing risk to patients and staff

Assessment of patient risk

• We looked at 22 care records of patients and found thateach of these contained a risk assessment. Staffcompleted a risk assessment for each patient when theywere admitted and reviewed this regularly, includingafter any incident. All risk assessments were up to datewith changes shown when risk changed.

• Staff used a recognised risk assessment tool. They useddifferent, but relevant, tools depending on the needs ofthe patient.

Management of patient risk

• Regular staff knew about any risks to each patient andacted to prevent or reduce risks. Each patient had adetailed positive behaviour support plan that clearlyshowed a good understanding of why the behaviourshappened and considered the person as a whole indetermining ways to safely support patients.

• Staff identified and responded to any changes in risksto, or posed by, patients. Regular staff were aware ofpatients’ presentation such as early warning signs,triggers and ways of intervening that included teachingnew skills.

• Although staff maintained enhanced observations asclinically agreed to keep patients safe and followed

procedures to minimise risks. Staffing levels on all wardswere not sufficient for staff to get regular breaks fromobservations, with the amount of enhancedobservations exceeding the number of staff available ifbreaks were considered. This meant that the providerdid not follow National Institute for Health and CareExcellence guidance (NG10) by ensuring that eachindividual staff member did not undertake a continuousperiod of observation above the general level for longerthan two hours. If observations were required for longerthan two hours, the provider did not ensure the staffmembers had regular breaks. For example, inMoneystone, there were six patients in total, four wereon 2:1 (requiring eight staff members) and two on 15minutes intermittent observations (requiring onemember of staff) and there were 10 staff on duty. Thatmeant there was only one member of staff free fromobservations at any given time and staff had to movedirectly from one set of close observations to anotherwithout a break to maintain the safety of patients. Theprovider’s observation policy was not in line withnational guidance.

• The practice on observations varied. Most observationson patients were carried out in a therapeutic wayparticularly where staff knew the patients well. In othercases, we observed that staff were not familiar withpatients and it was more custodial, and staff did notinteract or tried to engage with patients. Themultidisciplinary team regularly reviewed theobservations to ensure that this was proportionate tothe risk posed.

• The service did not have blanket restrictions approachto care and treatment. Staff individually risk assessedpatients according to their level of ability and risk posed.

• Staff followed provider policies and procedures whenthey needed to search patients or their bedrooms tokeep them safe from harm. Staff recorded the reasonsfor carrying out a search ensuring that the decision andmethod used to search was proportionate to the risks.Staff rarely conducted searches on patients and wereonly carried out where the risk was deemed high.

Use of restrictive interventions

• There had been no instances of seclusion over the last12 months up to June 2019. No wards used seclusion,they reported that they would not admit any patientthat would require seclusion.





• There had been no instances of long-term segregationover the last 12-month period up to June 2019. Theyreported that they do not practise segregation butwould find a better way of managing the patient.

• There was one incident of prone restraint over the sixmonths from 18 December 2018 to 18 June 2019. Duringthat same period, there were 882 incidents of restraint.They recorded any contact with patient as restraint andclassed in different ways. They reported 320 restraints asface up and 81 in seated position. The rest accountedfor standing and directing patients away. There hadbeen no instances of mechanical restraint over thereporting period. The manager told us mechanicalrestraint was not allowed in their service.

• Staff reported the use of restraint through the incidentreporting system. They told us that themulti-disciplinary team reviewed all incidents ofrestraint and that most were for self-harming behaviour.

• We concluded that the service had not done all it couldto minimise the use of restraint and two patientsreported that at times the restraints were forceful andexcessive. Although the positive behaviour supportplans described different proactive methods that couldbe used by staff before any restrictive methods such asrestraint could be used, some staff told us that they hadnot read the plans and other staff were new to the wardsand did not know the patients. Also, only seniormanagers understood and participated in the provider’srestrictive interventions reduction programme.Although there was a strong drive on reducing restrictivepractices which had been successful in ending the useof seclusion, avoiding long-term segregation, and noblanket restrictions, there was no restrictive practiceawareness campaign to support staff in understandingthe meaning of restrictive practice and its impact. Therewas no effective leadership on the wards to lead on theprogramme and therefore the reducing restrictivepractice strategy was not shared with staff in a forumwhere staff could participate.

• The provider trained staff in physical interventions andensured that all agency staff had the same training andthey were aware of the techniques required.

• There had been no incidents of rapid tranquilisationover the reporting period. The service understood rapidtranquilisation as the use of medication by the

intramuscular route as stated in NICE (NG10). Whenrequired (prn) oral medication was used as part of astrategy to de-escalate or prevent situations that maylead to violence and aggression. It was not used often.

Safeguarding

• A safeguarding referral is a request from a member ofthe public or a professional to the local authority or thepolice to intervene to support or protect a child orvulnerable adult from abuse.

• Commonly recognised forms of abuse include: physical,emotional, financial, sexual, neglect and institutional.

• Each authority has their own guidelines as to how toinvestigate and progress a safeguarding referral.Generally, if a concern is raised regarding a child orvulnerable adult, the organisation will work to ensurethe safety of the person and an assessment of theconcerns will also be conducted to determine whetheran external referral to Children’s Services, Adult Servicesor the police should take place.

• This hospital made 64 safeguarding referrals betweenJuly 2018 and June 2019.

• The hospital had no serious case reviews commencedor published in the last 12 months from July 2018 toJune 2019.

• Staff understood how to protect patients from abuseand the service worked well with other agencies to doso. There was an incident where staff reportedinappropriate use of restraint by other staff and themanagers took appropriate action against the staffmembers involved.

• Staff could give examples of how to protect patientsfrom harassment and discrimination, including thosewith protected characteristics under the Equality Act.

• Staff knew how to make a safeguarding referral and whoto inform if they had concerns.

• Staff had training on how to recognise and report abuse,and they knew how to apply it. Staff knew how toidentify adults and children at risk of, or suffering,significant harm.

• Staff followed the hospital’s policy for children visitingthe wards to ensure safety. Staff discussed, and riskassessed visits from children considering any childprotection issues. There where meeting rooms awayfrom the wards where visiting children could meet withpatients safely.





Staff access to essential information

• Staff used electronic patient records and they keptdetailed records of patients’ care and treatment.

• Records were clear, up-to-date and easily available to allstaff providing care including some of the regularagency staff but not all agency staff. It was alsoaccessible to all relevant staff when patients movedbetween wards.

• Staff used paper records for observations andprescription charts and this did not cause anydifficulties in entering or accessing information. Thewards had paper records with overview of patients’information on the wards meant to be given to newagency staff.

• Records were stored securely.

Medicines management

• Staff did not follow the correct process for recording andstoring of medicines consistently. Staff left gaps in thesigning of medicines charts on all wards, it was higheston Moneystone ward, and failed to indicate whethermedicines had been taken, omitted or refused. Staff didnot date medicines such as creams and liquid in bottlesthat required dating when they were opened. Thiswould have ensured that the effectiveness of themedicine could be monitored. The issues were pickedup in the provider’s medicines audits, but no action wastaken.

• Staff did not write down the dates that glucagonhypoglycaemia kit was first stored in the emergency bagoutside the refrigerator. There was no evidence of thenew expiry date as this medicine could only be kept for18 months outside the refrigerator for it to be stilleffective when given to patients. They relied on theexpiry date of the medicine from the manufacturerwhich dependent on the medicine always being storedin the fridge.

• There were no door signs on all wards to show therooms where oxygen cylinders were kept. This did notassure that all staff and patients would be aware of allsafety precautions to be taken where oxygen was stored.

• Staff reviewed patients’ medicines regularly andprovided specific advice to patients and carers abouttheir medicines. Patients were given easy read

information on possible drug interactions, minimumeffective doses, contra-indications and side effects. Staffmonitored and reviewed the effectiveness of themedicines prescribed.

• Staff followed current national practice to checkpatients had the correct medicines. They worked closelywith a local pharmacy that provided support and adviceto the hospital.

• The service had systems to ensure staff knew aboutsafety alerts and incidents, so patients received theirmedicines safely.

• Decision making processes were in place to ensurepatients’ behaviour was not controlled by excessive andinappropriate use of medicines. Staff knew about andworked towards achieving the aims of STOMP (StopOver-Medicating People with learning disabilities). Mostof the patients were on very low doses of medicines, nomore than two antipsychotic medicines and others weremedicine free.

• Staff reviewed the effects of each patient’s medicines ontheir physical health according to National Institute ofHealth and Care Excellence guidance. Health checkswere carried as required for those patients onantipsychotic medicines.

Track record on safety

• The service had a good track record on safety. BetweenJuly 2018 and June 2019 there were two seriousincidents reported by this service. Of the total number ofincidents reported, one was of a fall resulting in adislocated hip and the other one was of an unexpectedpatient death. The fall was unobserved, and the deathwas certified by the coroner as natural death.

• A ‘never event’ is classified as a wholly preventableserious incident that should not happen if the availablepreventative measures are in place. This servicereported zero never events during this reporting period.

• The number of serious incidents reported during thisinspection was higher than one reported at the lastinspection.

Reporting incidents and learning from when things gowrong

• Staff knew what incidents to report and how to reportthem. However, not all agency staff had access to theincident reporting system they had to ask those staffwith access to report incidents.





• Staff reported all incidents that should be reported. Staffrecognised incidents and reported them appropriately.We found that some of the incidents reported had notbeen linked through the system to patients’ notes afterthe incident had been reviewed. This was later resolvedafter realising that it was the whole organisation’sinformation technology problem.

• Staff reported serious incidents clearly and in line withprovider policy.

• The service had no never events on any wards.• Staff understood the duty of candour. They were open

and transparent and gave patients and families a fullexplanation if and when things went wrong.

• Managers did not always debrief and support staff afterserious incidents. Staff told us they did not always getdebrief and support after serious incidents, occasionallypsychology department offered debrief support, but itwas not consistent.

• Managers investigated incidents thoroughly. Patientsand their families were not always involved in theseinvestigations.

• Staff did not receive feedback from investigation ofincidents, both internal and external to the service. Stafftold us they were not aware of any feedback frominvestigations of incidents. The feedback was sharedamong the senior managers and nurses that attendedthe morning meetings where incidents were discussed.Due to lack of leadership on the wards the feedback wasnot shared with all staff on the wards.

• There was no formal or structured way where staff metto discuss the feedback and look at improvements topatient care. The manager circulated a hospital bulletinwith lessons learnt each month. However, staff told usthey were not aware of the lessons learnt as this was notembedded yet.

• There was evidence that changes had been made as aresult of feedback. Staff were not able to tell us changesthat had been made as a result of feedback. However,the managers gave a number of examples wherepractice had changed as a result of learning fromincidents, for example, improvements to handoversystem, a process for storing and archiving writtendocumentation and training for buccal midazolam forall agency nurses.

• Managers and staff were not aware of the Learning fromDeaths Mortality Review (LeDeR) Programme. Managersand staff had not learnt anything from the reviewprocess and were not aware of any learning itrecommended.

Are wards for people with learningdisabilities or autism effective?(for example, treatment is effective)


Assessment of needs and planning of care

• Staff completed a comprehensive mental healthassessment of each patient either on admission orbefore admission. We looked at 22 patients’ care recordsthat showed that staff assessed the mental health needsof all patients in a timely way and identified all patients’needs.

• Staff assessed patients’ physical health needs in atimely manner soon after admission. Staff ensured thatall patients had a physical examination within 24 hoursof admission and recorded any physical healthproblems. However, physical health was not monitoredconsistently, records seen from the live dashboardshowed that only 60% of patients had an up to dateannual physical health check. The records received laterfrom the hospital from their GP showed that all patientshad an up to date physical health check. Patients withconstipation had no care plans in place and bowelmonitoring charts were not always completed. TheNational Early Warning Score were not consistentlycompleted where care plans required patients to havethese completed as part of their physical healthmonitoring plan.

• Although some patients had an up to date hospitalpassport, 35% of patients had either no hospitalpassport in place or it was not fully completed with allrequired meaningful details. A hospital passport is adocument for people with learning disabilities thatcontain their health needs and other useful information,such as your interests, likes, dislikes and preferredmethod of communication to help hospital staff makethem feel more comfortable when admitted intohospital.





• The care plans developed by staff varied in their quality.There were cases were staff developed care plans thataddressed the needs identified during assessment.These care plans contained clear details of what theyaimed to achieve and how each identified need was tobe met. However, other care plans lacked detail of howimportant physical healthcare needs, and associatedrisks, would be addressed and managed – includingepilepsy and diabetes.

• Staff regularly reviewed the care plans but sometimesdelayed updating care plans and positive behavioursupport plans when patients’ needs changed.

• There was inconsistency in the degree ofpersonalisation of care plans. Although some care planswere personalised, holistic and recovery-orientated.There were areas where care plans were not personcentred, they did not have clear goals and represent thepatients’ views, contained the same information fordifferent patients and lacked detail about individualneeds.

• The hospital had just introduced new positive behavioursupport plans that incorporated the reinforceappropriate, implode disruptive (RAID) approach. This isa positive psychology least restrictive approach forworking with people that present with behaviour thatchallenge. Positive behaviour support plans werepresent for all patients and were supported by acomprehensive assessment. The positive behavioursupport plans were psychology led, person centred andinformed by a functional assessment carried out to helpunderstand the reasons behind the behaviour thatchallenged.

Best practice in treatment and care

• We looked at 22 patients care records and medicineprescriptions. The medication and psychologicaltherapies that were described were in line with NationalInstitute for Health and Care Excellence guidance. Theseincluded interventions that would enable patients toacquire independent living and social skills. However,although many patients had care plans that specifiedthe interventions that would address their needs, weconcluded that these intentions were often nottranslated into action. A number of staff told us that theyhad not read patients’ care plans or positive behavioursupport plans and we found instances where staff werenot following them or not completing monitoring

documents as required by the plan. This failure to enactcare plans was due to a lack of clear leadership at wardlevel and insufficient ward staff with the necessary skills,knowledge and familiarity with the patients.

• The hospital had a contract with a local GP that visitedthe hospital to see patients that were not able to go tothe GP surgery. Staff could make referrals to the GP atanytime for any physical health problems. Also, patientshad good access to physical healthcare specialists forspecific, identified needs. This included close links withneurologists for patients with epilepsy. The hospital hadbeen trying to recruit a registered general nurse to runthe physical health clinics.

• Staff assessed those needing specialist care for nutritionand hydration. Referrals to a dietician were made whenrequired. The speech and language therapist carried outsome assessments of patients experiencing difficultieswith their eating, drinking and swallowing. However,ward staff did not consistently monitor fluid and foodintake for patients that had nutritional and hydrationneeds, and records were not regularly reviewed.

• Staff helped patients live healthier lives by supportingthem to take part in programmes or giving advice. Thepatients had access to smoking cessation programmes,physical exercises, acting on healthy eating advice. Theservice offered a wide range of activities to patients. Theoccupational therapists assessed patients andencouraged them to actively engage in routinemeaningful and purposeful structured daily programmeof activities. However, patients with sensory needs hadno access to a sensory room to support their individualneeds.

• Staff used recognised rating scales to assess and recordthe severity of patients’ conditions and care andtreatment outcomes.

• Staff did not take part in clinical audits, benchmarkingand quality improvement initiatives apart frommedicines and National Early Warning Score audits. Thehospital had an audit programme of different clinicalareas to be monitored but was not used. These auditswere not detailed on their findings. Managers did notuse results or follow up any actions from these twoaudits to make improvements.

Skilled staff to deliver care

• The service had access to full range of specialistsrelevant to the needs of the patients on the ward. Thisincluded one full time and one part time locum doctor,





nurses, two full time occupational therapists, one fulltime psychologist, art psychotherapist, one full timespeech and language therapist, occupational therapistassistants, assistant psychologists, trainee nurseassociates and recovery support workers.

• In contrast, many of the staff that worked shifts on thewards lacked the skills or knowledge needed to meetthe complex needs of the patients with learningdisabilities and autism in their care or to put into effectthe care plans developed by the specialist staff. Asdescribed above, on many shifts only a small proportionof staff working directly with patients were regular,permanent staff and only a few were qualified nurses.Because a number of agency staff were new to thehospital, and because of the way that the servicedeployed agency staff who had worked at the hospitalbefore, many staff working on the wards did not knowthe patients well or what their care plans contained. Wespoke to one agency staff member who could not speakEnglish well.

• The managers of the hospital did not provide trainingthat mitigated the lack of knowledge or skills of many ofthe staff working on the wards. The hospital providednew, permanent staff members with an inductionprogramme but there was no structured inductionprogramme for agency staff that worked on the wards.Agency staff told us that they just had verbal inductionon the first day on duty but no written induction orfurther induction of the environment and patients whenmoved to other wards. This was a particular problem fornew agency staff that worked on wards that were fullystaffed by other agency workers.

• Although permanent recovery support workers hadaccess to training equivalent to care standardscertificate, agency staff told us they received no trainingfrom the provider and had not received training inlearning disabilities, autism and positive behavioursupport. Agency staff who worked regularly at thehospital received only basic mandatory training.

• Managers had not identified the training needs of theirstaff or given them the time and opportunity to developtheir skills and knowledge. Staff were not trained inpatients’ specific needs as outlined inrecommendations for treatment plans such as pictureexchange communication system (PECS) and Makaton.

Also, the provider did not ensure that ward staff hadreceived the training to equip them to meet patients’physical health conditions, such as diabetes andepilepsy.

• Managers did not support staff through regular,constructive clinical supervision and appraisal of theirwork. There was no regular appraisal and supervisionavailable to staff and managers did not have a reliablesystem to monitor this. Only about one-fifth of nursinghad received regular supervision or undergoneappraisal. Although managers had started to roll out aplan for implementing appraisal and supervision, moststaff we spoke with said they had not received either.

• Managers did not ensure that staff attended regularteam meetings. The wards had no staff meetings takingplace at all. There were no experienced ward leaders tomake this happen. The hospital had a nurse meetingonce every month. The psychologist ran reflectivepractice sessions where they discussed patient clinicalinformation, reflection and support to staff, but thesewere not attended by many staff.

• The nurses who managed the wards did not have theskills and experience to ensure that the wardsfunctioned effectively. Not every shift was covered by acharge nurse and the charge nurses had not receivedleadership training. Ward leaders did not effectivelysupport junior staff to follow care and treatment plansfor patients on the floor as recommended by themultidisciplinary or therapies team to meet the needs ofpatients.

• Poor staff performance was dealt with promptly andeffectively. The managers had readily available supportfrom human resources department to deal with this.

Multi-disciplinary and inter-agency team work

• Staff held regular multidisciplinary meetings to discusspatients and improve their care. They held in-depthdiscussions that addressed the identified needs of thepatients such as risk, safeguarding issues, physicalhealth issues, medication review, discharge planningand changes to care plans. However, we concluded thatelements of these plans were not enacted because thefront-line staff did not have the skills necessary to dothis.

• Staff shared information about patients and anychanges in their care, including during handovermeetings. The wards held handovers at the end and





start of each shift and had a comprehensive handoverform and the multidisciplinary team held meetings eachmorning to discuss any safety concerns. However, staffon the wards did not fully complete all information onhandover forms.

• Ward teams had good working relationships with otherteams in the organisation. They had regular discussionswith the therapies team, catering department and theadministration team.

• The provider had effective working relationships withexternal teams and organisations. They had effectiveworking relationships with staff from services that wouldprovide aftercare following the patient’s discharge andengaged with them early in the patient’s admission toplan discharge.

Adherence to the Mental Health Act and the MentalHealth Act Code of Practice

• Staff received and kept up to date with training on theMental Health Act and the Mental Health Act Code ofPractice and could describe the Code of Practiceguiding principles.

• As of June 2019, 91% of the bank and substantiveworkforce in this hospital had received training in theMental Health Act. The provider stated that this trainingwas mandatory for all clinical staff and was renewedyearly.

• Staff had easy access to administrative support andlegal advice on implementation of the Mental Health Actand its Code of Practice. Staff knew their Mental HealthAct administrators.

• The provider had relevant policies and procedures thatreflected the most recent guidance. Staff had easyaccess to local Mental Health Act policies andprocedures and to the Code of Practice.

• Patients had easy access to information aboutindependent mental health advocacy. Staff were awareof how to access and support patients to engage withthe independent mental health advocacy and patientswho lacked capacity were automatically referred to theservice.

• Staff explained to patients their rights under the MentalHealth Act in a way that they could understand,repeated it as required and recorded that they had doneit. Patients we spoke with confirmed that their rightsunder the Mental Health Act had been explained tothem.

• Staff ensured that patients who were on constantobservation were able to take Section 17 leave(permission for patients to leave hospital) when this wasagreed with the Responsible Clinician and/or with theMinistry of Justice. This was not always the case forpatients on general observations because of the staffingsituation. Staff made patients and their carers aware ofthe conditions of leave and any risks and advised themon what to do in the event of emergency.

• Staff requested an opinion from a Second OpinionAppointed Doctor when they needed to. Consent totreatment and capacity forms were appropriatelycompleted and attached to the medication charts ofdetained patients.

• Staff stored copies of patients' detention papers andassociated records (for example, Section 17 leave forms)correctly and so that they were available to all staff thatneeded access to them.

• Care plans included information about after-careservices available for those patients who qualified for itunder section 117 of the Mental Health Act.

• The Mental Health Act Administrators completed auditsto ensure that the Mental Health Act was being appliedcorrectly and there was evidence of learning from thoseaudits. One patient had a section that lapsed and wasdiscovered that the section was not renewed at the timeit required to be renewed. This issue was highlighted aspart of an audit and resolved.

Good practice in applying the Mental Capacity Act

• As of June 2019, 88.3% of staff had received training inthe Mental Capacity Act and Deprivation of LibertySafeguards. The provider stated that this training wasmandatory for all clinical staff and was renewed yearly.

• Most of the staff had a good understanding of theMental Capacity Act 2005, particularly the five statutoryprinciples.

• The training compliance reported during this inspectionwas higher than 86% reported at the last inspection.

• Regular staff understood the organisation’s policy onthe Mental Capacity Act 2005. The provider had a policyon the Mental Capacity Act. Staff were aware of thepolicy and had access to it.

• Staff were not sure where to get advice from within thehospital regarding the Mental Capacity Act andDeprivation of Liberty Safeguards. Staff did not knowtheir identified lead for the Mental Capacity Act.





• In some cases, staff gave patients all possible support tomake specific decisions for themselves before decidinga patient did not have the capacity to do so. Thepractice was not consistent. There were cases whenthere were good easy read and pictorial informationmade available and in other cases they were none.

• Staff did not always assess and record capacity toconsent clearly each time a patient needed to make animportant decision. This practice varied greatly withinthe service, where it was done there were very goodexamples of assessments and recording. However, therewere a number of incidences where no assessmentswere carried out or recorded around physical healthneeds and financial needs. We found cases where it wasjust recorded lacked capacity without any records toindicate how staff had arrived at that decision.

• Where staff assessed and recorded patients as nothaving capacity, they made decisions in the best interestof patients and considered the patient’s wishes, feelings,culture and history. However, where the assessmentswhere not recorded we could not be assured thatpatient’s wishes, feelings, culture and history wereconsidered. The decisions in the best interest of patientsand what had been considered were not recorded inthose cases.

• There were no Deprivations of Liberty Safeguardsapplications made in the last 12 months prior toinspection.

• The number of Deprivations of Liberty Safeguardsapplications made during this inspection was the sameas none reported at the last inspection.

• The service had no arrangements to monitor adherenceto the Mental Capacity Act. Staff did not audit theapplication of the Mental Capacity Act to make anychanges to improve where needed.

Are wards for people with learningdisabilities or autism caring?


Kindness, privacy, dignity, respect, compassion andsupport

• Staff attitudes and behaviours when interacting withpatients showed that they were discreet, respectful andresponsive, provided patients with help, emotional

support and advice at the time they needed it. Weobserved staff interacting with patients in a way thatdemonstrated respect and a caring nature. Staffsupported upset patients in a compassionate andsensitive way. Staff were always available to supportpatients. Patients that we spoke with told us that stafftreated them well and behaved appropriately towardsthem and spoke positively about their privacy, dignityand wellbeing at the hospital.

• The professional staff and regular ward staff who werefamiliar with the patients, used appropriatecommunication methods to support patients tounderstand and manage their own care treatment orcondition. However, a significant proportion of wardstaff were not familiar with the patients and did nothave this knowledge or these skills. Staff encouragedpatients to be independent as far as possible focussingon their strengths. Some patients self-medicated andothers understood their early warning signs and triggers.Staff enabled patients to participate in social skills,leisure skills and independent living skills that weretailored to individual needs.

• Staff directed patients to other services whenappropriate and, if required, supported them to accessthose services. All patients were registered with a localGP and dentist, and staff arranged and supportedpatients to attend appointments when they complain ofany physical health problem. However, staff did notalways follow care plans to monitor physical healthproblems, for example completing bowel movementand fluid and dietary intake charts. Carers told us thatstaff arranged appointments at times that suitedpatients. For example, if a patient was more likely tohave seizures in the morning, they would arrangeappointments in the afternoon.

• Regular staff understood and supported the individualneeds of patients, including their personal, cultural,social and religious needs. These staff responded topatients differently considering and being sensitive totheir individual needs. We saw care plans that detailedhow to support patients through Ramadan, withevidence of monitoring nutrition and hydration throughfood and fluid charts. However, a significant proportionof ward staff were unfamiliar with the patients and theircare plans and therefore could not work in this way.





• Staff felt that they could raise concerns aboutdisrespectful, discriminatory or abusive behaviour orattitudes towards patients. Staff gave good examples ofwhat they could report as concerning behaviourtowards patients.

• Staff followed policy to keep and maintain patientinformation confidential.

Involvement in care

• Staff introduced patients to the ward and the services aspart of their admission process. Welcome packs wereprovided to patients and were available in an easy readformat.

• The multidisciplinary team involved patients in the wardreviews and care programme approach as much as theycould and discussed treatment options with patients.Patients’ views were considered during care planning.Staff offered patients as much choice as possible abouttheir care and treatment. Patients had access to copiesof their care plans. Patients told us they wereencouraged to attend their reviews and were happy withtheir involvement in their care and treatment.

• Regular staff that knew patients well communicatedwith patients so that they understood their care andtreatment, including finding effective ways tocommunicate with patients with communicationdifficulties. However, it was not always the case withagency staff that were not familiar with the patients.There was easy read information available to patientsabout their medicines, Mental Health Act rights and easyread care plans. However, this was not consistent acrossall wards. Each patient had a communicationassessment that gave information on how best tocommunicate with each patient.

• Patients could give feedback on the service and theirtreatment and staff supported them to do this. Therewas a monthly patient community meeting that tookplace to enable patients to raise any concerns orsuggestions to improve the service. The hospital alsocarried out patient surveys.

• Staff supported patients to make advanced decisions ontheir care. The service had no patients with advancedecisions.

• Staff ensured patients had access to advocacy. Theadvocate was skilled in working with people with

learning disabilities and visited the hospital regularlyand attended multidisciplinary team meetings. Patientshad the contact details of the advocate and were able tocontact them when needed.

• Staff supported, informed and involved families orcarers. Carers told us that they were able to obtaininformation about their relative if they telephoned theservice. However, this depended upon whether amember of staff on shift knew the patient. Some carerstold us that they had requested to receive a weeklyupdate, but this did not always happen. All carers wereable to attend multidisciplinary team review meetingsregularly.

• The service had not supported families to give feedbackon the service. They had arranged their first carers/family day to take place on 5 July 2019. Families andcarers that we spoke with told us that they had not beenprovided with the opportunity to give feedback on theservice.

• Families and carers were not provided with informationor signposted on how to access carer’s assessment.

Are wards for people with learningdisabilities or autism responsive topeople’s needs?(for example, to feedback?)


Access and discharge

• The average bed occupancy between September 2018and February 2019 was 79%. Lockwood ward wasclosed for refurbishment from November 2018 to June2019.

• The provider accepted referrals from all of England. Theaverage length of stay for the service was 42 months,there were three outlier patients on restriction orderfrom the home office and had been at the hospital forover 10 years. The average length of stay was 27 monthsif those patients were excluded.

• There was always a bed available when patientsreturned home from leave.





• Patients were not moved between wards during anadmission episode unless it was justified on clinicalgrounds and was in the interest of the patient.

• When patients were moved or discharged, thishappened at an appropriate time of day. Themultidisciplinary team planned and co-ordinated thedischarges with other necessary external agencies in acollaborative way well in advance.

• It was rare for any patients to require a psychiatricintensive care bed. If this did occur, the service wouldcontinue to care for the patient while a moreappropriate bed was being sourced.

• Staff planned for patients discharge, including goodliaison with care managers and coordinators. The careprogramme approach meeting was held to discuss thedischarge plan that included the crisis plan. Eachpatient had a care and treatment review carried out inline with NHS England transforming care programme.Patients visited new placement on trial leave to see howthey coped as part of their transition. During ourinspection, staff members from a patient’s new servicewere visiting to provide support and getting familiarwith the patient’s needs.

• The service reported no delayed discharges betweenJanuary 2018 and February 2019.

• Staff supported patients during referrals and transfersbetween services. Staff stayed with patients whenadmitted into acute hospital for physical healthproblems.

• The service complied with transfer of care standards.

The facilities promote recovery, comfort, dignity andconfidentiality

• Patients had their own bedrooms with en-suite facilities.Whiston and Kingsley wards provided self-containedapartments where patients had their own lounge andkitchen area. Hawksmoor was about to go underrefurbishment to provide self-contained flats.

• Patients could personalise their bedrooms. We sawposters, photographs, personal bedding and otherpersonal items in patient bedrooms.

• Patients had somewhere secure to store theirpossessions. There were lockable facilities in bedroomswhich patients had a key for. Some patients had a key totheir own bedrooms.

• Staff and patients had access to the full range of roomsand equipment such as clinic rooms, activity andtherapy rooms and a family room, to support treatmentand care. However, there was no sensory room acrossthe hospital considering the needs of their patient groupthey could benefit from a sensory room.

• There were no quiet areas on some wards. This wasparticularly an issue where other patients were quitenoisy, and others did not like it. For example, onMoneystone one patient was isolating them self in theirbedroom because of the noisy ward environment. OnKingsley, one patient had noise as one of the triggers ontheir behaviour support plan and the ward was noisy attimes with loud music. The patient dynamics w notadequately and regularly reviewed to ensure theenvironment was comfortable for all patients. We didnot see how each patient’s individual risk and theirsocial interactions with other patients were consideredbefore placing in a particular ward.

• The ward environment for people with autism was nottherapeutic. The provider had not carried out an autismfriendly assessment (autism friendly environmentchecklist) to ensure that reasonable adjustments weremade to meet the national guidelines for autism friendlyenvironment National Institute of Health and CareExcellence clinical guideline [CG142]. The managers hadalso not considered the conflicting sensory needs ofpatients living in the same ward.

• There were rooms away from the wards where patientscould meet visitors.

• Patients could make a phone call in private. Somepatients had access to a mobile phone and could speakprivately in their bedrooms. This was individually riskassessed. Other patients that did not have a mobilephone, were able to use the ward mobile phone tomake and receive calls in private.

• Patients had access to the outside space. Patients onMoneystone and Highcroft ward did not have easyaccess to outside space as the wards were locatedupstairs.





• The service offered a variety of good quality food.However, there was no easy read/pictorial menu choiceto help patients understand their food choices. Staff toldus patients did not easily understand the availablewritten menu choices which often caused problems atmeal times. Patient were often confused about theirchoices when they saw the food being served. This ledto patients sometimes refusing meals and saying thatwas not what they ordered.

• Patients were able to independently make hot drinksand snacks 24/7, dependent upon their individual riskassessment.

Patients’ engagement with the wider community

• Staff made sure that patients had access toopportunities for education and work, and supportedpatients. The occupational therapy team had recentlydeveloped a scheme, where patients were employed tocarry out different jobs such as car maintenance. Onepatient had a voluntary job with a local charity group.

• Staff supported patients to maintain contact with theirfamilies and carers. Patients were able to visit home onleave and be visited by their relatives. Staff supportedpatients with phone calls to their relatives.

• Staff encouraged patients to develop and maintainrelationships that mattered to them, both within theservices and the wider community. Patients were able toget in contact with other professionals outside of theservice and list of contact details of those involved intheir care were maintained.

Meeting the needs of all people who use the service

• The service had not made enough suitable adjustmentsfor disabled patients or visitors to access the premises.The reception area was located above a flight of stairswith no lift or other disabled access. Moneystone andHighcroft had a lift. There was no disabled access to oneof the cottages.

• The service did not always ensure that the needs ofpatients with specific communication needs were met.We found that some staff working with patients’ whohad specific communication needs set out in their careand treatment plans’ such as picture exchangecommunication system and Makaton, had no training tomeet their needs.

• Staff ensured that patients could obtain information ontreatments, local services, patients’ rights and how tocomplain. The information provided was in a formaccessible to the patient group. There were easy readversions of documents such as care plans, rights,complaints and compliments. However, we found thatthese documents were not used available consistentlyacross all wards.

• Staff made information leaflets available in languagesspoken by patients.

• Managers ensured that staff and patients had access tointerpreters and/or signers when required.

• Patients had a choice of food to meet the dietaryrequirements of religious and ethnic groups.

• Staff ensured that patients had access to appropriatespiritual support. During our inspection, we found thatpatients were supported through Ramadan and thatthere was a multi-faith room available to patients.

Listening to and learning from concerns andcomplaints

• The service received four complaints from March 2018 toFebruary 2019, three of which were upheld, and nonewere referred to the Ombudsman. The service received13 compliments within the same period.

• Patients knew how to complain or raise concerns. Therewere complaints forms available to patients on eachward, with some wards providing easy read versions.Patients could go to staff as the first point on how toraise concerns. They could also raise their complaintsthrough the advocate.

• When patients complained or raised concerns, theyreceived feedback.

• Staff protected patients who raised concerns orcomplaints from discrimination and harassment. Staffwere aware of how to handle complaints appropriately

• Staff knew how to handle complaints appropriately.Staff we spoke to stated that they would pass thecomplaint onto the nurse in charge or the nursingmanager. Staff also said that they would try to resolvemore informal complaints at ward level.





• Staff did not receive feedback on the outcome ofinvestigations of complaints and acted on the findings.Staff told us managers did not share with themoutcomes from complaints and were not aware of anylessons learnt from complaints.

.

Are wards for people with learningdisabilities or autism well-led?


Leadership

• There was a lack of leadership at ward level. Thehospital had no ward managers and had only recentlyintroduced the charge nurse posts to manage thewards. There were not enough charge nurses with theright skills, knowledge and experience to perform theirroles. The hospital director, nurse manager, psychologylead, occupational lead and the consultant formed thesenior leadership team. The leadership resources werenot enough to allow them to effectively perform theirfull roles. The hospital had introduced two more seniorleaders to the team, a nurse manager and a lead nurseto support the leadership team. One was on inductionduring inspection and the other one was due to start inJuly. There was support from the regional nurse leadthree days a week to fill the gap in leadership at thesame time as the recruitment was done.

• The hospital director clearly understood most of theareas that required improvement and had come up withan improvement action plan to address these areas.There was lack of enough leaders with knowledge andexperience around to give adequate support. Theyunderstood their current challenges, risks and how theywere trying to mitigate these. They clearly explainedhow the teams worked and what were the future plansto achieve high quality care and the goals of the service.The hospital director was in post since October 2018and had been working hard on recruitment andretention strategy.

• The leaders were visible in the service andapproachable for patients and staff. However, there wasa mixed view from staff, most staff spoke highly of the

support they received from the managers. Some told usthey did not get enough support from managers, somesaid they are approachable but do no act on all mattersraised.

• The hospital had recently started to run leadershipcourses for managers and junior staff. The programmewas being gradually rolled out as part of their ongoingprofessional development plan for all staff. It was aprogramme to develop staff skills to take on more seniorroles.

Vision and strategy

• The service had a vision for what it wanted to achieveand a strategy to turn it into action. Most staff knew andunderstood the vision and values and how they wereapplied in their everyday work within the team.However, most agency staff did not understand theorganisation’s values. They did not always understandhow their role contributed to achieving the strategy.Managers did not make sure that agency staffunderstood their values and knew how to apply them.

• The provider’s senior leadership team hadcommunicated the provider’s vision and values to thefrontline staff in this service. The leaders knew very wellabout the future service they wanted to build.

• Staff had the opportunity to contribute to discussionsabout the strategy for their service, especially where theservice was changing. They reported that they were notinvolved in all discussions but at times they were askedfor ideas about how the service was run. They felt theyhad not been fully involved in developing the strategy ofthe service.

Culture

• Most staff felt respected, supported and valued by theirmanagers. However, there was mixed feelings aboutmanagement support on issues around sickness andwhen injured at work. From 18 December 2018 to 18June 2019 the hospital recorded 135 staff injured byassault and 23 by restraint. Some staff felt they did notget adequate psychological support from themanagement after they had been injured at work. Mostof the staff reported feeling positive and proud aboutworking for the organisation apart from a few staff.





• Staff felt able to raise concerns without fear ofretribution. The leaders took all concerns seriously,listened to their staff and supported them. Most of thestaff said they had seen a change since the new hospitaldirector had been in post.

• Staff knew how to use the whistle-blowing process andabout the role of the freedom to speak up guardian.They felt confident to do so when required.

• Managers dealt with poor staff performance whenneeded. There was support from the human resourcesteam if required.

• The teams did not work well together and where therewere difficulties they lacked ward managers to deal withthem appropriately. There were no established coreteams in each ward that had a leader and effectiveworking relationships. The teams were not cohesive,they were diluted by a lot of agency staff that were notestablished team members. However, staff were keen tosupport each other to deliver good quality patient care.

• Managers did not provide staff with appraisalsconsistently that included conversations about careerdevelopment and how that could be supported.However, support workers were supported to attendnurse associate training and all staff to attendleadership courses.

• There was no active strategy to consistently promoteequality and diversity around protected characteristicsin day to day work. Staff were not aware of anypromotion ways that provided opportunities for careerprogression through offering equal opportunities for all.The hospital did not have a champion/lead person or agroup that promoted equality and diversity aroundblack and Minority Ethnicity or Lesbian, Gay, Bisexual,and Transgender within the hospital.

• The service reported a staff sickness and absence rate of2.5% from June 2018 to May 2019.

• Staff had access to support for their own physical andemotional health needs through an occupational healthservice. Managers could signpost staff to occupationalhealth for well-being support if needed.

• The provider recognised staff success within the service.The hospital had a staff awards system to recognise staffand team achievements.

Governance

• The operational governance processes to managequality and safety did not operate effectively. Although

the service had a good dashboard that collectedessential information from all wards, this informationwas not fully used to monitor the quality andperformance of the service.

• There were no clear arrangements on how all keyinformation such as incidents, complaints,safeguarding, staffing, training and audits reported bystaff to management was analysed. There was no clearsystem in place on how the results of any analysedinformation was feedback to staff and patients on thewards to ensure improvements were made. There wasno clear framework of what was discussed at ward orservice level and any learning that was shared anddiscussed.

• Staff were not aware of recommendations implementedfrom reviews of deaths, incidents, complaints andsafeguarding alerts at the service level. However, themanagers could give examples of changes made.

• Staff did not undertake or participate in local clinicalaudits. There were not enough audits to provideassurance that the quality and standards of care wereeffectively monitored. The area that was monitored hadno actions or recommendations taken to address poorpractice that had been identified.

• Staff understood the arrangements for working withother teams, both within the organisation and externalto meet the needs of the patients. There were goodworking relationships with some commissioners, acutehospital, local authority, local community, voluntarysector and GP.

Management of risk, issues and performance

• The service had the processes to manage current andfuture performance. However, the process to identify,understand, monitor and address current and futurerisks was not linked effectively into the planningprocess. The managers maintained and had access tothe risk register for the service. Staff were not aware ofthe risk register and it was not shared with them. Theycould escalate concerns to management when requiredfrom a team level.

• Clinical and internal audit processes did not functionwell and did not have a positive impact on qualitygovernance, with no clear evidence to monitor actiontaken to resolve concerns.





• The service had plans for emergencies that set out themeasures the service would take to ensure safety ofpatients in the event of an emergency or adverseweather conditions.

• There were no cost improvements in place at the time ofinspection. The service was not under pressure to fill thebeds. They told us they had rejected about 70% of thereferrals in the last six months prior to inspection as theywere deemed clinically inappropriate. The sustainabledelivery of quality care was not put at risk by thefinancial challenge.

Information management

• The service used systems to collect data from wards andthat were not over-burdensome for frontline staff. Staffreported that methods used to give information tosenior management were easy to use.

• All permanent staff had access to the equipment andinformation technology needed to do their work. Not allagency staff had access to information technology. Theinformation technology infrastructure, including thetelephone system, worked well and helped to improvethe quality of care. The hospital intranet provided staffwith easy access to all relevant information such asprovider’s news, policies and sharing good practice.

• Information governance systems includedconfidentiality of patient records. There were systems toprotect patients’ data both electronic and paper based.

• Managers had access to information to support themwith their management role. This included informationon the performance of the service, staffing and patientcare. They had access to a live dashboard which covereda wide range of key areas of service performance.

• Information was in an accessible format, and wastimely, accurate, and identified areas for improvement.

• Staff made all notifications to external bodies asneeded. The Care Quality Commission received relevantnotifications as required. The local authority receivedsafeguarding alerts notifications.

Engagement

• Staff and patients had access to up-to-date informationabout the work of the provider and the services theyused. The carers and families told us thecommunication with the hospital was not very good tokeep them well informed about the service. The hospitalarranged its first carers and family’s day in July to

engage with them, seek their views, update them aboutthe service and provide them with any relevantinformation. The provider had a website withinformation about the services.

• The provider had ways to keep their staff and patientswell informed and up to date about the service. Theyused intranet, emails, newsletters, noticeboards andface to face meetings.

• Patients and carers had opportunities to give feedbackon the service they received in a manner that reflectedtheir individual needs. The service used ways such assuggestion box, surveys, meetings, open discussion, andthe advocate on how patients and carers could givefeedback to the service.

• The service welcomed feedback from patients, carersand staff and the managers used it to makeimprovements. There were examples of improvementsmade because of feedback from patients. Feedback wasalways reported and acted on in a timely way.

• Patients and carers were not always fully involved indecision-making about changes to the service. Patientsand carers were not always consulted about changes inthe service.

• Patients and staff could meet with members of theprovider’s senior leadership team to give feedback.Managers took the feedback from patients seriously.

• Directorate leaders engaged with external stakeholderssuch as commissioners and local authority.

Learning, continuous improvement and innovation

• Although the provider had a corporate providercompliance assessment team that visited all hospitalsto assist with any issues surrounding compliance. Staffwere not given the time and support to consideropportunities for improvements and innovation that ledto changes. There were no members of staff that wereallocated to take the lead in implementing best practiceand improvements in key clinical areas. Improvementswere not always identified, or action was not alwaystaken.

• Staff did not participate in research.• Some innovations were taking place in the service. The

psychology team reviewed the use of the latestpsychological models to work with their complexpatient groups. The speech and language therapist won





the National Learning Disabilities Award for “breakingthe barriers” for finding creative ways of enhancingcommunication with patients with communicationdifficulties.

• Although the organisation had systems to supportimprovement such as rewards, data systems, and ways

of sharing information. Staff did not use qualityimprovement methods and did not know how to applythem. Staff lacked the knowledge and skills to useimprovement methods.

• Staff did not participate in national audits andaccreditation schemes relevant to the service andlearned from them.





Areas for improvement

Action the provider MUST take to improve

• The provider must ensure that the ligature riskassessments for each ward are detailed enough toaddress identified risks and shared with staff on thewards.

• The provider must ensure that the checks made bystaff on emergency equipment and medicines arereliable and valid as true reflection of what was held inthe emergency bag.

• The provider must ensure that all wards have enoughnursing staff of all grades to meet the needs of thepatients and adequately put systems and processes tomitigate the risks associated with high use of agency.

• The provider must ensure that they accuratelycalculate and review the number and grade of nursesand support workers for each shift to allow staff to getrest breaks and regular breaks from enhancedobservations according to National Institute of Healthand Care Excellence guidance.

• The provider must ensure that there is clear leadershipat ward level and that staff on duty are alwaysexperienced and have the right skills and knowledgeto meet the needs of the patient group.

• The provider must ensure that the wards have goodstaff skill mix and that all staff including agency havereceived specific training to equip them with the rightskills required for working with people with learningdisabilities or autism. Staff must receive the necessaryspecialist training for their roles.

• The provider must ensure that there is acomprehensive structured induction programme foragency staff to all the wards.

• The provider must ensure that staff are supported withappraisals, regular supervision and opportunities toupdate and further develop their clinical andleadership skills.

• The provider must ensure that staff always followsystems and processes to safely store and managemedicines.

• The provider must ensure that there is clear learningfrom incidents discussed with staff, both internal andexternal to the service and that managers and staff aremade aware of the Learning from Deaths MortalityReview (LeDeR) Programme.

• The provider must ensure that physical health isconsistently monitored and that all patient monitoringrecords about annual physical health checks areaccurate.

• The provider must ensure that care plans are alwaysreflecting the assessed needs and are alwayspersonalised, holistic and recovery-oriented.

• The provider must ensure that all staff are aware ofcare plans and positive behavioural support plans anduse this information to enhance the quality of patientcare.

• The provider must ensure that staff always assess andrecord capacity to consent clearly each time a patientneeds to make an important decision where theymight have impaired mental capacity.

• The provider must ensure that they carry out anautism friendly assessment to ensure that theenvironment is therapeutic for patients with autismand that the patient dynamics are adequately andregularly reviewed to ensure the environment iscomfortable for all patients.

• The provider must ensure that the needs of patientswith specific communication needs are met.

• The provider must ensure that governance processesoperate effectively at all levels and that performanceand risk are managed well.

• The provider must ensure that staff participate inclinical and internal audit processes to include mentalcapacity audit and that they function well and have apositive impact on quality governance.

Action the provider SHOULD take to improve

• The provider should ensure that emergency drugs arein date and available in the resuscitation emergencybags. Regulation 12(2)(b).

• The provider should ensure that managers alwaysdebrief and support staff after serious incidents.Regulation 18(2).

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


• The provider should ensure that all patients have ahospital passport in place and it is fully completed.Regulation 9(3)(b).

• The provider should ensure that staff attend regularteam meetings on wards. Regulation18(2)(a).

• The provider should ensure that staff know who theidentified lead for Mental Capacity Act is and knowwhere to get advice within the hospital regarding theMental Capacity Act and Deprivation of LibertySafeguards. Regulation 17(2)

• The provider should ensure that families and carersare provided with information or signposted on how toaccess carer’s assessment. Regulation 9(3)(g).

• The provider should consider that there is a sensoryroom at the hospital to meet the needs of patients.

• The service should ensure that all suitableadjustments are made to cater for disabled patients orvisitors to access the premises. Regulation 17(1).

• The provider should ensure that there is clear learningand staff receive feedback on the outcome ofinvestigations of complaints and acted on the findings.Regulation 17(2)(a)

• The provider should ensure that there is an activestrategy to consistently promote equality and diversityin day to day work. Regulation 17(2)(b).

• The provider should consider that staff engage activelyin local and national quality improvement initiatives.Regulation 17(2)(f).

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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

Regulated activity

Assessment or medical treatment for persons detainedunder the Mental Health Act 1983

Treatment of disease, disorder or injury

Regulation 9 HSCA (RA) Regulations 2014 Person-centredcare

Care plans did not always reflect the assessed needs andwere not always personalised, holistic andrecovery-oriented. 9(3)(b)

Staff were not always aware of care plans and positivebehavioural support plans to use this information toenhance the quality of patient care. 9(3)(b)

The needs of patients with specific communicationneeds were not adequately met. 9(3)

This was a breach of regulation 9

Regulated activity



Regulation 11 HSCA (RA) Regulations 2014 Need forconsent

Staff did not always assess and record capacity toconsent clearly each time a patient needed to make animportant decision where they might have impairedmental capacity. 11(1)


Regulated activity



Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Regulation

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


The ligature risk assessments lacked clear actions onhow the risk identified was to be managed. 12(2)(b)

Staff did not always follow systems and processes tosafely store and manage medicines. 12(2)(g)

Physical health was not consistently monitored, patientswith constipation had no care plans in place and bowelmonitoring charts were not always completed. 12(2)(b)


Regulated activity



Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

The governance processes did not operate effectively atall levels and that performance and risk were notmanaged well.

Staff did not participate in clinical and internal auditprocesses and they did not function well and had apositive impact on quality governance.

The checks made by staff were not reliable and valid as atrue reflection of what was held in the emergency bag inMoneystone.

There was no clear learning from incidents discussedwith staff, both internal and external to the service andthat managers and staff were not aware of the Learningfrom Deaths Mortality Review (LeDeR) Programme.

The provider did not carry out an autism friendlyassessment to ensure that the environment wastherapeutic for patients with autism and that the patientdynamics was adequately and regularly reviewed toensure the environment was comfortable for all patients.

This was a breach of regulation 17(1)(2)(a)

Regulation


Requirement noticesRequirementnotices


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

Regulated activity



Regulation 18 HSCA (RA) Regulations 2014 Staffing

All wards did not have enough nursing staff of all gradesto meet the needs of the patients and no adequatesystems and processes in place to mitigate the risksassociated with high use of agency. 18(1)

The provider did not accurately calculate and review thenumber and grade of nurses and support workers foreach shift to allow staff to get rest breaks and regularbreaks from enhanced observations according to NICEguidance. 18(1)

There was clear leadership at ward level and that staff onduty were always experienced and had the right skillsand knowledge to meet the needs of the patient group.18(1)

The provider did not ensure that the wards had goodstaff skill mix and that all staff including agency hadreceived specific training to equip them with the rightskills required for working with people with learningdisabilities or autism. Staff had not received thenecessary specialist training for their roles. 18(2)(a)

The provider did not ensure that there was acomprehensive structured induction programme foragency staff to all the wards. 18(2)(a)

Staff were not supported with appraisals, regularsupervision and opportunities to update and furtherdevelop their skills. 18(2)(a)


Regulation


Enforcement actionsEnforcementactions


the woodhouse independent hospital - cqc

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