huntercombe hospital - maidenhead … · 2020. 2. 3. · backgroundtohuntercombehospital-maidenhead...

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 Good –––

Are services safe? Good –––

Are services effective? Requires improvement –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

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.

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Huntercombe Lane SouthTaplowMaidenheadSL6 0PQTel: 01628 667881Website: http://huntercombe.com/our-centres/the-huntercombe-hospital-maidenhead

Date of inspection visit: 16th – 18th February 2016Date of publication: 21/06/2016

1 Huntercombe Hospital - Maidenhead Quality Report 21/06/2016

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.

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

Overall summary

We rated Huntercombe Hospital Maidenhead asgood because:

• Processes were in place to manage environmentalrisks and the hospital complied with same-sexaccommodation guidelines. Emergency equipmentwas available and checked regularly. Wards were cleanand there were nurse call bells for patients andpersonal alarms for staff. Each nursing shift throughoutthe day and night was covered with qualified andunqualified staff and there was appropriate use ofagency staff. Staff assessed risks and observedpatients according to their risk. There were robust linkswith the local authority and staff were aware ofsafeguarding procedures. Following incidents therewas good investigation and learning, and changeswere made. Staff had processes in place to ensure thatphysical health needs were met.

• There was timely assessment of needs on admission.Medicines and therapy were provided as directed inNICE guidance. Staff used a range of evidence basedpsychometric tests and outcome measures. Staffreceived induction and training relevant to their rolesand had access to a specialist training budget. Theyreceived regular supervision from their managers. Wefound there to be comprehensive, informativeshift-to-shift handovers on all wards. Mental Health Actpaperwork was in good order.

• Staff were caring, treated patients with dignity andrespect and were knowledgeable of patients’ needs.There was excellent involvement in hospital affairs andpatients’ views were sought and implementedregarding changes to the hospital.

• Transition options were available for patients to stepup to a more secure ward or down to a ward withgreater freedom dependant on risk. There were a

range of facilities inside the wards and in the grounds.Patients were able to personalise their bedrooms.Activities were available throughout the week.Catering was provided and the team were able to caterfor individual patients’ ethnic or religious dietaryneeds. Complaints were dealt with appropriately andthe provider fulfilled its duty of candour.

• The hospital management were visible and supportiveto staff. There was oversight of performance throughmonitoring and review. The hospital responded to staffand patient needs from the results of questionnaires,user involvement groups and a staff forum.Communication from management had beenimproved with the addition of a newsletter. There hadbeen a recent restructuring of the senior managementteam which had a positive effect on morale andteamwork.

However:

• Staff knowledge of the Mental Capacity Act wasinconsistent and knowledge of Gillick Competencywas poor.

• A decision had been made to allow staff to use a roomfor seclusion that did not comply with their own policyor the guidance in the Mental Health Act Code ofPractice.

• We found that there were blanket restrictions on all ofthe wards rather than patients being individuallyassessed for restrictions.

• Staff did not consistently report all lower levelincidents on the wards and tended to focus onrecording incidents of restraint.

• Patients gave some negative comments about thenight staff.

• There were mixed reports on the quality of the food.

Summary of findings


Contents

PageSummary of this inspectionBackground to Huntercombe Hospital - Maidenhead 5

Our inspection team 5

Why we carried out this inspection 5

How we carried out this inspection 5

What people who use the service say 6

The five questions we ask about services and what we found 7

Detailed findings from this inspectionMental Health Act responsibilities 12

Mental Capacity Act and Deprivation of Liberty Safeguards 12

Overview of ratings 12

Outstanding practice 28

Areas for improvement 28

Action we have told the provider to take 29

Summary of findings


Huntercombe HospitalMaidenhead

Services we looked at -Child and adolescent mental health wards

HuntercombeHospitalMaidenhead

Good –––


Background to Huntercombe Hospital - Maidenhead

Huntercombe Hospital Maidenhead is a specialist childand adolescent mental health inpatient hospital(CAMHS). It is a 60 bedded independent hospital ownedby Four Seasons Ltd. It provides specialist mental healthservices for adolescents and young people from 12 to 25years of age and is registered to treat patients who aredetained under the Mental health Act 1983. It also haspatients who are informal. Huntercombe deliversspecialised clinical care for young people of both gendersrequiring CAMHS, including eating disorders.

The hospital and its surrounding grounds are within arural setting and are situated near a town with easyaccess to transport links and shops. In-house sports andsocial facilities include a gymnasium, an enclosed gardenand asports area. Patients are supported in theireducation via the hospital school. Where appropriate thepatients have access to the hospital grounds and localcommunity facilities.

The hospital consists of four wards, all wards are mixedgender:

• Kennet ward provides eating disorder services and has20 beds.

• Tamar ward provides Tier 4 CAMHS general adolescentservices and has 11 beds.

• Thames ward with 14 beds and Severn ward with 15beds provide psychiatric intensive care services (PICU).

The hospital was previously inspected in December 2014as part of the pilot for Care Quality Commission’s newinspection methodology, it was therefore not rated. Theprevious inspection report was positive about care at thehospital but found there was some action for them totake around patient risk assessment. The complianceaction related to a breach of regulation 9 of the Healthand Social Care Act 2008 (Regulated Activities) Thismeant that the hospital had to ensure that riskmanagement plans were clear and updated regularly,when new risks were identified. Following this inspectionwe were satisfied that improvements had been made andthe compliance action had been met.

Our inspection team

Team leader: David Harvey, CQC Inspector. The team that inspected the service consisted of threeCQC inspectors, an inspection manager, a mental healthact reviewer and two specialist advisors with experiencein CAMHS services.

Why we carried out this inspection

We inspected this service as part of our on-goingcomprehensive mental health inspection programme.

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?

Summaryofthisinspection

Summary of this inspection


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

During the inspection visit, the inspection team:

• visited all four wards at the hospital, looked at thequality of the ward environment and observed howstaff were caring for patients

• spoke with the hospital director and registeredmanager

• spoke with 23 patients who were using the service• looked at 35 care and treatment records of patients• spoke with the managers for each of the wards• spoke with 19 other staff members; including doctors,

nurses, occupational therapists, occupational therapyassistants, support workers and support workermanagers

• spoke with a social worker, lead nurse and a drug andalcohol worker

• received feedback about the service from advocatesand commissioners

• attended and observed three hand-over meetings,activity groups and two multi-disciplinary meetings

• reviewed employment records, serious incidents,complaints and training records

• carried out a specific check of the medicationmanagement on all wards

• looked at a range of policies, procedures and otherdocuments relating to the running of the service.

What people who use the service say

• Patients gave mixed reports about how staff treatedthem. Some patients felt cared for, reported staff werefriendly, and that they were included in decisionsabout their care.

• Nurses knocked before entering their rooms and knewpatients preferred names.

• Staff were respectful. One patient stated that youcould tell the staff cared, as they gave time when it wasneeded and another patient stated that staff went the

extra mile. The 2015 CAMHS patient experiencequestionnaire showed that 85% of patients feltsupported by staff when they needed help and 81%felt that staff treated them with dignity and respect.

• However, we heard from some patients that they feltpoorly treated by certain staff. Several patientsreported that the night staff were rude, often talked intheir own language, were noisy and fell asleep onobservations. The issues with night staff had beenraised in the user involvement group and wardmanagers were aware and taking action to resolvethis.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?• Wards were clean and tidy and staff had assessed the

environment for risks, and were aware of risks from ligatures. Allwards were mixed gender and consideration was given togender separation.

• The resuscitation equipment and emergency drugs werechecked regularly. Staff complied with infection controlprocedures, two staff had been trained to lead on infectioncontrol.

• Shifts were covered by qualified and unqualified staff. Agencynurses were known by the hospital and booked appropriately.There was enough staff to monitor physical health and toundertake physical interventions. A consultant psychiatrist wason call to provide out of hours medical cover.

• Staff assessed patients’ risks on admission, at regular intervals,and following an incident. Patients’ rights were explained tothem regularly. Observations were prescribed according to risksand these were reviewed by staff regularly. Care plans werecreated for when to administer ‘as required’ medications. Thismeant that staff were well informed of a stepped approach tomanaging patients’ mental state with medication.

• Review of seclusion was in line with the hospital policy. Staffcreated reintegration plans for the patient in seclusion andthere were efforts made to discontinue seclusion.

• Staff received training in safeguarding and were knowledgeableof the procedures relating to these. A safeguarding lead for thehospital had oversight of safeguarding and there were goodlinks with the local authority.

• Incidents of restraint were recorded. Serious incidents wereinvestigated and there were changes made as a result. A safetyand governance meeting had been set up to share and discussindividual incidents.

However:

• A decision had been made to use an en-suite bedroom onThames ward as seclusion room. The room did not comply withthe guidelines set out in the Mental Health Act Code of Practiceor the hospitals own seclusion policy.

• Staff were underreporting incidents on the wards with the focusof incident reporting on incidents of restraint. Hospitalmanagement had increased staff training to address this.

Good –––




• While it was clearly documented when patients had refusedphysical health monitoring following rapid tranquilisation wefound that staff monitoring for patients following rapidtranquilisation was inconsistent.

• We found that there were blanket restrictions on all of thewards such as locked toilets and lounges, therefore restrictionswere not put in place according to individual patient need.

Are services effective?• Staff knowledge of the Mental Capacity Act was inconsistent

and there was poor understanding of Gillick Competency.Gillick Competence is a test in medical law to decide whether achild of 16 years or younger is competent to consent to medicalexamination or treatment without the need for parentalpermission or knowledge. Particularly on Kennet ward therewas a tendency to consider under 16’s to need parental consentrather than assessing capacity to gauge whether the patientwas able to consent for themselves as Gillick Competent.

• We found instances where medication had been prescribedand administered without it being included on theaccompanying T2 or T3 document. Form T2 is a certificate ofconsent to treatment completed by a doctor to record that apatient understands the treatment being given and hasconsented to it. Form T3 is a document completed by a secondopinion appointed doctor to record that a patient is notcapable of understanding the treatment he or she needs or hasnot consented to treatment, but that the treatment is necessaryand can be provided without the patient’s consent.

• We found that care plans were often instructional towards staffrather than written in the patients’ voice.

However:

• Patients’ needs were assessed on admission. Physical healthand food and fluid intake was monitored. Staff completed careplans for a range of needs.

• Medication and therapy was provided as guided by theNational Institute for Health and Care Excellence (NICE). Therewere a range of therapies provided by therapy staff. Staff usedpsychometric testing and outcome measures.

• Staff engaged in clinical audits and made changes to theirpractice based on the outcomes. The eating disorder servicehad been audited against NICE guidance and found to becompliant.

• Induction processes were sound and there was inductionbased on the care certificate. Staff received regular supervision

Requires improvement –––




from their line manager. Poor staff performance was addressedappropriately. There was separate management of supportworkers meaning supervision that was given by nurses in thepast was now provided by support worker managers.

• Patients were reviewed weekly by the multidisciplinary team.There was comprehensive shift-to-shift handover on all wards.Care Programme Approach (CPA) meetings took place sixweekly with the inclusion of community teams and families.

• Mental Health Act documentation was in good order.

Are services caring?• Staff were knowledgeable of patient needs, interacted well and

treated patients with dignity and respect. Patients reported thatstaff were caring.

• Patients were oriented to the ward on admission and weredesignated a key worker and co-keyworker.

• An independent mental health advocate visited the hospitalweekly.

• Families and carers felt the hospital was compassionate andthat patients were well looked after. There was a bi-monthlyfamily and carers day so that they could meet staff and askquestions about the care provided.

• Staff facilitated a user involvement group which allowedpatients to make changes around the hospital. Participation inthe ‘glamour your manor’ scheme had given patients thechance to request and get an all-weather sports pitch, gazeboand outdoor furniture budgeted and planned for bythemselves.

• The hospital organised an annual fete for discharged patientsto come back and show staff and patients how they wereprogressing in their recovery. This was an incentive for currentpatients to recover and for them to see the face of recovery.

However:

• We heard negative reports from patients about the conduct ofsome night staff.

• Some families and carers reported that they were not alwaysinformed of treatment decisions.

Good –––

Are services responsive?• The hospital provided staff to take and support patients on

community and home leave. There were hospital cars availableto enable this.

• There was the option for patients to move through the hospitaldependent on their needs.

Good –––




• There were a variety of clinic and treatment rooms. There was awell-equipped school that was registered with Ofsted. Therewas a large amount of outside space for all wards includingsecure gardens for Thames and Severn.

• Patients were allowed to personalise their bedrooms, they hadaccess to a lockable safer storage area for personal belongings.

• Staff provided a range of recreational and therapeutic activitiesthroughout the week and weekends. These were based both onand off the wards.

• A welcome pack containing information about staying in thehospital was given to all patients on admission.

• The hospital provided Skype and FaceTime so that patientscould contact their families and carers. It was also used to helpfamilies and carers take part in care programme approach (CPA)meetings if they were unable to attend.

• The catering team catered for patients differing diets based onpersonal dietary choices and their cultural or religious needs.

• Complaints were reviewed effectively, and learning was sharedwith staff teams.

However:

• There were varying reports on the quality of the food.

Are services well-led?• The hospital was well-led and the management were visible

and known throughout the hospital, Regular drop-in sessionswere provided to meet the hospital director and registeredmanager.

• The hospital management had good oversight of performancethrough auditing. Staff numbers were adjusted according tochanges in need. Demand on the service was monitoredthrough a dashboard.

• The induction process had been changed so that new staffstarted together and mandatory training was delivered in ablock session.

• The hospital was seeking to improve its risk assessmentprocess by looking at best practice in other services.

• Following challenges posed by their new incident reportingsystem it was re-launched with increased training to improvepractice.

• Risks throughout the hospital were inputted and managedthrough a risk register.

• Sickness levels were low, staff were aware of the whistleblowingprocess. Staff felt supported by their line manager.

Good –––




• There was communication from senior management through amonthly newsletter and organisational health posters.

• There was commitment to quality improvement by internal andexternal review.

However:

• Staff we spoke with were not always aware of the hospitalvisions and values but as they were working within the statedvalues this did not have an adverse impact on patients.




Mental Health Act responsibilities

We do not rate responsibilities under the Mental HealthAct 1983. We use our findings as a determiner in reachingan overall judgement about the Provider.

• Staff received joint Mental Health Act (MHA) and MentalCapacity Act (MCA) training. The hospital completionrate for doctors and nurses was 62%. Staff wereknowledgeable about the different sections of the MHAand the restrictions that applied in practice.

• MHA oversight was by a mental health act administratorwho also completed audits of the paperwork. We foundevidence that paperwork was kept in good order, wascomplete, up to date and stored appropriately.

• Many of the patients were treated under parentalconsent rather than the individual consent of the youngperson. All care records documented who gave consentto treatment. Many of the patients who were treatedunder parental consent were treated on the eatingdisorder programme. Many of them had been assessedas not able to consent to treatment for their eatingdisorder. Therefore their parents had consented to thetreatment.

• Young people who were detained under the MentalHealth Act were informed of their rights in accordance

with the Code of Practice. There were signs up askinginformal patients to speak to a nurse if they wanted toleave the ward and staff explained this would be riskassessed on an individual basis.

• Medication was generally given in accordance with theconsent to treatment provisions of the MHA and Code ofPractice. However, we found instances wheremedication had been prescribed and administeredwithout it being included on the accompanying T2 or T3document. Form T2 is a certificate of consent totreatment completed by a doctor to record that apatient understands the treatment being given and hasconsented to it. Form T3 is a document completed by asecond opinion appointed doctor to record that apatient is not capable of understanding the treatmenthe or she needs or has not consented to treatment butthat the treatment is necessary and can be providedwithout the patient’s consent.

• The decision to use inappropriate facilities for seclusiondid not comply with the guidance in the Mental HealthAct Code of Practice. However, we found evidence ofrobust reviews of seclusion taking place and plans forreintegration to the ward.

• Independent Mental Health Advocacy was provided byan independent advocacy charity.

Mental Capacity Act and Deprivation of Liberty Safeguards

Staff received joint Mental Health Act (MHA) and MentalCapacity Act (MCA) training. The hospital completion ratefor doctors and nurses was 62%. An annual e-learningmodule on the MCA had been introduced in 2015 and hadachieved a completion rate of 64%.

The Mental Capacity Act (MCA) act does not apply toyoung people aged 16 or under. For children under theage of 16, the young person’s decision making ability isgoverned by Gillick competence. The concept of Gillickcompetence recognises that some children may havesufficient maturity to make some decisions for

themselves. Staff had varying degrees of knowledge ofthe MCA. Some staff we spoke to were not conversantwith the principles of Gillick and particularly on Kennetward there was a tendency to consider under 16’s to needparental consent rather than assessing capacity to gaugewhether the patient was able to consent for themselvesas Gillick Competent. Of the 17 records reviewed wecould find no rationale or assessments relating to thecapacity of young people to make decisions about theircare.

Detailed findings from this inspection


Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Child and adolescentmental health wards Good Requires

improvement Good Good Good Good

Overall Good Requiresimprovement Good Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Requires improvement –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Are child and adolescent mental healthwards safe?

Good –––

Safe and clean environment

• Kennet Ward was set inside the manor house atHuntercombe Hospital. The house was a grade 1 listedbuilding which meant the provider had limited optionsto adapt the building. As a result there were not clearlines of sight down the corridors and bedrooms weresituated at varying levels. This meant that staff were notable to observe all parts of the ward. Tamar Ward wassituated in a grade 2 listed building across a court yardfrom the manor house. There was CCTV to observe partsof the ward but staff were not able to have clear lines ofsight due to the nature of the ward being set over twofloors. Despite the issue with lines of sight, staffing levelsand observations mitigated these risks. Thames andSevern wards were in a purpose built building to theside of Tamar. Thames had two large areas that couldbe zoned to separate to male and female bedroomareas while Severn ward had bedrooms off a maincorridor and a separate annexe for patients that neededto spend time in a quieter area. Both wards had lines ofsight that made it easier for staff to observe larger partsof the ward.

• Assessment of ligature points were carried out by staff.Ligature points are places to which patients intent onself harm might tie something to strangle themselves.Wards were fitted with anti-ligature fittings such as doorhandles and collapsible curtain rails. Identified ligaturepoints were recorded on the environmental risk

assessment and staff were aware of how to manage therisks. Ligature cutters were available at several pointsaround each ward and handovers covered what to do inthe event of a ligature incident.

• All wards were mixed gender and complied with samesex accommodation guidance. Staff were able toseparate bedrooms according to gender mix. Therewere identified female lounges and toilets andbathrooms were designated according to gender.Thames had one en-suite bedroom and Severn hadfour. We found consideration given to the availabilityand mix of staff to ensure that care was given bysomeone of the same sex if needed.

• Each ward had resuscitation equipment, emergencydrugs and oxygen available to staff in the event of anemergency medical situation. These were kept in thestaff office and checked at the start of each shift toensure that items were working and in date. There werefully stocked clinic rooms on each ward that heldmedication, protective equipment such as gloves andsyringes and a medication fridge which was checkedregularly by staff. Equipment to measure bloodpressure, height and weight was available. However, wefound that there was only one examination couch in thehospital situated in the manor house near Kennet ward.Staff told us that the doctor would therefore examinepatients in their bedrooms or in the doctor’s offices.

• There were no dedicated seclusion rooms in any of thefour wards. A decision had been made to use theen-suite bedroom on Thames ward as a seclusion roomin order to manage risk. This room did not comply withthe Mental Health Act Code of Practice on seclusionrooms. Staff were guided to use this room as ‘openseclusion’ where the door would remain open but threemembers of staff would stop the patient from leaving, as

Childandadolescentmentalhealthwards

Child and adolescent mentalhealth wards

Good –––


well as having the door shut to contain the patient atother times. The bed was not visible from the viewingpanel in the door and the bathroom was not in aposition where staff could easily observe a patient usingit, without entering the bedroom. We found that theroom had only been used to seclude one patient,regular reviews took place by both the medical andnursing team and the local authority safeguarding teamwere notified of the use of the room. There was a clearrationale in the notes detailing why the patient neededto be nursed in seclusion, and there had been attemptsmade to end seclusion however the decision to use aroom which was not fit for purpose had potentially putstaff and the patient at risk and there had been assaultson staff. This patient had been referred to anotherhospital which was more suitable for their needs andwas waiting for a bed to become available. Hospitalmanagement gave assurances that this room would notbe used for seclusion in the future, and plans were inplace to develop a seclusion room within the extra carearea on Severn ward.

• We found the wards were cleaned and well furnished.Severn, Tamar and Thames appeared tired in placeshowever, they were generally well maintained. Reportsfrom patients at Kennet Ward at the time of theinspection were that the unit was dirty and in need ofredecorating. However, results from the patientexperience questionnaire showed that 83% of patientsat Maidenhead had found the wards to be clean. We sawdocumented evidence that ward and communal areasaround the hospital had been checked and cleanedregularly.

• Guidelines were available to staff around hand hygieneand all staff had received training in hand hygieneprocedures. A recent infection control audit hadidentified areas of the wards that needed attention, forexample, a build-up of lime scale around taps, areaswith scuff marks and medical equipment had notalways been cleaned. An action plan was developed asa result of the audit and a nurse and support worker hadbeen trained in infection control in order for them totake the lead in implementing the action plan. Therewere regular meetings, where progress against theaction plan was monitored.

• Call systems were available to patients to summon forstaff assistance. These were situated on the wall in theirbedrooms and at different areas throughout the wards.Staff carried alarms to summon help, these alarms fed

into a display in the main areas of the ward so that staffcould pinpoint the exact area where help was needed.There were plans to update this with a newer morerobust alarm system. Staff checked alarms weekly.

Safe staffing

• Shifts throughout the day and night were covered withnurses depending on the needs of the patients. Forexample Thames and Severn had a minimum of onemember of staff per patient which reflected the level ofobservations and risk that they were dealing with.Staffing numbers on top of this were adjusted accordingto increases in observations and we found that thewards were generously covered. Tamar and Kennet hadlower staffing levels which reflected the need of thepatients. There was always at least one qualified nurseon duty throughout the day and night with supportworkers making up the numbers.

• Ward managers reported staffing levels and the levels ofobservations via a daily shift report in order for seniormanagement to gauge the level of need on the wardsand supply staff accordingly. We found that generallywhen agency staff were used, they were familiar with thewards. The hospital used agencies that had trained theirstaff to an agreed level. The hospital had set up a pilotto offer additional shifts to their own staff, rather thancontacting agencies. A text system had been put inplace to text availability to staff. The result was areduction in next-day agency shifts by 29% with 249shifts going to their own staff.

• There had been previously been a high turnover ofsupport workers. The hospital had gone from 40 supportworker vacancies in September 2015 to -1.8 in Januarymeaning they had over recruited into posts.

• The hospital had a sickness level of 3.% over theprevious 12 months. There was 1.2 whole timeequivalent (WTE) qualified nurse vacancies, one vacancyfor a family therapist and there was locum cover for anassociate specialist doctor vacancy.

• The staffing levels across the hospital meant that therewere enough people to carry out physical interventionssuch as restraint. We found that when a ward wasunsettled staff could call for assistance from otherwards, using the radios to communicate.

• We found that patients were able to access a nurseeasily with their presence visible on the wards. Staff toldus that there were enough staff to provide 1:1 keyworker sessions and we found evidence of these taking



Good –––


place regularly in the notes. Activities were only evercancelled due to either risk or a lack of interest. If therewas staff shortage cover would be provided. We foundthat shifts were planned appropriately so that there wasconsideration given to external appointments. Thehospital had a number of cars that meant patients couldbe escorted home if the family were unable to collectthem.

• Medical cover was provided by a consultant psychiatristfor each ward, there was an associate specialist doctoravailable and out of hours, there was medical cover witha doctor on call. Staff were able to call on a local GPservice to provide general physical health support andmonitoring.

• A recent overhaul of the staff induction process meantthat staff would receive a week of mandatory training intheir first week of employment. This system meant thatstart dates could be synchronised and all employeeswould receive necessary training, in areas such asintermediate life support, child protection, health andsafety and Control of Substances Hazardous to Health(COSHH). This induction programme had achieved acompletion rate of 86%. We found that training in theMental Capacity Act, Fire Evacuation & Safety, ManualHandling Practical and Breakaway were below 75%completion

Assessing and managing risk to patients and staff

• There was one episode of seclusion in the previous sixmonths that occurred on Thames ward. Informationprovided prior to the inspection showed that there hadbeen 490 incidents of restraint in the six months of Mayto October 2015. Of these, 240 were on Thames and 188were on Severn, this included protective holds wherestaff would prevent a patient from self-harming. Staff didnot use prone restraint in their practice (prone restraintis when a person is restrained face down on the floor).

• Staff assessed the risk of patients on admission using arisk screening tool contained in the electronic recordsystem. We found that this risk assessment wasregularly updated by the multidisciplinary team (MDT) inthe patient’s clinical team meeting (CTM). Staff wereknowledgeable of patient risk and risk was discussed inhandovers as well as throughout the shift. Riskassessments were updated following incidents. Riskassessment was uniform across the four wards andoften the assessment linked into specific care plans. Thehospital had been found as needing improvement to its

process and documentation of risk in a previousinspection. It had therefore looked at best practice inrisk assessment to inform its current practice. It hadidentified the risk management approach used by anNHS Trust as a basis to improve their practice further.There was a separate specialist risk assessment foreating disorders.

• We found that blanket restrictions were in place acrossthe hospital. For example on Kennet, Severn andThames wards all toilet doors were locked and onSevern and Thames lounges were locked when not inuse. Staff stated that due to the nature of the patientgroup it was necessary to impose these restrictionsparticularly to reduce the risk of purging behavioursamong patients with eating disorders. We found thatpatients were not able to progress past 15 minuteobservations whilst staying at the hospital. Thereforepatients that had previously been on home leave andexperiencing a greater liberty, were then restricted whenthey returned to the hospital. This approach was notconsiderate to the patient’s recovery and impacted on apatient’s privacy and dignity.

• Patients’ rights were explained to them regularly ifdetained under a section of the Mental Health Act andthere were signs up in wards areas explaining about apatient’s right to leave if they were informal. Thisinformation was also in the patients admissioninformation pack. Doors were locked to restrictmovement into and out of the hospital. Staff explainedthat if a patient wanted to leave the hospital and theywere informal they would discuss this with the patient,assess risk and if appropriate offer to have a member ofstaff accompany them, particularly for younger patients.

• The level of observation was determined by the riskposed by the patient and where they were in theirrecovery. Nurses were able to increase observations, butonly a consultant was able to reduce the level ofobservations. We found that on Severn and Thamesthere was use of observations that meant a patient wassupervised by between one and three members of staffat all times. Observation levels for constant supervisionwere documented on an ‘Enhanced ObservationPrescription Form’. This form guided staff on the level ofobservations, reasons for the enhanced observations,documented risks staff should be aware of such asdeliberate self-harm and what level of privacy thepatient should have, for example, whether they shouldbe supervised in the toilet or bathroom. Enhanced



Good –––


observations were reviewed by the team daily anddocumented on the form. This form was shared with thebusiness administrator and clinical services managerdue to the enhanced level of observations oftenrequiring an increase in staffing levels. We found thatobservation levels were reviewed regularly and thatthere was discussion in handover and with themultidisciplinary team (MDT) about actively trying toreduce observation levels. Morning handover was anopportunity for nursing staff to inform the next shiftabout the levels of observation and what risks the staffmembers would need to be aware of.

• Staff were trained in Protecting Rights in the CareEnvironment (PRICE) in order to safely physicallyrestrain patients. PRICE techniques were only used as alast resort. Staff actively engaged with patients, knewtheir risks and attempted verbal de-escalation through1:1 rather than use restraint. There had been incidentsof restraint multiple times on the same patients due totheir behaviour.

• Rapid tranquilisation was used throughout the hospitalboth orally and by intramuscular injection (IM). This wasonly used as a last resort when other less intrusiveoptions had failed such as 1:1 time and distractiontechniques. Staff formulated a care plan for as required(PRN) medication. The care plan, called the PRNAlgorithm, stated short and long term goals for usingPRN. This was a stepped approach, instructing use ofde-escalation techniques as a first line of treatment,using oral as the second line of treatment and then IMas the third line. It also instructed staff what medicationto use first if the decision was made to medicate. Staffdid not always consistently complete physicalobservations following IM medication as directed by theNational Institute for Health and Care Excellence (NICE)guidance – Violence and Aggression: short termmanagement in mental health and community settings.In some cases it was documented in the notes thatphysical monitoring was refused. In order to improveconsistency a staff member and a pharmacist hadcreated a new form , which clearly set out NICE guidancefor documenting physical health post IM, this was in theearly stages of being implemented. The form guidedstaff on when to increase observations for example if thepatient had taken illicit drugs or alcohol or had apre-existing physical health problem. It provided

guidance on normal ranges for blood pressure,respiratory rates, and temperature with written advice tocontact the doctor if the patient was outside theseranges.

• Seclusion is the supervised confinement of a patient ina room, which may be locked. Its sole aim is to containseverely disturbed behaviour likely to cause harm toothers. Staff reviewed seclusion and documented thesereviews in accordance with their policy and in line withthe Mental Health Act 1983 Code of Practice. Therationale for seclusion was clearly stated in the notes asto why it was considered least restrictive option and inthe best interests of the patient. A care plan forseclusion was completed which set goals for the patient,for example, to reduce deliberate self-harm and forreintegration onto the ward. Regular reviews weredocumented by both nurses and doctors with evidencethat attempts had been made to end seclusion. Thisensured that the secluded patient was regularlyreviewed and not secluded for longer than wasnecessary, in accordance with the Mental Health Act1983 code of practice. Staff documented observations ina contemporaneous record of mental health andbehaviour while maintaining on-going physical healthmonitoring. However, we found that there continued tobe assaults on staff during the episode of seclusion,. Thelack of appropriate facilities around the environment ofthe room used for seclusion, meant that neither the staffnor patient’s safety was protected despite the aim of theseclusion being to reduce the risk of harm.

• Staff received training in safeguarding adults at risk andchild protection and knew how to identify safeguardingissues. Staff were knowledgeable about safeguardingprocedures and there was good oversight from asafeguarding lead, who was a social worker. There was asafeguarding nurse and a lead doctor for safeguarding.The safeguarding lead checked with the wards regularlyto identify safeguarding issues and if any incidentswarranted an alert to be raised. A flow chart was ondisplay in ward offices to remind staff how to respond toa safeguarding concern and all knew how to completedocumentation if disclosures were made. There weregood links with the local authority and where action wasneeded there was evidence that the staff at the hospitalworked in conjunction with the local authority tosafeguard patients. A spreadsheet of all safeguardingalerts made was held by the safeguarding lead andreviewed regularly.



Good –––


• Medicines were stored appropriately in clinic rooms.Staff checked controlled drugs regularly and monitoredthe temperature of the medicine fridge and the clinicroom. Pharmacy provision was supplied by an externalcompany who delivered medication daily. Thepharmacist attended weekly to conduct a prescriptionchart audit on each ward. Staff kept photos of patientson the medicines charts and allergies were written onthe front. Staff received training in medicinesmanagement via e-learning. Ward managers completedaudits of medication charts to ensure there were nodiscrepancies, for example checking to see allmedications had clear dose, route of administration,form and instruction. An action plan was put in place toaddress discrepancies on charts before beingre-audited.

• Visitor’s rooms were available for family visits for allwards. Both Thames and Severn wards had visitor’srooms accessible from the wards but were lockable toallow children to visit.

Track record on safety

• Over the previous twelve months there had been sixserious incidents requiring investigation (SIRI) and twoserious incidents requiring review (SIRR). The SIRI’sincluded attempts to abscond and incidents ofself-harm leading to serious injury. One of the self-harmincidents involved a Control of Substances Hazardous toHealth (COSHH) incident, where a patient ingestedcleaning chemicals obtained from the cleaning trolley.The SIRI was reviewed and discussed in the clinicalgovernance and senior management team meetingsand also in the health and safety meeting. As a result ofthis incident COSHH items used by cleaners on wardswere kept in locked containers to make it more difficultfor patients to access them.

Reporting incidents and learning from when things gowrong

• The hospital had moved from a paper-based to anelectronic incident management system, Datix. Datixallowed management to centrally monitor and manageincidents while allowing it to recognise trends andfeedback learning to the original reporter. Staff weretrained in Datix, however, since its implementation in2015 there had been challenges in embedding iteffectively, it was noted by hospital management thatout of 156 incidents reported 126 of these involved

restraint. The senior management team felt that staffwere therefore not reporting lower levels of incidentssuch as verbal aggression and this was being addressedwith staff teams. As a result, the hospital re-launchedDatix in order to focus on good practice in the reportingof incidents. More training was being provided for staffin order to raise awareness of what should be reported.

• At ward level incidents were discussed in the morningmulti-disciplinary team (MDT) handover and whether anincident had been recorded on Datix was addressed.The MDT reviewed incidents weekly in the Clinical TeamMeeting and this was documented in the patients’notes. More uncommon incidents were reviewed weeklyin the safety and governance meeting, in order to sharethinking and for staff to look for advice. The minuteswere cascaded to ward managers to share outcomeswith staff. Lessons learnt had been implementedfollowing incidents, for example on Tamar wardfollowing a patient’s money and property going missingthe safe had been moved so only nurses had access andzip lock bags were being purchased.

• Staff received de-brief but not after every incident, theywere given time off of the ward following restraint if theyneeded it. Staff stated that at times senior managementattended the ward following an incident in order to offertheir support.

Are child and adolescent mental healthwards effective?(for example, treatment is effective)

Requires improvement –––

Assessment of needs and planning of care

• Medical staff completed an initial history, mental stateand physical health examination on admission. Aroutine blood test and electrocardiogram (ECG) wasconducted for all new eating disorder patients. Consentwas sought and observations agreed upon. There wason-going assessment of mental and physical health bynursing staff which helped formulate care plans. Aninitial care plan was completed upon admission beforemore detailed care plans were completed.

• Staff monitored physical health completing vital signsweekly or more often if prescribed. Food and fluid intake



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was monitored for patients with an eating disorder.Physical health care plans were in place when neededto manage eating disorders or for monitoring clozapinefor example.

• We reviewed 35 sets of care records across the fourwards, including the electronic records on the patientinformation system Care Notes. We also looked at theaccompanying paper files. Staff completed care plans tomanage the risk and care of patients. A variety of careplans were in place such as risk related behaviour,occupational therapy, likes & dislikes and exercise andhealthy eating plans. There were a number ofstandardised care plans found in the hospital, forexample sleep hygiene, discharge and leave of absencecare plans. There was clear patient involvement in thecare planning process for a number of the care plans wereviewed, but this was inconsistent across the hospital.Staff documented whether or not a patient had beenoffered or accepted a copy of the care plan. Patientsstated that they did feel involved in decisions abouttheir care and patients’ views were included in someform even on the standardised plans.

Best practice in treatment and care

• Staff followed the National Institute for Health and CareExcellence (NICE) guidance, such as the guidance on‘depression in children and young people: identificationand management’, when planning the treatment andcare for patients. For example, medication wasprescribed in conjunction with psychological therapiessuch as individual therapy and family interventions. PRNmedication was prescribed in accordance with theguidance on violence and aggression. Care plans wereimplemented appropriately to reflect NICE guidance,which was linked to the website. The eating disorderservice, Kennet, had been reviewed against NICEguidance and was found to be fully compliant. Theself-assessment of Kennet in the Quality Network forInpatient CAMHS (QNIC) had referenced NICE guidanceregarding its provision of therapies in conjunction withmedication. For example the notes showed us thatdoctors reviewed medication weekly and we found thatchanges had been made through the physicalmonitoring of patients.

• The hospital employed psychologists, family therapists,occupational therapists and occupational therapyassistants and an art therapist. A dietician wasemployed to provide support for those with an eating

disorder. There was a total of 14 staff in the therapiesteam which was led by a Head of Therapies who wasalso a member of the senior management team. Wefound evidence that a range of therapies such ascognitive behavioural therapy (CBT) and dialecticalbehaviour therapy (DBT) offered by the therapists on a1:1 and group basis. Psychologists were assigned toindividual wards rather than throughout the hospital ashad previously been the case.

• An external GP provided general physical healthcare forpatients and visited the hospital weekly with all wardsable to book appointments. Staff were able to takepatients to the GP surgery if needed outside of theweekly visit. An associate specialist doctor completedblood tests and ECG’s on admission and when requiredthroughout a patients stay.

• Staff used the recognised rating scales Health of TheNation Outcome Scale Child and Adolescents(HONOSCA) and Children’s Global Assessment Scale(CGAS) throughout admission to assess and recordseverity and outcomes. Staff used the Connors-Wellsself-report scale to help recognise problem behavioursassociated with Attention Deficit Hyperactivity Disorder.Psychologists used the psychometric testing Beck YouthInventory (BYI) to evaluate patients emotional andsocial functioning with every patient. Staff on Kennetward completed the Eating Disorders ExaminationQuestionnaire (EDEQ) for all patients admitted. TheEDEQ concerns the frequency in which the patientengages in behaviors indicative of an eating disorderover a 28-day period. The completion of the EDEQ wasincluded in the Commissioning for Quality andInnovation Framework (CQUIN) to collect outcomes forpatients with an eating disorder. The CQUIN paymentframework enables commissioners to reward excellenceby linking a proportion of English healthcare providers'income to the achievement of local qualityimprovement goals. Throughout the 2014/15contractual year the hospital had achieved 87%completion in EDEQ.

• Staff engaged in a mixture of clinical and managementaudits on a wide range of topics. This included,medicines, Mental Capacity Act (MCA) Mental Health Act(MHA), supervision, outcome measures and infectioncontrol. Staff audited risk assessments and care plans toensure quality and completion. Audits were conductedby ward based nursing staff as well as management. Wefound evidence that when an audit tool was not



Good –––


available, for example, for safeguarding, it wasdiscussed in the senior management team meeting sothat the required staff would do a self-check. Staffcompleted environmental clinical checks monthly.Regularity of 1:1 key worker sessions was audited toensure that patients were receiving weekly 1:1 sessionswith their designated key worker. Outcomes of theseaudits were documented and action plans put in placeto ensure improvement in practice. The hospital hadidentified that there had been gaps in documentingthese sessions. Since the audit had been done andaction taken, there had been significant improvement inthis area. We saw notes that showed us that 1-1s wereregularly documented. An audit committee was in placeto ensure that audits were of good quality, containedrobust action plans and were completed on time. Thisthen fed into the clinical governance meeting.

Skilled staff to deliver care

• Staff from a range of backgrounds provided the care forthe patients at the hospital. There was a mixture ofnursing, therapeutic and medical disciplines making upthe MDT who all played a part in supporting a patient’srecovery. Each ward had a dedicated consultant andevery patient was appointed a key worker and co-keyworker. Support workers were employed to aid therunning of the ward and support the nursing team.There was great value placed in support workersthroughout the hospital and it was a role that was beingdeveloped further. There was a senior nurse in place toprovide nursing leadership and to develop the currentnursing team and to embed good practice.Occupational therapy and a therapeutic activitytimetable were provided with support fromoccupational therapy assistants. A drug and alcoholworker provided substance misuse focussed groupwork.

• Staff received induction in the hospital using a welcomepack, induction checklist and induction training. Staffwere given a clinical induction pack introducing hospitalpolicies and procedures, helping staff understand theirrole in keeping patients safe and well. Support workershad an induction based on the Care Certificate toprovide more structured learning and a qualification forsupport workers. This certificate needed to becompleted in the first 12 weeks of employment. A seniorsupport worker role had been developed to providecareer development for support workers. This helped to

improve the capacity of the workforce and these seniorsupport workers provided mentoring for new startersand helped to free qualified nursing staff. There was atraining budget for staff to request specialist training forprofessional development. Senior staff and nurses wereable to access specialist leadership training.

• Staff received regular supervision every six weeks.Hospital management had recently recruited twosupport worker managers to provide supervision and toaid the recruitment of support workers. These supportworker managers provided supervision during the dayand night in order to provide support for all supportworkers rather than relying on nursing staff to providesupervision that often got missed. An audit ofsupervision found that all nurses had receivedsupervision in the previous six weeks and only three out141 support workers had not received supervision in thesame period. Of these three, two were on night shiftsand one was on annual leave. An action plan had beenput in place to ensure that the remaining three hadbeen supervised by the end of February 2016. Alltherapy, medical, management and admin staff hadreceived supervision six weekly. Therapy staff facilitateda weekly reflective practice group. Staff received a yearlyappraisal.

• We found evidence that concerns with staff performancehad been addressed; for example if there was poorquality agency staff then this was raised with the agencyand the individual was not booked again. There wereother examples of managers taking action where thiswas needed.

Multi-disciplinary and inter-agency team work

• Ward consultants facilitated the clinical team meeting(CTM) once weekly. The CTM was an opportunity forprofessionals involved in the care of the patient todiscuss progress. This was done with patients andtogether care plans were put in place. Staffcomprehensively reviewed risks, observation levels,mood, behaviour, incidents, family contact, medication,interactions and group activities, sleep and diet andweight. This holistic approach was complemented byinput from the psychologist involved. Patients attendedthe CTM and were given the opportunity to askquestions and be included in the decision making. Staffgave patients a ‘what I want to say at my CTM’ form to



Good –––


write questions they wanted to ask the team. Actionsand outcomes were documented and evidencedprogression, for example, observations being reducedand home leave being agreed.

• Staff conducted shift to shift handovers led by the nursein charge. The handover was comprehensive andstructured, giving a summary of all risks that staffneeded to be aware of for each patient. Staffcommunicated sensitive personal issues such asbathroom privacy, reasons for observations, compliancewith medication and physical health issues. The nursehanding over reminded staff of generalised practicesuch as maintaining patient dignity, the procedure formanaging people tying ligatures, checking patients haveswallowed meds. Following on from this handover therewas an MDT handover for the medical and therapeuticstaff.

• Staff throughout the hospital ensured there was careplanning with external agencies such as communitymental health teams. Six weekly Care ProgrammeApproach meetings took place and always included thepatient’s community team. If an external agency orpatient’s family member was not able to make themeeting in person then there was the possibility of usingSkype.

Adherence to the Mental Health Act and the MHA Codeof Practice

• Staff received joint Mental Health Act (MHA) and MentalCapacity Act (MCA) training. The hospital completionrate for doctors and nurses was 62%.

• MHA oversight was kept by a mental health actadministrator who also completed audits of thepaperwork. We found evidence that paperwork waskept in good order, was complete up to date and storedappropriately.

• All patients under the age of 16 were treated underparental consent rather than the individual consent ofthe young person. All care records documented whogave consent to treatment. Many of the patients whowere treated under parental consent were on the eatingdisorder programme and many of them had beenassessed as not able to consent to treatment for theireating disorder. Therefore their parents had consentedto the treatment.

• Young people who were detained under the MentalHealth Act were informed of their rights in accordancewith the Code of Practice. Informal patients were

informed of their right to leave the ward. Staff explainedthat if a patient wanted to leave the hospital and theywere informal they would discuss this with the patient,assess risk and if appropriate offer to have a member ofstaff accompany them, particularly for younger patients

• Medication was generally given in accordance with theconsent to treatment provisions of the Mental Health Actand Code of Practice. However, we found instanceswhere medication had been prescribed andadministered without it being included on theaccompanying T2 or T3 document. Form T2 is acertificate of consent to treatment completed by adoctor to record that a patient understands thetreatment being given and has consented to it. Form T3is a document completed by a second opinionappointed doctor to record that a patient is not capableof understanding the treatment he or she needs or hasnot consented to treatment, but that the treatment isnecessary and can be provided without the patient’sconsent.

• The use of inappropriate facilities for seclusion did notcomply with the guidance in the Mental Health Act Codeof Practice. However, we found evidence of robustreviews of seclusion taking place and plans forreintegration to the ward.

• Independent Mental Health Advocacy was provided byan independent advocacy charity.

Good practice in applying the Mental Capacity Act.

• Staff received joint Mental Health Act (MHA) and MentalCapacity Act (MCA) training. The hospital completionrate for doctors and nurses was low at 62%. An annuale-learning module on the MCA had been introduced in2015 and had achieved a completion rate of 64%.

• Staff had varying degrees of knowledge of the MCA andin particular there was very poor understanding ofGillick Competency. Gillick Competence is a test inmedical law to decide whether a child of 16 years oryounger is competent to consent to medicalexamination or treatment without the need for parentalpermission or knowledge. Particularly on Kennet wardthere was a tendency to consider under 16’s to needparental consent rather than assessing capacity togauge whether the patient was able to consent forthemselves as Gillick Competent. Of the 17 recordsreviewed we could find no rationale or assessment ofmental capacity.



Good –––


Are child and adolescent mental healthwards caring?

Good –––

Kindness, dignity, respect and support

• The 2015 CAMHS patient experience questionnaireshowed that 85% of patients felt supported by staffwhen they needed help and 81% felt that staff treatedthem with dignity and respect.

• Staff interacted well with patients on the wards; theyappeared to treat them with dignity and respect andprovided both emotional and practical support. Staffengaged in activities on both a formal and informalbasis. We found an impromptu knitting and crochetgroup taking place on Thames ward and there appearedto be the freedom for patients to request and engage inactivities they wanted to do. Despite the complexity ofpatients at the hospital, many staff had been in post fora number of years and were dedicated. They engagedpatients that were quieter and less confident thanothers and joined in general conversations about musicand other interests.

• We heard staff talk about patient’s personalities andpersonal aspects of their care. We observedcomprehensive handovers and on the ward staff weresensitive to individual patient needs. We heard staff saythings such as ‘we never give up’, that the patients were‘great’ and that they loved their job. Staff appearedgenuinely pleased when a patient had reached amilestone that meant they could go out on the trip.

• Patients had mixed reports about how staff treatedthem. Some patients felt cared for and that staff werefriendly, they were included in decisions about theircare. Nurses knocked before entering their rooms andthey knew their preferred names. Staff were respectfuland a patient stated that you could tell they cared, gavetime when it was needed and another patient statedthat staff went the extra mile. However, we heard frompatients that felt poorly treated by some night staff.Several patients reported that the night staff were rude,often talked in their own language, were noisy and fellasleep on observations. Issues with night staff had beenbrought up in the user involvement group and wardmanagers were addressing these issues.

• The hospital had implemented the Friends and FamilyTest (FFT) which was a CQUIN but then built into theirstandard contract. The FFT was asked in 100% ofdischarges with 68% likely or extremely likely torecommend the service to a family or friend.

The involvement of people in the care they receive

• Patients reported that they felt involved in the planningof their care, but this was not consistently reflected incare plans, which often lacked patients views or asignature. It was not always clear when a patient hadbeen given a care plan. Risk assessments werecompleted with the patient in the weekly Clinical TeamMeeting (CTM). Patients were given the opportunity tobe a part of CTM and able to have their say. The hospitalhad piloted the inclusion of patients in the CTM onSevern ward and due to its success rolled this out toThames and Tamar wards. Patients on Kennet declinedthis approach and said they were happy with 1:1feedback.

• An advocate visited the wards weekly and there wassignage up in ward areas advertising the advocacyservice provided by an independent advocacy charity.Despite having a presence on the ward there was anelectronic referral system for advocacy as well as aninformal point towards patients that might needadvocate support. Prior to the inspection we gainedfeedback from advocacy who felt ward staff wereextremely helpful and went out of their way to besupportive, staff were friendly and good care was given.However the hospital was not proactive in telling theadvocate about care programme approach meetingdates.

• Staff stated families and carers were informed ofprogress in care following patient CTM’s and when therehad been an incident. Family therapy was provided anda new ‘solutions focussed’ approach had beendeveloped for families to support patients with aneating disorder post discharge. Families we spoke withfelt the hospital was compassionate, there was access totherapy, patients were looked after and that the hospitalwent above and beyond the call of duty. Some reportedregular contact from the consultant, however, this wasnot consistent and we found that decisions abouttreatment and changes in condition occurred withoutfamilies knowing. There was a bi-monthly psycho



Good –––


education group for families and there was a family andcarers day, so that families and carers could meet staffand other parents to ask questions about the care andtreatment available.

• Staff held a community meeting each morning to planthe day on the ward and inform the patients whatactivities were being provided. Patients facilitatedweekly community meetings on the wards as anopportunity to provide feedback about the service andto engage in discussion about what could be improved.The meeting was attended by members of the MDT andfollowed a set agenda that included items such asfeedback about staff, ward rules, complaints andreminded patients of their named key worker. Minutesof this meeting were kept on the wall in the patientlounge.

• Staff facilitated a user involvement group, which was ajoint meeting between patients and staff from all wardsin the hospital. This group was an opportunity forpatients to request improvements and shareexperiences in the hospital, both good and bad.Requests from this group were considered and thehospital made appropriate changes when possible. Forexample; patients had requested new carpets in thelounges, the hospital therefore replaced all the carpetsin all the lounges; patients said that they wanted acooked breakfast at weekends, the occupationaltherapists had therefore begun buying ingredients forpatients to cook their own breakfasts at weekends.Changes in the hospital were communicated to patientson ‘You said, We Did’ posters.

• Patients at the hospital had triggered large changes andimprovements by taking part in the ‘Glamour YourManor’ scheme. This scheme provided funding tosuccessful applicants with a budget to carry out theirimprovement plans for the hospital. In 2015 the userinvolvement group had requested an all-weather sportspitch usable for football, basketball and other activities,planting for the gardens, sports equipment such as goalposts, picnic benches, tables and gazebos and a sensoryroom. The proposal was service user led and budgeted.The hospital won the money and made theimprovements. Patients and families were asked whatimprovements could be made in the hospital in 2016.Plans for the Glamour Your Manor 2016, included

securing funds to update the kitchen so that patientswith an eating disorder could cook and eat with theirfamilies, improve parking facilities and installing betterair conditioning in the Psychiatric Intensive Care Units.

• The hospital put on an annual fete in the grounds andinvited ex-patients of the hospital back to attend. Theyfelt it was an incentive for patients to come back and letthe staff at the hospital know how they were doing andstaff could hear about the care they provided in a morereflective way. Patients could also meet former patientsand see recovery in action. The hospital provided abouncy castle and put on a barbecue.

Are child and adolescent mental healthwards responsive to people’s needs?(for example, to feedback?)

Good –––

Access and discharge

• Data submitted by the hospital prior to the inspectionshowed average bed occupancy of 88%. Both Kennetand Severn wards had bed occupancy of 85%, whichshows that while there was a high demand for thisservice beds were available when needed.

• Patients were admitted to the hospital from across thecountry to be admitted to the hospital, staff often had tofacilitate leave for patients. Staff therefore took patientsto their homes using the hospital cars and we heardfrom parents who said the hospital had supported theirchild in building confidence to use the train. Staff didnot admit other patients into those beds when patientswere on leave. Therefore if there were issues whilst apatient was out on leave there was always a bed ontheir return.

• Due to the hospital providing step up and step downcare there was the possibility that when patients healthimproved they could progress to one of the wards withless security. Equally there was the ability to move apatient to a Psychiatric Intensive Care Unit (PICU) bed ifrisks increased. Staff told us that commissioners werehappy for patients to move through the hospital. Movesthrough the hospital only occurred when it was clinicallyjustified but there were always attempts to movepatients closer to home if they were not local.



Good –––


• Referrals were considered on clinical grounds and theoverall decision to admit was with the consultantpsychiatrist, however, there was a full discussion withinthe MDT and the needs of the other patients wasconsidered. Patients were usually admitted to thehospital during the day but if an urgent admission wasneeded this was facilitated. Kennet ward tried to admitonly on a Tuesday but were able to accommodateadmissions on a different day if needed. Dischargeoccurred at an appropriate time and was plannedduring the Care Plan Approach (CPA) process.

• Data submitted prior to the inspection showed thatthere was one delayed discharge due to the patientbeing over 18. The hospital had been working closelywith commissioners to find an appropriate placement.

The facilities promote recovery, comfort, dignity andconfidentiality

• The hospital had a variety of clinic rooms, therapyrooms, activity rooms and visitors rooms. There was aschool that had been registered with Ofsted whichincluded several classrooms with books, art equipmentand computers. Wards had an occupational therapykitchen for functional assessments, there was a pop-upsensory room and ample outside space. There werelounges with sofas and televisions.

• Staff oriented patients to the ward on admission, a keyworker was designated and an admission pack given.The admission pack contained information on therunning of the ward, meal times, medication times,patient rights, advocacy contacts and the role of staffmembers in the multidisciplinary team. We found theadmission pack to be informative and easy to read

• Staff did not allow mobile phones onto Thames andSevern so provided a cordless phone for patients to use.Tamar and Kennet allowed mobile phones providingthey did not have a camera.

• The hospital was set in 8-9 acres of grounds, most ofwhich was accessible to patients. Access to outsidespace was restricted for patients on Thames and Severnbut staff provided outside activities and stated that theytried to get patients outside in the garden as often asthey could.

• Patients reported mixed feelings about the food onoffer. There was a choice of food available and there hadrecently been a menu revamp at the request of patientsin the user involvement group. Patients told us the food

was getting better but that often they did notunderstand what was in the food provided, as therewere obscure names for some of the dishes. Drinks andsnacks were available at the request of patients. The2015 Child and Adolescent Mental Health Service(CAMHS) patient experience questionnaire showed thatonly 45% of patients were asked about their views onthe food, 89% felt they were given enough food anddrink and 69% felt supported at meal times.

• Patients’ bedrooms were personalised with posters onthe wall and own bedding in places, a wall was paintedwith blackboard paint in each bedroom. Patients wereable to personalise their bedrooms, Patients had accessto their bedrooms throughout the day.

• Staff stored patients personal belongings in designatedcupboards, belongings were inventoried on arrival atthe hospital. Due to risk it was sometimes necessary forpersonal belongings to be moved and stored away for ashort time. We found that when that happened itemswere stored safely, staff reported that they kept a recordof what was kept in the store rooms.

• Staff facilitated a range of hospital and communitybased activities. A therapeutic timetable was in place forweekdays where structured psycho educationalactivities, coping skills, individual occupational therapy/psychotherapy slots and general activity wasintertwined with school. There were evening physicalactivity sessions such as yoga and Zumba and also amovie night. Weekend activity was timetabled and aseparate half term timetable was put in place for eachward. Both term time and half term activities providedcommunity visits such as cinema trips and library visits.

Meeting the needs of all people who use the service

• There were few adaptations for disabled people. Therewas a lift available in the PICU building but neitherTamar and Kennet were wheelchair friendlyenvironments.

• There was information available to patients throughoutthe hospital and in the admission pack; staff were ableto provide information on medication and treatments.Notices were up in the corridors of the wards advertisingservices provided for example advocacy. Patient rightswere displayed on the walls of the wards as wereprocesses on how to make a complaint. We found thaton days where there was a Clinical Team Meeting there



Good –––


was an order of patients to be seen displayed. Staffpictures and names were displayed, showing who wason shift that day and who their allocated key worker andco-key worker was.

• The hospital provided a tablet for Skype and Facetimefor patients and families to keep in touch and forfamilies who were a long way from the hospital to usefor care programme approach (CPA) meetings. We foundthat when the use of these was agreed there was a careplan in place.

• On Tamar ward there was a board patients could use toreflect their mood if they did not feel confidentapproaching a member of staff. There were pictures andcolours they were able to put up on the board thatreflected how they were feeling and space to tell staffwhat sort of interaction would be helpful. For examplethe colour green and a smiley face indicated that theywere feeling good whereas the colour red and a sad orangry face would show the opposite.

• The catering team were able to provide food dependingon personal dietary choice or on religious need andwere supplying halal meals to a patient. There wasaccess to a prayer box and the hospital had links to localfaith groups. There was access to an interpreter whichneeded to be arranged through the hospital socialworker.

Listening to and learning from concerns andcomplaints

• Data provided prior to the inspection showed that thehospital had received 14 complaints over a 12 monthperiod. Seven of these were on Severn ward, five onTamar and two on Thames. Of the 14 complaints sixwere upheld with four of these six only partially upheld.

• We reviewed complaints made to the hospital andfound that the hospital were transparent andacknowledged when they had made mistakes. Staff toldus that patients knew how to complain, there wasinformation available displayed on the notice boards.There was ward level focus on complaints which meantthat complaints were dealt with in community meetingsand the patients CTM to try and resolve issues early on.

• We found that following a complaint being made therewas communication about investigation time frameswith the complainant. When there was more timeneeded there was a letter sent asking the complainantfor more time. We found evidence of change whenformal complaints were upheld. For example, following

a complaint regarding care for a patient with an AutisticSpectrum Disorder (ASD) there was ASD trainingimplemented. Lessons learned were circulated by theinvestigating officer and added to the priority list inhandover so that issues were discussed.

Are child and adolescent mental healthwards well-led?

Good –––

Vision and values

• Hospital management was visible throughout thehospital, we found that senior managers spent time onthe wards and were approachable. Staff told us thatward level managers and the senior managers had anopen door policy. At the request of staff they introducedregular drop in sessions to meet with the RegisteredManager and Hospital Director. We heard that over thepast year where there had been a transition to newmanagement that there had been a focus oncommunication and team-work. Staff found themanagement on the whole very supportive and knewwho the senior management in the hospital were.

• Staff we spoke with were not always aware of thehospital visions and values but as they were workingwithin the stated values this did not have an adverseimpact on patients.

Good governance

• The management at the hospital had oversight ofperformance through regular review and monitoring aswell as auditing of care notes for completion andquality. Numbers needed for shifts were fed back dailyto the management so that staff could be providedwhen needed. Management kept records of bedoccupancy, monitored sickness, annual leave,observation levels, agency usage and training as well asthe staff needed for escorts. Incidents and complaintswere logged and fed back to commissioners weekly.There was a weekly dashboard showing demand on theservice.

• There were processes in place to ensure that staffreceived mandatory training and a recent change instructure of recruiting and starting new staff on thesame induction date meant that mandatory training



Good –––


could be given in one go. The introduction of trainingbased on the care certificate for support workers waspartly implemented to improve recruitment andretention. The new induction process involved all staffmeeting the senior management team.

• We found evidence that shifts were covered generouslywith Psychiatric Intensive Care Unit (PICU) staffing beingset at one staff member per patient minimum. Thehospital ensured that staff were provided when needed.

• Following past action by the Care Quality Commission,regarding a lack of documented risk assessment,changes had been made to ensure that risk assessmentquality and completion was improved. While on theinspection we found that there was strong evidence ofrisk assessment taking place and there were furtherplans to implement best practice using the work of anNHS trust as a basis for further progress. A senior nursehad been put in place to ensure best practice wasembedded going forward.

• Management responded to complaints and the hospitalfulfilled its duty of candour, staff issues were addressedappropriately and there was feedback throughhandovers and staff meetings about changes madethrough incidents and complaints. A new electronicincident recording system had been a challenge whenfirst implemented so the hospital had taken the decisionto relaunch providing more training to ensuring staffknew how it was best utilised. We found that there wasgood ward level knowledge of the use of this system.Safety and governance meetings had been started toreview incidents and complaints

• There was comprehensive auditing taking place andthere was evidence of change as a result of the auditprocess. We found that safeguarding processes werefollowed and there was good oversight of safeguardingand robust relationships with the local authority.

• There was an issue however with the managementdecision to allow the en-suite room on Thames ward tobe used for seclusion. The decision had put the patientand staff at risk and as a result there was staff sicknessdue to assaults.

• The hospital held a risk register which was reviewed atthe senior management team meeting. Items were ableto be added to this according to risks at the time, riskswere rated red amber or green in order of severity andthere were plans to manage risk.

• Due to feedback from the staff survey showing thatthere was a lack of management capacity there was

strengthening of the senior management team throughthe creation of a new hospital director post, head oftherapy to have oversight of the whole therapy functionand a facilities manager to bring together estates,catering and housekeeping. Support worker managerswere put into place to ensure that oversight of supportworker performance was kept and that staff weresupervised, they were also there to help recruit. Thesenior support worker post had been created to allownursing staff more time for direct care activities.

Leadership, morale and staff engagement

• The hospital had low sickness rates at 3% for theprevious 12 months.

• Staff were aware of the whistleblowing process. Therewas an internal whistleblowing line for theHuntercombe Group which meant that if staff did notfeel confident approaching their manager then theywere able to anonymously use that line.

• Staff stated that they felt supported by their immediateline manager and by the hospital as a whole. Many saidthat where previously the hospital had problems thingswere getting better and that morale was improving.They felt that there was good team work and althoughthere were claims that at ward level there was ahierarchy, on the whole staff felt that they were treatedas equal. There was a hospital drive to promote andstrengthen the role of the support worker and addgreater value to the role.

• For staff working at the hospital there was anopportunity to engage in leadership courses, there wasa budget for continuous professional development.

• Senior management had started a monthly newslettercalled Four Rivers News which was a newsletter for staffinforming them of updates in the hospital, new rolesavailable to staff, new starters and leavers.

• The staff survey had showed an increase in ten pointsfor their organisational health score. With the surveyshowing that 84% of staff felt that Huntercombe’s toppriority was care of patients and 93% feeling that theirrole makes a difference to patients.

• Management had begun communicating changethrough organisational health posters. Acommunication forum had been set up to see how theycould improve staff communications across thehospital.

Commitment to quality improvement and innovation



Good –––


• The hospital was a pilot site for looking at their caremodel to see how they can get the most out of staffengagement with the patients with less “specialling”(specialling is a term used for when a patient has a staffmember observing them continuously on a one-to-onebasis) and less agency usage.

• The Huntercombe Group had set up a clinical cabinetfor heads of hospitals and leads to attend in order todiscuss treatment and to ensure that they wereproviding a good service.

• Kennet ward had participated in the Quality Network forInpatient CAMHS and was being assessed at the time ofthe inspection.



Good –––


Outstanding practice

• Patients at the hospital had triggered large changesand improvements by taking part in the Glamour YourManor scheme. This scheme provided the winninghospital with a budget to carry out their improvementplans. In 2015 the user involvement group hadrequested an all-weather sports pitch usable forfootball, basketball and other activities, planting forthe gardens, equipment such as goal posts, picnicbenches, tables and gazebos and a sensory room.Patients led the proposal. The hospital won the moneyand carried out the improvements. Patients andfamilies were asked what improvements could bemade in the hospital in 2016. Plans for the GlamourYour Manor 2016 included securing funds to update

the OT kitchen so that patients with an eating disordercould cook and eat with their families, improveparking facilities and getting better air conditioning inthe PICU’s.

• The hospital put on an annual fete in the grounds andinvited ex-patients of the hospital back to attend. Theyfelt it was an incentive for patients to come back andlet the staff at the hospital know how they were doingand staff could hear about the care they provided in amore reflective way. Patients could also meet formerpatients and see recovery in action. The hospitalprovided a bouncy castle and put on a barbecue.

• There was a bi-monthly family and carers day providedso that families and carers could meet staff providingmedical, nursing and therapy within the hospital, meetother parents and to ask questions about the care andtreatment available.

Areas for improvement

Action the provider MUST take to improve

• The provider must ensure that all staff understand theMental Capacity Act and Gillick competence. This iswhen a patient under the legal age of consent isconsidered to be competent enough to consent totheir own treatment rather than have their parentsconsent.

• The provider must ensure that Gillick competence isassessed for each patient under 16 years of age andensure that capacity is assessed for those over the ageof 16. The Mental Capacity Act (MCA) does not apply toyoung people aged 16 or under. For children under theage of 16, the young person’s decision making ability isgoverned by Gillick competence. The concept of Gillickcompetence recognises that some children may havesufficient maturity to make some decisions forthemselves.

• The provider must ensure that all patients have theirphysical health monitored following rapidtranquilisation.

Action the provider SHOULD take to improve

• The provider should consider the appropriateness ofthe facilities used for seclusion. The en-suite room onThames ward had been used as a seclusion room andthis failed to comply with the hospitals policy onseclusion and the guidelines set out in the MentalHealth Act Code of Practice. The use of this room forseclusion should be reviewed and changes should beimplemented following the review.

• The provider should review blanket restriction on all ofthe wards to ensure they are clinically justified.

• The provider should ensure that all incidents arereported appropriately.

• The provider should ensure that care plans are lessinstructional to staff and reflect the patients view

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

Diagnostic and screening procedures

Treatment of disease, disorder or injury

Regulation 11 HSCA (RA) Regulations 2014 Need forconsent

Regulation 11 HSCA (RA) Regulations 2014 Need forconsent.

All patients under the age of 16 were treated underparental consent rather than the individual consent ofthe young person. Staff had varying degrees ofknowledge of the MCA and in particular there was verypoor understanding of Gillick Competency

This is a breach of regulation 11 (1) & (2)

Regulation

This section is primarily information for the provider

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.

This section is primarily information for the provider

Enforcement actionsEnforcementactions


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