the raphael hospital · the raphael hospital is operated by raphael medical centre limited (the),...

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 Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Requires improvement –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Requires improvement –––

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 RRaphaelaphael HospitHospitalalQuality Report

Hollanden ParkColdharbour LaneHildenbouroughTonbridgeKentTN11 9LETel:(01732) 833924Website:www.raphaelmedicalcentre.co.uk

Date of inspection visit: 15 January 2019Date of publication: 15/04/2019

1 The Raphael Hospital Quality Report 15/04/2019

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

Overall summary

The Raphael Hospital is operated by Raphael MedicalCentre Limited (The), an organisation that also providessocial care services for people with acquired braininjuries. The Raphael Hospital is an independent hospitalspecialising in neuro-rehabilitation of adults withcomplex neurological disabilities with cognitive andbehavioural impairment.

The long-term conditions service at the hospital focuseson the care, treatment and rehabilitation of people withacquired brain injuries. There are facilities toaccommodate a total of 60 patients. There is space for 31patients in two wards in the main building and 21patients in Tobias House which is designated as an areafor the treatment of prolonged disorders ofconsciousness. There is a further capacity to treat eightpatients in the special care unit for neurobehavioralrehabilitation and this unit also accommodates patientsadmitted under the Mental Health Act. Facilities availableat the hospital included a physiotherapy gymnasium, ahydrotherapy pool, therapy rooms, consultant rooms andcommon areas.

We inspected this service using our comprehensiveinspection methodology. We carried out the inspectionon 15 January 2019.

To get to the heart of patients’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do sowe rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

Throughout the inspection, we took account of whatpeople told us and how the provider understood andcomplied with the Mental Capacity Act 2005.

Services we rate

Our rating of this hospital/service stayed the same. Werated it as Requires improvement overall.

• The service did not have managers at all levels withthe necessary experience, knowledge and skills tolead effectively. The main house was managed by anexperienced ward manager who had been in postsince 2015. However, during inspection it wasidentified that three out of four of the wards did nothave a ward manager.

• Managers could not demonstrate adequate systemsand processes that assured us they had full oversightof the service in terms of risk, quality, safety, andperformance.

• The service used a systematic approach tocontinually improve the quality of its services andsafeguarding high standards of care, but there wereareas that were not fully effective.

• The systems used to identify risks, and eliminatethem, were not always carried out in a timelymanner. Although there was a risk register, there wasno robust way of ensuring effective risk reductionstrategies had been undertaken, or potential risksnot fully recognised.

• The service provided mandatory training in key skillsto all staff; however, not all staff were up to date withtheir training.

• Infection control issues identified in the last reportremained. Although there was a plan to makechanges, the pace of making sure compliance withinfection control regulations was slow.

• The service generally had suitable premises, but thedesign, maintenance and use of facilities andpremises did not always keep people safe.

• The service audit programme was not robust;although audits were undertaken, non-complianceswere not always rectified and we saw the samenon-compliances repeated on multiple audits.

Summary of findings


• Staff and patients did not always have access tocall-bells to get help. Communal areas such as thelounge, activity room and corridors did not have callpoints available

• Emergency buzzers were available, but staff wespoke with were unaware if these had been tested orwhose responsibility this was.

• Staff on the special care unit were not able tocommunicate effectively, particularly in anemergency. Two-way radios were available, but wefound only two were working and of the two workingradios, only one could make and receive calls.

• Best interest meeting notes, were not completedconsistently, and the least restrictive option was notalways clearly identified.

However:

• Staff in different roles worked together as a team tobenefit patients. Doctors, nurses and otherhealthcare professionals supported each other toprovide care. Staff respected their colleague’sopinions.

• Staff cared for patients with compassion. Feedbackfrom patients confirmed staff treated them well andwith kindness.

• Staff provided emotional support to patients tominimise distress. Staff were on hand to offeremotional support to patients and those close tothem. Patients told us they felt able to approach staffif they felt they needed any aspect of support.

• Staff involved patients and those close to them indecisions about their care and treatment. We saweffective interactions between staff and patients.

• There were systems and processes to assess, planand review staffing levels at the location, includingstaff skill mix.

• There were systems and processes to protect peoplefrom abuse and harm. Staff understood theirresponsibilities and the process to take in the eventof any safeguarding concerns.

• The service gave, recorded and stored medicineswell. Patients received the right medication at theright dose at the right time.

• Staff gave patients enough food and drink to meettheir needs. Nutritional assessments werecompleted on admission.

• Staff monitored and assessed patients regularly tosee if they were in pain.

• The service took account of patient’s individualneeds.

Nigel Acheson

Summary of findings


Deputy Chief Inspector of Hospitals( London and South Regions)

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Long termconditions

Requires improvement –––

Neuro-rehabilitation of adults with complexneurological disabilities with cognitive andbehavioural impairment, were the main activity atthe location. We rated this service as requiresimprovement in the safe, effective and well leddomains. Good in caring and responsive.

Summary of findings


Contents

PageSummary of this inspectionBackground to The Raphael Hospital 8

Our inspection team 8

Information about The Raphael Hospital 8

The five questions we ask about services and what we found 10

Detailed findings from this inspectionOverview of ratings 14

Outstanding practice 39

Areas for improvement 39

Action we have told the provider to take 40

Summary of findings


Location name here

Services we looked atLong term conditions

Locationnamehere



Background to The Raphael Hospital

The Raphael Hospital is operated by Raphael MedicalCentre Limited (The). The hospital opened in 1983 and isa private hospital in Hildenborough, Kent. Referrals areaccepted from across the south-east of England. Themajority of the referrals are received from the clinicalcommissioning groups (CCG’s) for NHS patients. Thehospital also accepts private patients, funded by patientsthemselves or insurance companies.

The hospital specialises in the neurorehabilitation ofadults following acquired brain injury. It provides aservice for people over the age of 18 years, both male andfemale. The service does not treat children or youngpeople.

The Raphael Hospital is registered with the Care QualityCommission to provide the following regulated activities:

• Treatment of disease, disorder or injury

• Diagnostic and screening procedures

• Assessment or medical treatment for personsdetained under the Mental Health Act 1983

The hospital has been registered since 1983. There is aControlled Drugs Accountable Officer at the location.

The service employs 134 whole time equivalent clinicalstaff including doctors, nurses, therapists andrehabilitation assistances. The hospital also has astep-down facility. The step-down facility was notinspected on this occasion.

Our inspection team

The team that inspected the service comprised a CQClead inspector, one other CQC inspector with expertise in

mental health, two inspection managers and a specialistadvisor with expertise in neurorehabilitation. Theinspection team was overseen by Catherine Campbell,Head of Hospital Inspection.

Information about The Raphael Hospital

The hospital has four wards and is registered to providethe following regulated activities:

• Treatment of disease, disorder or injury

• Assessment or medical treatment for personsdetained under the 1983 act

• Diagnostic and screening procedures

During the inspection, we visited all areas of the service.We spoke with 19 staff including registered nurses, healthcare assistants, reception staff, medical staff, and seniormanagers. We spoke with nine patients.

During our inspection we reviewed 14 sets of patientrecords, including seven medicine charts.

There were no special reviews or investigations of thehospital ongoing by the CQC at any time during the 12months before this inspection.

The service has been inspected four times, and the mostrecent inspection took place in February 2017.

Activity (January 2018 to December 2018)

• In the reporting period January 2018 to December2018, the hospital received 63 referrals for admission.At the time of inspection there were 48 patients witha further ten in the stepdown accommodation (notinspected). The majority of patients (95%) were NHSfunded.

• There were eight patients on the neurobehavioralrehabilitation ward (for patients with dual diagnosisand mental health issues, and for patients subject to

Summaryofthisinspection

Summary of this inspection


section under the Mental Health Act), 31 patients inthe main house acute neurorehabilitation wards (forpatients with complex degenerative neurologicalconditions, slow stream neurorehabilitation anddisorders of consciousness), and 21 in Tobias House(for patients with disorders of consciousness andslow stream rehabilitation).

• Three doctors worked under rules of practisingprivileges, one full time and two-part time. Thehospital employed one doctor was full time.Practising privileges is a term used when doctorshave been granted the right to practise in anindependent hospital. There were 18 nursing staffwho worked full time. The hospital employed 17therapists, 21 other allied health care professionalsand 72 health care assistants. The hospital made useof both bank and agency staff when necessary.

Track record on safety

• No never events

• The service reported 254 incidents within thereporting period.

• Three incidences of hospital acquiredMeticillin-resistant Staphylococcus aureus (MRSA),

• No incidences of hospital acquiredMeticillin-sensitive staphylococcus aureus (MSSA)

• No incidences of hospital acquired Clostridiumdifficile (C.diff)

• The hospital received 10 complaints betweenJanuary 2018 and December 2018.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Are services safe?

Our rating of safe stayed the same. We rated it as Requiresimprovement because:

• Infection control issues identified in the last report remained.Although there was a plan to make changes, the pace ofmaking sure compliance with infection control regulations wasslow.

• Systems and processes to protect patients against crossinfection were not always effective. We found cleaning productsand other liquids were not stored securely. Flooring andfurniture in the special care unit was not fit for purpose.

• The service generally had suitable premises, but the design,maintenance and use of facilities and premises did not alwayskeep people safe. For example, we found ligature risks in thespecial care unit which had not been risk assessed for fiveyears, along with multiple hazards identified in garden.

• Staff and patients did not always have access to call-bells to gethelp. Communal areas such as the lounge, activity room andcorridors did not have call points available

• Emergency buzzers were available, but staff we spoke to wereunaware if these had been tested or whose responsibility thiswas.

• Staff on the special care unit were not able to communicateeffectively, particularly in an emergency. two-way radios wereavailable, but we found only two were working and of the twoworking radios, only one was able to make and receive calls.

However,

• There were systems and processes to assess, plan and reviewstaffing levels at the location, including staff skill mix.

• Staff understood how to protect patients from abuse. Staff hadtraining on how to recognise and report abuse, and they knewhow to apply it.

• The service gave, recorded and stored medicines well. Patientsreceived the right medication at the right dose at the right time.

• Risks to patients were assessed, monitored and managed on aday-to-day basis.





Are services effective?Are services effective?

Our rating of effective went down. We rated it as Requiresimprovement because:

• The service completed local audits but the results did notalways drive the necessary improvements. For example, therewas limited formal process to monitor staff adherence tonational guidelines and local policies, such as hand hygiene,and ligature risks.

• Best interest meeting notes, were not consistently completed,and the least restrictive option was not always clearlyidentified.

However:

• Staff assessed the patient’s physical, mental health and socialneeds holistically. Overall, staff provided care, treatment andsupport in line with evidence-based guidance.

• Staff gave patients enough food and drink to meet their needsand improve their health. The service adjusted for patient’sdietary requirements, and used special feeding and hydrationtechniques when necessary.

• Patients’ pain was assessed and managed appropriately.

• The service monitored the effectiveness of care and treatmentand used the findings to improve them.

• The service made efforts to ensure staff were competent fortheir roles. Overall 91.5% of staff had received an appraisal. Allstaff received a one-week induction.

• Staff from different disciplines worked together as a team tobenefit patients. They supported each other to make surepatients had received care that met all their needs, includingphysical, emotional and social needs. Doctors, nurses andother health care professionals supported each other toprovide care. Staff respected their colleagues’ opinions.

• Services supported care to be delivered seven days a week.

• Staff understood their roles and responsibilities under theMental Health Act 1983 and the Mental Capacity Act 2005. Theyknew how to support patients experiencing mental ill healthand those who lacked the capacity to make decisions abouttheir care.


Are services caring?Are services caring?

Good –––




Our rating of caring stayed the same. We rated it as Good because:

• Staff cared for patients with compassion. Feedback frompeople who used the service, and those who are close to themwas positive about the way staff treated people.

• Staff gave emotional support to patients to minimise distress.Staff were on hand to offer emotional support to patients andthose close to them. Patients and relatives told us they felt ableto approach staff if they felt they needed any aspect of support.

• Staff involved patients and those close to them in decisionsabout their care and treatment. We saw effective interactionsbetween staff and patients. Staff kept patients and those closeto them, informed and included them in their care andtreatment decisions from pre-admission to discharge.

• The service used a goal setting approach to work in partnershipwith patients, supporting each patient individualdecision-making process of their care and treatment.

Are services responsive?Are services responsive?

Our rating of responsive stayed the same. We rated it as Goodbecause:

• The service planned and provided services in a way that metthe needs of the local people.

• Services were planned to take into account the individualneeds of patients. There were arrangements for patients withcomplex health and social care needs. Adjustments were madefor patients living with a variety of disabilities.

• People could access the service when they needed it.Arrangements to admit, treat and discharge patients werepeople-centred and in line with good practice.

• The service treated concerns and complaints seriously,investigated them and learned lessons from the results.

Good –––

Are services well-led?Are services well-led?

Our rating of well-led stayed the same. We rated it as Requiresimprovement because:

• The service did not have managers at all levels with thenecessary experience, knowledge and skills to lead effectively.





The main house was managed by an experienced wardmanager who had been in post since 2015. However, duringinspection it was identified that three out of four of the wardsdid not have a ward manager.

• Managers could not demonstrate adequate systems andprocesses that assured us they had full oversight of the servicein terms of risk, quality, safety, and performance.

• The service used a systematic approach to continually improvethe quality of its services and safeguarding high standards ofcare but there were some areas that were not fully effective.These included the arrangements for monitoring the progressof actions from internal audits, and oversight, managementand reduction of risk to patient safety.

• The systems used to identify risks and eliminate them were notalways carried out in a timely manager. Although there was arisk register, there was no robust way of ensuring effective riskreduction strategies had been undertaken, or risks not fullyrecognised.

However:

• Staff had effective working relationships with each other. Therewere clear staff support networks and all staff we spoke withfelt supported by their colleagues.

• The service routinely collected, managed and used informationto support its activities.

• The service encouraged patients and relatives to contribute tothe running of the service, and give ideas for improvement,through regular meetings and feedback surveys.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Long term conditions Requiresimprovement

Requiresimprovement Good Good Requires

improvementRequires

improvement

Overall Requiresimprovement

Requiresimprovement Good Good Requires

improvementRequires

improvement

Detailed findings from this inspection


Safe Requires improvement –––

Effective Requires improvement –––

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

Are long term conditions safe?


Our rating of safe stayed the same. We rated it as requiresimprovement.

Mandatory training

The service provided mandatory training in keyskills to all staff, however not all staff were up todate with their training. The service did not settarget for completion.

Staff received mandatory training in safety systems,processes, and practices. Mandatory training consisted ofa range of topics, which included fire safety, infectioncontrol, moving and handling, stress management,health and safety, risk assessment and equality diversity.Staff received their mandatory training either face to face,attending an offsite course or via watching a DVD. Thehospital had recently introduced an e-learning packagefor some of their mandatory training.

The service did not separate their mandatory trainingdata by staff group. Mandatory training was broken downby departments. The service did not have a set target forcompletion of all mandatory training. However, theoperations director told us the target was 100%.

Compliance with mandatory training was as follows:

• Control of substances hazardous to health 83%

• Fire safety 67%

• Infection control 84%

• De-escalation 54%

• Moving and handling 81%

• Health and safety 88%

• Risk assessment 75%

• Confidentiality and data protection 73%

• Food hygiene 69%

• Stress management 69%

• Basic life support and cardiopulmonary resuscitation66%

• Equality and diversity 83%

• Deprivation of Liberty 81%

• Challenging behaviour 75%

• Safeguarding adults and children 67%

We saw compliance with mandatory training varied, andno departments or modules achieved the 100%compliance target. For example, from the figuresprovided, we saw the subjects with the best overallmandatory compliance rates was health and safety. Theleast overall compliance was de-escalation training. Theoperations director, told us they were aware of gaps intraining, this was due to the movement to the newsystem. Training compliance was being closely monitoredvia appraisals and supervision meetings.

Following inspection, the provider told us they reviewedthe method for calculating mandatory training, as at thetime of the inspection and found inaccuracy.

They provided data, which indicated the actualcompliance rate at the time of the inspection was 93%averaged for all mandatory courses.

Longtermconditions

Long term conditions



• Manual Handling – 88%

• DoLS – 98%

• Safeguarding – 100%

• Mental Capacity Act – 100%

• Equality, Diversity & Inclusion – 70%

• Confidentiality/DPA – 81%

• Health and Safety – 100%

• Fire Safety – 100%

• Infection Control – 100%

The operations director and the human resources teamwere responsible for the oversight of mandatory trainingcompliance. Staff we spoke with told us they felt theirtraining was good.

Safeguarding

There were systems and processes to protect peoplefrom abuse and harm. Staff understood theirresponsibilities and the process to take in the eventof any safeguarding concerns.

The service had an up to date safeguarding adult’s policyfor staff which was available to guide staff on how toprotect people from abuse. This referred to relevantlegislation and guidance. The policy included flow chartsproviding a quick reference guide to staff on what to doshould a concern be identified. The safeguarding policyalso contained sections on recognising and actions totake if domestic abuse, or female genital mutilation wasfound or suspected.

All staff we spoke to knew how to raise a safeguardingissue or concern. Staff confidently described whatconstituted abuse and described their own experiencesof escalating safeguarding concerns to the nurse incharge. An electronic incident form was completed andthe director of nursing or operational director were told.All staff said they were up to date with their training onsafeguarding.

During our inspection we looked at three safeguardingrecords. We saw all referrals were made in line with theservice’s policy, and had been investigated and records ofany actions taken to lessen the risk. We saw there wereprocesses to inform the local safeguarding authority andthe Care Quality Commission.

In addition, following a safeguarding referral staffcompleted a reflective account of what happened.Undertaking a reflective account following an incident isa way of studying your own experiences to improve theway you work, and help prevent a reoccurrence of anevent or incident and aids learning. We looked at tworeflective accounts during our inspection, and saw theyshowed staff considered how they could improve theirpractices. Managers used them as a way to clarify the staffmembers expectations and a way of giving feedback.

Staff could identify the safeguarding leads for the service,and could explain the actions they would take if they hadany concerns. Named professionals have a key role inpromoting good practice within their organisation,providing advice, and expertise for colleagues.

Safeguarding training level two was mandatory for allclinical staff, and was undertaken three times a year. Dataindicated between January and December 2018, theoverall compliance was 67%. The departments rangedbetween 75% for nursing staff in the special care unit, and61% for nursing staff in the main house. Followinginspection, the provider sent us data, which indicated thecompliance rate for safeguarding training was 100%. Inaddition, the provider sent us data which indicated, 15members of staff were required to complete level 4/5safeguarding training and 91% had completed thetraining.

Cleanliness, infection control and hygiene

There were processes to protect patients againstcross infection. However, these systems were notalways effective. Infection control issues identifiedin the last report remained. Although there was aplan to make changes, the pace of making surecompliance with infection control regulations wasslow. Equipment was visibly clean and staff had agood understanding of responsibilities in relation tocleaning.

The service had an up to date infection prevention andcontrol policies for staff to follow. This included but wasnot limited to hand hygiene, waste management, andblood spillage. However, the policy lacked references, soit was unclear if the policy was in line with best practice.

Infection control training was mandatory for all staffgroups, and was undertaken twice a year in June and

Longtermconditions




December. Data indicated for December 2018 trainingcompliance rates ranged between 75% compliance forkitchen and maintenance staff and administration staffand 90% and 91% for nursing staff in Special Care Unitand domestic and laundry staff. The therapy departmentswere 89% compliant with this training and nursing staff inthe main house were 82% compliant. We did not haveinfection control training compliance figures for medicalstaff. The service did not have target for compliance.

We saw personal protective equipment, andalcohol-based hand-sanitising gel was availablethroughout the location. However, in the special care unitwe found alcohol-based hand-sanitising gel was freelyavailable in the lounge area and in all the bedroom areas.The bottles were free standing, and could be thrown, oringested by patients.

We looked at the dirty utility room at Tobias House, whichhad a separate dedicated hand wash basin. The dirtyutility room was small and cluttered. Staff were unable touse the sink as multiple bags of linen blocked access to it.This meant staff were not able to clean their hands orremove their personal protective equipment correctly,and increased a risk of cross infection. The provider toldus the sluice was inspected and cleared on an hourlybasis.

The linen room at Tobias House was fully stocked andlinen correctly stored. However, we found unusedmattresses were stored in the linen room. We inspectedthe mattresses and found them to not be clean. We fedthis back to staff at the time of inspection.

Staff could not always clean their hands in line withNational Institute for Health and Care Excellence qualitystandard 61. Alcohol-based hand-sanitising gel, wasavailable at the point of care, there were no dedicatedhand wash basins in patients’ bedrooms, staff and visitorsused the basins in the bedrooms en-suite bathroom orthe hand wash basins in the corridors. Quality standard61 recommends hands can be cleaned using thealcohol-based hand sanitising gel except in the followingsituations, when soap and water must be used. Whenhands are visibly soiled or potentially contaminated withbody fluids, or when caring for patients with vomiting ordiarrhoeal illness, regardless if gloves have been worn.

The hospital corridors had carpet which could not be aseasily cleaned as the laminated flooring when spills

occurred. Department of Health’s Hospital Building Note(HBN) 00-09: infection control in the built environmentstates ‘Spillage can occur in all clinical areas, corridorsand entrances’ and ‘in areas of frequent spillage or heavytraffic, they can quickly become unsightly’. We saw someof the carpet looked visibly clean, while other parts of thecarpet were stained. We found this at our previousinspection in February 2017. The registered manager toldus they were going to keep the carpet in the maincorridor, and had just sourced the correct colour, whichwas due to be replaced.

There was a plan to make changes to the flooring inpatient bedrooms, but the pace of making surecompliance with infection control regulations was slow.At the previous inspection in February 2017, we identifiedthat patient’s bedrooms and bathrooms had carpet. Theregistered manager told us they were changing theflooring in patients’ bedrooms to a laminate type, buthad only managed to change the flooring in sevenbedrooms, due to occupancy levels.

The flooring in the special care unit was in a poor state ofrepair, and not clean. We saw the flooring was not intact,and was torn or had holes in place. The carpet andflooring, was stained and appeared to be visibly dirty.

In the special care unit, the kitchen area, used by staffand patients to prepare all meals, was untidy and was notvisibly clean. There was no tile grouting in the area at theback of the kitchen sink and cupboards, which wasextremely dirty with visible dirt and old food debris at theback of the sink unit, underneath the unit and in allcupboards. The kitchen table and work surfaces wereheavily scratched and stained, again with visible dirt andold food debris across all the work surfaces.

The hospital did not recognise these issues as a risk andpotentially placed patients at risk of cross infection.These issues were not included on the risk register.

There were processes to monitor and audit thecleanliness of the environment, but measures to rectifythe non-compliances were ineffective. We saw cleaningaudits were undertaken regularly. We looked at thecleaning audits for the ground floor (main house) and thespecial care unit.

We looked at the cleaning audits for ground floor (mainhouse) for October, November and December 2018.Action plans were developed for any non-compliances

Longtermconditions




identified. This included the issue identified, actionrequired and person responsible. However, we saw thesame non-compliance was identified for three monthsand no corrective action had been taken.

Dedicated cleaning time was provided for the special careunit, however the poor state of repair impeded effectivecleaning. Two bathrooms we looked at were visibly dirtywith old stains on the toilets and floors. We asked staff toshow us any environmental audits carried out and wewere told there were none. We subsequently saw oneaudit of special care unit, dated September 2018although it was not clear who had carried out the audit.The audit undertaken had no overall percentage ofachievement calculated and there was no evidence ofany further audits. In the September 2018 audit, we saw20 areas out of 61 (33%) had fallen below the requiredstandard and had failed. There was no evidence of anyform of corrective actions relating to the areas that hadfallen below the expected standard and in the undatedspecial care unit local quality improvement plan theissues raised about poor cleanliness had been given a“closed” status. We had concerns about poor cleanlinessat our previous inspection in 2017. Infection control riskswere not recorded on the risk register.

Control of substances hazardous to health training wasmandatory for staff and undertaken once a year. Dataindicated for June 2018, an overall compliance rate of83%. The departments ranged between 58% foradministration staff and 91% for nursing staff in TobiasHouse. We saw 87% of staff working at the special careunit, were compliant with their COSHH training

Cleaning products and other liquids were not storedsecurely. We identified other concerns and unmitigatedrisks relating to the availability of liquids, on the specialcare unit. For example, plant feed liquid was on a windowsill in the unlocked activity room. The cupboard underthe kitchen sink was unlocked, despite staff saying itshould be locked and it housed liquids such as washingup liquid and household cleaning fluid. In addition, wefound the cleaning cupboard in Tobias to be unlocked.

As all patients were nursed in single rooms any patientswith an infection were isolated. We spoke with staff whocould tell us the infection control precautions they woulduse in the event of a patient developing an infection.

Waste was separated and in different coloured bags tosignify the different categories of waste. In addition, wechecked the outside waste compound and found it tolocked. This was in accordance with the Health TechnicalMemorandum 07-01, control of substance hazardous tohealth (COSHH), health, and safety at work regulations.

Water supplies were maintained at safe temperaturesand there was regular testing and operation of systems tominimise the risk of pseudomonas and Legionellabacteria. We saw the hydrotherapy pool was closed dueto an abnormal result, and corrective action was beingtaken.

Between January and December 2018, there had been nocases of Clostridium difficile or Meticillin-sensitiveStaphylococcus aureus (MSSA). There were three cases ofMeticillin-resistant Staphylococcus aureus. MRSA andMSSA are infections that have the capability of causingharm to patients. MRSA is a type of bacterial infection andis resistant to many antibiotics. MSSA is a type of bacteriain the same family as MRSA but is more easily treated.Clostridium difficile is a type of bacteria, which can infectthe bowel and cause diarrhoea. We saw patients werescreened for MRSA on initial admission to the hospitaland re-admission after hospital stays.

Environment and equipment

The service generally had suitable premises, but thedesign, maintenance and use of facilities andpremises did not always keep people safe. We foundequipment well maintained, with a regular and up todate programme for servicing.

The main house had three floors, and had 22 en-suitebedrooms on the first floor, and eight on the second floor.On the ground floor there were the reception, a commonlounge area, a dining room and kitchen. Thephysiotherapy gymnasium, hydrotherapy pool and threetherapy rooms were also located on the ground floor.

Tobias House had 20 en-suite bedrooms, a gymnasium,therapy rooms for speech and language therapy ordietitian review, music therapy, and art therapy.

The special care unit, was for patients with dual diagnosisand mental health issues, both pre and post trauma. Inaddition, patients subject to detention under the Mental

Longtermconditions




Health Act were admitted to the unit. The unit was on onefloor, and consisted of nine patient bedrooms, a nursingoffice, consulting room, kitchen/dining room and largetherapy room.

We found the special care unit, presented challenges forclear observation of the patients and staff managed thisthrough individual risk assessed observation levels. Astaff member was always available in the communallounge areas.

Ligature risks and lack of audit were not included on therisk register. This meant the service, did not recognisetheir issues as a risk to patient safety.

The special care unit provided a service for any patientsexperiencing poor mental health who may have hadfeelings of self-harm and/ or suicide. Staff were not ableto describe where the high-risk ligature anchor pointsand ligatures were and how these risks were lessenedand managed. We found there were many ligature risksthroughout the special care unit and these included,bedroom curtains rails fixed to the wall, fixed wardroberails, hanging basket fixed to the wall fittings throughoutall areas, including all bedrooms and bathrooms.

Staff said the last ligature risk assessment had beencarried out over five years prior to our inspection andthey were unable to locate this audit. A ligature point is aplace to which patients’ who are intent on self-harmmight tie something too, to harm themselves. There wasno clear guidance on the special care unit about howligature risks were managed and how to report new risks.Staff could say they reduced risk by individually assessingpatients and increasing their levels of staff observation ifrequired. Staff said they were not aware the special careunit was undergoing any improvement schedule toup-grade the anti-ligature specification of the ward andpatients’ bedrooms and bathrooms.

Patients’ rooms were made to look like a homeenvironment rather than a clinical area. In each roomthere was an electric bed, chest of drawers, wardrobe.Not all bedroom doors had window recesses whichmeant staff could not see into the room if the door wasclosed. The ensuite facilities in the rooms either had bath,shower or were of a ‘wet room’ style, a toilet and handwash basin. We saw that there were rails present to helppatients with their stability.

We saw patients’ rooms were bright and airy and made tolook like a home environment rather than a clinical areaand some reflected the resident’s individuality. Windowslooked onto gardens.

The garden in the special care unit was not a safe areaand we found several unmitigated risks in the gardenarea which we raised with staff. The special care unit hada private garden area. Staff told us patients used thegarden area on a regular basis and that weatherpermitting therapy groups took place in this area duringthe summer months.

However, the garden area was untidy, for example, wesaw items of rubbish scattered around including an oldtelephone box, scaffolding poles, fence panels, a disusedshed and uneven patio slabs. The garden fence, in someareas had barbed wire across the top which was withinarm’s length from the garden. Patients admitted tospecial care unit had complex diagnosis andpresentations which included marked cognitiveimpairment and mental ill health. Patients could injurethemselves either by accident or deliberately in thegarden area.

The therapy gymnasium was well equipped withequipment that looked new and well maintained.Treatment couches in the physiotherapy departmentwere covered with a wipeable fabric. The fabric on everypiece of equipment we checked was intact.

Decoration was not in line with Health Building Note00-09; Infection control in the built environment.Throughout the service walls were covered in a texturedsurface coating. The walls were not smooth and thecoating had been applied in such a way as to be of arough cast finish. This meant the cleaning of walls wouldbe difficult.

On the special care unit, we found the fixtures and fittingwere not maintained. For example, all the arm chairs inthe lounge and activity room were heavily stained andripped. We also saw walls were stained throughout. Weasked staff to show us any environmental audits carriedout relating to equipment, fixtures and fittings and weretold there were none. We subsequently saw one audit ofthe special care unit, dated September 2018, although itwas not clear who had carried out the audit. The auditundertaken had no overall percentage of achievementcalculated and no evidence of any further audits taking

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place. In the September 2018 audit, we saw five areas outof 19 (26%) had fallen below the standard and had failed.There was no evidence of any form of corrective actionsrelating to the areas that had fallen below the expectedstandard and in the undated special care unit localquality improvement plan the issues raised about poorenvironment and equipment had been given a “closed”status. We found the same concerns in our 2017inspection.

We saw there was a rolling programme of plannedpreventative maintenance for equipment. Equipmentwas regularly serviced. The service records showedequipment had been serviced within the 12 months priorto inspection. We saw an electrical safety checkcertificate, dated December 2017. We saw ten pieces ofequipment had safety checks completed within the last12 months.

Staff told us there were no issues accessing equipmentfor patients, and felt they had enough equipment to runthe service. We were told there were no issues aroundsecuring the necessary equipment for individual patients,which would be identified on pre-admission, and duringregular assessments.

Assessing and responding to patient risk

Risks to patients were assessed, monitored andmanaged on a day-to-day basis. These includedsigns of deteriorating health, medical emergenciesor behaviour that challenges. People were involvedin managing risks and risk assessments wereperson-centred, proportionate and reviewedregularly.

The service had a clear process which set out safe andagreed criteria for the admission to the hospital. Whenreferrals were made to the hospital an admissioncommittee reviewed it, to assess for suitability for careand treatment provided. All patients were reviewed priorto admission and a detailed treatment plan decided.

Patients were assessed for risk through a set of riskassessments on admission to the service. These includedrisk assessments for falls, malnutrition, pressure ulcers,and risk of developing a blood clot. All risk assessmentswere completed and reviewed regularly. For example, allpatients were risk assessed on admission for their risk of

developing a type of blood clot called, venousthromboembolism (VTE). This was in line with theNational Institute for Health and Care Excellence (NICE),quality standard three, statement one.

We reviewed 10 sets of patient records and saw riskassessments were documented for each patient andstored within the notes, or on their electronic record.Each patient had a range of risk assessments undertakenon admission. These included the risk of falls, nutritionstatus, skin integrity and pain. We saw the riskassessment documents were continuously reviewed, andrisk lessening strategies or medical interventions startedif needed.

All patients received a range of multi-disciplinaryassessments which included assessments by doctors(physical and psychiatry), physiotherapy,neuropsychology, occupational therapy, speech andlanguage therapy, art therapy, music therapy, eurythmy(expression of movement art), drama and neurofunctional reorganisation. All the assessments identifiedrisks and care plans were generated on how risks wouldbe mitigated and reduced.

Patients in the special care unit had additional checks toensure their safety and reduce any identified risks. Forexample, patients had checks on their whereabouts, foodand fluid intake, records, on personal care delivery andany challenging behaviour.

Patients were monitored for the risk of deterioration andpatients received an early medical intervention toimprove their clinical condition in the event ofdeterioration, in line with National Institute for Healthand Care Excellence (NICE), guideline (NG), 51, sepsis:recognition, diagnosis and management. The serviceused the National Early Warning System (NEWS) track andtrigger flow charts. National Early Warning System is asimple scoring system of physiological measurements(for example, blood pressure, temperature and pulse) forpatient monitoring. This allowed staff to identify patientswho were becoming unwell, before they became critical,and provide them with increased support. We looked ateight sets of national early warning system charts, andsaw they were completed fully, and scored correctly. Wesaw the escalation process was followed for patients

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whose observations showed they be experiencing adeterioration in their clinical health. Staff on the wardstold us that in the case of a deteriorating patient therewas never any difficulty in accessing medical support.

The hospital did not have facilities for an acutely illpatient and they were transferred to a local NHS trust.Staff could give us examples of when this had occurredand how the situation had been managed. Basic lifesupport (BLS) and cardiopulmonary resuscitation (CPR)training were mandatory for all staff and undertakentwice a year. Data showed for December 2018, an overallcompliance rate of 66%. The departments ranged from46% compliance for nursing staff in Tobias House and82% for all therapy departments. The operationsmanager told us they were aware of the gaps in trainingand the compliance rates were being closely monitoredvia appraisals and supervision meetings.

The hospital undertook regular safety checks on patients.The checks were a structured process, called ‘intentionalrounding’ where nurses carried out regular checks withindividual patients using a standardised protocol toaddress issues of positioning, pain, personal needs andplacement of items.

Emergency buzzers were available, including in thetherapy rooms and the physiotherapy gymnasium, andpatients carried their own personal emergency alarms.Staff we spoke to were unaware if these had been testedor whose responsibility this was.

Staff on the special care unit were not able tocommunicate effectively, particularly in an emergency.Staff on the special care unit, did not carry individualalarms. As a risk reduction strategy, staff had been issuedwith two-way radios to communicate with one another.However, staff told us all but two radios were not workingand of the two working radios, only one was able to makeand receive calls. When staff were asked what happenedin an emergency they said all they could do was, “shout”.The layout of the special care unit meant there wereareas of the unit where shouting would not be heard. Thisput staff and patients at risk in making sure a prompt andtimely response by staff in an emergency. In addition,there was no method of summoning emergencyassistance from the rest of the hospital, other than viatelephone. Staff not being able to communicateeffectively in the event of an emergency, was not includedon the risk register.

Staff and patients did not always have access to call-bellsto get help. Patient bedrooms had a nurse call bellsystem for patients to use but there were rooms, such asthe staff office and all communal areas such as thelounge, activity room and corridors which did not havecall points.

Some patients had ‘do not attempt cardiopulmonaryresuscitation’ (DNACPR) decisions made in their notes.The DNACPR was recorded electronically in the electronicsystem, and a paper version was kept in the patient’smedical file. We saw the DNACPR status was recorded onthe nurse handover sheets.

Nurse staffing

There were systems and processes to assess, planand review staffing levels at the location, includingstaff skill mix.

Staff were from various professional backgrounds,including medical, nursing (psychiatric, general, learningdisability) psychology, occupational therapy, speech andlanguage therapy, and social work and activityspecialists.

There were systems and processes to assess, plan andreview staffing levels on the wards, including staff skillmix. Staffing levels adhered to national guidancerecommendations, such as the British Society ofRehabilitation Medicine (BSRM), the National ServiceFrameworks for Long Term Conditions, the Royal Collegeof Physicians Guidelines on Rehabilitation FollowingAcquired Brain Injury and the Royal College of PhysiciansGuidelines on Prolonged Disorders of Consciousness.

The service employed 18 whole time equivalent (WTE)registered nursing staff and 72 whole time equivalenthealth care assistants.

Rotas were planned, which allowed for adjustments to bemade to make ensure the correct skill mix to provide safepatient care. Shortfalls in the staffing levels were coveredby either bank staff or agency staff.

Information provided by the hospital showed in the threemonths prior to inspection two shifts were covered byregistered nurses and three by health care assistants asbank staff. During the same period, 123 shifts werecovered by registered nursing and 181 by health care

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assistants as agency staff. At the time of inspection therewere 10 registered nursing (eight general nurses and twomental health nurses), and seven health care assistantvacancies.

One of the vacancies was for a ward manager on thespecial care unit, who had left the hospital ten monthsprior to inspection. Staff told they felt this had led to alack of clear leadership.

The average sickness rate for the three months prior toinspection was 27% for registered nurses and 17% forhealth care assistants.

Allied Health Care Staffing

The service had enough allied health care staff tokeep people to keep patients safe and provide theright care and treatment.

The hospital had a large therapy team which includedphysiotherapists, occupational therapists, psychologists,speech and language therapists, art therapists, musictherapists, drama therapist, eurhythmy and externalapplication therapists. Therapist staffing levels adheredto the recommendations as defined by nationalguidelines including the British Society of RehabilitationMedicine (BSRM), the National Service Frameworks forLong Term Conditions, the Royal College of PhysiciansGuidelines on Rehabilitation Following Acquired BrainInjury and the Royal College of Physicians Guidelines onProlonged Disorders of Consciousness.

The service employed 16 whole time equivalent (WTE)and one-part time therapists and 21 whole timeequivalent and two-part time, other allied health careprofessionals.

Information provided by the hospital showed in the lastthree months prior to inspection, no shifts were coveredby bank or agency for this staffing group. At the time ofinspection there was one therapist and two other alliedhealth professional vacancy.

The average sickness rate for the three months prior toinspection was 25% for therapists and 20% for otherallied health care professional.

Medical staffing

The service had enough medical staff to keep peopleto keep patients safe and provide the right care andtreatment.

Medical staffing levels adhered to the recommendationsas defined by national guidelines including the BritishSociety of Rehabilitation Medicine (BSRM), the NationalService Frameworks for Long Term Conditions, the RoyalCollege of Physicians Guidelines on RehabilitationFollowing Acquired Brain Injury, and the Royal College ofPhysicians Guidelines on Prolonged Disorders ofConsciousness.

All patients were under the care of a consultant for theirrelevant conditions. There were consultants availableacross the wider hospital who specialised in psychiatry,rehabilitation medicine and neuropsychiatry. Staff saidthey had timely access to doctors.

The hospital directly employed one doctor full time andthree doctors under practising privileges (one full timeand two-part time). Information provided by the hospitalshowed that no shifts had been covered by an agencydoctor.

Medical staff had a low sickness rate during the reportingperiod, which was 0%.

Records

Staff kept records of patients’ care and treatment.Records were clear, up-to date and available to allstaff providing care. We looked at 10 patient recordsand found they contained patient reviews, and cleartreatment plans. All entries of patient admissionwere signed and dated. There was clear recordingfrom therapy staff. We found up to date andcompleted risk assessments and saw they werereviewed regularly.

Records were both paper based and electronic.Electronic care plan records had been trialled at TobiasHouse, and were due to be rolled out across the wholeservice. We looked at five paper based records and fiveelectronic records. All records both paper and electronicwere stored securely when not in use, in line with theData Protection Act 1988.

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The electronic patient records were only accessiblethrough password protected systems to authorised staff.Staff could view and share patient information to deliversafe care and treatment in a timely and accessible way.

The paper-based records we looked at were generallyfound to be accurate and fit for purpose. We saw theywere stored securely when not in use. Most entries weresigned and dated, and easy to follow. However, medicalstaff did not always print their name or time their entries.Medical, therapy and nursing staff wrote in patients’medical notes. This is in line with National Institute forHealth and Care Excellence (NICE), quality standard (QS)15, statement 12, patient experience in adult services,which says health and social care professionals shouldensure they support coordinated care through clear andaccurate information exchange.

Nursing risk assessments and care records, such asobservations charts, and fluid balance charts, wereplaced in a folder at the end of the patient’s bed, alongwith the patient’s medication chart.

Care plans were personalised, holistic and recoveryfocused. We found they were completed in a timelymanner and regularly reviewed. The care plans, charts,daily progress notes and three-monthly evaluations wereof a very good standard and covered all aspects ofphysical, mental health and social needs. There was acare plan summary available for each patient whichcould, in addition to providing information for staff, beprinted off and accompany the patient to any hospitalappointments. Each patient had a full care plan review atleast every three months and all patients and theirrelatives were invited to participate. Care plan topicsincluded: physical health care, recovery and lifestyle,capacity, communication, moving and handling, eatingand drinking, medicine, mental state and behaviour,mobility, keeping active, personal hygiene and preferredday time routines. Information in the care recordsincluded patient bibliographies, previous employment,key family history, likes, dislikes, preferences andadvanced directives should the patients’ healthdeteriorate. All staff we spoke with said their patients,“received effective care” and that “we are here to provideeffective and person-centred care, our patients are thepriority here”.

Physical health care plans were completed to a goodstandard with information about referrals and

assessments by the wider multi-disciplinary team. Forexample, with one patient there was clear guidance forstaff on safely managing dysphagia and associated risk ofchoking, management of epilepsy and organic braindamage with unsteady gait. In another example therewas clear and concise guidance on brain degenerativedisease and associated psychosis. We saw the familywere involved in the care planning process.

Charts for checking where patients were, and food andfluid intake were well maintained. All patients had theseassessed and recorded. Targets were clearly identifiedand actions to be taken detailed should targets not bemade.

Medicines

Staff gave, and recorded medicines well. Patient’sreceived the right medication and the right dose atthe right time. Fridge and room temperatures wererecorded.

This service had systems to ensure the safe supply,administration and disposal of medicines.

Staff stored medicines securely. We saw medicines werestored securely and handled safely. We saw medicineswere stored in locked cupboards which were accessed viaa key which only registered nurses held. There weresystems to check for out of date medicines. Staff told us amember of staff checked the medicines to make surethey were all in date. During the inspection we randomlychecked medicines and found them to be in date

We saw there were specific blue medicines disposal binsfor staff to use to dispose of unused, expired or medicinesthat were no longer needed. This is in line with HealthTechnical Memorandum (HTM) 07-01: Safe managementof healthcare waste.

Controlled drugs, such as morphine, are a group ofmedicines liable for misuse that require specialmanagement. All controlled drugs were kept securely insuitable locked cupboards, which were bolted to the walland access to them was restricted. We saw the controlleddrug register was completed, had the correct balancerecorded and dated with two staff signatures.

The service had a controlled drug accountable officer(CDAO). The controlled drugs accountable officer wasresponsible for establishing, operating and reviewingappropriate arrangements for safe management of and

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use of controlled drugs. Controlled drugs audits wereundertaken every three months. We looked at thecontrolled drugs audits for September 2018 andNovember 2018. We saw staff were 100% compliant.

Medicines were stored within the recommendedtemperature ranges to maintain their function and safety.Appropriate medicines were stored in dedicatedmedicine fridges and records showed daily temperaturechecks were undertaken. We also checked the records forthe ambient temperatures of the treatment room wheremedicines were stored which showed these had beencompleted correctly.

We reviewed prescription charts for five patients. Thesewere signed and dated by the prescriber. Chartsdocumented patients’ allergies. There were no omissionsof medicines on the patients’ prescription charts.Consultants reviewed patients’ medicines regularly.

There were processes for the stewardship ofantimicrobials (drugs used to treat infections due tobacteria, viruses or fungi). We looked at five drug charts ofpatients who had been prescribed antimicrobialtreatment. All prescriptions were signed and dated, andallergies were recorded. We saw all five had the dose andduration documented. This is in line with NationalInstitute for Health and Care Excellence (NICE) qualitystandard (QS), 121, statement 3, recording information.However, only three out of the five reviewed had theclinical indication recorded, this is not in line with qualitystandard 121, statement 3.

The hospital had a service level agreement pharmacy tosupply medications to the hospital. The hospitalemployed a pharmacist, who visited the wards regularly.The pharmacist audited and advised to ensuremedications were clinically appropriate and to optimiseoutcomes. We looked at the agreement and saw it wassigned and dated by the provider. However, the copy welooked at was not signed by the pharmacy provider.

Incidents

There were effective systems to report incidents.Incidents were monitored and reviewed and staffgave examples of learning as a result. Staffunderstood the principles of Duty of Candourregulations, were confident in applying the practicalelements of the legislation.

The hospital had a process for categorising and handlingincidents, including and up to date ‘Accident and Incidentreporting policy’ version 4.2 (dated January 2017).

The service had not reported any never events in the last12 months. Never events are serious patient safetyincidents that should not happen if healthcare providersfollow national guidance on how to prevent them. Eachnever event type has the potential to cause seriouspatient harm or death but neither need have happenedfor an incident to be a never event.

Between January and December 2018, the service did notreport any serious untoward incidents. Serious incidentsare incidents where on or more patients, staff members,visitors or members of the public experience serious orpermanent harm, alleged abuse or a service provision isthreatened.

The service reported 254 incidents within the reportingperiod. Most incidents reported were behaviouralincidents (148), followed by other (24), equipment failure(16) and falls (14). The least related to incidents of abuse(1) or suicide or attempted suicide (1), care practice (2),patients fainting (2) self-harm (3), and medication errors(3). The incident reporting rate was variable throughoutthe year.

All senior members of the management team were awareof any issues or concerns. The management teaminvestigated the incidents to establish the cause. Newincidents were discussed at the newly implemented dailymeetings.

An electronic based system was used to report incidents.Staff were aware of the system and knew how to use. Stafftold us they received feedback from incidents at teammeetings.

Staff were encouraged to report incidents and they wereconfident about reporting issues. They were aware of thetype of incidents they needed to escalate and report.Staff told us they made time to report incidents

Patient specific issues were communicated via care plansand individual support guidelines. Senior cliniciansprovided patient specific training for staff where theclinical team assessed the treatment plan neededadditional support and guidance, for example, educationon epilepsy and seizures. We looked at the four mostrecent incidents on special care unit, in addition to two

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incidents of restraint and saw staff had discussed theincidents and reviewed patient risk assessments and careplans accordingly. For example, successful interactionsand communications were reviewed by the team toencourage a patient who had been refusing to carry outtheir personal care.

Staff described the principle and application of duty ofcandour, Regulation 20 of the Health and Social Care Act2008 (Regulated Activities) Regulations 2014, whichrelates to openness and transparency. It requiresproviders of health and social care services to notifypatients (or other relevant person) of ‘certain notifiablesafety incidents’ and provide reasonable support to thatperson. Patients and their families were told when theywere affected by an event where something unexpectedor unintentional had happened.

Mortality and morbidity incidents were discussed as partof the Medical Advisory Committee (MAC) meetings whichmet every four months.

Safety Thermometer (or equivalent)

The service formally collected safety performancedata. However, we did not see safety performancedata collected was discussed in meetings. Safetyperformance data was not on display to keeppatients and visitors informed about the wardperformance.

Medical records showed patients were assessed for theirrisk of venous thromboembolism (VTE). This was in linewith National Institute for Health and Care Excellence(NICE) Quality standard three, statement one. BetweenJanuary and December 2018, there had been noincidences of hospital-acquired venousthromboembolism.

Risk assessments for pressure ulcers and falls were part ofthe nursing assessment documentation and we sawthese were up to date, completed and regularly reviewed.We saw actions were appropriately followed up, such asuse of a pressure care relieving mattress in records whichidentified patients at risk of developing pressure ulcers.

Between January and December 2018, there had beenfive cases of pressure ulcers at the hospital. Two wereacquired at the hospital and three related to patients whohad pressure ulcers present on admission.

Between January and December 2018 there had been 27incidents of urinary tract infections, which was animprovement since our previous inspection. At ourprevious inspection the service told us they had recentlyintroduced a process to reduce the number of urinarytract infections (UTI’s). The process involved all patientshad their urine tested weekly, according to the urinarytract infection protocol and care pathway. We saw tenrecords during our inspection which showed the weeklytesting of urine was completed.

Safety performance data was not effectivelycommunicated or used to drive improvement. Safetyperformance data was not displayed to keep patients,relatives and visitors informed. In meeting minutes welooked at, we did not see any safety data that wascollected was discussed to see how data was used todrive improvements to the service or patient care.

Are long term conditions effective?(for example, treatment is effective)


Our rating of effective went down. We rated it as requiresimprovement.

Evidence-based care and treatment

Staff assessed the patient’s physical, mental healthand social needs holistically. Overall, staff providedcare, treatment and support in line withevidence-based guidance. However, we found therewas limited formal process to monitor staffadherence to national guidelines and local policies,such as hand hygiene, and ligature risks.

The service commissioned external reviews from the ISO(International Organisation for Standardisation), to makesure aspects of its service met defined criteria. Thehospital had been subject to external review in the last 12months for ISO 9001 Quality Management Systems, ISO14001 Environment Management Systems, ISO 18001 andISO 45001 Occupational Health and Safety Systems, andISO 22000 Food Safety Management.

The provider reviewed the service it provided in line withBritish Society of Rehabilitation Medicine (BSRM)Guidelines, National Service Framework for Long Term

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Conditions, The Royal College of Physician Guidelines forAcquired Brain Injury and Prolonged Disorders ofConsciousness (PDOC). We saw in the clinical governancecommittee, there was a dedicated section on the agendafor this.

Patients were assessed using recognised risk assessmenttools to holistically assess patients physical, mentalhealth and social needs. For example, the risk ofdeveloping pressure damage was assessed using anationally recognised practice tool. Staff undertook fallsrisk assessments, nutrition status, and skin integrity

We saw the hospital had developed their service forpatients who were in altered states of consciousness inline with the Royal College of Physicians Guidelines forpeople with prolonged disorders of consciousness(PDOC). They utilised the recommended structuredassessment tools to aid accurate diagnosis and tomonitor patients. For example, they used the WessexHead Injury Matrix (WHIM) and the JFK Coma RecoveryScale. The provider ensured all patients were providedwith appropriate diagnosis and we were told they wouldseek further opinions if required.

There was limited formal process followed to monitorstaff adherence to national guidelines and local policies,such as hand hygiene, and ligature risks. For example,there were regular audits to monitor the environmentand cleaning, we looked at multiple audits and founddespite there being an action plan, we saw the samenon-compliance was identified for multiple audits and nocorrective action had been taken.

Nutrition and hydration

Staff gave patients enough food and drink to meettheir needs and improve their health. They usedspecial feeding and hydration techniques whennecessary.

Staff completed a nutritional risk assessment whenpatients were admitted to the hospital. This is in line withNational Institute for Health and Care Excellence, qualitystandard 24, statement one: screening for the risk ofmalnutrition. The risk assessment included amalnutrition universal screening tool (MUST) usedthroughout the United Kingdom, to assess people for riskof malnutrition. We looked at 10 during our inspectionand saw they were fully completed.

Dietitians were available to support patients withnutritional advice. Speech and language therapists(SALT), were available if a patient needed help withswallowing.

The service supported patients with special dietaryrequirements, such as diabetes, lactose intolerance orsoft/pureed diet.

The hospital used special feeding and hydrationtechniques when necessary. Staff explained thatdietitians monitored patients who received nutritionthrough a nasogastric or parenteral feeding tube.Parenteral feeding is the process by which a patientreceives nutrients intravenously by-passing the usualprocess of eating and digestion. We looked at the recordsof four patients who were receiving parental feeding. Wesaw all patients had an up to date feeding regime, whichhad been regularly reviewed. We did not speak to anydietitians during our inspection, but staff told us theywere accessible.

The chefs worked with the dietitian and speech andlanguage therapist team to provide suitable menus inkeeping with agreed standards.

We observed staff supported patients to eatindependently and placed drinks within their reach.

Food hygiene training was mandatory for all staff andundertaken once a year. Data showed an overallcompliance rate of 69% for June 2018. The departmentsranged between 43% for nursing staff in the main houseand 90% for domestic and laundry staff. Eighty-fivepercent of nursing staff in Tobias House had completedthis training and 61% of nursing staff working in specialcare unit. Only 50% of kitchen and maintenance staffwere compliant.

Food was transported from the kitchen in the main houseto Tobias House via a plastic box on a trolley. We saw thatfood was put onto plates, and covered, this was thenwrapped. The food was then placed into a plasticcontainer on a trolley for transfer. Once the food arrivedat Tobias House it was then given to patients. We did notsee that there were any checks to make sure the foodremained hot, or at a reasonable temperature forpatients to eat. This meant, patients may not alwaysreceive food at a reasonable temperature.

Pain relief

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Patients’ pain was assessed and managedappropriately.

The hospital had implemented the Faculty of PainMedicine’s Core Standards for Pain Management (2015)which states all in-patients with acute pain must haveregular pain assessments using consistent and validatedtools, with results recorded with other vital signs

We saw staff completed pain assessment tools forpatients on the vital signs chart in eight of the ten recordswe reviewed. Staff used a non-verbal pain assessment toestablish individual pain needs when a patient was notable to communicate verbally. This included byinterpreting body language and facial expression. We sawthat staff asked patients about pain, and documented theaction they had taken.

Patient outcomes

The service monitored the effectiveness of care andtreatment and used the findings to improve them.

The service participated in national audits, includingthose outlined by the United Kingdom SpecialistRehabilitation Outcomes Collaborative. Where possiblethe results were used to benchmark and compare withother similar services nationally. In addition, patients areassessed against a range of criteria, initially at the point ofadmission, to decide their level of independence andfurther needs, and routinely throughout their stay. Theseassessments supported patients and their families to seethe individual’s progress.

The hospital took part in the United Kingdom SpecialistRehabilitation Outcomes Collaborative (UKROC)developed a national database collating all specialistneuro-rehabilitation services (level 1 and 2) across theUK. It provided information on rehabilitationrequirements, the inputs provided to meet them,outcomes and cost benefits of rehabilitation for patientswith different levels of needs.

The hospital used the Function Independence Measure(FIM) and the Function Assessment Measure (FAM) inauditing function changes. The functional independencemeasure is a global measure of disability and can bescored alone or with the functional assessment measure.We saw there had been a 32% improvement in theirscores, from the previous year.

All patients were assessed using the ‘health of the nationoutcome scales’ (HoNOS). These covered twelve healthand social domains and allowed clinicians to build up apicture over time of their patients’ responses tointerventions. Staff told us how effective the treatmentand therapy programme was, one said, “We had a patientadmitted who could not walk and it was so rewarding tosee how the therapy and treatment enabled the patientto walk and return home”.

Other assessments used to measure patient outcomesincluded range of motion assessments, the JFK comarecovery scale and the scale for the assessment andrating of ataxia (SARA).

The hospital used the Northwick Park TherapyDependency assessment (NPTDA) tool provided anassessment of therapy dependency. It is a measure oftherapy intervention used in specialistneuro-rehabilitation settings, where rehabilitation isprovided by a multidisciplinary team. The NPTDAincluded 30 items of therapy dependency in sevendomains; physical handling programme, basic function,activities of daily living, cognitive/psychosocial/familysupport, discharge planning, indirect interventions andadditional activities, specialist facilities, andinvestigations and procedures. The hospital had a 40%improvement their Northwick Park Therapy Dependencyassessment scores.

The therapy teams audited patient outcomes by using agoal setting approach to each patient’s rehabilitation. Wesaw every patient had an individual goals action plan inhis or her medical notes. The multidisciplinary teamdiscussed and reviewed these goals at internal teammeetings.

Competent staff

The service made efforts to ensure staff werecompetent for their roles. Overall 91.5% of staff hadreceived an appraisal. All staff received a one-weekinduction which included the completion of abooklet.

Staff training and professional development needs wereidentified through informal one to one meetings withtheir managers and annual appraisals. During theinspection we looked at five appraisals. We saw the

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annual appraisals gave an opportunity for staff andmanagers to meet, review performance and developmentopportunities which promoted competence, well-being,and capability.

Data provided to us showed that overall 91.5% of staffhad received an appraisal within the last 12 months.One-hundred percent of doctors, therapists and otherallied health professionals had up to date appraisals.However, only 81.2% of nursing staff and 76.3%healthcare assistants had, had an appraisal within thelast 12 months. Lack of appraisals may have meant theservice did not address any potential staff performanceissues.

Staff who had, had an appraisal told us they wereundertaken yearly. They felt it was useful and managersdiscussed performance and opportunities for trainingand progression. We saw the system was used when pooror variable staff performance was identified. However, wefound limited evidence that staff were supported toimprove.

We reviewed five staff personnel records. All containedrecords of interviews, references, identification checks,contracts of employment and enhanced disclosure andbarring service checks, and were completed within thelast three years.

All new staff completed an induction programmeensuring new staff had all the information andcompetencies they needed to do their jobs. Staff told usthe comprehensive programme included departmenttours, introduction to colleagues and completion of aninduction booklet. During our inspection, we looked atfive induction booklets and saw they were eithercompleted or in the process of completion.

There were good opportunities for development andtraining for nursing, rehabilitation support assistants andallied professional staff. They were encouraged andsupported to develop their expertise and competenciesand extend their skills.

In discussion with staff they appeared veryknowledgeable and confident in their roles. All the staffwe spoke to commented on how much training theyreceived. All staff received an induction period,completed mandatory training which included trainingon basic life support, first aid, mental health awareness,

care planning, risk assessing and safeguarding. Theprovider had organised for a tutor to attend the hospitalweekly to teach English for those staff who did not haveEnglish as a first language.

Applications for practising privileges from consultantswere reviewed and granted or declined by the MedicalAdvisory Committee (MAC). This involved checking theirsuitability to work at the hospital, checks on theirqualification, references, immunisation, and indemnityinsurance. The hospital only granted practising privilegesfor procedures or techniques that were part of theconsultant’s normal practice.

At the time of inspection, there were two-part time andone full time consultants employed under practisingprivileges. Practising privileges is a term used whendoctors have been granted the right to practise in anindependent hospital. We looked at two practicingprivileges folders, both contained references, GeneralMedical Council (GMC) registration, indemnity insurance,up to date appraisal, identification, disclosure andbarring service checks, and records of mandatory trainingcompliance.

Multidisciplinary working

Staff from different disciplines worked together as ateam to benefit patients. They supported each otherto make sure patients received care that met alltheir needs, including physical, emotional and socialneeds. Doctors, nurses and other health careprofessionals supported each other to provide care.Staff respected their colleague’s opinions.

Patients had access to a variety of psychologicaltherapies. Psychologists, occupational therapists andactivity therapists were part of the multidisciplinaryteams and were actively involved. Patients had access toa range of therapies such as cognitive behaviour therapy,occupational therapy, drama and movement therapy,music therapy and art therapy. There was evidence ofdetailed psychological assessments and assessments ofneuropsychological functioning in patients records andcare plans.

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There was very good multidisciplinary team working; allstaff disciplines had input into the planning, assessingand delivering of patients’ care and treatment. Thepatients’ holistic needs were assessed and therapies ortreatments were tailored to their requirements.

Staff of all disciplines, clinical and non-clinical, workedalongside each other throughout the service. Weobserved good communication amongst all members ofthe staff. They reported that they worked well as a team.

Staff told us they were proud of good multidisciplinaryteam working, and we saw this in practice. Staff werecourteous and supportive of one another. Staff workedhard as a team to ensure patient care was safe. Staff toldus the consultants and management team wereapproachable and they felt comfortable asking themquestions and raising concerns with them.

The hospital used integrated patient records, which wereshared by clinical staff and therapists. This improvedcommunication and provision of care was betterco-ordinated between healthcare professionals.

Staff told us they had access to a dietitian sometimeswho attended regularly to assess and manage thenutritional needs of patients. We saw dietitianscontributed to the patient’s care plan and recordedinstructions for other members of the multidisciplinaryteam.

Regular multidisciplinary meetings were held to discusspatients and their ongoing needs. This meeting wasattended by therapist, nurses, doctors and patients’relatives or cares, and whoever commissioned theservices.

Seven-day services

Services were made available that supported care tobe delivered seven days a week.

There was not a responsible consultant available on siteat all times, however arrangements existed to managethis. Consultants provided a 24 hour on call service.In-house physicians delivered the day to day medicalservice, who dealt with any routine and emergency inconsultation with the relevant consultant assigned to thepatient.

Between the hours of 6pm and 10am medical cover wasprovided by telephone. Staff told us they had never had

any issues contacting the doctor out of hours. Staff toldus in an emergency they would call 999 and the patientwould be transferred to the local NHS acute hospital viaan ambulance.

Rehabilitation continued seven days a week. Patients hadaccess to therapy service seven days a week 9am to 8pm.

Health promotion

We did not gather evidence for this as part of theinspection.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

Staff understood their roles and responsibilitiesunder the Mental Health Act 1983 and the MentalCapacity Act 2005. They knew how to supportpatients experiencing mental ill health and thosewho lacked the capacity to make decisions abouttheir care.

The Mental Capacity Act 2005 is legislation applying toEngland and Wales. Its primary purpose is to provide alegal framework for acting and making decisions onbehalf of adults who lack the capacity to make decisionsfor themselves. The Deprivation of Liberty Safeguards arepart of the Mental Capacity Act 2005. Deprivation ofLiberty Safeguards aim to make sure that people in carehomes and hospitals are looked after in a way that doesnot inappropriately restrict their freedom.

There was a consent policy which staff adhered to. Thepolicy was in date and provided information on gaining,and recording consent for provision of care andtreatment.

Staff understood the relevant consent anddecision-making requirements of legislation andguidance, including the Mental Capacity Act 2005.

Deprivation of liberty training, was mandatory for all staff,and undertaken once a year. Data indicated for June2018, an overall compliance rate of 81%. Thedepartments ranged from 67% for domestic and laundrystaff to 90% for nursing staff on the special care unit. Wedid not have deprivation of liberty training figures formedical staff. The service did not have a target forcompliance.

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Staff received training on the Mental Health Act as part oftheir induction training. We looked at the Mental HealthAct documentation for one patient and all was in goodorder. Staff documented in the patients notes that rightshad been explained to the patient as required by section132 of the Mental Health Act.

Data provided to us showed that five patients had amental health disorder and were in receipt of a formalcare plan under the Care Programme Approach. Fivepatients who had their liberty, rights and choicesaffected, were supported by care plans. Twenty-four weresubject to an authorisation under the Deprivation ofLiberty Safeguards (DoLS). The provider had informed theCQC of all DoLS statutory notifications as required by theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014.

At the time of inspection, three patients had a deputyappointed by the Court of Protection with powers to takedecisions about the service provided. No patients weresubject to an order by the Court of Protection thatresulted in the restricting their liberty, rights and choices.

Staff gave patients all possible support to make specificdecisions for themselves before deciding a patient didnot have the capacity to do so. When a patient lackedcapacity, staff made decisions in their best interests. Staffalso considered and documented the patients’ capacityto consent to care plans.

A standard template was used for the assessment ofcapacity. This made sure the requirements of the MentalHealth Act were met. We looked at three mental capacityassessments and saw evidence of best interest decisionsbeing made and documentation regarding conversationsabout a patient’s care with the patient’s family. We alsosaw this reflected in care plans and additionalassessments for specific interventions such as medicalprocedures and personal care delivery. Documentationwas available around best interest decisions in patients’notes and staff told us confidently what this meant.

Best interest meeting notes, were not written in aconstant format, and the least restrictive option was notalways clearly identified. We reviewed four best interestmeeting records.

Are long term conditions caring?

Good –––

Our rating of caring stayed the same. We rated it as good.

Compassionate care

Patients were treated with compassion, kindness,dignity and respect, when receiving care. Feedbackfrom people who used the service, those who areclose to them was positive about the way stafftreated people.

Patients were treated with dignity and respect. All staff wespoke with were passionate about their roles and werededicated to making sure patients received the bestpatient-centred care possible. Relatives we spoke withtold us staff were caring, attentive and professional. Apatient told us “The staff are very kind here, lovely”.Another said, “Staff really care for us here”.

We saw and heard staff delivering kind andcompassionate care, going beyond the requirement andhelped patients feel at ease. Staff interacted with patientsin a positive, professional, and informative manner. Thiswas in line with National Institute for Health and CareExcellence Quality Standard 15, statement one.

Staff respected patients’ privacy and dignity. For example,we saw care interventions were carried out behind closeddoors. We observed staff placed signs on doors ‘do notdisturb, personal hygiene in progress’. We saw how staffspoke to patients with respect and gave time for them torespond. Staff showed an understanding and anon-judgemental attitude when talking with patients.

Where possible staff made the service feel as normal aspossible, for example, patients were encouraged to eatmeals in the dining room, and wear their own clothes.Staff encouraged independence, for example, we heardstaff offering and encouraging patients to make their ownchoices which included examples such as, “When wouldyou like to go out on leave today? would you like to makeyour own drink? When would you like me to help you withyour laundry? Do you want to try to do this yourself?”

On the special care unit, despite the complex needs ofpatients using the service, the atmosphere was calm andrelaxed. We saw many swift interactions where staff saw

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that patients were becoming agitated, distressed oroverly stimulated, particularly with visitors on the ward.Staff immediately attended to their patients in a kind andgentle manner.

Emotional support

Staff provided emotional support to patients,relatives, and carers to minimise their distress.

Staff were on hand to offer emotional support to patientsand were very happy to offer a listening ear. Both patientsand relatives told us they felt able to approach staff if theyfelt they needed any aspect of support.

Staff told us they helped patients or their relatives, whobecame distressed in an open environment. Theymaintained their privacy and dignity by taking them to aprivate room where they could voice their concerns andworries. Staff told us they offered as much support asthey could by listening to their patient’s or relativesworries or concerns.

We found good examples of mental well-being careplans. If a patient should become distressed or anxious,guidance was given to staff about how they shouldrespond and what interventions they could use. Careplans detailed positive behaviour plans and how apatient’s independence could be supported safely.

All staff we spoke with had an in-depth knowledge abouttheir patients including their likes, dislikes andpreferences. This information was very detailed and wassummarised in the patients’ individual care plans. Forexample, we spoke to staff who were able to confidentlydiscuss their approach to patients and the model of carepracticed. They spoke about enabling patients to take asmuch responsibility as possible for their care pathways.We saw evidence of patient involvement in the carerecords we looked at, particularly captured in theindividual care plans. This approach was person centred,individualised and recovery orientated. We also saw thatall patients reviewed their care plan once every threemonths with the multi-disciplinary care team and inregular meetings with a member of the ward nursingteam. This is in line with National Institute for Health andCare Excellence (NICE) quality standard 15, statementnine: Patients experience care that is tailored to theirneeds and personal preferences, taking into account theircircumstances, their ability to access services and theircoexisting conditions.

Understanding and involvement of patients andthose close to them

Staff involved patients and those close to them indecisions about their care and treatment.

Staff communicated well with patients and those close tothem in a manner so they could understand their care,treatment and condition. Staff responded positively toquestions and took time to explain things in a way,patients and their relatives could understand. This is inline with National Institute of Health and Care Excellencequality standard 15, statement two.

The patients and relatives we spoke with told us theyfound all members of staff respectful, responsive andapproachable. They reported staff of all levels listened towhat they had to say, acted upon their concerns andaddressed any issues.

We saw effective interactions between staff and patients.Patients and those close to them were kept informed andincluded in their care and treatment decisions,throughout the process from pre-admission to discharge.The service used a goal setting approach to workpartnership with patients, supporting each patientindividual decision-making process of their care andtreatment. This is in line with National Institute of Healthand Care Excellence, quality standard 15, statement four.

Staff had accessible ways to communicate with peoplewhen their protected equality or other characteristicsmake this necessary. Information about care andtreatment was provided in appropriate ways that patientswere supported to understand the benefits and possiblecomplications of treatment. This is in line with NationalInstitute of Health and Care Excellence, quality standard15, statement five.

Are long term conditions responsive topeople’s needs?(for example, to feedback?)

Good –––

Our rating of responsive stayed the same. We rated it asgood.

Service delivery to meet the needs of local people

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The service planned and provided services in a waythat met the needs of the local people.

The service mainly treated NHS patients, but also treatedthose who were either privately funded, or fundedthrough insurance companies. At the time of inspectionthere were 59 NHS funded patients and one privatelyfunded.

The service worked closely with the relevantcommissioning services. There were regular meetings tomake sure the service can respond to the needs of thelocal people. The service produced a pre-admissionreport to whoever commissions the service, this isreviewed and funding agreed before the patient moves tothe service.

The grounds of the hospital were accessible to patientsand their family and friends. Family and friends whowanted a private space were able to use the sitting roomsin the main building. However, the hospital did not have adesignated area or the facilities for friends and family ofpatients to stay at the hospital. We were told if a flat wasavailable in the step-down facilities this was offered for alimited time and in an emergency.

Meeting people’s individual needs

Services were planned to take into account theindividual needs of patients. There werearrangements for patients with complex health andsocial care needs. Adjustments were made forpatients living with a variety of disabilities.

Care and treatment was tailored to meet the needs of theindividual patients. All patients were risk assessed prior toadmission to ensure the unit provided a safeenvironment. This allowed the service to make sure theyhad all the equipment necessary and could provide theappropriate therapy.

Patients ability to undertake activities of daily living (forexample, help with walking, dressing, using the toilet orusing the stairs) was measured using the Barthel scale.These assessment measures allowed staff to provideeach patient with the right amount of support andsupervision to keep them safe while in hospital.

The service was accessible by patients with a physicaldisability, or who used a wheelchair. We saw there wereramps to ease access to and from areas, doors were wide

and bathrooms which had easy access showers, with nosteps, and had handrails to provide extra support andstability when showering. There were good supplies ofmobility aids and hoists to help staff care for patients. Allpatients were assessed prior to admission for theirindividual needs, and any specific equipment neededwas ordered and available on admission.

There was strong individual patient needs assessmentand care planning. We saw there were records ofpersonalised assessment and care plans, where patientshad given details about their preferences, likes anddislikes. Staff used information to tailor care, treatmentand therapies for individual patients. For example, stafftold us of a patient who had limited communication skillswhen they first arrived at the hospital. By identifying theirlikes and dislikes they were able to create a therapyprogramme that was unique to them. Staff told us as aresult of this programme, the patient had started torespond and was able to communicate.

There were processes in place to help staff communicatewith patients. Staff had accessible ways to communicatewith people when their protected equality or othercharacteristics make this necessary. For example,patients who were unable to communicate verbally usednon-verbal communication charts. We saw patient’sindividual communication needs were documented intheir care plans.

Therapy was tailored to the individual needs of thepatient. We saw all patients had their own weekly plan,which included a variety of therapies, such as art, musicand relaxing therapies. Each patient had a board in theirbedrooms displaying their schedule for the week. Theschedule was updated weekly and was based on eachpatient’s needs and objectives.

Care pathways were designed to be flexible to make suredifferent services worked together to meet the patient’schanging needs. The hospital held regularmultidisciplinary meetings, where goals and outcomesare discussed with the team, patients and their families,to discuss the patients ongoing needs.

We saw there was a choice of food options for patients.We spoke with the chef who told us they could make sure

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patient preferences, religious or cultural needs, such asvegetarian, vegan or kosher meals. This was in line withthe National Institute for Health and Care Excellencequality standard 15, statement 10.

The service provided three meals a day for patients, on aprogramme. Choices could be seen on menus and thestaff spoke with patients daily to discuss any individualneeds. The service could cater for any special dietaryrequirements such as allergies and intolerances orreligious preferences, as food was cooked daily.

Staff supported patients who wanted ‘home leave’.Patients were risk assessed which highlighted andconcerns or barriers, and allowed measure to be put inplace to facilitate the home leave. This was recorded inthe patient’s notes.

Anything about interpretation and translation service andleaflets/info in alternative languages or formats

Access and flow

People could access the service when they needed it.Arrangements to admit, treat and discharge patientswere people-centred and in line with good practice.

The service has the facility for 60 patients. At the time ofinspection there were 28 patients for acute neurorehabilitation, 22 for continuing health care and seven forneuro behavioural rehabilitation.

The hospital received 62 referrals for admission betweenJanuary and December 2018. Most (90%) of patientsreferred had complex disabilities. The service prioritisedreferrals for admission on the need of the patient andtheir current location. The service currently had fourpeople on the waiting list.

When a new referral was received the admissionscommittee met to discuss the suitability of the patientbased on the information received. If the referral wassuitable a pre-assessment of the patient was arrangedwith members of the multidisciplinary team, appropriateto the patient’s individual needs. If the referral wasappropriate, the provider worked in partnership with thecommissioning group and the admission process wasstarted.

Based on the content of the referral a specialist teamassessed the patient prior to admission to make sure theappropriate equipment was available to meet individualneeds.

A nursing assessment was completed within 72 hours anda therapy assessment within seven days. With thepermission of patients all commissioners, families (ifprivately funded) or insurance companies were invited toattend case conferences. The first happened after eight to10 days following admission, a second after six weeks,and then every three months. Discharge planning wasstarted at admission, and we saw comprehensivedischarge reports were completed on discharge. Thisallowed for continuity of care.

Peoples relatives were able to visit, without beingunnecessarily restricted. People could visit between 10am and 8 pm. Visiting times were displayed on the noticeboard on reception.

Learning from complaints and concerns

The service treated concerns and complaintsseriously, investigated them and learned lessonsfrom the results. However, it was unclear how thelessons learned were actioned, monitored andshared with staff.

The hospital had a process for categorising and handlingcomplaints and concerns, including an up to date‘Complaints and Compliments Policy’ (dated January2017). Staff we spoke to were aware of the complaintsprocedure. We saw posters on display throughout thehospital detailing how to make a complaint and how thiswould be dealt with.

People could make a complaint in three ways, face toface, via the telephone or in writing by either email orletter. Staff were able to describe how they would dealwith a complaint; staff told us they always try to resolveany issues immediately. If issues were not resolved, thepatient, relatives or carer was directed to the complaintsprocess.

A senior manager had overall responsibility forresponding to all written complaints. The hospitalacknowledged complaints within two working days ofreceiving the complaint with an aim to have the

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complaint reviewed and completed within 20 days. Therewas an expectation that complaints would be resolvedwithin 20 days. If they were not, a letter was sent to thecomplainant explaining why.

Complaints were dealt with promptly and responses wereclearly written. During the inspection we looked at fourcomplaints. We saw the complaints we looked at wereacknowledged and responded to promptly. We saw theywere investigated and responses were emailed to thecomplainant with an apology and explanation andoutcome of the investigation. All letters were written inplain English.

We saw that lessons were learned as a result of acomplaint. However, it was not clear from our review howlessons learned were actioned or monitored and sharedwith staff.

The hospital received 10 complaints between January2018 and December 2018.

Are long term conditions well-led?


Our rating of well-led stayed the same. We rated it asrequires improvement.

Leadership

The service did not have managers at all levels withthe necessary experience, knowledge and skills tolead effectively. During inspection it was identifiedthat three of the wards did not currently have award manager. Managers could not demonstrateadequate systems and processes that showed theyhad full oversight of the service in terms of risk,quality, safety, and performance.

The service had a registered manager. The Health andSocial Care Act 2008 requires the Care Qualitycommission to impose a registered manager conditionon organisations that requires them to have one or moreregistered managers for the regulated activities they arecarrying on.

The registered manager led the management team andwas supported by an operations manager. Theoperations manager had been in post less than a year. At

previous inspection we found the registered managemaintained control of the most aspects of the hospital. Atinterview the registered manager confirmed they weredelegating more responsibility to the operationsmanager, and that they had a good working relationship.The operations manager, confirmed this when we spokewith them.

The medical team, director of nursing and consultantneuro physiologist and therapy lead all reported to theoperations manager.

The service did not have managers at all levels with thenecessary experience, knowledge and skills to leadeffectively. Three wards did not currently have a wardmanager in post. The registered manager told us atinterview that two of the vacant posts were currentlybeing filled with an interim manager, which they werehopeful would take up the substantive post. However, thespecial care unit had not had a ward manager for anumber of months.

Managers could not demonstrate adequate systems andprocesses that assured us they had full oversight of theservice in terms of risk, quality, safety, and performance.For example, the lack of leadership with no identifiedperson having full oversight of the special care unit.Without a ward manager, there were clear signs thatsome responsibilities were not covered which hasweakened the governance and management systems. Forexample, the lack of audits, poor environment, poorcleanliness, poor fixtures and fittings and no anti- ligatureworks programme.

We fed this back at the end of the inspection, but theregistered manager felt they had suitable arrangementsto make sure patients received safe care. These includeda programme of works to upgrade the special care unit,and had put additional clinical support. They told us theycould only make changes when rooms were vacated.However, we were not assured that the managementteam had taken sufficient action to minimise thesechallenges.

Staff told us they felt well supported by their immediateline manager. They felt the leaders and senior staff werevery approachable. If there was any conflict within the

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service, they would go to their line manager and seeksupport. Staff told us there was a ‘door always open’policy, which meant staff could approach themanagement team with any queries they had.

Vision and strategy

The service had a vision and mission statement forthe type of care it wanted to achieve. However, thevision and mission statement were not developedwith staff or patients.

The vision and mission statement for the service wasbased on the anthroposophical image of humans, whichrecognised people as being of body, soul and spirit. Therewas a set of values, which underpinned the vision. Theseincluded open and transparent service; to supporteducate staff in rehabilitation incorporating ananthroposophical approach; to provide holistic care witha multidisciplinary approach; supporting both patientand loved ones through their journey.

We did not see the vision or mission for the service ondisplay in any of the areas where patients or visitors couldsee them. However, the mission for the service was on thepublic website.

We asked the registered manager if the vision andmission statement was developed in conjunction withstaff or patients. They told us the vision was notdeveloped with staff, but staff are reminded of the visionof the service at all training. Staff confirmed this when wespoke with them.

Culture

Staff had effective working relationships with eachother. There were clear staff support networks andall staff we spoke with felt supported by theircolleagues. However, staff felt they would not belistened to by senior leaders with ideas on how toimprove the service.

It was clear from our observations that all staff within theservice were committed and passionate about the workthey did. Staff we spoke with showed a positive attitudetowards delivering care that is patient centred.

Staff reported positive working relationships, and weobserved staff were respectful towards each. Staff wespoke with were passionate about the service theyprovided; we saw that staff worked well together and

supported one another during their day to day work. Stafftold us, “this is the best place I have ever worked”, and“the nursing staff are just wonderful, they offer so muchsupport and this work is so very rewarding”.

All staff told us they felt part of a team and felt theyworked well together and supported each other. Moraleappeared to be good.

The registered manager told us they had an ‘open door’policy where patients and their relatives were able todiscuss their care and treatment. This could be at anytime, should they be happy or not pleased with their careand treatment.

However, some of the staff we spoke with thought thatchallenging of senior leaders was futile as the registeredmanager was resistant to change. They told us they hadideas on how to improve the service, but did not raisethese with managers as they felt they would not belistened to.

Governance

The service used a systematic approach tocontinually improve the quality of its services andsafeguarding high standards of care, but there weresome areas that were not fully effective. Theseincluded the arrangements for monitoring theprogress of actions from internal audits, andoversight, management and reduction of risk topatient safety.

The hospital held meetings through which governanceissues were addressed. The meetings included MedicalAdvisory Committee (MAC), Clinical governancecommittee (CGC), Team Leaders meetings andOperations meetings.

The service had started a daily operations meeting thesewere introduced to reduce potential patient harm. Thismeeting was attended by the leads of the services suchas the registered manager, director of nursing, andoperations director. This enabled them to shareinformation and act on any risks in a timely way. Itemsdiscussed included, incidents, staffing (vacancies, leavers,sickness), the environment and complaints. We attendedthe daily meeting on 15 January 2019, and saw all staffpresent were involved and included in the discussion.

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The medical advisory committee met every threemonths. During our inspection we looked at the minutesfrom the most recent committee, we saw issues such aspractising privileges, incidents and complaints werediscussed.

The clinical governance committee met monthly anddiscussed complaints and incidents, patient safety issuessuch as safeguarding and infection control, complaints,compliments and training. There was also a standingagenda item to review external and national guidanceand new legislation. However, we did not see the riskregister discussed at this meeting. We saw there was asection for matters arising from the previous meeting,where actions were identified, with a designated personto complete them within clear timeframes. Duringinspection we looked at the minutes for 3 December2018.

There were limited systems, such as auditing, to monitorthe quality and safety of the service, including staffadherence to policy. Audits that were showed there waslimited or ineffective action taken following an audit,where the same non-compliances were identified onmultiple audits.

Managing risks, issues and performance

The organisation had systems for identifying risks,however action to reduce or eliminate them was notalways carried out in a timely manner. Althoughthere was a risk register, there was no robust way ofensuring effective risk reduction strategies had beenundertaken, or all risks fully recognised.

There was a risk register to record risks within thehospital. Each risk was categorised as green (low risk),amber (medium risk), red (significant risk). The hospitalhad 33 risks recorded on the risk register, 31 were green(low risk), and two were amber (medium risk). Thehospital had no red (significant risks) on the register.

The risk register had an explanation of the risks, but therewere no named members of staff that had responsibilityto make sure existing risk controls and actions werecompleted or maintained for each identified risk, or datefor completion or review. The risk register was undated,and we did not see the risk register discussed at any of

the meeting minutes we looked at. We found the risksrecorded on the register provided false assurances andrisk reduction strategies were not effective, and potentialrisks were not fully recognised.

From review of the risk register, we saw risk reductionstrategies were not always in place. For example, controlof substances hazardous to health (COSHH), had beenrisk assessed as a low risk for the hospital, and the riskreduction strategy was to make sure managers ensuredchemicals were locked in designated areas. However, wefound multiple concerns in the special care unit, wherepatients could access chemicals.

We saw infection control was on the risk register andrated as medium. However, the hospital did not recogniseissues such as lack of dedicated hand hygiene facilities,carpet in patient bedrooms and bathrooms, torn flooringand furniture as risks. In addition, we saw on the minutesfor quality and governance committee, dated 3December 2018, the hospital did not have a lead forinfection control. The management team had notincluded this on the risk register.

The risk register did not reflect all risks identified by staff.For example, staff expressed concern about the riskposed by vacancies of ward managers, and impact thishad on the service they provided. We found the lack of award manager on the special care unit, meant there wasno named person, who had full oversight andresponsibility to resolve the identified issues.

We did not see other areas identified in our report, on therisk register, for example the poor environmentalcondition of the special care unit, including the identifiedligature risks. This meant the service, did not recognisethese as risks and did not have risk reduction orpreventative measures to ensure patient safety.

There were limited systems or programmes for clinicaland internal audit to check the quality and operationalprocesses and systems, to identify when action should betaken.

Local audits were not always undertaken to highlightareas of poor performance or risk and we were notassured all areas risk and poor performance would beidentified and action taken to address these areas. Forexample, there was no formal audit of hand hygienepractices. There was limited or ineffective action takenfollowing an audit, where the same non-compliances

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were identified on multiple audits. The registeredmanager told us they were aware of the issues with theiraudits and had registered with a quality assurancecompany, to improve their quality of auditing. However,this was not at the time of the audit and, we could notassess the impact of it on the quality of auditing and howit made improvements to the service.

Managing information

The service routinely collected, managed and usedinformation to support its activities.

The service formally collected safety performance data.However, we did not see the safety data collecteddiscussed in the minutes of the meetings we looked at.

Senior managers demonstrated to us they had anunderstanding of performance across the service andwere able to give examples of how performance andpatient and staff feedback were used to driveimprovements across the service.

Systems and processes ensured data and notificationswere submitted to external bodies. For example,statutory notifications about serious injuries were madeto the Care Quality Commission.

Staff had access to up-to-date accurate information onpatients’ care and treatment. Staff were aware of how touse and store confidential information. Records forpatients were always kept securely. An electronic systemcare plan system had been recently introduced in TobiasHouse. Staff showed us how to use the system on amobile electronic device. Each member of staff had aunique pass code to use the system. These devices werestored securely when not in use.

Confidentiality and data protection training, wasmandatory for all staff, and undertaken twice a year. Dataindicated for December 2018, an overall compliance rateof 73%. The department ranged from 51% for nursingstaff in the special care unit to 92% for all therapydepartments. We did not have confidentiality and dataprotection compliance figures for medical staff. Theservice did not have target for compliance.

Engagement

Patients and relatives were encouraged tocontribute to the running of the service, and giveideas for improvement, through regular meetings,and feedback surveys.

The hospital had a family meeting held every othermonth. These consisted of peer support, feedback onservices and an educational training programme.Families were actively involved in choosing the topics forthe meetings.

Monthly patient meetings were held, where patients andfamilies were encouraged to discuss or express concernsor thoughts about any changes in the service, and to takean active role in planning meeting or education topics,and external trips.

The registered manager told us they have an ‘open door’policy for family and patients to discuss their care andtreatment, at any time, including complaints, concernsand compliments.

Patients and relatives are invited to attend theconsultant’s weekly ward round and all case reviews. Thisallowed patients to be involved in their care, and givefeedback which could be instantly acted on.

The hospital acknowledged staff with an ‘employee of themonth’ award. This was an award where staff couldnominate colleagues or patients could nominate amember of staff.

The hospital held regular team meetings. Staff used themeetings for two-way information sharing. We did not seeany minutes from these meeting during our inspection,but staff told us they found them useful and informative.

Learning, continuous improvement and innovation

The service was committed to improving services bypromoting training, research and innovation.

The service and its staff demonstrated a willingness todevelop and improve the service provided. The hospitalhad a strong culture of research and showed theeffectiveness of its care and procedures through research.We saw that the service was involved in various local andnational research and innovation development projects.These included United Kingdom Specialist RehabilitationOutcomes Collaborative, Improving Functional UpperLimb in the real world and learning to listen.

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We saw that members of staff attended or presented thefindings at national and international conferences andhad published their research in clinical journals.

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Areas for improvement

Action the provider MUST take to improveThe provider must ensure that all patient safety risks arecaptured on an appropriate risk register, which mustdescribe planned and completed mitigating actions.

The provider must improve the completion of mandatorytraining rates so it meets organisational targets.

The provider must undertake a ligature risk assessmentand make sure mitigating action is put in place, includingensuring anti-ligature specification is included in anyimprovement schedule.

The provider must ensure the flooring and décor of wallsmeet the Department of Health’s Health Building Note00-09.

The provider must ensure the fixtures and fittings meetthe Department of Health’s Health Building Note 00-09.

The provider must ensure the infection control andenvironment issues identified at this and a previousinspection are addressed in a timely manner.

The provider must ensure all substances hazardous tohealth are stored in a secure area.

The provider must ensure clinical oversight of activityprovided and ensure audit trails and qualitymeasurement tools are in place.

The provider must take steps to ensure managementresponsibilities in the special care unit are adequatelycovered.

The provider must ensure the hazards in the special careunit garden are eliminated and it is safe for use and fit forpurpose.

Action the provider SHOULD take to improveThe service should strengthen and develop auditprocesses to obtain more reliable, valid and accuratedata, particularly regarding staff compliance with clinicalstandards, and ensuring non-compliances are addressed.

The service should ensure there is a standard approachto documenting best interest decisions.

The provider should ensure staff have access toemergency buzzers, and make sure these are testedregularly.

The provider should ensure the two-radios used on thespecial care unit are in full working order.

The service should ensure that safety dated collected isdiscussed at meetings and used to drive improvementsto the service or patient care.

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 12 HSCA (RA) Regulations 2014 Safe care andtreatment

(2) (a) assessing the risks to the health and safety ofservice users of receiving the care or treatment.

(2) (h) assessing the risk of, preventing, detecting andcontrolling the spread of, infections, including those thatare health care associated.

Regulated activity




Regulation 15 HSCA (RA) Regulations 2014 Premises andequipment

(1) (c) suitable for the purpose for which they are beingused

15 (1) (d) properly used

15 (1) (e) properly maintained

Regulated activity




Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

(2) (a) assess, monitor and improve the quality andsafety of the services provided in the carrying on of theregulated activity (including the quality of theexperience of service users in receiving those services)

(2) (b) assess, monitor and mitigate the risks relating tothe health, safety and welfare of service users and otherswho may be at risk which arise from the carrying on ofthe regulated activity

Regulation

Regulation

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


the raphael hospital · the raphael hospital is operated by raphael medical centre limited (the),...

Documents