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St Matthews Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 February 2018

We rated St Matthews Hospital as requires improvement because:

  • The service had blind spots, which were not addressed by any mitigating actions.
  • Ligature assessments were not robust and did not cover all areas of the building.
  • The process for ensuring that staff received feedback from incidents and complaints was not robust. Staff did not understand what lessons had been learned from, or how they were shared.
  • Training compliance was below the providers’ target of 90% at 75% and there was a discrepancy over data. Compliance to the Mental Capacity Act training was low at 68%.
  • Blanket restrictions were in place for patients to have access fresh air.
  • Pat down searches were being conducted in the entrance to the service. This practice compromised patients dignity and privacy and was a blanket restriction.
  • Relevant checks that are required under the regulation of fit and proper person had not been undertaken.

However:

  • The service was clean, presentable and well maintained.
  • Data supplied by the provider showed compliance with supervision of 87%.
  • Data supplied by the provider showed compliance with appraisal of 84%.
  • Staff were aware of the provider’s visions and values and demonstrated these in their behaviours.
  • We observed staff to be passionate and motivated to meets the patients’ care needs.
  • Staff demonstrated a good understanding of patients’ individual needs
  • All patients had received a timely risk assessment on admission. There was evidence that risks assessments are updated after incidents.
  • The Mental Health Act administrators had good oversight of the service, they provided support to the services and staff were aware of how to contact them.
  • Shift to shift handovers were taking place daily.
  • Senior managers had good oversight of the services and clinical governance.

Inspection areas

Safe

Requires improvement

Updated 7 February 2018

We rated safe as requires improvement because:

  • The service had blind spots which were not addressed by mitigating actions.

  • Ligature risk assessments were not robust and did not cover all areas of the building or accurately reflect all risks.

  • Staff did not understand what lessons learned were or how they were shared.

  • Training compliance was below the providers’ target of 90% and there was discrepancy over data.

  • Mental Capacity Act training compliance was 68%

  • Blanket restrictions were in place to access fresh air.

However:

  • The service was clean, tidy and well maintained.

  • The clinic was fully equipped clinic rooms and there were access resuscitation equipment and emergency drugs on the service.

  • Staff undertook a risk assessment with every patient upon admission.

  • All staff had access to personal alarms.

  • Cleaning records were up to date and demonstrated that staff regularly cleaned the environment.

  • The service had appropriate medical cover.

  • There was a robust process in place for reporting and documenting incidents.

  • Medication management was safe and well managed.

Effective

Good

Updated 7 February 2018

We rated effective as good because:

  • All patients had an assessment within twenty four hours of admission.

  • All patients received on going comprehensive physical health assessments and on-going physical health monitoring.

  • All care plans were up to date, patient centred, recovery focused and holistic

  • Staff follow National Institute for Health and Care Excellence guidance when prescribing medication.

  • There was evidence of collaborative joint multi-disciplinary team working.

  • The provider carried out regular audits to ensure that the Mental Health Act was applied correctly.

  • The compliance rate for staff receiving supervision was 87%

  • We observed evidence of on-going clinical audit activity within the unit.

However

  • Not all staff had received an annual appraisal.

  • Only 68% of staff had received training in the Mental Capacity Act.

  • Staff showed a minimal understanding of the Mental Capacity Act and its application.

Caring

Good

Updated 7 February 2018

We rated caring as good because:

  • Staff were positive, supportive and caring in their interactions with patients.

  • Patients described the staff as polite and helpful.

  • Patients were actively involved in their care planning and given copies of their care plans.

  • Staff demonstrated a good understanding of patients’ individual needs, including care plans, observations and risks.

  • All patients had access to independent advocacy.

  • Patients were involved in decisions about the unit via the house meetings.

Responsive

Good

Updated 7 February 2018

We rated responsive as good because:

  • Patient transfers and discharges were planned in advance and occur during normal working hours.

  • Staff actively engaged with external agencies.

  • The service had a full range of rooms and equipment in order to support treatment and care

  • A visitors room was available for patient visits

  • Patients had access to cold and hot drinks and snacks at all times

  • Patients had good access to spiritual support.

  • Information leaflets were available for patients.

  • Patients advised that they knew how to complain, and forms were available on the service. The service had a comment box for comments that patients could use.

However

  • The patient payphone was situated in the service entrance so was not private.

  • Staff carried out searches of patients in the entrance to the hospital.

Well-led

Requires improvement

Updated 7 February 2018

We rated well-led as requires improvement because:

  • The manager was not visible on the unit. Staff told us that the manager was inaccessible at times and was not visible within the service. This was experienced by inspectors during the visit.

  • Oversight of compliance at service level was not thorough and robust, and senior managers resubmitted compliance data at the time of and following inspection.

  • The manager had not identified all ligature points and the scoring within the risk assessment was not always accurately recorded.

  • There was limited evidence that staff received feedback from incidents, lessons learnt, complaints or patients.

  • Training compliance was 75% against a service target of 90%.

  • Relevant checks that were required under the regulation of fit and proper person had not been undertaken.

However:

  • Supervision compliance was 87%

  • Appraisal compliance was 84%

  • The vision and values of the service objectives were reflected in practice.

  • There was evidence of staff involvement in clinical audit.

  • Safeguarding and the Mental Health Act procedures were being followed.

  • Service staff had the ability to submit items to the risk register.

  • There was a strong sense of team working on the service.

  • Oversight of compliance at service level was not thorough and robust, and senior managers resubmitted compliance data at the time of and following inspection.

Checks on specific services

Long stay/rehabilitation mental health wards for working age adults

Requires improvement

Updated 7 February 2018