All inspections: Eldertree Lodge - Care Quality Commission

Eldertree Lodge is an independent mental health 41 bedded hospital. It provides specialist inpatient service for adults aged 18 years and over in rehabilitation units specifically for patients with a learning disability or autism.

Our rating of this service went down. We rated it as requires improvement because:

The provider had not made sure that the environment was suitable for all patients it provided care to. Although it was providing care to adults with a learning disability and autism the wards were not ‘autism friendly’ in line with national recognised best practice. For example, managers had not considered the conflicting sensory needs of patients living on the same ward. Ward environments were not tailored to the sensory needs of individual patients.
The provider had not ensured that staff received specialist training in caring for people with autism, including training in specialist communication skills.
The provider did not ensure that the systems used to access information was well organised, staff were struggling to find essential information to support safe and effective care delivery, whether it was on electronic or within paper notes.
Staff did not always follow best practice when storing and dispensing medication. Staff on Maple Ward did not routinely record the date of opening of new creams and bottles. They therefore could not be assureds the medications were still effective when given to patients. The providers own audits of medicines management had not identified the error we found on inspection.
Staff supervision was not managed well; managers did not have robust systems to ensure they knew whether staff received regular supervision.

However:

The service generally provided safe care. The ward environments were safe. The wards had enough nurses and doctors. Staff assessed and managed risk well, followed good practice with respect to safeguarding and minimised the use of restrictive practices.
Staff implemented good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging. The service had identified a local theme in self-harm through swallowing batteries and provided an individualised response to patient risk.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. The multidisciplinary team involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Patients led discussions of their experience of care in a programme of ‘noise, voice, choice’ meetings. Carers, families and external agencies were extremely positive about the service and believed the service always managed challenging behaviour well.
Staff planned and managed discharge well and liaised with services that would provide aftercare. The provider had developed some local accommodation options that the hospital clinical team could continue to provide some support to patients as they settled in and got to know a new staff group. Staff helped patients with advocacy, cultural and spiritual support.

Staff identified and mitigated environmental risks such as blind spots and ligature points on the wards. Wards had up-to-date environmental risk assessments, staff maintained daily environmental checks.
The wards had access to emergency and medical equipment that was regularly checked and well maintained. Although nursing vacancies were a continuing challenge for the hospital, there were systems to ensure staffing levels were sufficient to provide safe patient care.
Staff completed patients’ comprehensive assessments and risk assessments that they reviewed and updated as a multidisciplinary team. Staff regularly reviewed and updated care plans. Staff were involved in a wide range of clinical audits to monitor the quality of service provided.
The wards worked well as a multidisciplinary team and with other external organisations to ensure that patients were discharged with the right support. Patients knew how to raise complaints and were involved in decisions about how the hospital was run.
The hospital had a good approach to assessing, and responding to, patients’ physical health needs. Patients had access to a full time practice nurse who carried out ongoing monitoring of physical health checks.
The hospital had robust governance processes to manage quality and safety. The hospital used key performance indicators and other measures to gauge the performance of the team.

However:

Oakley West ward environment did not appropriately meet one patient’s care and treatment needs and the short term alternative plan of care was not appropriately designed to meet all the needs without impact on other patients using the ward. The ward did not have a clear long term plan in place to ensure that the needs of the patient would be appropriately met.
Staff supervision was not consistently carried out in a structured way that captured areas of discussions; it varied in detail and quality.

During our visit we found that the hospital was aware of the concerns around staffing levels that at times they fell below the required numbers. The hospital was had a robust action plan to address the issues around staffing and it was work in progress. They had implemented an action plan around staff recruitment and retention.

The hospital monitored and investigated all incidents and concerns around staffing, responses to emergency alarm calls and the maintenance of patient observations. They responded with a range of recruitment initiatives and independent reviews to staffing levels.

The governance meetings discussed all incidents and actions were put in place to address any shortfalls. They had increased the number of support workers required and offered agency nurses six-month contracts.

The hospital regularly used agency staff to cover special observations, staffing shortfalls and annual leave.

The hospital had a range of human resources policies that were followed when staff were injured at work or reported concerns about bullying.

We saw that staff met to review, update and implement patient care and treatment that was responsive to changing needs. Staff monitored and responded to changes in patients physical health presentations.

However:

Where staff gave short notice of sickness and absence the wards struggled to meet the needs of patients.
Not all staff were offered debrief and support following any incidents of abuse or assault.

We rated Ashley House Hospital as good because:

The hospital had taken steps to address the requirement notice issued following the inspection in October 2015.
The hospital provided separate accommodation for male and female patients.
All areas were clean and maintained.
All patients had a detailed risk assessment and management plan in place.
Staff carried out environmental risk assessments including ligature risks and infection control.
Care notes contained care plans individualised to patients’ needs and staff reviewed these regularly.
Patients were registered with a GP and staff assessed patients’ physical health annually. The hospital employed a full time equivalent practice nurse to meet the physical health needs of patients.
Patients had access to psychological therapies as part of their treatment.
There were regular and effective clinical review meetings that involved all necessary members of the multi-disciplinary team.
Hospital staff were caring and treated patients with kindness, respect and support.
Patients engaged in a range of activities that included regular visits in the community.
Admissions and discharges were discussed in the multi-disciplinary team meeting and were managed in a planned and co-ordinated way.
Patients were provided with a choice of meals and specialist diets were available.
Patients had access to a range of rooms and equipment that supported their care and treatment.
Patients had access to a wide range of community activities available seven days a week.
Staff knew who their senior managers were on site and how to contact them if needed.
Staff knew how to use the whistle-blowing process and felt free to raise any concerns.
The hospital participated in the quality for forensic mental health services low secure network.
The hospital had a governance process that escalated information to divisional level and cascaded it to staff on wards.

However:

We saw that on occasions the resuscitation equipment and the automated external defibrillator was not being checked or recorded in accordance with hospital policy.
Weekly resuscitation drills to assess that staff could transport emergency equipment to the location of a casualty and deliver defibrillation within a target time of three minutes was not being met consistently.
The hospital policy for the use of seclusion was found not to be in line with the Mental Health Act Code of Practice in respect to medical reviews. Medical staff had not been attending the site to conduct a review in person as required.

The hospital were going through a number of transitional changes, which included new management structure and a refurbishment. There were improvements since the last inspection which included a focus on improving the environment through reallocation of the multi-disciplinary team (MDT) and placing the MDT on the wards to support better joint working with ward staff and improve access to the MDT for patients on the wards.

The hospital was clean, the newly refurbished wards were much improved, promoted recovery and there was a good security system in place to ensure the safety of patients.

Each ward had at least one nurse on a shift. The hospital still had vacancies and were taking steps to rectify this through targeted recruitment programme.

The hospital staff treated patients with kindness, dignity, respect and support. We saw that the patients were engaged in a range of activities, including the option to go offsite regularly.

Mr Simon Yates is jointly named as the registered manager of Ashley House in this report. Mr Yates has left the company; his details appear as he has yet to formally notify us of us that he has left. We carried out this unannounced inspection in order to follow up on concerns which had been identified to us and to monitor the areas for improvement noted during our previous inspection which we conducted in February 2014.

During our inspection visit, we spoke with four members of staff, three people who used the service and two relatives. We also spoke with the Hospital Manager and Senior Charge Nurse.

We saw that people were treated with dignity and respect by staff. Care and treatment was provided in a caring and compassionate manner. Improvements had been made in areas previously considered of concern, in regard to environment and restrictive practices.

We saw that care plans were comprehensive and people's needs were individually assessed. Care plans contained a good level of information about how they should be supported to ensure their needs were met.

We found people had received their rights under the Mental Health Act and received a copy in an easy to read format. People told us that advocacy workers attended the ward reviews and gave support at tribunal hearings.

People and relatives we spoke with said they felt safe and able to speak with staff if they were unhappy or worried. We found that people who used the service were protected from the risk of abuse.

Records showed that provision of supervision and annual appraisals were irregular. Staff we met with confirmed that they were not receiving regular planned supervision or appraisal. This meant that the provider was failing to provide a support structure for staff in line with good practice and their own policy.

There was an effective system in place to deal with complaints. Information about how to make a complaint was available in a variety of formats for people, their relatives and visitors to refer to.

Mr Simon Yates is named as the registered manager of Ashley House in this report. Mr Yates has left the company, his details appear as he has yet to formally notify us of us that he has left. A new manager is in the process of registering with us. References in this report to the hospital manager are references to the new manager.

We carried out this inspection in order to follow up on concerns which had been identified during our previous inspection which we conducted in July 2013, and to monitor areas of concern from other earlier inspections. Concerns regarding the services compliance with the requirements of the Mental Health Act 1983, had also been identified by CQC's mental health act commissioners (MHAC's), during a records review conducted in November 2013. A follow up visit by MHAC's on 4 February 2014 revealed that whilst the concerns had been partly addressed some minor issues still remained.

Since the last compliance inspection the provider has employed additional senior nursing staff and the service has a new hospital manager. Changes in senior clinical staff have also occurred. In addition to clinical and nursing staff a dedicated Mental Health Act administrator has been appointed.

We saw that care was provided in a safe environment and the staffing numbers reflected the needs of the patients on the ward. The staff understood the procedures in place to report safety concerns. This meant that patients were cared for in a safe environment by an appropriate number of staff.

Patient risk was assessed on admission. Plans to manage people's risks relating to behaviours that challenged were completed and updated at regular intervals.

Staff told us and staff records confirmed that adequate pre-employment checks were completed prior to people being employed.

We saw that the care and treatment provided was based upon national guidance. Treatment was based on evidence based practice.

We saw that patients were treated with dignity and respect by staff. Care and treatment was provided in a caring and compassionate manner. However, the general appearance of the hospital and the state of it's d'cor made the environment very clinical and oppressive.

We found that effective systems were in place to ensure that all the staff consistently understood the individual needs of the patients. This meant that patients were treated in a caring and compassionate manner.

Improvements had been made in all areas previously considered at risk. Evidence showed that one area of minor concern remains. Regulation 17 of the Health and Social Care Act 2008 identified a number of institutional restrictions and lack of community mobility which was judged to have a minor impact on the quality of patient's lives. Improvements in other regulations continue to progress as the provider is anxious to demonstrate their willingness and ability to do better than simply meet the minimum standard.

We inspected the hospital to check on progress with the improvements required to ensure that patients received the right care, at the right time. We found that further progress had been made.

Patients were treated with compassion, dignity and respect. We found that there were barriers to some patients being able to be fully involved in the planning and delivery of their care and recovery. The hospital was developing a two way dialogue with patients and their families to understand how they felt about the quality of their care. A patient told us, 'The manager listens to what I'm saying and takes on board my points of view.'

A large number of families lived a long way from the hospital. A relative told us, 'I don't have any concerns about his care but it's too far away for me to visit him, there is talk about getting him closer.'

We found continued improvements in the governance and monitoring arrangements. We still found that the quality of recording in some records needed to improve. We also could not evidence that patients' health needs were fully monitored to ensure that any early signs of changes in their health needs could be identified quickly.

We were unable to check how the provider ensured they had enough staff in place to meet planned staffing needs and identified times when these had not been met. The recruitment and selection of staff were not always fully completed before staff started to work with vulnerable people.

We inspected the hospital to check on progress with the improvements required to ensure that patients received the right care, at the right time. We found that further progress had been made.

Patients were more involved and had greater ownership in the planning and delivery of their care and support. We found that patients' plans of care were reviewed and regularly updated with the wider team of professionals involved in each patient's care. A number of different patients told us that life at the hospital could be uninteresting. One patient told us, 'We don't have anything to look forward to. There are not many activities.'

Improvements in the governance and monitoring arrangements were also in progress. A full review of the policies and procedures in place had been completed, to ensure that the guidance in place for staff was up to date and fit for purpose. There were ongoing actions that needed to take place to ensure that staff received adequate information and training on the new policies and procedures. Information available was starting to be used more effectively to identify any risks of unsafe or inappropriate care.

The use of seclusion was still not fully compliant with the requirements of the Mental Health Act. The provider had introduced supporting guidance to reflect where the management of seclusion did not meet with the requirements of the Mental Health Act.

At our inspection in November 2012, we found that the delivery of care did not always ensure that patients were safe and had their care needs met. The use of seclusion at the hospital was also not compliant with the Mental Health Act 1983. The purpose of this inspection was to check on compliance with the warning notice issued.

We spoke with 13 patients, who all felt that their care was good and was meeting their needs. We found a caring and attentive team of staff, who went out of their way to encourage people to be involved with conversations and things happening on the units. We looked at the care records for seven patients in detail and a brief overview of a further three to check how well the planning of patients' care and treatment now focused on their individual needs. There was evidence that progress had started to be made.

There were still some concerns in the planning of patient care that needed to be addressed. Care plans did not always adequately set out the risks to patients' health and wellbeing and say how these should be managed. Staffing arrangements did not always ensure that patients' needs would be met safely and appropriately.

The use of seclusion was still not fully compliant with the requirements of the Mental Health Act. The provider had plans in place to develop seclusion facilities that would be compliant with the Mental Health Act. There was no definite completion date for this work to be completed.

During our inspection, we visited all four of the units that were currently open. We met with staff and patients on all four wards. Bromley, Knighton and Fairoak were designated as low secure units. The fourth unit, Oakley, had only been opened a couple of weeks and was designated as a step down rehabilitation unit.

This inspection was completed to ensure that the hospital was safe for people living at the hospital. This followed concerns we received about the safety of people following changes to where in the hospital they lived and alterations to one of the units. The hospital did not know we were coming to complete our inspection. We visited two units and found that reasonable steps were being taken to ensure the hospital remained a safe place to live.

At the time of our inspection, the hospital was going through a programme of change, supported by investment in the premises and a review of where people lived in the hospital. The immediate changes were part of longer term developments at the hospital.

During our inspection visit, we spoke with two people about life at Ashley House. We asked them about how they felt about the recent changes and future changes to come. Both had recently moved to the second unit we visited and were very positive about the changes. They told us they were very happy and settled in their new unit. One person told us that they had enough privacy and that they had access to their own bathroom facilities. One person told us 'I feel very safe and really enjoy living on this unit: I do not want to move again.' They both felt very involved in the changes and told us if they had any concerns they would not hesitate to discuss these with the manager.

We found that updated risk assessments and care plans had been completed and staffing arrangements had been revisited to reflect the changes. We understood from our discussions with the registered manager that the work on one of the units would continue for a further week. Following completion of the work, people currently living elsewhere at the hospital would be moving to live on this unit.

We visited Ashley House and carried out an inspection on 12-13 April 2012.

We talked with a number of patients in Fairoak, Lordsley and Drayton wards.

We heard staff talking to patients and explaining what they could do that day giving them a choice of activities that they were known to like.

We talked to five of the patients about their care plans. They told us that they had been asked about their likes, dislikes and hopes by the staff. Two told us that they had a copy of their care plan and the others told us that they could see them if they asked. All were happy with these arrangements. One person said 'If I ask they always tell me what I want to know'.

We talked to the staff and they were all aware of the contents of patients care plans. One patient said 'They always know what I'm supposed to be doing-they talk to me about what I want to do'. The relatives of one of the patients told us that they had been consulted about the care of their family member who had difficulty communicating for themselves.

The patients that we talked to told us that they had seen doctors, dentists and other healthcare professionals when they needed to.

We talked to a number of patients. They all told us that they felt able to raise issues with the staff should they need to. Patients told us how they felt able to talk freely with the staff about lots of issues. We saw many examples of short, relaxed and friendly chats between patients and staff. One patient said 'They are not a bad lot really'.

We watched and listened to the staff as they worked with the patients who had difficulty in expressing themselves. We saw that they staff were sensitive to the ways that individuals expressed themselves.

Patients told us about the different ways that they could raise issues with the hospital's senior managers. They told us about how they could access the 'Noise Voice Choice' meetings and the 'User Involvement and Feedback Sub Group' to do this. One also told us how they used the complaints procedure to resolve issues.

We met with most of the patients living on Drayton Ward, Lordsley Ward and Knighton Ward and spoke with nine patients about their care and treatment. We spoke with one relative of patient who used the service. We did not visit the Fairoak or Bromley wards during our visit. The security policy and procedures at Ashley House meant that we could not walk freely around the wards and we were advised that a staff member should be with us when we met with patients. This meant that we did not have opportunity to speak with patients alone.

Patients we spoke with told us about the reasons they had come to Ashley House and had some knowledge about the plans for their discharge. One patient told us, 'I came here because of a Home Office decision. I am supported well by the multi disciplinary teams at the hospital, the occupational therapy team and staff.' Another patient told us, 'It's good here. I've been here 12 months due to the Mental Health Act but will be moving on dependent on my behaviour.' One person we spoke with however could not tell us why they had moved to Ashley House from their previous placement.

Patients told us about sitting with care staff and writing their care plans. One patient told us they had been asked if they wanted a copy of their care plan but had chosen not to. He said, 'I can see it whenever I want if I ask the nurse.' Most patients we spoke with had involvement with meetings regarding their care. One patient told us, 'My main nurse and doctor talk about my care plan. No one from outside talks about my care plan.' One patient told us they did not know what was written in their care plan but did think it was, 'a lot about risks.'

We asked patients how their health was cared for and generally patients had no concerns. One patient said, 'Every month my, pulse, weight, ears, eyes are all checked.' Another patient however told us that although they were supported with their health needs they had not got a dentist and would like to see one. Another patient we spoke with told us they had regular dental appointments and saw an optician 'often for check ups.'

We saw patients on Drayton ward were involved in a range of activities outside of their ward and in the lounges on their wards. We asked the patients about the activities they could do and one patient told us, 'There is quite a lot of choice really.' Another patient said, 'We have church every Wednesday, people come from outside.' One patient told us about trips into the community and how they enjoyed this, they said, 'I am doing a big shop soon. I have been to the museum, swimming and horse riding. I haven't done any work experience for ages. This was mucking out at the stables. I really enjoyed it but taken off it to give others a chance.'

Patient's experiences on Lordsley ward however were not as positive. One patient we spoke with told us, 'I hardly do anything. No activities are offered although I have been shopping for clothes. I am going shopping again in two weeks for new clothes. I choose my own.' Another patient ward told us, 'I do activities now and again. I did some cooking in another building I made a cup of tea. I am going to make a curry to eat tonight.'

Patients told us about how staff kept them safe and supported them to manage some of their behaviours that could cause harm to people. One patient told us, 'If you are 'kicking off' staff ask you to go to the quiet room. They take you out of the communal area so you don't hurt yourself or others.' Another patient told us they did not have a key to their room because of the risk they may harm themselves with the key. One patient told us 'I feel very safe and have learnt lots of coping strategies and moving on behaviours.'

We asked patients if they knew what to do if they felt unsafe and wanted to tell someone about this. One patient told us, 'a patient had been calling me nasty names, go back to your country, you don't belong here. I told the staff and the police came then no more racism comments after that.' Another patient told us, 'I made a complaint about an agency staff, he didn't treat me nice; he pushed me over when I was watching football on TV. He does not work on this ward now.'

We asked to speak with relatives of the patients we had spoken with but only one was available talk to us at the time. They told us they did not think their family member had enough activities to do and had written to Ashley House about this and was waiting for a response to their concerns. They were happy that Ashley House was nearer to the family home than the previous placement but concerned that it was difficult to find suitable places. The relative told us they visited their family member when they could and were involved in the planning of their care. They told us they were aware of how to contact advocacy services.

Archived: Eldertree Lodge

All Inspections

28 - 30 January 2020

During a routine inspection

26 -27 September 2017

During a routine inspection

24 August and 09 September 2016

During an inspection looking at part of the service

4th and 5th April 2016

During a routine inspection

13 October 2015

During an inspection looking at part of the service

14 August 2014

During an inspection in response to concerns

24 February 2014

During an inspection looking at part of the service

13, 17, 18 June and 31 July 2013

During a routine inspection

15, 26 February 2013

During an inspection looking at part of the service

21 December 2012

During an inspection looking at part of the service

8, 9, 13 November 2012

During an inspection in response to concerns

28 September 2012

During an inspection in response to concerns

12 April 2012

During an inspection looking at part of the service

28, 29 November 2011

During a themed inspection looking at Learning Disability Services