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Inspection Summary


Overall summary & rating

Good

Updated 13 June 2018

We rated Beverley Mews as good because:

  • The environment was well considered and fit for purpose. As this unit was potentially the last stage for patients before returning to the community, the management had found a balance between mitigating risk and providing patients with an environment that closely resembles independent living. Risk assessments were in place and there was a culture of positive risk taking.
  • Care records and risk assessments reflected individual needs and had been created in collaboration with patients, family and carers and outside agencies. Staff were trained and able to deliver care packages whilst also assisting patients to be independent.
  • We observed very high levels of patient engagement from staff that were knowledgeable of individual needs. All staff were able to speak with us at length about patients histories and how best to engage them.
  • We saw very high levels of communication between staff and patients at Beverley Mews. Patients were able to raise concerns with staff immediately and as a result, staff responded to these concerns and acted upon them quickly
  • Governance structures were clear and specific to the service. Management were a visible presence at the unit and staff felt supported by them. We were told that they were approachable and staff felt that they were listened to. Staff reported high levels of job satisfaction. Supervision and appraisal rates were high and there were low levels of staff sickness and absence.
Inspection areas

Safe

Good

Updated 13 June 2018

We rated safe as good because:

  • Beverley House was a service for women coming to the end of their care pathway and preparing to return to the community. As such it was set up to closely resemble the homes that patients would be returning to. There were ligature points in all rooms but these had been assessed and were mitigated using risk assessment, observation and monitoring of patients health. The unit was clean and well kept. It was a welcoming environment that was bright and well furnished.

  • The unit only had one full time qualified nurse who acted as the unit manager and was shared with their sister unit. This meant that health care assistants undertook most clinical tasks such as taking bloods and administering medication. They had received training to enable them to do this and were monitored and regularly audited by the qualified nurse.

  • Comprehensive risk assessments were undertaken on admission using nationally recognised tools such as Recovery Star for example. These were updated regularly throughout each patients stay. Physical health checks and monitoring were also carried out for all patients

  • There had been no incidents in the six months prior to our inspection. Staff were aware of how to report incidents and what to report. They stated that they felt comfortable with the process and would be confident to make a report if required.

Effective

Good

Updated 13 June 2018

We rated effective as good because:

  • Assessments started for every patient at the pre admission stage and were regularly updated throughout patients stay. They were personalised and recovery focussed. The patients had been involved actively in the creation of their care plans. There were advanced decisions in place. These mostly related to detrition of mental state and set out what the patients expectations of staff and the organisation were.

  • Healthcare assistants received specialist training in clinic processes. They were knowledgeable about national guidance and were able to quote these to us. The service used nationally recognised rating scales to monitor patient’s health.

  • Staff received mandatory training annually. The subjects included in the mandatory training calendar were varied and gave staff the knowledge they needed to undertake their role.

  • Staff received training in the Mental Health Act and the Mental Capacity Act and demonstrated good knowledge of both. We found no errors in the application or recording relating to the Mental Health Act and Mental Capacity Act.

Caring

Good

Updated 13 June 2018

We rated caring as good because:

  • We observed high levels of interaction between the staff and patients. We observed staff that were engaging and friendly. They had good knowledge of the patients’ needs and were able to engage them on a level that felt supportive. Patients stated that staff at the unit were professional and that they were happy with the quality of care delivery.

  • Beverley Mews worked well with outside agencies such as advocacy services and local social service bodies to ensure patients received a complete care package whilst preparing them to return to the community.

Responsive

Good

Updated 13 June 2018

We rated responsive as good because:

  • The environment that had been created at Beverely Mews had been designed to closely represent community living. Patients had access to a number of rooms for relaxation and social gathering and they were encouraged to personalise their bedrooms with decorations and furnishings. This was monitored to ensure safety but it gave the overall impression that patients had developed an environment that suited their needs

  • There was information on a range of subjects posted around the unit. This included services in the local community. Staff also encouraged patients to develop links with groups in the community as part of their rehabilitation.

  • Being a small unit it was apparent from observing interactions that staff had developed good relationships with the patient group. There was no formal period set aside for patients meetings but information passed between the staff and patients well. Patients were able to raise concerns or request change or support from staff as and when any issues came up. There had been no formal complaints made in the 12 months prior to our inspection.

Well-led

Good

Updated 13 June 2018

We rated well-led as good because:

  • Staff were well engaged by managers and were vocal about their level of job satisfaction. They stated that they felt valued and that they were proud of the work that they did. Managers were a visible presence around the unit and staff were aware who their most senior managers were.

  • Staff stated that they knew the organisations visions and values and that they agreed with these. Appraisal objectives and working processes had been developed to adhere to these values. Appraisal and supervision levels were good with supervision being at 92% and appraisal rates at 96%

  • The organisation used key performance indicators to monitor quality and service development. These were in an accessible format and easy to interpret. Managers had a dashboard that laid out key performance indicators using a rag rated system (Red, Amber, Green) which meant that staff could quickly view information and develop action plans to manage any shortfall.

  • All staff were involved in clinical audit and service development. We spoke with staff that had received specialist training and were using the knowledge that they had developed to implement new sessions and ways of working.

Checks on specific services

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 13 June 2018