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The Raphael Hospital Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 6 June 2017

Raphael Medical Centre is operated by Raphael Medical Centre Limited, an organisation which also provides social care services for people with acquired brain injuries. The Raphael Medical Centre is an independent hospital mainly specialising in the neuro-rehabilitation of adults suffering from complex neurological disabilities with cognitive and behavioural impairment.

The long term conditions service at the hospital focuses on the care, treatment and rehabilitation of people with acquired brain injuries. There are facilities to accommodate a total of 50 patients. There is space for 33 patients in two wards in the main building, and nine patients in Tobias House which is designated as an area for the treatment of prolonged disorders of consciousness. There is further capacity to treat eight patients in the special care unit for neurobehavioral rehabilitation and this unit also accommodates patients admitted under the Mental Health Act. Facilities available at the hospital included a physiotherapy gymnasium, a hydrotherapy pool, therapy rooms, consulting rooms and common areas.

We inspected the long term conditions service using our comprehensive inspection methodology. We carried out the inspection on 6 and 7 February 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

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

Overall we rated the long term conditions services at Raphael Medical Centre as requires improvement because:

  • We had concerns regarding some aspects of patient safety. This related to some areas in medicine storage, the environment and shortfalls in infection control procedures.

  • Although there were suitable systems to report and investigate incidents and complaints received, staff did not consistently receive feedback on either. Additionally we saw no evidence of lessons learned.

  • The provider did not provide assurances that doctors working under the rules of practising privileges had appropriate references and criminal checks as per their policy and best practice guidelines.

  • The audit plan was not fully embedded and we were told it was in the process of being redesigned. This meant staff were unable to monitor performance and areas of risk.

  • Risks and issues identified were not sufficiently monitored or documented. For example some audits were being carried out but the provider was unable to show the results of these were consistently acted upon or used to improve service.

  • The management team had a lack of knowledge and no plan in place to implement the Workforce Race Equality Standard (WRES) requirement.


  • We found treatment followed current national guidance. The hospital had policies and guidelines in place for most areas of the hospital.

  • Patients were cared for by a multidisciplinary team working in a cohesive way and generally had access to service seven days a week.

  • We found there were arrangements to ensure nursing, therapists and support staff were competent and confident to look after patients.

  • Patients’ dietary and nutritional needs were met and were supported appropriately when problems occurred.

  • Consent was obtained and recorded in patients’ notes in line with relevant guidance and legislation. Where patients lacked capacity to make decisions for themselves, staff acted in accordance with their obligation under the Mental Health Act.

  • We observed compassionate care that promoted patients’ privacy and dignity. Patients and their relatives were involved in their care and treatment and were given the appropriate amount of information to support their decision making.

  • Discharge planning was started upon a patient’s admission.The service encouraged and supported social reintegration from the point of admission. The provider acknowledged end of life care, advance care planning and the recognition for emotional support and spiritual needs of the patient.

  • The arrangements and quality of leadership had improved. Committee meetings identified areas of concern and acted to address these. Delegation of duties had been passed to directors and managers to empower staff to make decisions for the good of the hospital and its patients.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notices that affected Raphael Medical Centre. Details are at the end of the report.

Professor Edward Baker

Deputy Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 6 June 2017

We rated safe as requires improvement because:

  • Although there were many good things about the service, it breached a regulation relating to Regulation 12: Safe care and treatment. Medicines were stored appropriately with the relevant checks in place, however actions were not always recorded when discrepancies were noted for medicine fridges which fell outside the required temperatures. This could impact on the safety and efficacy of medicines.

  • Although staff had a clear understanding of their role in reporting incidents, investigations when incidents occurred were not effective and learning was not widely disseminated. Staff reporting incidents did not always receive feedback. However, the provider had improved the policy and process since the last inspection.

  • There was limited measurement or monitoring of safety performance. The hospital did not follow best practice guidelines from the Department of Health. This related to shower heads, carpets, wall surfaces and waste. The hospital had a strategic plan and policy for cleaning, however these plans were not adequate as they did not provide guidance for staff.

  • The hospital had a risk management policy for business continuity planning and a ‘human side of business and technical plan’. However, these plans were not adequate as they did not provide guidance for staff in the event of a disaster.


  • The hospital was visibly clean and tidy. Staff in all areas used appropriate hand hygiene techniques and complied with the hospital’s policies and guidance on the use of personal protective equipment.

  • Mandatory training was being completed which meant staff had the necessary current skills to do their job. Staff were aware of their responsibilities concerning the protection of people in vulnerable circumstances.

  • We saw there were processes for regular equipment checks both from internal and external maintenance sources and a clear preventative maintenance process.

  • Confidential patient records were securely stored. Records showed patients were risk assessed in key safety areas using nationally validated tools and goals set according to national guidance. Additionally, an early warning system for the deteriorating patient was used.

  • All patients were under the care of a consultant for their relevant conditions. Nursing therapy and medical staffing levels adhered to relevant guidelines such as the British Society of Rehabilitation Medicine (BSRM) and the Royal College of Physicians Guidelines on Prolonged Disorders of Consciousness.



Updated 6 June 2017

We rated effective as good because:

  • We found care and treatment reflected current national guidance, standards, best practice and legislations relevant to rehabilitation services. Patients were screened for the risk of malnutrition, and patients who received artificial support, via feeding tubes, were reviewed regularly by the speech and language therapists.

  • There were formal systems for collecting comparative data on patient outcomes. Information on rehabilitation requirements was collected as a multi-disciplinary team and sent monthly to United Kingdom Specialist Rehabilitation Outcomes Collaborative (UKROC).

  • Staff worked together effectively to provide comprehensive care to patients. We saw data which confirmed staff received an appraisal. There was a formal system to track themes or trends identified.

  • Care was provided consistently throughout the week. The day to day medical service was provided by the in house physicians during the day and an on call service between 8pm and 8am. Consultants provided a 24 hour on call service. Patients had access to therapy services seven days a week 8am to 8pm.

  • We saw there were clear procedures for patients subject to the Mental Health Act as well as for Deprivation of Liberty Safeguards (DoLS). The ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) decision making process complied with national guidelines.


  • The provider did not provide assurances doctors working under the rules of practising privileges had appropriate appraisals, references and disclosure and barring service (DBS) checks as per their policy and best practice guidelines.



Updated 6 June 2017

We rated caring as good because:

  • Staff provided sensitive, caring and individualised personal care to patients. Staff supported patients to cope emotionally with their care and treatment as needed.
  • Feedback from patients and those close to them was positive about the care provided from all staff they interacted with. Staff treated patients courteously and with respect.
  • Staff involved patients in their own care and treated them as partners. Each patient was assigned two key workers who worked opposing shifts to provide continuity of care for patients. Patients were supported to increase and maintain their independence.



Updated 6 June 2017

We rated responsive as good because:

  • The provider understood the needs of the patients it served. It designed services to meet those needs which included active engagement with commissioners, families and carers and other healthcare agencies. Patients received care and treatment in a timely way. There was a proactive approach to managing referrals, assessments, admissions and discharge from the service.

  • Patients and those close to them had the information they needed and were supported to provide feedback or make a complaint. Complaints were taken seriously, investigated and resolved.


  • Complaints showed there was no evidence of discussion with staff involved or changes made owing to the outcome. Additionally, lessons learned were a broad statement and there was no evidence this was shared with staff.


Requires improvement

Updated 6 June 2017

We rated well-led as requires improvement because:

  • Risks and concerns identified were not sufficiently monitored or documented. For example, some audits were being carried out but the provider was unable to show that the results of these were consistently acted upon or used to improve the service.

  • The management team had a lack of knowledge or a plan in place to implement the Workforce Race Equality Standard (WRES) requirement.

  • The hospital did not have suitable governance arrangements in place for the monitoring of doctors worked under practising privileges agreements.

  • The hospital did not have a current staff survey to collate the views of staff.


  • The vision of the hospital was to provide and develop a rehabilitation medical hospital, based on the anthroposophical image of humans which recognised humans as being of body, soul and spirit. Staff understood this philosophy and were supportive of it.

  • The arrangements and quality of leadership had improved since our last inspection. Committee meetings identified concerns and took action. Duties had been delegated to directors and managers to empower staff to make decisions for the good of the hospital and its patients.

  • Leaders modelled and encouraged cooperative, supportive relationships among staff so that they felt respected, valued and supported. Staff said managers were available, visible, and approachable.

  • The unit had a strong focus on continuous learning and improvement and staff innovation was supported. Staff asked patients to complete satisfaction surveys on the quality of care and service provided. Departments used the results of the survey to improve services.

Checks on specific services

Outpatients and diagnostic imaging

Updated 21 April 2016

We found that the outpatient service was not providing a safe, effective and responsive service. There were concerns abut the quality of leadership and some aspects of caring were not good.

Safety was not a sufficient priority. There were inadequate systems in place for staff to assess, monitor or manage the risks to people who used the services.

There was insufficient assurance to demonstrate people received effective care based on current evidence-based guidance, standards and practice. There was no monitoring of people’s outcomes of care and treatment.

The governance arrangements and their purpose were unclear with ineffective arrangements for the systematic provision of assurance to the board that risks were being adequately assessed or managed.

The majority of patients we spoke with gave positive feedback about the way staff treated them but people’s emotional and social needs were not always viewed as important or reflected in their care and treatment.

People with long term conditions

Requires improvement

Updated 6 June 2017