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Archived: The Raphael Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 April 2019

The Raphael Hospital is operated by Raphael Medical Centre Limited (The), an organisation that also provides social care services for people with acquired brain injuries. The Raphael Hospital is an independent hospital specialising in neuro-rehabilitation of adults with 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 60 patients. There is space for 31 patients in two wards in the main building and 21 patients in Tobias House which is designated as an area for the treatment of prolonged disorders of consciousness. There is a 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, consultant rooms and common areas.

We inspected this service using our comprehensive inspection methodology. We carried out the inspection on 15 January 2019.

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.

Services we rate

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

  • The service did not have managers at all levels with the necessary experience, knowledge and skills to lead effectively. The main house was managed by an experienced ward manager who had been in post since 2015. However, during inspection it was identified that three out of four of the wards did not have a ward manager.

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

  • The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care, but there were areas that were not fully effective.

  • The systems used to identify risks, and eliminate them, were not always carried out in a timely manner. Although there was a risk register, there was no robust way of ensuring effective risk reduction strategies had been undertaken, or potential risks not fully recognised.

  • The service provided mandatory training in key skills to all staff; however, not all staff were up to date with their training.

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

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

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

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

  • Emergency buzzers were available, but staff we spoke with were unaware if these had been tested or whose responsibility this was.

  • Staff on the special care unit were not able to communicate effectively, particularly in an emergency. Two-way radios were available, but we found only two were working and of the two working radios, only one could make and receive calls.

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

However:

  • Staff in different roles worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide care. Staff respected their colleague’s opinions.

  • Staff cared for patients with compassion. Feedback from patients confirmed staff treated them well and with kindness.

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

  • Staff involved patients and those close to them in decisions about their care and treatment. We saw effective interactions between staff and patients.

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

  • There were systems and processes to protect people from abuse and harm. Staff understood their responsibilities and the process to take in the event of any safeguarding concerns.

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

  • Staff gave patients enough food and drink to meet their needs. Nutritional assessments were completed on admission.

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

  • The service took account of patient’s individual needs.

Nigel Acheson

Deputy Chief Inspector of Hospitals

( London and South Regions)

Inspection areas

Safe

Requires improvement

Updated 15 April 2019

Are services safe?

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

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

  • Systems and processes to protect patients against cross infection were not always effective. We found cleaning products and other liquids were not stored securely. Flooring and furniture 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 always keep people safe. For example, we found ligature risks in the special care unit which had not been risk assessed for five years, along with multiple hazards identified in garden.

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

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

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

However,

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

  • Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse, and they knew how to apply it.

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

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

Effective

Requires improvement

Updated 15 April 2019

Are services effective?

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

  • The service completed local audits but the results did not always drive the necessary improvements. For example, there was limited formal process to monitor staff adherence to national 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 clearly identified.

However:

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

  • Staff gave patients enough food and drink to meet their needs and improve their health. The service adjusted for patient’s dietary requirements, and used special feeding and hydration techniques when necessary.

  • Patients’ pain was assessed and managed appropriately.

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

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

  • Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had received care that met all their needs, including physical, emotional and social needs. Doctors, nurses and other health care professionals supported each other to provide care. Staff respected their colleagues’ opinions.

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

  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

Caring

Good

Updated 15 April 2019

Are services caring?

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

  • Staff cared for patients with compassion. Feedback from people who used the service, and those who are close to them was 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 and those close to them. Patients and relatives told us they felt able to approach staff if they felt they needed any aspect of support.

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

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

Responsive

Good

Updated 15 April 2019

Are services responsive?

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

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

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

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

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

Well-led

Requires improvement

Updated 15 April 2019

Are services well-led?

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

  • The service did not have managers at all levels with the necessary experience, knowledge and skills to lead effectively. The main house was managed by an experienced ward manager who had been in post since 2015. However, during inspection it was identified that three out of four of the wards did not have a ward manager.

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

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

  • The systems used to identify risks and eliminate them were not always carried out in a timely manager. Although there was a risk register, there was no robust way of ensuring effective risk reduction strategies had been undertaken, or risks not fully recognised.

However:

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

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

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

People with long term conditions

Requires improvement

Updated 15 April 2019

Neuro-rehabilitation of adults with complex neurological disabilities with cognitive and behavioural impairment, were the main activity at the location. We rated this service as requires improvement in the safe, effective and well led domains. Good in caring and responsive.

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.