The Care Quality Commission
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  • Independent hospital

Royal Hospital for Neuro-Disability

Overall: Requires improvement read more about inspection ratings

West Hill, Putney, London, SW15 3SW (020) 8780 4500

Provided and run by:
Royal Hospital for Neuro-Disability

All Inspections

14th June 2023 - 16th June 2023

During an inspection looking at part of the service

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

  • The service did not always ensure that medicines were managed in a safe way. We found expired medications available for use in ward areas, unsafe storage and use of medical gases, unsupervised dispensing of medications by untrained staff, and an out-of-date medicines management policy.
  • The service did not have effective governance systems in place to ensure that actions were taken in response to national patient safety alerts. National Patient Safety Alerts (NatPSAs) are official notices from NHS England giving instructions to providers on how to prevent risks which might cause serious harm or death. We found the service had not taken all actions required from a medical gases alert issued in June 2021, meaning patients remained at risk of serious harm or death.
  • The service did not always ensure that all equipment was clean and ready for use, or labelled to show when it had been cleaned.
  • The service did not always ensure that equipment used for obtaining laboratory specimens were within their expiration date.
  • Leaders did not always have clear oversight of the risks to their patients.

However

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well.
  • The service controlled infection risk well. Staff assessed risks to patients, acted on them, and kept good care records.
  • The service managed safety incidents well and learned lessons from them.
  • Leaders supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.
  • The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

08 September - 16 September 2021

During an inspection looking at part of the service

Our rating of this location improved. We rated it as good because:

  • The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept detailed records of their assessments. They managed medicines well. Staff collected safety information and used it to improve the service. Managers investigated incidents. There was a system to share lessons learned with the teams on the ward and the wider service.
  • The service had produced a safeguarding policy aligned to NHS England’s Safeguarding Assurance Accountability Framework. Staff received training specific for their role on how to recognise and report abuse. All staff, both clinical and non-clinical were trained to the right level of safeguarding competency for both children and adults, this training was all in date and in accordance with their role.
  • The service had achieved all of the seven standards of NHS England’s Safeguarding Accountability & Assurance Framework (SAAF).
  • The service had staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well.
  • Staff understood how to manage infection prevention and control and all areas were visibly clean. Staff wore appropriate personal protective equipment (PPE), including gloves and aprons to keep themselves and others safe from cross infection.
  • There were systems in place for infection prevention and control. All staff and patients adhered to personal protective equipment (PPE) guidelines. There were clear isolation and separation areas to manage the care for patients, due to COVID-19.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up to date, and easily available to all staff providing care. Patient records were managed securely.
  • Leaders had improved safeguarding processes and operated effective safeguarding processes throughout the service and liaised with local authorities for safeguarding monitoring. Staff at all levels were clear about their roles and accountabilities about safeguarding and had regular opportunities to meet, discuss and learn from the performance of the service.
  • Governance processes had improved with clearer accountability and more multidisciplinary work. The service had improved the way they shared learning with staff. Information on how to leave feedback was clearly displayed in all service areas. Most staff were positive about their work, relationships with colleagues, support from managers and development opportunities.
  • The leadership for patient safety and safeguarding was clear and was a thread throughout the service. Patient safety incidents and safeguarding were discussed and reported to the senior leadership team on a weekly basis. All incidents were reported on each ward along with action being taken.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.

19-20 & 22 November 2019

During an inspection looking at part of the service

The Royal Hospital for Neuro-Disability (RHN) is an independent medical charity which provides neurological services to the entire adult population of England. The hospital specialises in the care and management of adults with a wide range of neurological problems, including those with highly dependent and complex care needs, people in a minimally aware state, people with challenging behaviour, and people needing mechanical ventilation.

At our last comprehensive inspection in March and April 2017, this provider was rated as Good overall. Safe was rated as Requires Improvement. All other key questions were rated as Good. We also conducted a focused inspection in July 2018.

This is a report of a focused inspection we carried out on 19-20, and 22 November 2019. We carried out this inspection in response to concerns about some incidents the provider had notified us of. The incidents took place on Chatsworth and Drapers Ward, and our concerns were about the safety and leadership of these wards. We also visited a sample of other wards. As this inspection was focused on specific areas of concern, we did not look at all aspects of all key questions, and we have not re-rated this service.

We found the following issues that the service provider needs to improve:

  • We found examples of where the service did not make a safeguarding referral to the local authority in a timely manner. Not all staff had received safeguarding training which was tailored to the particular vulnerabilities and needs of the patient group they were caring for.

  • The service did not consistently control infection risks on Chatsworth Ward. Staff on that ward did not always use control measures to protect patients, themselves and others from infection. Staff did not keep all equipment and ward areas clean.

  • On Chatsworth Ward, we could not be assured that the design, maintenance and use of facilities, premises and equipment kept people safe. Staff did not manage waste well.

  • Handover processes on Chatsworth Ward were not fully effective.

  • Some staff expressed concerns on whether the service had enough nursing and support staff to keep patients safe from avoidable harm and to provide the right care and treatment.

  • Staff did not keep detailed records of patients’ care and treatment. Records were not consistently clear or up-to-date on Chatsworth and Wellesley Wards.

  • We found one example where staff did not escalate out of range medication fridge temperatures in a timely manner.

  • The hospital did not always manage patient safety incidents well. Managers did not always robustly investigate incidents and there was limited evidence that lessons learned were shared with the whole team and the wider service.

  • We were not assured that all local leaders understood and managed the priorities and issues the service faced, or always took timely action to address them.

  • Families we spoke to did not always feel they could raise concerns without fear. We were also concerned that healthcare assistants on Chatsworth Ward did not have the training to cope with violence and aggression displayed by some patients.

  • Managers we spoke to could not always identify relevant risks and issues, and therefore actions to reduce their impact.

  • We found one example where a statutory notification was not submitted to CQC without delay.

However, we also found the following areas of good practice:

  • We found good practice in relation to infection prevention, cleanliness, hygiene, environment and equipment on other wards at the hospital. We found an example of innovation in use of equipment on Drapers Ward.

  • Staff identified and quickly acted upon patients at risk of deterioration.

  • The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

  • The service used systems and processes to safely prescribe, administer and record medicines.

  • Executive leaders were visible and approachable in the service for patients and staff.

  • Staff consistently told us they could raise concerns without fear.

  • The hospital demonstrated they had plans to cope with unexpected events, such as a major incident.

Following this inspection, we issued the provider with an urgent notice of decision to impose conditions on their registration, under Section 31 of the Health and Social Care Act 2008. Details are at the end of the report. Since then, the hospital has provided us with an action plan detailing how they have addressed, or are working towards resolving, the issues we identified. For some issues, we have seen or received evidence that these have been resolved, and where this is the case we have referenced this in the report below.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London & South)

16 July 2018

During an inspection looking at part of the service

The Royal Hospital for Neuro-Disability (RHN) is an independent medical charity which provides neurological services to the entire adult population of England. The hospital specialises in the care and management of adults with a wide range of neurological problems, including those with highly dependent and complex care needs, people in a minimally aware state, people with challenging behaviour, and people needing mechanical ventilation.

At our last inspection in March and April 2017, this provider was rated as Good overall. Safe was rated as Requires Improvement. All other key questions were rated as Good. This is a report of a focused inspection of the long-term conditions service we carried out on 16 July 2018. We carried out this inspection in response to concerns about some incidents the provider had notified us of. These were concerns about assessing and responding to patient risk, including care for deteriorating patients, prevention of pressure ulcers and learning from incidents, in the long-term conditions core service. As this inspection was focused on specific areas of concern, we did not look at all aspects of all key questions, and we have not re-rated this service.

On our last inspection, we found areas where the provider needed to improve. We issued the provider with a requirement notice, telling the provider to make improvements, in order to meet legal requirements. Therefore, we also followed up on these areas during this inspection. These were as follows:

The provider must:

  • Ensure ward staff have more training both on the different degrees of decision-making ability among patients and residents, and the types of decisions each can make, and on the risks to patients and residents of not following the guidance for eating and drinking.

  • Ensure all staff have an annual appraisal.

Our key findings from this inspection were:

  • The hospital had completed the actions of the requirement notice we issued on our last inspection. Ward staff had improved training on the risks to patients and residents of not following guidance for eating and drinking. Ward staff had more training on the different degrees of decision-making ability amongst patients and residents, and the types of decisions each could make.

  • All staff received an annual appraisal.

  • Staff knew how to assess and respond to patient risk, and could explain the processes for doing so.

  • Prevention, identification and management of pressure ulcers was generally well managed.

  • Residents of the specialist nursing home had all aspects of their care plans reviewed in line with national practice.

  • Staff understood their responsibilities to raise concerns, record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate. Learning from incidents was shared amongst staff.

  • Staff awareness of the need for reasonable adjustments to help patient decision-making had improved.

  • The complaints handling process had improved, with a more structured approach and measures to determine whether complainants were satisfied with the outcome.

  • Leaders understood the challenges to quality and sustainability and could identify actions needed to address them.

However:

  • Patient records were not always consistently detailed or complete. Recording of key clinical interventions such as completing turning charts, and escalation of NEWS scores, were inconsistent. This meant there was a risk that patient care records were not always accurate, which could result in patients not having their care needs met, particularly by new or temporary staff who were not familiar with the patient. Staff told us that they did not always have time to complete care records thoroughly. Senior leaders were aware of this, and had introduced some pilot mitigating actions, but these were not yet embedded.

  • Hand hygiene audits showed mixed results, although they had improved since our last inspection.

  • We found one instance of where a patient’s fluid balances were not monitored systematically, as they had not been totalled. Totalling fluid balances is important to ensure that patients are optimally hydrated. This was an action we told the provider they should take to improve at our last inspection. We highlighted this to staff during inspection, who corrected the lack of totals. However, it should be noted that this was an improvement on our last inspection, where we found we did not find any charts where scores had been added up.

  • Sections of care plans covering the Mental Capacity Act (MCA) were not always sufficiently detailed, and senior leaders did not always robustly monitor this. These sections, referred to as MCA care plans, contained details as to whether a patient could make some, none or all decisions for themselves. Where a patient could make ‘some’ decisions for themselves, details of what this meant were not listed. MCA care plans were reviewed as part of the hospital’s programme of mock inspections, but there was no formal audit programme for MCA care plans. Senior leaders told us they tried to set aside time monthly to look at MCA specific care plans, templates and data, but this was not always possible.

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 one requirement notice. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals

28 - 30 March 2017, and 12 April 2017

During a routine inspection

The Royal Hospital for Neuro-disability is an independent medical charity which provides neurological services to the entire adult population of England.

The hospital specialises in the care and management of adults with a wide range of neurological problems including those with highly dependent and complex care needs, people in a minimally aware state, people with challenging behaviour and people needing mechanical ventilation.

The hospital was inspected in June 2015 and not rated as that was a pilot inspection. This inspection has followed up on issues identified in the June 2015 inspection and the hospital is now rated.

Our key findings are as follows:

  • We found improvements in all the areas of concern that we had identified in the previous inspection, such as staff understanding of the mental capacity act and lack of patients and residents with authorisations for deprivation of liberty safeguards, staff understanding of aspects of duty of candour and safeguarding. Medical cover had improved and efforts were being made to make the environment for long term residents more homely, and the quality and presentation of food was better.
  • There were systems to report and investigate incidents, to control the spread of infection, to manage medicines in line with legislation and current guidelines and to report and investigate suspected abuse
  • We saw good use of audit to assess progress of patients
  • There were enough staff to care for patients and residents.
  • Patient records in the BIS and the specialist unit reflected a multi-disciplinary approach to care with individual outcome goals that were regularly reviewed.
  • Research was beginning to influence patient care.

We found some outstanding practice, particularly the wide availability of a range of advanced communication aids such as eye gaze technology customised to the needs of the individual, and the support to patients, residents, families and staff by the chaplaincy service. .

However, we also found areas where that the provider needs to improve.

Importantly the provider must:

  • Ensure ward staff have more training both on the different degrees of decision-making ability among patients and residents, and the types of decisions each is able to make, and also on the risks to patients and residents of not following the guidance for eating and drinking.
  • Ensure all staff have an annual appraisal

In addition the provider should;

  • Ensure staff are encouraged to record patient notes contemporaneously, and have time to do this.
  • Improve standards of hand hygiene.
  • Ensure that all residents in the specialist nursing home have all aspects of their care plans reviewed at intervals in line with national practice.
  • Adopt a more structured process for handling complaints, working with the complainant as a far as possible to ensure both sides were satisfied with the outcome.
  • Ensure that patients’ fluid balances are monitored systematically by adding up fluid balances on charts.

​Professor Edward Baker

Chief Inspector of Hospitals

23-25 June and 8 July 2015. Unannounced visits on 4 and 5 July 2015

During a routine inspection

The Royal Hospital for Neuro-disability is an independent medical charity which provides neurological services to the entire adult population of England.

The hospital specialises in the care and management of adults with a wide range of neurological problems including those with highly dependent and complex care needs, people in a minimally aware state, people with challenging behaviour and people needing mechanical ventilation.

Our key findings were as follows:

Safe

  • There were sufficient staff but only with heavy reliance on agency nurses and healthcare assistants who were not trained in neuro-rehabilitation. Some nurses did not have the full range of competencies to work in all areas of the hospital, for example with tracheostomy patients.
  • The hospital had many patients requiring long term assistance with breathing but did not have in-house medical expertise.
  • The out-of-hour’s system was not robust and a doctor was not always available when required.
  • Incidents were reported and investigated but the electronic reporting system was new and there was as yet limited analysis of trends and little feedback to ward level.
  • Staff had basic in-house training in adult safeguarding but no training at higher levels in the protection of vulnerable adults and their understanding of safeguarding was weak. Most staff were unaware of wider safeguarding issues such as risks of financial abuse.
  • The environment was visibly clean and records demonstrated that equipment was maintained and checked regularly.
  • Medicines were safely managed.
  • Record keeping was inconsistent across different areas of the hospital, and for most patients very clinical. A unified and more holistic record keeping system had been introduced for new patients and was being rolled out for all patients.

Effective

  • Consent and capacity of patients were not always considered for simple decisions and there was a danger that staff were using a blanket “lacks capacity” for most patients when each capacity assessment should be decision-specific.
  • Staff showed a very limited awareness of their roles and responsibilities under the Mental Capacity Act, 2005 and Deprivation of Liberty Safeguards. In particular, they did not recognise that patients who might not be able to make a complex decision, may be able to make more straightforward decisions.
  • Forty two patients at the hospital had the capacity to consent to treatment and seven were awaiting a capacity assessment. The remainder of patients either had authorisations in place in accordance with the Safeguards, were awaiting assessment by the Local Authority or had been assessed by the Local Authority but waiting for authorisation under the Safeguards.
  • Staff made the assumption that they were working in a patient’s best interests without the appropriate supporting documentation and there was limited documentation of the views of families being sought.
  • Staff recognised the challenges in measuring the effectiveness of care and treatment of many of the patients, but had not developed other outcome measures. However, where guidelines for treating this group of patients existed, they were followed.
  • Goal planning and risk assessments were good on the neuro-behavioural unit, but on other wards, goal planning was not always sufficiently individualised.

Caring

  • Most staff treated patients with dignity and respect. However, we also saw some staff that were very task-oriented and who spoke little to patients.
  • There was room for improvement in care plans to give a more holistic view of patient needs.
  • The hospital chaplain provided excellent support for patients, their families and staff.

Responsive

  • Improvements in patient flow were needed as the hospital was an outlier for length of stay. This would shorten waiting lists.
  • There were many complaints about the quality of food. The food choice was limited and the presentation poor. There was little account taken of individual preferences and we saw no Asian, Caribbean or African food.
  • Patients had access to assistive communication technologies such as communicating using a computer and powered wheelchair controls.
  • Patients had meal mats with their photograph and a visual guide to the placement of food and the appropriate diet.
  • Religious needs were respected and patients could be taken to services in line with their faith.
  • Many services, both clinical and leisure were provided on site which reduced the need for wheelchair users to travel and a range of leisure activities were available to long stay residents.
  • For those living in the specialist nursing home, the environment was not sufficiently homely given that for many residents this was their home.
  • Complaints were dealt with in a timely way, but we noticed that some issues tended to recur, indicating that long term solutions to concerns raised had not been found.

Well-led

  • Significant changes in leadership, governance structure, senior staff and organisational culture had been made in the previous year, but yet to be embedded. The new leadership team was not yet well established and had a significant task ahead to embed the changes they were making.
  • The duty of candour and the requirements of the Mental Capacity Act 2005 were not well understood by staff working at the hospital.
  • There was still work to do to refine the unique specialisms of the hospital and its associated specialist nursing home; and to strengthen the culture of listening to patients, relatives and staff as well as to develop quality outcome measures that would demonstrate the impact the hospital staff were having on patients with profound disorders of consciousness.
  • Staff supported the vision for the hospital to become a centre of excellence in acquired brain injury.
  • A business transformation plan was in place. The prime focus for the year ahead was on achieving financial stability and developing the competencies of nursing staff.
  • A patient representative committee and family peer support group was available for patients and relatives/carers.

We found the following area of practice to be outstanding:

  • Eye-gaze technology was an innovative form of electronic assistive technology to help people with very limited or no physical movement, such as people with motor neurone disease or locked in syndrome, to communicate and make full use of computers. The hospital had successfully trained several of its patients to use this.

There were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure appropriate medical cover for all patients at all times, particularly for those who need long term assistance with breathing for whom there was no in-house medical expertise.
  • Improve the understanding of all staff on the range of potential safeguarding concerns that can arise with this patient group.
  • Ensure that all staff comply with the Mental Capacity Act, 2005, with regards to consent, mental capacity assessments and Deprivation of Liberty Safeguards, including recording the detail of decision-making meetings about patients' mental capacity and best interests; and arrange for appropriate patients to have Independent Mental Capacity Advocates.
  • Ensure that staff understand the legal requirements of the duty of candour in relation to being open and honest with patients and their families when things go wrong with care and treatment.

We found breaches of regulations in relation to the need for patient consent, the safe care and treatment and safeguarding service users from abuse and improper treatment. We have taken action against the provider and will report on this when our action is completed.

In addition the provider should

  • Improve the coordination of medical care currently split between GPs and hospital doctors.
  • Implement seven day therapeutic services for patients on the Brain Injury Unit.
  • Involve families in decisions about Do Not Attempt Cardiopulmonary Resuscitation and End of Life care and ensure these conversations are documented.
  • Improve the training and support for permanent and agency nurses and healthcare assistants including safeguarding, resuscitation and for nurses the full range of competences needed to care for all patient groups in the hospital.
  • Improve the choice and presentation of the food provided.
  • Individualise the goal planning for all patients in the hospital.
  • Improve patient flow through the hospital by reducing the length of stay of appropriate patients.
  • Where appropriate, make the environment for long stay patients more ‘homely’ in line with current expectations of facilities for residential accommodation.
  • Actively encourage family involvement on all wards.

Professor Sir Mike Richards

Chief Inspector of Hospitals

29 October 2014

During an inspection looking at part of the service

We carried out this inspection to monitor the standards that we had judged to be non-compliant at our inspection of November 2013.

We found that there had been improvements in caring for people using the service. Care plans were up to date and more focused on people's individual needs, and there was professional and respectful staff interaction with people they were caring for. Everyone living in the hospital had individual passports that gave simple information about important things to know about the person's relationships, medical, nursing and social needs.

Medications were now accurately recorded in people's daily medication charts, including dosage and frequency. Emergency medicines were accessible and up to date.

Ward environments had been improved by using off ward storage for some equipment and making all areas tidier. Andrew Reed Ward, Wolfson and Wellesley wards had been fully refurbished since our last visit.

Records were organised and medical and care records were stored together, and securely. The records we sampled were up to date and had completed forms relating to the person's resuscitation wishes and Deprivation of Liberty safeguards where appropriate

13 November 2013

During a routine inspection

During our visit we visited Glyn Ward, the Jack Emerson Centre, Andrew Reed Ward, Wellesley Unit and we reviewed the pharmacy system in place at the hospital. We spoke with people using the service, relatives, staff and senior managers.

A member of housekeeping staff we spoke with said 'I feel part of the staff, we are important to the patients'.

The relative of a person using the service said 'They couldn't be anywhere better', 'This is the best of both worlds' and 'They are very happy, they laugh a lot. The nursing care is very good and there are plenty of activities off the ward to join in with. They can attend church each week and the priest visits the ward'.

When asked about staffing levels on their ward most said their felt there was enough staff but one nurse said 'You need more time on the ward to talk to people and the HCA, to watch them and train them'.

During the visit we identified issues with person-centred care plans and staff interaction with people using the service, the suitability of the premises, medication management, staffing levels and record keeping.

25 February 2013

During a routine inspection

During our inspection we visited Chatsworth Ward, the Jack Emmerson Ward, Evitt Ward and Coombs Ward. We spoke with a number of patients, relatives and staff during our visit and by telephone shortly afterwards.

We asked people about the care that was being provided and one person said "I am happy here, staff are very nice". Another person said "It's good here, staff are considerate, understanding and have a good sense of humour but caring".

Two relatives we spoke with felt the care their family member received was good and they were confident that they could speak to the senior nurse if they had any concerns about the care provided. One person did comment that "some days there is good care and the next not so good as it depends who is on duty".

The staff members we spoke with were happy with the training they received and they felt that the dignity of the patients was respected. A member of staff commented that where they worked was "a small, happy unit with long term patients you get to know well and understand their likes and dislikes". Some of the staff felt that they would like more time to spend with the patients that could be achieved with additional staff or volunteers.