The Care Quality Commission
  • Mental Health
  • Independent mental health service

Archived: Walkern Lodge

14a Walkern Road, Stevenage, Hertfordshire, SG1 3QX (01438) 360501

Provided and run by:
Cygnet Learning Disabilities Limited

All Inspections

3 September 2015

During an inspection looking at part of the service

From our inspection we found:

  • The provider was not providing safe care and treatment.
  • Staffing duty rotas showed there were often not enough staff. In one three-week period, 15 nursing shifts were short staffed.
  • The provider did not have robust governance systems in place to consistently assess and monitor the quality of the service. We found gaps in patient and management records for risk assessments, safeguarding and incident investigation. Staff were not receiving regular training and support for their role.
  • Staff had not carried out adequate assessments of risk for individual patients under their care and care plans were not updated.
  • There were environmental risks. The service had no dedicated cleaning staff. Some areas were not clean and this posed a risk that patients and others may get an infection. Two bedroom floors had water from the shower overflow, which posed a risk of people slipping.
  • We found risks regarding medicines management practice. Actions by the provider after a pharmacy audit were incomplete.
  • Patients’ files did not have key Mental Health Act 1983 and Mental Capacity Act 2005 documents. For example, the record for the renewal of section for a patient after November 2014 was not in the patient’s file.
  • Current complaints records were not available and we had concerns that the provider was not responding to patients' concerns raised.
  • There had been three managers since May 2015. There had been significant changes to the core staffing and management in the last year. This had affected staff morale.

However:

  • A new part time manager from another hospital had just started working at Walkern Lodge. A regional director with oversight of this hospital and others in the area had taken action to ensure manager was available for the hospital.
  • Staff used nationally recognised assessments such as the short-term assessment of risk and treatability (START) assessment tool as part of their initial and on-going assessment of risk.
  • Staff had ensured that patients who needed higher levels of observation had bedrooms on the ground floor. Staff had easier access to observe and support them if they became unsettled.
  • Staff supported patients to keep contact with their family and friends.
  • Patients could contact independent advocates as required to help communicate their needs.
  • Patients personalised their rooms. Pictorial information and sensory, sound and light objects for patients’ stimulation were available.

Following this inspection, we identified that the provider was not meeting Regulation 12, The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at this location. We carried out enforcement action with the provider and told them to ensure compliance by 13 October 2015. The provider sent us their action plan to meet the regulation and informed us they had plans to close the location by 31 December 2015.

13 June 2013

During a routine inspection

During our inspection we saw that people were involved in the planning of their care and in the way the service was run. We spoke with two people who used the service and were told they felt listened to.

We looked at the care and welfare of people who used the service and found that people's individual needs were promoted. We viewed four people's care plans and saw that regular reviews had taken place.

We looked at the arrangements for safeguarding people who used the service due to information we had received. The service had systems in place to protect people from the risk of abuse and staff were aware of their roles should abuse occur.

We saw that staff were given support and access to training. We spoke with staff and one person told us, 'I don't feel like I need to leave things until supervision, I can go to the manager as things crop up.'

The provider had systems in place to monitor and assess the quality of service provided which included gaining feedback from people who used the service.

18 March 2013

During a routine inspection

People experienced care, treatment and support that met their needs and protected their rights. They were given information in a way they could understand and were involved in making decisions about their care and treatment. One person said, 'Staff are so nice. Staff always ask if we want anything. They plan with us and ask us what we want to do.'

People lived in an environment that was well maintained and considered their safety and well being. We found that additional living space had recently been provided. This offered people improved opportunity for dining, activity or quiet places.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. We saw that staff spoke to and treated people with respect. People using the service approached staff confidently and expressed their views and needs. There was an effective complaints system available. We saw that people using the service had made complaints and had been listened to.

25 January 2012

During an inspection looking at part of the service

People living in Walkern Lodge told us they felt confident to speak their minds if they had anything concerning them. They told us they felt much happier now and that they felt they were part of one big family.

People living at Walkern Lodge told us that they felt safe and happy living at Walkern Lodge. They said there had been a lot of changes made since our previous visit to the home in November 2011 and these had all been very positive. One person said that the interim manager deserved "a big pay rise because he is the best manager ever and has made things so much better."

People living in Walkern Lodge said they liked and respected the staff that supported them.

23, 24 November 2011

During a themed inspection looking at Learning Disability Services

There were five patients at Walkern Lodge when we visited. We met and introduced ourselves and spoke with all of the five patients using the service. We spoke with three patients in more depth to get their views of the service. Overall patients living at Walkern Lodge said they were happy living there, one person told us it was the best place they had ever lived. Two patients said that staff were generally nice people. Comments included: 'They just help you' and 'I couldn't ask for nicer people, they're lovely, and very caring'. However, one patient said, 'If I'm nasty to them they don't talk to me, but if I'm nice to them, they're nice to me.' A fourth patient commented, 'I reckon this place would be a lot better if the staff treated me with respect'.

Patients told us they were encouraged to make healthy choices, about what they eat and smoking. In addition they were encouraged to do things that make them look and feel good. One patient said that staff regularly help them to apply make-up and paint their nails.

We asked patients if there were things for them to do at Walkern Lodge every day. Patients told us that at the moment the therapist was not always there, so there were limited activities available, but staff do take them out. One patient said they did not really like the choice of activities that were offered, and commented they would like to do more sporty activities. A second patient commented 'there are things to do, although I don't always do them because I get bored easily'. Patients provided examples of activities, which included cooking, art, and bowling. One patient told us there was 'always something to do'. They also said that staff will support them with things such as budgeting. Two patients said that staff expect them to do certain tasks on their own, such as cooking and commented 'I can't do it on my own'. Another patient told us that patients and staff play a lot of scrabble, however they told us they were unable to read and write and that they get left out because they can not spell. They commented, 'I would like staff to talk to me and not leave me out'.

Three parents we spoke with told us that they felt their relatives would say if they were being mistreated. One parent said they liked the staff and that they were protective of their relative. They felt that staff did not abuse their position in relation to borrowing money and said that staff were good at supporting their relative to manage their finances. All three parents said they were unaware of any restraint being used at the service.

The advocate informed us that in their opinion all of the patients living at Walkern Lodge would speak up for themselves, providing an example where a patient had disclosed concerns about the way two members of staff spoke to them.