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The WoodHouse Independent Hospital Inadequate

We are carrying out a review of quality at The WoodHouse Independent Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Reports


Inspection carried out on 18 – 20 June 2019

During a routine inspection

We rated The Woodhouse Independent Hospital as inadequate because:

  • The hospital was not adequately staffed. Nearly 90% of the establishment ward staff posts were unqualified support workers and 40% of posts for both nurses and support workers were vacant. As a result, unqualified agency staff covered a high number of shifts. This included most of the night shifts. Some of the agency staff were new to the hospital and did not know the patients. This meant that the care plans and positive behaviour support plans developed by the specialist staff were not always enacted by the ward-based staff – some of whom told us that they had not read the plans. Also, the staffing situation meant that a qualified nurse was not always present in communal areas of the ward, that staff were often unable to take rest breaks or regular breaks from enhanced observations, that escorted leave was often cancelled for patients on general observations and that patients did not have regular one-to-one time with their named nurse.
  • Managers did not provide staff with the induction, training, supervision or appraisal that would have mitigated the staff’s lack of qualifications and specialist skills required to provide high quality care to people with such complex needs.
  • The service was not well led at ward level and there was a lack of resource at all levels of leadership. The governance processes did not operate effectively at ward level meaning that performance and risk were not managed well. Clinical and internal audit processes did not have a positive impact on quality governance. There was no structured induction programme for agency staff. Staff were not supported through appraisals and regular supervision to enable them to carry out the duties they were employed to perform. There were no regular team meetings for staff to discuss clinical concerns and learning as a team with managers.
  • Staff did not always follow systems and processes to safely store and manage medicines. Learning from incidents was not discussed with staff. Managers did not always debrief and support staff after serious incidents.
  • The ligature risk assessments lacked clear actions on how the risk was managed. There was no emergency drug (Adrenaline) available to treat anaphylaxis. The checks were not always reliable and valid.
  • Staff did not monitor the physical health of patients consistently. Care plans did not always reflect the assessed needs of patients. They were not always personalised, holistic and recovery-oriented nor always updated in a timely manner. Staff did not participate in clinical audits, benchmarking and quality improvement initiatives.
  • Staff did not always assess and record capacity to consent clearly where patients might have impaired mental capacity. Staff did not know their identified lead for the Mental Capacity Act.
  • There was no sensory room within the hospital to meet the needs of patients who would benefit. Quiet areas on some wards were not available to allow patients an opportunity to avoid noise and disruption. Managers did not regularly review the mix of patients on the wards to ensure the environment was comfortable for all patients.
  • The provider had not carried out an autism friendly assessment to ensure that the environment was suitable for patients with autism. The service did not ensure that the needs of patients with specific communication needs were met.

However:

  • Staff understood how to safeguard patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • Staff regularly reviewed the effects of medications on each patient’s physical health. They knew about and worked towards achieving the aims of the STOMP programme (stop over-medicating people with learning disabilities).
  • We observed staff treating patients with compassion and kindness. They respected patients’ privacy and dignity. The multidisciplinary team involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided.
  • Staff planned and managed discharge well. Staff helped patients with advocacy, cultural and spiritual support.

Inspection carried out on 7 November 2017

During an inspection to make sure that the improvements required had been made

We rated The Woodhouse Independent Hospital as good for the Safe domain because:

  • During the most recent inspection, we found that the service had addressed the issues that led us to rate the Safe domain as requires improvement following the January 2017 inspection.
  • We found that when staff gave oral medication for the purposes of rapid tranquillisation, they completed the necessary physical observations. The provider had removed restrictions that meant that it no longer had a patient living in long-term segregation. The provider had a floating nurse to support the wards for people with learning disabilities or autism, in addition to the staffing establishment for each of the wards. Moneystone ward had sufficient staffing levels to meet patients’ needs.

  • We found that the provider had allocated a lead nurse for infection prevention and control to the wards for people with learning disability or autism. Staff completed checks on emergency bags on all the wards. Staff completed records to show they had cleaned portable clinical equipment on all the wards. Staff had de-cluttered and tidied the storeroom, and cleaned, redecorated and re-floored the sluice room on Moneystone ward.
  • The provider offered overtime to its staff and had a bank staff system to help fill shifts. The provider used agency staff frequently, and wherever possible, they tried to use staff who were familiar with the service. Most staff in the core service had received training in autism.

However:

  • Staff did not always record the time of the physical observations they completed after they gave oral rapid tranquillisation.
  • There were different processes for recording physical observations on the wards.
  • The provider’s rapid tranquillisation policy lacked guidance on monitoring physical observations after oral rapid tranquillisation. 

Inspection carried out on 17-19 January 2017

During a routine inspection

We rated The Woodhouse Independent Hospital as good overall because:

  • During this inspection, we found that the provider had addressed most of the issues that made us rate forensic inpatients/secure wards and wards for people with learning disabilities or autism as requires improvement for the safe, effective and well led domains in our last inspection in October 2015.
  • All wards had access to emergency equipment such as automated external defibrillators and oxygen cylinders. Staff practised good infection control and food hygiene.
  • Wards did not have nurse call systems but the provider had a specific risk assessment that identified the risks and how they mitigated them. This was mainly through designated support levels for each patient, observation and supervised access to high-risk areas.
  • Staff received training in, and had a good understanding of, the revised Mental Health Act Code of Practice and the Mental Capacity Act. The hospital had effective and robust arrangements to monitor adherence to the Mental Health Act and Mental Capacity Act.
  • The provider had improved its focus on autism and set clear aims and objectives for the service. Wards had autism-friendly features, staff assessed and met patients’ individual communication needs, and staff had access to specialist training.
  • The provider had developed two clear service pathways - learning disability (incorporating the forensic inpatient/secure ward service), and autism. It had strengthened its leadership with designated operational managers and clinical leads for each service, and recruited a consultant psychiatrist with specialist skills for the autism service.
  • The provider had improved its governance systems and processes for monitoring all aspects of care. For example, the provider had robust incident monitoring processes and held regular meetings to review restrictive practices.

However:

  • When staff on Moneystone and Highcroft wards gave oral medication for the purposes of rapid tranquillisation, they did not always complete the necessary physical observations.
  • The hospital did not have an active clinical lead role (for example, a named nurse) allocated to infection prevention and control.
  • There were short periods when there was no qualified nurse present on Moneystone ward, and there were occasions when staffing levels were insufficient to meet patients’ observation requirements.
  • We found gaps in the checks on the emergency bags on Moneystone and Highcroft wards.
  • There were no records that confirmed the cleaning of portable clinical equipment on Moneystone and Highcroft wards.
  • There were inconsistencies in the completion of forms used for recording observations of the patient in long-term segregation.

Inspection carried out on 20 - 21 October 2015

During a routine inspection

We rated Woodhouse hospital as requires improvement because:

  • Staff did not regularly check medical emergency equipment for Lockwood and Highcroft to ensure it was in good working order when needed. Moneystone did not have automated external defibrillators and oxygen.
  • Staff in Moneystone and Whiston did not practice good infection control procedures and food hygiene to protect patients and staff against the risks of infection.
  • The wards were not fitted with nurse call systems in bedrooms and bathrooms for patients to alert staff to any emergency.
  • Staffing levels fell below the required levels particularly at weekends and nights. There was a high rate of staff turnover and high use of agency. Activities and community leave were cancelled because there were not enough staff on duty.
  • On call doctor covered a large geographical area including all the Lighthouse hospitals. This meant that the doctor would not always be able to get on site on time to support staff during an emergency when needed.
  • There was no evidence that the safeguarding team were alerted to the patients in long-term segregation. Patients in long-term segregation did not have independent reviews taking place.
  • Although staff had received training in autism, they demonstrated a limited understanding of caring for patients with autism. Staff did not recognise the need for a consistent structured routine to follow on a daily basis with individual patients.
  • Staff had not received training on the revised Mental Health Act Code of Practice.
  • Staff in wards for people with autism demonstrated a poor understanding of the Mental Capacity Act and found it difficult to demonstrate how the five statutory principles applied to practice.
  • All staff should be receiving supervision in line with the provider’s policy and good practice. The minimum standard for management supervision was one hour once every three months. 25% of permanent staff had not received supervision in the three months prior to our inspection on 21st October. There was system to monitor the additional requirement for clinical staff to receive clinical supervision.
  • Staff did not always give patients copies of their care plans and record their views in care plans. Staff did not record patients’ advance decisions. These are decisions made by patients about their wishes for future care.
  • The hospital did not have an examination couch to carry out physical examination of patients. Moneystone and Highcroft wards did not have sensory rooms.
  • The units did not offer enough meaningful and purposeful activities that promoted independent living skills. The activities appeared to focus more on leisure. Patients, relatives and staff told us that activities were limited on weekends and evenings.
  • Relevant information for patients on subjects such as advocacy services, their rights and complaints was not available in easy-read versions.
  • Staff from wards for people with autism did not demonstrate a good understanding of their team objectives and reported receiving mixed messages from senior management about the aims and objectives of the service.
  • Staff morale was low particularly on the wards for people with autism where staff felt that senior management did not listen to their concerns. Staff told us that opportunities for clinical and professional development courses were limited.
  • The governance processes to manage quality and safety did not effectively monitor and address these areas.
  • The occupational therapy assistants felt they were working without clear clinical leadership and support in the absence of a qualified occupational therapist.

However:

  • The wards were clean and staff had carried out environmental risk assessments to identify potential ligature risks that might put patients at risk. They had put mitigating plans in place to manage them safely.
  • All units carried out comprehensive assessments of need on admission. These included detailed risk assessments and risk management plans that were updated regularly after every incident. These care plans followed a positive behaviour support approach.
  • Staff were trained in safeguarding and demonstrated a good understanding of how to identify and report abuse. Staff knew how to recognise and report incidents through the reporting system. Learning from incidents was shared with staff.
  • In the clinical records we checked, we saw details of regular physical health checks.
  • Patients could access psychological therapies as part of their treatment. For example, anxiety management and the adapted sex offender’s treatment programme recommended by the National Institute for Health and Care Excellence.
  • Staff treated patients with respect and dignity. They were polite, kind and willing to help. Patients and families were happy with the support they received from the staff and felt that they got the help they needed.
  • Staff involved patients in their clinical reviews and care planning and encouraged them to involve relatives and friends if they wished. Patients and their families told us that they could access advocacy services when needed.
  • Families and carers told us that they could raise any concerns and complaints freely.

Inspection carried out on 15, 17 April and 8 May 2013

During a routine inspection

We inspected the hospital as part of our annual schedule of inspections and to check on progress with the areas for improvement we identified at our inspection in May 2012. We found that a number of changes had been made to ensure patients were involved in their care and fully understood their rights and how to report any concerns with their welfare.

During this inspection, we spoke with six patients. All the patients were happy with their care. Several patients told us that their families were also happy with their care. One patient told us, “My mum is happy with the care I receive and visits every week.” The patients were happy with the staff looking after them. One person told us, “I can trust some of the staff with my problems and they will try to help me.”

We found detailed care plans and risk assessments were in place and up to date and that safe practice in the handling of medicines was being followed. We found that some records were not always fully completed or reliable to support decision making and the review of people’s needs.

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The hospital kept the overall number of staff required under review to ensure that patients’ needs were met. There were effective staff recruitment and selection processes in place to ensure that staff were suitable to be working in the hospital.

The arrangements in place did not provide a fully effective system to manage the risks to the quality and safety of care at the hospital.

Inspection carried out on 24 April 2012

During an inspection to make sure that the improvements required had been made

We undertook this visit to follow up on issues raised at our previous inspection. Wehad also received some concerns about the service. We undertook a joint visit with the Mental Health Act Commission. We shared information although the Mental Health Act Commissioner will provide a separate report. The visit concentrated on two of the eight units at The Woodhouse. We looked at six outcome areas. These included people's health and welfare, their involvement in decisions about their care, medication, the systems in place to make sure people were kept safe and staff support and training. We also looked at how the provider was making sure people were receiving appropriate care.

When we visited last time we noted that some people were not involved in planning their own care. On this occasion we saw during this visit that the service had started to make some progress in achieving this although further work was needed. We identified that the service had started to work with people to look at their needs and to identify their preferences and important things in their lives.

On our last visit we identified improvements that the service could make in how it gave staff information about plans of restraints and restrictions. We saw that the service had made progress in this area. We had also identified that some people were not being supported sufficiently with undertaking activities. Most people we spoke with on this visit told us that they took part in activities although in some instances the records did not fully support this.

We and the Mental Health Act Commissioner (MHAC) spoke to some people about their care. Some people were not able to tell us about their care. People we spoke with told us that they were satisfied with the support they received. We saw that in one of the units we visited that patient involvement meetings were held where people could raise issues and any concerns. On another unit we were told that staff met with people individually to gain their views but the records did not fully show that these were always held. An advocate visited all the units to support people to express their views.

We saw evidence that the service had started to develop information in a more user friendly manner. A part time speech and language therapist had been apppointed and was working with people on communication passports and was starting to train staff in developing a range of key signs to develop more effective communication.

We identified areas for improvement in the way some medication was being stored and administered.

We saw that the service had introduced additional systems to keep people safe and to respond to any incidents of concern. We saw that staff were trained in recognising and reporting safeguarding issues and the service had developed an easy to read leaflet about abuse, although this had not yet been introduced. We felt that staff needed to be more aware of issues relating to the Mental Capacity Act 2005 and the manager confirmed this would be included in staff's annual training. We saw that some of the annual updates on physical intervention were overdue.

The service had systems in place to review and monitor the care people received.

Inspection carried out on 20 October and 14 November 2011

During a themed inspection looking at Learning Disability Services

There were 43 patients at Woodhouse Hospital when we visited. We met and introduced ourselves to all the patients. We spoke to 15 patients across the eight units in more depth to get their views of the service.

Patients who could verbally communicate told us that they were involved in their care plans, so they had a say in how they were supported. Patients who have non verbal communication skills were not involved and not supported to be. Some relatives felt that they were not as involved as much as they would like to be in their relatives care plans. This means that if the patient is unable to communicate their needs and preferences they may not be supported in the way they want.

We saw that a range of educational and social activities were provided and patients told us they were supported to take part in the activities they were interested in.

Patients said they have access to advocates who help them to have a say in how they are supported and ensure their rights are upheld.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.