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Lakeside Requires improvement


Other CQC inspections of services

Community & mental health inspection reports for Lakeside can be found at Accomplish Group Support Limited.

Inspection carried out on 29-30 October 2019

During a routine inspection

This service was placed in special measures following the comprehensive inspection carried out in March 2018. Whilst we identified improvements during the comprehensive inspection carried out in January 2019, the provider remained in special measures due to insufficient improvement in the safe domain. As a result of this inspection, the provider is no longer rated as inadequate for any of the five key questions and has demonstrated improvements have been made. The decision has been made to exit the service from special measures.

We rated Lakeside as requires improvement because:

  • Emergency grab bags contained some expired stock and some stock was missing. One emergency grab bag was secured with an incorrect tag meaning it could not be accessed quickly in an emergency. Defibrillation machines had parts missing or were not working and one staff member was unclear how to use them. Some wards did not have blood monitoring equipment or urine testing strips. wards that had blood monitoring equipment had not had it calibrated regularly. Emergency drugs bags were stored at ceiling height and some staff could not reach them. However, all issues were rectified during or shortly after the inspection.
  • There were delays in signing off and closing incidents that had been reported using the internal incident reporting system.
  • Although most care plans had been updated regularly, we found five care plans which had not been updated within the providers monthly timescale, this equated to 21%. One care plan had been reviewed within the providers timescale, but the review lacked detail. Some care plans contained several goals that could have been merged to make them less complicated for patients.
  • Staff we spoke with knew the hospital had a freedom to speak up champion, but some were not sure who it was.


  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a hospital for people with a learning disability and/or autism and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the wards who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff spoke highly of the newly-appointed service director. Leaders knew patients well. Senior managers knew the names and individual personalities of patients. Staff felt respected, supported, listened to and valued.

Inspection carried out on 22-24 January 2019

During a routine inspection

This service was placed in special measures following the comprehensive inspection carried out in March 2018. While there has been improvement overall there has been insufficient improvement in the safe domain and the service therefore remains in special measures. The service will be kept under review and where necessary another inspection will be conducted within six months. If there is not enough improvement we will move to urgent enforcement action.

We rated Lakeside as requires improvement because:  

  • There were some improvements needed to the physical environment. Cooper 3, the behavioural support unit for patients in long-term segregation was cramped, dark and tired. The floors in the bathrooms and communal areas were dirty and the unit needed refurbishment. Staff had not adequately carried out security checks. On Elstow 1 unit there was a strong smell of drains. Some bedrooms and bathrooms on Elstow 1 and Elstow 2 units were cold.
  • On Elstow 2 unit, only one of the four patients on the unit had access to a key for their own room. This was not indicated in patients’ individual risk assessments or care plans to clearly justify this level of restriction.
  • The provider’s observation policy did not follow National Institute for Health and Care Excellence guidance, which meant staff were spending longer than recommended observing patients.
  • We found issues with paperwork including staff not completing required evaluation forms following rapid tranquilisation, some long-term segregation daily review notes had been cut and pasted from previous days and physical health care plans that did not reflect patients’ current needs and were not always being adhered to.
  • Three monthly independent reviews of long term segregation by an external hospital were not being carried out.
  • We found delays in reviewing patients’ mental capacity to consent to treatment and staff did not provide patients with information relating to their section 17 leave.
  • Healthcare assistants did not feel involved or informed about outcomes from clinical governance meetings.


  • Staff completed ligature risk assessments annually or more frequently when needed. Staff completed patient specific fixed-point ligature risk assessments for each patient.
  • Staff assessed the physical and mental health of patients within 48 hours of admission. Staff developed individual care plans which were reviewed and updated as needed. Care plans were personalised, holistic and recovery-oriented. Staff completed individualised positive behavioural support plans for patients. Staff had a good understanding of individual needs of patients. The hospital employed a practice nurse to manage patients’ physical health alongside the GP. A specialist dentist also attended bi-weekly.
  • The hospital offered employment opportunities to eligible patients within the hospital grounds and had a recovery college based on site. Patients could take part in volunteering within the local community. Patients had access to the star centre, a multifunctional space for therapy groups and leisure activities. All patients were asked if they wished to have carers or relatives involved in discussions about their care.
  • The hospital was taking steps to improve morale and staff retention. The management team had worked towards a cultural shift within the hospital and an opportunity to refresh the workforce with a successful recruitment process, which resulted in a higher than average turnover of staff. The hospital recruited a new team of unit general managers in September 2018, which improved staff morale and supported developing leadership within the hospital. Unit general managers felt valued, respected, rewarded and supported. Staff were passionate about the client group they were working with and reflected the providers values.

Inspection carried out on 06 to 08 March 2018

During a routine inspection

We rated Lakeside as inadequate because:

  • The provider did not manage environmental risks to patients effectively. Ligature risk assessments on all eight wards were not accurate and did not mitigate all risks. The service did not exclude admissions of patients with self-harming behaviours.
  • Staff were not carrying out and documenting all checks on all patients. We found gaps in patient observation records on three wards. This placed patients at risk.
  • Staff were not adhering to the Mental Health Act Code of Practice in regards to seclusion and long-term segregation. There were gaps in documentation and staff did not always follow the correct procedures. Staff did not complete seclusion records in full. Reviews of four patients in long-term segregation were not in line with the Mental Health Act Code of Practice.
  • Staff did not manage equipment or medicines safely. Two clinic rooms contained out of date equipment. We found unlabelled, ‘patient-only’ medication in clinics on three wards. Staff did not accurately record patients’ allergies on medication charts on four of the eight wards.
  • The wards were not always staffed safely. Between November 2016 and October 2017 Staff turnover was at 35%. As a result, the service had been running with low levels of registered staff . In addition, the service had a high level of new and inexperienced staff and relied heavily on agency staff. Managers did not ensure that all shifts were staffed to the required establishment.
  • The provider did not ensure that staff had adequate training or supervision. Not all staff had completed the induction training. Compliance with mandatory training was low for bank staff and low in some areas for permanent staff. Managers were not reviewing staff performance and development needs. The overall compliance with appraisal was low at 36%. The provider did not ensure that bank staff received supervision.
  • Staff did not ensure that all confidential patient information was stored safely. We found confidential patient information left unattended in communal areas on two wards. We found handover documentation left in a toilet.
  • The quality of care planning was poor. Care plans were not always personalised, recovery focused or accurate. Staff did not capture patients’ views in care plans. We saw limited evidence in care records of staff supporting patients to make decisions.
  • Engagement and activity levels were low. Patients spent long periods asleep or in their room alone. We saw little evidence of activities and therapy taking place. Staff were not prompting or supporting patients to improve their engagement. The service provided a limited range of psychological interventions that were recommended by the National Institute of Health and Care Excellence. Some but not all patients’ had sensory profiles and formulations in place.
  • Not all staff were caring in their interactions with patients. Interactions between staff and patients were not positive and supportive on three wards. Staff did not always take action to ensure that patients’ dignity was maintained.
  • Staff did not discuss actions and learning from complaints at clinical governance meetings.


  • The units complied with Department of Health guidance on eliminating mixed sex accommodation.
  • All wards had emergency medical equipment in place.
  • Staff discussed patients’ care and treatment at monthly multi-disciplinary meetings. Staff completed risk assessments upon admission and updated them at regular intervals.
  • The provider held daily meetings where key staff would meet to review issues across the service including staffing and incidents.
  • The ward environments had improved, they were clean and tidy, and some had been decorated.
  • Most staff knew how to use the whistle-blowing process and felt able to raise concerns without fear of victimisation. Staff told us that morale was slowly improving.
  • Staff were aware of and usually followed safeguarding procedures and the provider had a positive working relationship with the local safeguarding team.

Inspection carried out on 6 & 7 June 2018

During an inspection looking at part of the service

We did not rate this service.

We found the following areas the provider needs to improve:

  • Data given to us during inspection showed that the provider had 11 vacancies for full time registered staff having in 22 full time registered nurses in post and a vacancy rate of 35% for registered staff.
  • There were vacancies for 31 healthcare assistants. The provider had recently recruited 26 healthcare assistants who were waiting to go through the induction process leaving a 15% vacancy rate for unregistered staff once induction of these staff is completed.
  • We noticed that some ward areas needed redecoration and repair. Staff told us that issues such as door frames that had been ripped down on Cooper 3 had been reported to the maintenance department and were awaiting repair.
  • Staff told us that there was always a registered nurse present on the wards. However, we observed that there were two occasions on different wards when the registered nurse was not present on the ward for example; due to attending meetings or taking breaks.
  • Patients with epilepsy did not have up to date risk assessments about bathing or restraint.
  • Not all staff were trained in how to care for patients with epilepsy. At the time of inspection, 55% of staff had received training. Managers told us that further training was planned. There was a risk that patients could die if they were not cared for safely in the event of a seizure.

  • The process of assessing, planning and evaluating care appeared disjointed. There was different information in different sections of the records. Three separate folders for each patient were kept.
  • It was not easy for staff to find significant information quickly in care records. The patient voice was not always evident indicating whether the patient had agreed to the plan or not. Action plans and other documents did not all have dates and signatures on.
  • Three out of eight care plans on Elstow 1 contained unrealistic goals, relating to time frames for settled behaviour without clear explanation.
  • We found a discrepancy between one care plan and the prescription. We brought this to the manager’s attention and the issue was rectified immediately.

We also found the following areas of good practice:

  • The mandatory training compliance rate for permanent staff at this provider was 92% on 7 June 2018.
  • The provider had been interviewing three days per week during the weeks prior to inspection and had recruited 26 unregistered staff and one registered nurse to these posts although seven staff were yet to complete induction.
  • Ward managers told us they could adjust staffing levels in response to patient acuity and could increase staffing if necessary.
  • We saw that care records had comprehensive assessments that were completed promptly after admission.
  • Care records showed that patients received physical examination on admission and that there was ongoing monitoring of physical health problems.
  • The provider had recently recruited a practice nurse who worked between the hours of nine in the morning to five in the afternoon to address the physical healthcare needs of patients. There was a local GP who attended the hospital on a weekly basis to conduct a surgery.
  • The recently appointed psychology lead had introduced a range of evidenced based outcome measures to ensure psychological therapies were evidence based.
  • We observed staff speaking with patients in a positive and caring manner.

Inspection carried out on 27- 29 November 2017, 12 December 2017

During an inspection looking at part of the service

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

  • Ward environments were dirty, unkempt and poorly maintained. They were not welcoming or appealing.

  • All wards had blind spots and ligature risk assessments were not robust enough to effectively mitigate risk where there were poor lines of sight.

  • The providers’ management of medication was poor. Clinic rooms contained out of date medication and equipment.

  • Shifts were not consistently covered with a sufficient number of staff. The service had a high level of new and inexperienced staff and relied heavily on bank and agency staff. Staff turnover was high at 56%.

  • Registered staff were not visible on the wards and staff were not having regular individual sessions with patients.

  • Staff told us that leave and activities were cancelled due to staffing issues.

  • Compliance with mandatory training was low for bank staff and low in some areas for permanent staff.

  • There were gaps in patient observation records that meant we could not be assured that patients were always kept safe.

  • The seclusion room did not meet the Mental Health Act Code of Practice guidance and some seclusion records were incomplete.

  • There were unlawful restrictions placed on informal patients.

  • Staff morale was low and staff did not have confidence that senior managers would address issues and make improvements.

  • Not all staff were receiving supervision in line with policy. Bank staff were not receiving regular supervision and the compliance rate for managers was low at 61%.Staff told us that supervision was not individualised and did not met their needs.

  • Staff were not receiving annual appraisals.

  • The clinical governance process was not robust at improving standards of care and treatment for patients.

  • Staff told us that they did not  receive de-brief or felt supported following incidents. The process for sharing lessons learnt was not robust.

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

  • All wards complied with Department of Health guidance on eliminating mixed sex accommodation.

  • Most staff were aware of safeguarding procedures and how to report an incident should they need to.

  • Staff completed risk assessments for each patient upon admission.

  • Ward managers were described as supportive and approachable.

  • There was an established whistle blowing process that staff used.

  • We observed some positive team working at ward level.

Inspection carried out on 13-14 September 2016

During a routine inspection

We rated Milton Park Therapeutic Campus for safe and well-led as requires improvement because:

  • Some units had high levels of new and inexperienced staff due to increased recruitment.
  • The service had one functional seclusion room at the time of inspection on Cooper 1. This seclusion room did not meet the requirements of the Mental Health Act Code of Practice.
  • Staff did not follow the National Institute for Health and Care Excellence guidelines for monitoring patients following administering medication.
  • Some staff reported a lack of confidence in using oxygen in an emergency situation.
  • Staff did not follow best practice for storage and disposal of sharps and medication.
  • Clinics did not have examination couches. One patient reported having dressings changed in the corridor.
  • Staff reported reduced numbers of cleaning staff and that clinical staff were responsible for daily cleaning of the units. Some units did not maintain up to date cleaning records.
  • Managers did not provide staff with regular appraisals.


  • The unit environments were clean and tidy and the furnishings in most areas were in good condition. There was a plan of works to update and modernise all unit areas.
  • Staff updated risk assessments and care plans following incidents. Staff recorded incidents on the electronic recording system.
  • Staff were aware of patients individual risk assessments and management plans.
  • Mandatory training figures showed 86% of staff were up to date with their training.
  • A new induction programme was in place for all new starters. There was specific induction process for agency staff.
  • Managers had a programme in place to reduce blanket restrictions unless clinically indicated and individually care planned.
  • There was a system in place for tracking and learning from incidents and other reportable events.
  • Staff used recognised risk assessment and outcome tools to monitor patients’ progress.
  • Managers involved both staff and patients in workshops to agree the providers’ new visions and values.
  • There was a full programme of clinical audits completed by clinical staff and managers.

Inspection carried out on 9 July and 5 - 6 August 2015

During a routine inspection

We rated Milton Park Therapeutic Campus as inadequate because:

  • Gifford A and B and Cooper 1 and 2 were not clean, were poorly maintained and had unpleasant smells. These areas were not maintained in line with infection control standards

  • The safeguarding lead had not received relevant training

  • On Gifford B, two fire extinguishers were past their expiry date of February 2015

  • Staff did not check resuscitation equipment regularly or make sure that this equipment was sufficiently available

  • Not all staff had received mandatory training, with gaps in safeguarding children and adults training for staff, infection control, life support and defibrillator training

  • An effective induction was not in place for agency and bank staff

  • There were not enough staff on duty to meet the needs of patients. This meant that escorted leave and unit activities were regularly cancelled. Due to a lack of attendance records, the provider were unable to demonstrate activities were delivered as planned.

  • The hospital used high levels of agency and bank staff meaning patients did not always know staff working on the wards.

  • On Cooper 1 and 2 had obstructed lines of sight, which meant that staff could not properly observe patients and ensure their safety

  • Potential ligature points were found in some units that had not been appropriately mitigated

  • There was a breach of ministry of justice conditions for one patient

  • Some practices were restrictive such as restricting patients’ access to fresh air. Staff did not use long-term segregation correctly

  • The seclusion suites did not meet the requirements of the Mental Health Act code of practice

  • The incidents of restraint were high on wards Cooper 1, Ashwood and Cooper 3. The hospital were not taking steps to reduce the number of incidents of restraint

  • Staff induction training was not updated or refreshed. Only 23 staff had completed their induction training out of 112 staff

  • The hospital had not provided age-appropriate care and treatment for a 17 year old patient. Appropriate environmental arrangements, educational provision, and specialist staffing were not in place

  • There were no effective systems for identifying, capturing and managing issues and risks at unit and organisational levels.

  • Some patients reported staff were not always aware of their individual needs

  • There was a lack of discharge planning for patients moving to residential care services

  • The hospital received 208 complaints from January 2015, 86 of which were upheld. While staff knew the complaints process and showed patients how to register a complaint, the complaints system did not capture the lessons learnt or identify themes and trends in the hospital

  • Significant issues that threatened the delivery of safe and effective care were not identified or action taken.

  • The information systems were a combination of paper and electronic records. This caused difficulties for staff while updating and reviewing patients care records

  • There was some engagement with relatives of patients, carers, and the public. The hospital did not respond to what patients’ relatives, carers, and the public said. As a result, their views were not reflected in the planning and delivery of the service

  • There was a lack of openness and transparency, which resulted in the identification of risk, issues and concerns being discouraged

  • Patients were able to personalise their bedrooms. However most bedrooms were not personalised. This was the responsibility of staff on wards, together with the individual patient. The lack of personalisation of bedrooms was a feature throughout the hospital.


  • Medical records and medicine management systems were robust and ensured that patients received their medication as prescribed

  • There was good access to physical health care, including access to specialists when needed. Physical healthcare screening was completed as part of the admission assessment process

  • Care plans were updated regularly with the information required by staff. Patients understand, and had a copy, where possible, of the information that is shared about them.

  • Staff had regular supervision

  • The hospital complied with the legislative requirements of the Mental Health Act. Patients were supported to make decisions and, where appropriate, their mental capacity were assessed and recorded. Staff used outcome measures

  • There was a choice of food to meet the specific dietary requirements of religious and ethnic groups

  • There were examples of positive patient and staff interactions seen on all units. There were particularly caring and respectful interactions between patients and staff on Ashwood unit

  • Patients and staff knew the senior hospital managers and they regularly visited the units

  • Staff knew and agreed with the organisation’s values

  • Staff told us there was good team work on the units, access to specialist training, and opportunities for leadership development.

Inspection carried out on 28 August 2013

During an inspection looking at part of the service

When we inspected Milton Park Hospital in May 2013, we identified non compliance in relation to record keeping and recruitment. As a result of our findings we made compliance actions, and told the provider they must make improvements. The provider responded swiftly with an action plan and put new systems in place to ensure improvements were made.

When we carried out this inspection on 28 August 2013, we found new documentation relating to the delivery of care had been introduced and there were significant improvements in the standard of record keeping.

The provider had 'activated' a new electronic system to ensure recruitment processes were robust, and the renewal of professional and employment documents was managed efficiently.

Inspection carried out on 21, 24 May 2013

During a routine inspection

This inspection of Milton Park Hospital on 21 and 24 May 2013 was carried out by a team of four inspectors from the Care Quality Commission (CQC). We were accompanied by an expert by experience, a specialist professional advisor and a local commissioner. We visited seven units in the hospital; spoke with 20 people who use the service and 40 staff.

We found most people were satisfied with treatment they received. They looked at ease in the company of staff, who they said were helpful and supportive. One person said. �Staff treat me with respect and observe my dignity.�

People were given treatment in line with their care and support plans, and there were safe systems in place to ensure people received their medication appropriately. Where people were detained under the Mental Health Act, they were aware of their rights, and how to appeal against their placement at the hospital. There was a robust complaints procedure in place and people told us the staff were approachable and would listen to them if they had concerns. One person said. �I can talk to the staff, if I had any concerns I could speak with them and they will help me."

We found there were sufficient staff on duty. They were knowledgeable about people's treatment needs, and had completed a wide range of training. However there were some gaps in the recruitment process, which could mean people who use the service were at risk.

We found inconsistencies with standard of record keeping across the hospital.

Inspection carried out on 18, 19 September 2012

During a routine inspection

During our visit to Milton Park Hospital on 18 and 19 September 2012, we saw that people looked well cared for on all units. Several people told us that they were regularly asked for their opinions and these were acted upon through the regular patient forum meetings. People at Milton Park Hospital had various degrees of ability to communicate. In all cases, the hospital had assessed the most appropriate way to communicate with people and in this way we saw that most people were happy and well cared for, even if they could not speak with us.

We saw that person centred care plans were in place and regularly reviewed at Multi Disciplinary Team (MDT) meetings. People were given the opportunity to attend the meetings and were asked to contribute to their individual plans. Risk assessments were in place to maximise the ability of people to take part in activities and participate in the local community if possible.

Inspection carried out on 13 July 2011

During a routine inspection

During our visit to Milton Park hospital on the 09 June 2011 people that we spoke with told us that they were treated well and were involved in making choices about their day to day care and support and discharge planning.

One person said, �I think I have been treated well�, and another person said, �I do not have any complaints, the staff are all very supportive�.

Generally people were aware of what was in their records and they had been involved in the review of care plans and risk assessments relating to their care.

We spoke with numerous people during this visit on 09 June 2011, and those that were mentally well enough to discuss the matter of consent told us that they understood and agreed with the care that they were receiving. They told us that they appreciated that at times they had not been well enough to verbally give consent, but they knew that some procedures such as restraint had to be done in their best interests, and to safeguard themselves and others.

The only negative comments that we received were in relation to activities. Some people told us that their activities were sometimes cut short or cancelled because there were not enough staff available to drive the hospital vehicles and transport them into the community. However on the wards people generally felt well cared for.

Reports under our old system of regulation (including those from before CQC was created)

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.