Cheadle Royal Hospital

Ratings - Child and adolescent mental health wards

• Overall

  Requires improvement

• Safe

  Requires improvement

• Effective

  Good

• Caring

  Good

• Responsive

  Requires improvement

• Well-led

  Requires improvement

Our view of the service

The CAMHS service was last inspected in February 2023 and was rated Inadequate overall. We served a warning notice in relation to effective management processes. At this current assessment the service had met all of the warning notice actions except in relation to the environmental concerns. The overall rating for the service has changed from Inadequate to Requires Improvement.

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Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

• 96% of staff had received training in the Mental Health Act.
• Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
• Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.
• The provider had relevant policies and procedures that reflected the most recent guidance.
• Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.
• Patients had easy access to information about independent mental health advocacy.
• Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.
• Staff mostly ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted. However, three of the four young people we spoke to told us about delays to leave on occasions due to acuity on the ward and staff availability.
• Staff requested an opinion from a second opinion appointed doctor when necessary.
• Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.
• Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

Mental Capacity Act

• 97.8% of staff had had training in the Mental Capacity Act.
• Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.
• Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.
• Staff took all practical steps to enable patients to make their own decisions.
• For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions, for example for food and dietary preferences.
• When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person's wishes, feelings, culture and history.
• Staff made safeguards applications when required and monitored the progress of applications to supervisory bodies.
• The service had arrangements to monitor adherence to the Mental Capacity Act.
• Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.
• The provider has a Gillick competency policy for consent in healthcare settings (a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment without the need for parental consent or knowledge).

People's experience of this service

We spoke with 4 young people during the on-site assessment and 6 parents following the on-site assessment. We received feedback from 5 stakeholders including advocacy services, commissioners, and the provider collaborative. We conducted a Short Observation Framework for Inspection 2 (SOFI2) observation in the service, which are structured observations which capture people’s experience of care during the on-site assessment.  

Young People’s Experience 

We spoke with 4 young people during the on site assessment of Woodlands Ward.  

Young people talked about staff being friendly, respectful and nice. Overall young people felt supported and safe on Woodlands ward and were generally happy with their treatment. They said they felt involved in their care. Young people had visitors to the ward or were able to take leave from hospital with them to visit local amenities. They said that staff were polite and nice to their families.  

The young people we spoke with particularly commented on limited staff availability at times when there were young people on the ward with higher levels of need. At these times they said there were fewer staff to talk with if they needed to, or to take them on escorted leave, activities or into the garden. At these times some young people told us they could feel forgotten about.  

We were told by young people that staff used de-escalation approaches and avoided restraint where possible. However, they reported that they did not always feel supported after a restraint incident. 

Poor cleanliness of the ward and especially their bedrooms was reported by young people. They told us about mould in bathrooms and windows in bedrooms that could not be opened. They felt able to raise these and similar concerns at ward meetings but told us that little had been done about some of the issues they raised.  

The ward environment could be noisy and young people with noise sensitivity were especially affected by banging doors, and noise at night time, including disturbance from staff talking.  

Young people told us that food choices were limited and not very healthy, especially daytime meals. Those with special nutritional needs reported that their diets were not always catered for, and that menu options were repetitive.  

Young people spoke positively about the education service and described school as a safe space. They told us about the different therapies they received from psychologists, occupational therapists, and art therapists.  

Advocacy services were used by young people who reported knowing who the advocates were and how to request to speak to an advocate. Young people knew how to raise concerns and complaints with staff. 

Young people wanted more regular meetings with doctors. They said meetings with doctors mainly happened in ward meetings, which occurred two-weekly.  

Carer Experience 

We spoke to 6 parents of young people on Woodlands ward following the on site assessment. 

All parents of young people told us that staff cared about their children and their well-being and that they had confidence in Woodlands staff. They recognised that staff worked in the least restrictive way with young people and that they were informed if incidents occurred.  

Parents were able to visit young people in a designated visitor room on Woodlands ward, or if Section 17 leave was permitted, they were able to take young people out for leave. Parents commented that on occasions this leave had been delayed due to staff shortages.  

Parents received updates on young people’s care and progress and could have daily or weekly emails from staff. Parents were updated after any incidents. However, parents told us that updates could lack detail, and they were not always received in a timely way.  

Parents told us that they were informed about treatment plans, but that they did not feel actively involved in young peoples’ care planning. It was not standard practice to invite parents to ward meetings on Woodland ward.  

Stakeholder Experience  

Stakeholders told us that Woodlands ward is friendly and welcoming and that the ward staff look at ways to improve. They described staff as managing risks well, and that they were responsive to young people and their needs and prioritised physical health needs. It was felt that assessments were person- centred, understanding and realistic about goals and expectations for treatment and engagement. 

Stakeholders described having observed staff using de-escalation techniques and that when restraint had been used this was done in a safe, structured, and supported way.  

Stakeholders reported mixed responsiveness to external professionals. Some stakeholders commented that they had to sometimes send several emails to request information, while other stakeholders described timely updates regarding incidents. 

We were told by stakeholders that discharge planning could be more effective to ensure robust plans were in place and found there could be a lack of social care presence in meetings.  

Observations  

We observed young people accessing the kitchen and dining room areas of the ward, and their bedrooms.  

The main ward corridor, also the bedroom corridor, was a congregation point for staff and young people. During our visit there was little use of the ward lounge area and no use of the sensory room.   

During our visit, response to a fire alarm incident was observed. Staff moved young people and staff members to the designated meeting point. Staff provided ear defenders for young people sensitive to and disturbed by the alarm. However, not all staff responded to the fire alarm and remained in rooms rather than attended designated meeting points.  

We saw young people disturbed and startled by loud doors banging in this area, which young people described as a problem at night time as well as during the day.  

When staff were interacting with patients, these interactions were positive. We also observed staff managing young people experiencing high distress and de-escalation techniques used in this situation. Alarm systems were used appropriately to call for additional staff support.