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Inspection carried out on 12 & 13 November 2019

During a routine inspection

We rated Bradley Complex Care as Good because:

  • Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Staff provided a range of treatment and care for patients based on national guidance and best practice. This included access to psychological therapies, support for self-care and the development of everyday living skills and meaningful occupation. Staff supported patients with their physical health and encouraged them to live healthier lives. Staff used recognised rating scales to assess and record severity and outcomes.
  • The hospital included or had access to the full range of specialists required to meet the needs of patients. Managers ensured that these staff received training, supervision and appraisal. The hospital staff worked well together as a multidisciplinary team and with those outside the hospital 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 involved patients in decisions around their care and treatment.
  • Staff managed admissions and bed occupancy well and ensured patients always had a bed on return from leave. They carefully planned patients’ discharges with external services to make sure this went well and supported patients when they were transferred to prevent readmission.
  • Managers had the skills and experience to perform their roles, Staff felt supported and able to raise concerns without fear. The provider had an effective governance structure to monitor and improve performance.

However:

  • The service did not have enough night time medical cover available to attend the hospital quickly in an emergency. Managers could not be assured that staff were recognising incidences of seclusion and therefore keeping appropriate records which are required to ensure the necessary safeguards are applied.
  • The hospital environment had some areas where staff had limited visibility and some of the apartments had bathrooms which were damp and musty.
  • Staff did not document all the patient’s needs in their care plans and ensure that they were recovery orientated. Records did not clearly show the patient’s discharge plans.
  • Staff did not fully involve families and carers in decisions around the care and treatment of the patient.
  • The service did not always use effective communication formats for patient information such as signage and care plans. 

Inspection carried out on 16, 18 & 19 June 2019

During an inspection looking at part of the service

We rated Bradley Complex Care as requires improvement because:

  • Poor management of agency staff increased risks to patients. The hospital used a high percentage of agency staff. They did not have effective protocols and systems in place to ensure the suitability of these staff in relation to convictions and training. There was a high number of patient restraints and some agency staff were not trained appropriately to restrain patients when required.
  • Staff imposed blanket restrictions which restricted the freedom of patients. All apartment doors were locked without being individually assessed. There was an action plan to phase in the removal of locked doors around the hospital but there was no target date for completion of this.
  • Not all permanent staff had undertaken the basic training that the provider deemed to be mandatory. This included training around safe administration of medicines, food hygiene, infection control and the Mental Capacity Act.
  • The information needed to plan and deliver effective care, treatment and support was not consistently or appropriately shared. Staff had varying methods to access the information. however, this was done with an inconsistent approach and the potential for paper copies to be out of date.

However:

  • Staff assessed and managed risks to patients and themselves well. Risks were shared amongst staff in handover meetings and through patient records. They responded well to changes in risks and used the organisational observation policy to minimise incidents.
  • Staff understood how to protect patients from abuse. They had training in how to recognise and report abuse, and they knew how to apply it. The service alerted the local safeguarding authority appropriately and informed the Care Quality Commission as required.
  • Staff knew what constituted an incident and how to record it. Details of incidents were automatically exported from the incident reporting system directly onto the individual patients care records.
  • Managers had the skills, knowledge and experience to perform their roles. They had a good understanding of the service and how they were working to provide and improve on the quality of care.

Inspection carried out on 12 & 13 February 2018

During a routine inspection

We rated Bradley Woodlands Low Secure Hospital as good because:

  • The hospital had systems in place to protect patients from harm. Staff identified and managed risks appropriately. They recognised safeguarding concerns and had effective engagement with the local safeguarding procedures.
  • The hospital met good practice standards described in relevant national guidance for prescribing medications safely. Patients received their medications as prescribed and attendeded regular reviews. Staff kept accurate records of medicines.
  • There was a full range of disciplines to input into the hospital. Staff received the appropriate training and regular supervision to provide safe and effective care to patients. There was effective multi-disciplinary team working with respect for each role.
  • Patients received a comprehensive assessment of their needs, which included physical health. Staff ensured care plans were up to date, holistic and recovery focussed.
  • Staff had effective systems in place to ensure the hospital adhered to the Mental Health Act 1983, the Mental Health Act Code of Practice and applied good practice with regards to the Mental Capacity Act 2005.
  • Patients were involved and encouraged to be partners in their care. The hospital used appropriate language and easy read material to aid the patient’s understanding. They were involved in their care plans and contributed to, or chaired their review meetings.
  • The hospital was clean and tidy with comfortable facilities that promoted independence. There was a full range of rooms and equipment to support treatment. Staff supported patients in the planning and preparation of their meals taking into account specific dietary needs.
  • Patients knew how to give feedback about the hospital and felt confident to complain if required. Staff explored complaints appropriately and informed patients of the outcome.
  • The organisation’s governance structure ensured effective communication from the hospital to board level and vice versa. There were effective systems in place to monitor performance, share good practice and manage risks.

However:

  • Staff occasionally cancelled or postponed planned or escorted leave due to lack of resources.
  • Staff did not always monitor the keys for the clinic fridge appropriately.
  • Staff did not have specific care plans or protocols in place to manage bathing for patients with epilepsy or for carrying out restraint on asthmatic patients.
  • Staff did not always consider confidentiality when discussing patients in communal areas.
  • Some staff were unclear about the new provider’s vision and values.

Inspection carried out on 10/10/2016

During an inspection looking at part of the service

  • The management team checked and reviewed staffing levels. Managers could adjust staffing levels to meet the needs of the wards. However, when cover for shifts could not be arranged staff felt unable to meet all the needs of patients.

  • When two qualified nurses were on duty during the day shift, staff felt under too much pressure to complete their workload and spend enough time in the apartments with patients and support workers.

  • We observed staff who knew individual patients well, the staff and patient interaction we saw seemed familiar and comfortable.

  • The patients we spoke to told us most staff cared, were kind and spoke to them nicely. However, two patients said that at times some staff looked for arguments and could be rude to them.

  • Staff reported incidents. Staff reviewed and analysed incidents at a range of meetings across the hospital.

Inspection carried out on 9 August 2016

During an inspection looking at part of the service

We rated Bradley Woodlands Low-secure Hospital as good because:

  • The hospital had clear criteria for accepting referrals, ahead of admissions a pre-assessment was completed and reviewed by the team to ensure the provision would meet the needs of an individual.

  • Following admission named nurses spent time with patients involving them in care planning within a recovery pathway. We saw examples of individualised care documents containing graphics and adapted language that made them accessible to patients.

  • Individual care planning in relation to risk and staff awareness of patient’s current risk levels seemed high. There was evidence that clinical risk assessments were regularly updated, live documents that contained good examples of multidisciplinary team formulations.

  • Staff knew how to report incidents and there was evidence of sharing lessons learned. Over long days, all staff believed teamwork was positive, with staff pulling together for support, especially following an incident.

  • Patients were encouraged to chair their own multidisciplinary team meetings using prompt cards to follow the agenda. At the meeting we attended, the patient was empowered to speak about their concerns, and given time to say what they wanted to.

  • Mental capacity assessments and paperwork relating to best interest decisions used language that reflected the patient group and showed questions revisited to assess the patients’ understanding and retention.

  • Advocacy was available on site three days a week; staff in this service knew all the patients in the hospital and held a clear separation between their independent role and that of the hospital team.

  • Visitors’ rooms were private and available for patients to use to make phone calls and see visitors. Relatives described staff as being supportive and accommodating when arranging for them to visit.

  • Staff were aware of key messages from management about patient centred care and positive behaviour support showed commitment to work towards this.

  • Before the end of the first inspection day all emergency equipment had been checked, was in date and returned to the clinic room with signage to indicate this. A laminated list of the contents of the emergency box was available.

However,

  • Emergency equipment had not been consistently stored in the places indicated by notices so any staff unfamiliar with the hospital would not know where to find it. Emergency equipment needed checking regularly to ensure it remained suitable for use, until inspection on 9 August 2016, there was no evidence this had happened since March 2016. There was no content list with the emergency equipment box, a number of items had expired and some items appeared used and unsterile. It is important items are sterile and in date when used to ensure optimum performance and to prevent infection.

  • There had been a gap from March to August 2016, in the regular monitoring of fridge temperatures to ensure the safety of medicines that could not be explained. Regular clinical audits took place to monitor a range of practice, although internal and external medicines audits had been completed neither had identified medication issues found on the first day of inspection.

  • The patients we spoke with told us staff were polite and most spoke to them nicely, though others did not because they shouted.

  • Staffing levels were checked and reviewed by the management team and could be adjusted however, on days with only two qualified nurses staff felt under too much pressure to complete their workload. There was a mismatch on a day shift between the stated establishment of qualified nurses required and the number determined by the providers staffing ladder.

  • Over three months 36% of section 17 leave was cancelled, whilst this was rearranged whenever possible, at the time of cancellation this caused distress to both patients and relatives

  • Complaints made by patients were listened to and recorded by managers, however; we saw no recording of investigations having taken place. Copies of letters written in response to patients complaints were formal and it was unclear how accessible this format would be to the patient on receipt.relatives

  • Systems contracted by the hospital, for example the contract to deliver physical healthcare to the patients did not always work effectively, with issues raised by staff taking some time to be resolved.  

Inspection carried out on 20 to 22 July 2015

During a routine inspection

We rated Bradley Woodlands Low-secure Hospital as requires improvement because:

  • Staff lacked a basic understanding of the Mental Capacity Act 2005 and their individual responsibilities in relation to it. They could not provide examples of its use in their work and were seen making decisions without assessing the capacity of the patient.

  • Staff did not treat patients with kindness and respect when they expressed their wishes and feelings.

  • Patients’ access to activities was limited and planned activities were too often cancelled. From April to July 2015, 186 out of 637 planned activities did not go ahead. Of these, the hospital cancelled 68 activities because of low staffing levels. The physical spaces for planned activities were not always available.

  • The service wanted to deliver patient-centred care; they had introduced a care pathway approach to increase patient involvement. However, we still saw interventions and choices being made by staff rather than patients.

  • The layout of the wards created challenges for staff to work as a team. Support workers in the apartments felt isolated from the rest of the hospital. They did not have access to the internet, and most paper information was stored in the nursing office. Nurses and support workers found meetings difficult to attend when on shift.

  • A low-secure hospital requires a seclusion facility. At the time of our inspection, this had not been available since June 2015. Plans were in place for it to be refurbished and re-opened by September 2015.

  • The provider target for staff completing their mandatory training was 90%; however, only 73% of staff had completed this at the time of the inspection.

    However,

  • The hospital assessed each patient before they were admitted to make sure the hospital was the right environment for them and that it was able to meet their needs.

  • The hospital had a wide range of facilities and amenities for treatment and rehabilitation. If patients had greater access to these, their care would be improved.

  • Managers were visible on the wards and talked with patients on a daily basis.

  • The new management team expected high standards and consistency from itself and its staff, and had put systems in place to ensure this.

  • Managers and staff saw safeguarding as the responsibility of all those working in the hospital. Staff were well-trained in safeguarding and knew how to report concerns to external agencies.

  • All staff had quarterly meetings with their supervisors and new staff had these monthly during their probationary period. The service was working towards increasing the one-to-one support for clinical staff through monthly supervision.

  • There were good systems in place to ensure staff complied with the Mental Health Act 1983.

Inspection carried out on 19 March 2014

During an inspection looking at part of the service

When we inspected the service on 10 October 2013 we found patient's legal paperwork was not always correct in relation to their consent to treatment under the Mental Health Act 1983 (MHA). We received an action plan which detailed all the improvements the provider planned to make.

We re-visited the service with the Mental Health Act commissioner to check that the necessary improvements had been made. We did not speak with any patients during this follow up inspection; the main focus of the visit was to review the quality of the records.

We found improvements had been made to the quality of the care records; we found staff were now completing assessments of patients' capacity to consent to their treatment. We also found the language used in the care plans was much less restrictive.

Records showed patients were given accurate information about their detention and these records were easily accessible and well maintained.

Improvements had been made to the recording of discussions between the responsible clinician and the patient about their treatment. However, we still found some inaccurate recording of treatment authorised under the MHA.

Inspection carried out on 10 October 2013

During an inspection looking at part of the service

We visited the service to follow up improvements since our last scheduled visit in June 2013.

We saw evidence of warm, respectful relationships between staff and patients as we walked around the hospital and observed that many patients participated in a range of activities. Patients we spoke with were positive about the support they received from the service. One patient said, "I like it here, staff help me." Another told us they felt safe and said they felt they had made good progress whilst using the service.

Patient's legal paperwork was not always correct in relation to their consent to treatment.

Some patients told us that activities and formal leave arrangements had improved a lot, but that there continued to be some occasions when things were cancelled due to low staffing levels. Comments included, �Activities have changed because we get out more,� �I get my leave� and �I�ve had one lot of leave cancelled because of staff shortages, but it was a while ago.�

We found staff had received more specialist training and supervision to support them to carry out their work.

Improvements had been made to risk management in the hospital to support positive outcomes for patients.

In this report the name of the registered manager appeared who was not in post and not managing regulatory activities at this location at the time of the inspection. Their name appeared because they were still on our register at the time. A new manager had been appointed.

Inspection carried out on 4, 5 June 2013

During a routine inspection

Some patients had complex needs and we were unable to verbally communicate with them about their views and experiences. However, we did speak with several others who told us they were treated with respect, felt safe and staff supported them well. Comments included; �I like the staff, I have a laugh with them and they always treat me with respect�, �They listen and don�t dismiss what I say� and �I feel safe here.�

We spoke with other visiting health and social care professionals involved in supporting patients, who told us the care and support offered was tailored to meet the individual needs of patients. However, all spoken with told us they felt the activities were cancelled too often and staffing levels were too low to ensure patients had access to a full range of occupation and activity.

We looked at various documentation including the care plans, risk and behaviour management plans and incident recording. This showed us that there had been improvements made and care plans included more detail about the patient�s needs. Behaviour management plans were specific and gave a clear step by step guide to staff about how they should intervene, using the least restrictive technique first. We saw that the way the service recorded and reported allegations of abuse, incidents and the use of physical interventions had improved significantly.

We spoke with several members of staff who raised concerns about the staffing levels and said, �We have told management that we feel patients are at risk as we do not have enough staff to respond in an emergency� and �There are times when many minutes go by before staff can respond to alarms�. We saw evidence to confirm that activities had been cancelled on a regular basis. One patient told us when their Section 17 or authorised leave was cancelled due to lack of staff they felt as though they were being punished.

We saw that training in essential areas such as Autism, learning disability, mental health and epilepsy had not been undertaken. This meant that some staff may not have the necessary skills or knowledge to support people with diverse or specialised need.

We looked at the systems to monitor and evaluate the service offered and although we saw improvements had been made, this was not sufficient to determine compliance had been achieved. Records showed audits had been undertaken in various areas including the environment, care plans, medication and incidents. However, these did not always give a clear indication how the action identified as needed would be achieved and there was little written evidence to confirm the analysis of incidents had taken place.

Inspection carried out on 31 January 2013

During a routine inspection

We spoke with people who used the service and they told us that they were satisfied with the care and treatment they received. They also said they felt safe at Bradley Woodlands. Comments included, �I agree with my care plan and I have chaired my own review�, �Staff treat me with respect and keep me calm� and �I feel safe here.�

However, several people also said there were some things they were not happy with and told us, �When the nurse call is pressed, care staff switch it off and walk away�, �I feel that no-one listens to us� and �If I�m unsettled they take my TV away and I feel like I�m being punished.�

We saw that restrictions were in place and some practices were controlling and felt punitive. Although the care and treatment was planned, delivered and overall met the basic needs of people who used the service, we were concerned about the high numbers of physical interventions or �restraint� used. We saw records that showed incidents were recorded. However, we found that not all incidents had been reported appropriately and there was a lack of evidence to show these had been analysed and this showed us the service was not effectively monitored.

We saw that the environment was clean and hygienic and some bedrooms were personalised.

People told us that activities did take place, but were often cancelled due to staff shortages.

Inspection carried out on 28, 29 November 2011

During a themed inspection looking at Learning Disability Services

At the time of the inspection visit, there were 24 patients present.

Twelve female patients were living in four apartments in Willow unit. Eight male patients were living in three apartments in Maple and three female patients were living in an apartment in Beech unit. We met and introduced ourselves to 11 patients and spoke with six patients in more depth to get their views of the service.

Overall, patients told us they were satisfied with the care and treatment at Bradley Woodlands. Activities that patients said they were involved in included: going to the supermarket, budgeting and cooking for themselves. Patients told us the staff supported them to be involved in putting their care plans together and going to review meetings and that they had access to independent advocates. Patients said that they could have a copy of their care plan and copies were kept in a cupboard in their apartment. Everyone mentioned that they had advocates. That was someone from outside of Bradley Woodlands who came in and spoke up for them.

We spoke with the relatives of four patients about how they felt about the care, treatment and support provided. Two relatives gave generally positive feedback about the service, saying that their relatives were happy, well cared for and had made good progress. One comment was, �Communication always very good about the important things.�

One relative told us that, although the staff were very good and that the patient always looked well cared for, they did not think that the patient was happy at Bradley Woodlands. This patient�s relative said they would like the patient to move closer to their family.

The expert by experience who was part of our inspection team said that they thought that the apartments were a good idea for patients to live in. The professional advisor thought that the way the apartments were set up helped in providing individualised personal care, especially for those patients who were likely to find it difficult living with others.

Inspection carried out on 4 April 2011

During an inspection in response to concerns

We have not spoken directly to people who use services in assessing the outcome areas for this review. The Mental Health Act Commissioner spoke to people using the service during the visit and people told him that they felt safe.

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.