Weaver Lodge

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last inspection we rated this key question good. At this inspection the rating has remained as good. This meant people’s needs were met through good organisation and delivery. Staff helped patients with communication, advocacy and cultural and spiritual support. Staff supported patients to maintain contact with their families and carers. The service treated concerns and complaints seriously, investigated them and learned lessons from the result. The service provided information to patients and their families in formats that supported their understanding. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. There was a positive culture within the service, that encouraged people to engage with the service and their care and treatment. 

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

In the 9 care records we reviewed, we found that although patient’s views were recorded, the patient’s voice was not always present in care plans and risk assessments. We also found that there was a patient who had a history of falls, but this was not reflected in their health passport. 

However, the service also had a translator for one patient during MDT meetings where discussion would be more complex, to the ensure the patient could still engage and understand what was being said.  Patients we spoke with mostly felt involved in decisions about their care treatment, and where relevant their families were involved too. Patients were mostly aware of their recovery goals, and felt able to discuss their medication, care and treatment with staff. Patients were also aware of advocacy. 

One patient had raised concerns that they did not feel listened to when they requested a change to their medication, however, we also observed MDT meetings in which medication changes had been discussed, and saw that the consultant considered feedback, gave clear rationales and took a measured approach to any changes. For example, when a patient had raised that the side effects of a medication were causing increased anxiety for them, the consultant worked with them to find a suitable alternative. 

Each patient had their own bedroom, with an ensuite bathroom, and those in bedsits also had their own kitchen space. All patients had access to keys to lock their bedrooms to ensure that their items could be kept secure.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Where appropriate, staff ensured that patients had access to education and work opportunities. Staff had examples of patients who had previously accessed education and work opportunities while in the service, but at the time of our inspection there were no examples. One patient’s goal was to access volunteer work when it was safe and appropriate for them to do so. 

Staff supported patients to maintain contact with their families and carers. There was space for families to visit the service, and patients told us of occasions where staff had facilitated visits. There were monthly meet ups for carers, which took place offsite, led by the OT. The service also had regular open days, welcome days and Christmas parties which the families and carers of patients were invited to attend. 

Staff supported patients to access their chosen place of worship and had a recent example of staff supporting a patient to attend a local church. There was also a multifaith room onsite, which gave patients a private place to pray or use for personal contemplation. 

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. This included safeguarding alerts to local authorities and commissioners and sending notifications to the Care Quality Commission. 

Information governance systems included confidentiality of patient records. All patient records were stored securely on an electronic record system. Paper records, such as mental health paperwork were kept in a locked filing cabinet in a staff only office. The service complied with the Accessible Information Standard.

When admitted into the service patients and carers were provided with a welcome book, which explained the service and expectations as well as visiting information and useful contacts for support. This included the role of staff in treatment, their rights, 1 to 1 sessions and clinical reviews. Staff ensured that patients had information on treatments, local services, patients’ rights and how to complain. Some of this was available through information boards around the service or was discussed in MDT meetings. 

Staff were able to request information in other accessible forms, such as easy read formats or in another language. During the inspection we saw evidence that translators were requested to support a patient during the more complex discussion during MDT meetings. The service’s welcome book also referred to accessing information in languages and formats that supported patient understanding. 

Staff ensured carers, families and commissioners were regularly updated about the patient’s progress. 

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

In the 12 months before the inspection, Weaver Lodge received 1 complaint which had been upheld, and no complaints were referred to the Ombudsman. As there were few complaints within the service, they could not be analysed for themes and trends. However, the investigation of the one complaint had found learning which was followed up within supervision and wider team discussions to re-enforce the learning. 

Patients we spoke with felt confident in raising complaints or concerns, there were also signs and leaflets around the service which explained how patients could raise their concerns. The service also had a complaints box, and patients had the opportunity to raise concerns in community meetings if preferred. Staff knew how to handle complaints appropriately and ensured that patients who raised concerns were protected from discrimination and harassment. 

Complaints and concerns were shared with the manager who would discuss the issue with the patient or person raising the concern. Once an investigation was completed, staff would ensure that the outcome was satisfactory for the person who raised the concern. 

In the same 12-month period before the inspection, the service had also received 6 compliments. These included words of thanks from patients and family members following discharge, previous placements and external stakeholders. 

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff ensured the needs of patients with mobility issues were met, the service was all on one level, which ensured accessibility for all patients and visitors. Reasonable adjustments were made for patients such as ensuring access to walking aids or translation services. 

The service had adequate medical cover day and night, consultants and junior doctors were available outside of their days onsite, and there was a rota in place which included doctors across the provider. A doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital.

Staff ensured patients had access to post-discharge care, for example section 117 aftercare, or community mental health services, and this was included within the discharge planning process. During the discharge meeting we observed the local community mental health team was involved in the meeting and engaged with the patient. 

The service monitored expected discharge timelines for each patient. The average length of stay was 14.5 months. In the last 12 months, there were 5 delayed discharges, the most common reason for discharge was sourcing an appropriate placement for patients to be discharged to. 

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service promoted a culture in which the people using the service felt empowered to give their views. The service had a daily patient morning meeting, which allowed patients to raise concerns, review the activities and contribute to planning. In addition to this, there was a weekly community meeting which allowed patients to suggest improvements, discuss environmental issues, activities, and wider issues. Actions from these meetings were reviewed and patients received a response. 

The service was also working to develop a Patient Council with an aim to strengthen co-production in the service and were looking to establish a patient representative within the patient cohort. 

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Staff were trained in equality, diversity, inclusion and human rights, and the completion rate was 100%. 

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff were proactive with discharge planning and had good oversight of actions needed to be completed for discharge, and any potential causes for delays. Staff ensure all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.

During admission, patients were encouraged to make an advanced statement to express their preference for care and treatment, values, beliefs and how staff can support wellbeing. However, care plans were not always written in a way that included the patient’s voice, so it was not always clear if the patient’s needs, wishes and feelings had been accounted for.