Weaver Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service did not always manage risks well. The new electronic system was difficult to navigate, and it was not clear when records had been updated. Patient voice was not always present in care records, and we found one care record that did not have all the required risk assessments in place. Physical health observations were not always completed consistently. The completion of Oliver McGowan training (nationally recommended training on meeting the needs of people with a learning disability and autistic people) was below 75%.

However, there was a robust learning culture in the service, and clear admission processes to ensure safe care and treatment. 

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. 

In the 12 months before the inspection, there were 140 serious incidents, the service categorised incidents by their severity, as high, medium and low. There were 8 incidents categorised high, 27 incidents categorised medium and 105 incidents categorised low. Incidents included safeguarding, medication errors, patient’s health, aggression and self-harm. 

Following incidents a full review would be completed to identify any learning for the service; the service reviewed incidents for themes and implemented actions to address these themes. For example, there were concerns with medicine management and stock availability. To address this the service introduced a medicine stock count 3 times a week, increased oversight through clinical audits, and reinforced safe medicine management within clinical supervision, which had reduced incidents. 

Lessons learnt were displayed on the staff information board, as well as being emailed to staff, and shared in team meetings. The service had also identified learning to improve consistency in clinical practice, for example serious incidents were now routinely reviewed in clinical supervision. Nurses were encouraged and empowered to escalate concerns early and take an active role in resolving and mitigating concerns. 

In the staff meeting we observed that leaders checked that the implemented actions were being followed, and they were not overly burdensome to staff. Learning from other services in the provider were also shared with staff in Weaver Lodge.

Staff were confident identifying incidents and reported all incidents appropriately; detailing the incident and the immediate actions they had taken in response. The service had a policy and procedure for reporting, managing and reviewing incidents, this provided staff with clear guidance and expectations. Following incidents that involved patients, staff were open and transparent with the patient and their families, and provided a full explanation when things went wrong. When required patients would also receive a formal letter in response to the incident. In the last 12 months the service made 2 duty of candour reports, both incidents were related to medication. Following both incidents the patient was informed, an apology offered and the outcome recorded, and additional actions were put in place such as regular significant incident reviews to assess incidents and identify themes. 

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had a clear admissions policy and process that staff followed. Each patient was reviewed on an individual basis to ensure they were suitable for admission into the service. This included the patient’s ability to engage with the treatment programme and the treatment options available within the service. The provider also had a Complex Case Advisory Group to support the team in assessments of potential patients and ensure their needs could be safely met. 

Before admission, staff began the START (Short-Term Assessment of Risk and Treatability) tool, which was followed up after admission. Staff also had an admission checklist in place to ensure that essential information had been gathered and required action, such as risk assessments and care plans, had been completed. The service also had a discharge checklist to support safe discharge. 

During admission and discharge staff worked closely with external healthcare and social care services to ensure patients had continuity of safe care. We observed a discharge meeting during the inspection, and saw a range of services involved, including the local authority, the community mental health team, staff from the patient’s new placement, and the local drug and alcohol provider, as well as the patient. Managers and staff told us that relationships with external teams were mostly good, however there were some gaps with the local mental health Trust that commissioned beds. To address this, the service was working with the Trust to improve communication. 

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, 95% of staff had completed safeguarding adults level 1 and children level 1, and 100% had completed safeguarding adults level 2. Staff knew how to make a safeguarding alert and felt confident to do so when required. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act 2010. 

In the 12 months before the inspection, the service had made 8 safeguarding referrals to the local authority. These incidents were also reviewed in governance meetings within the service to ensure that risk assessments were updated and learning identified promptly. 

The service had safeguarding policies in place to support staff to identify adults and children at risk of, or suffering, significant harm. The policy provided definitions of different types of abuse, how individuals should be supported and how to reduce the risk of abuse. The policy also established the responsibilities for staff when they were made aware of a concern, such as what information staff needed to gather to escalate the concern, how to access support, and the importance of accurate record keeping. This also included the procedures for working with individual local authorities.

Staff followed safe procedures for children visiting the service. A risk assessment would be completed to ensure that the visit would be appropriate, and one of the conservatory lounges with access to the outside grounds would be used. A staff member would also be present outside of the room to ensure safety and prevent other patients from using the area. 

The service kept restrictive practices to a minimum, patients had free access to the outdoor space and laundry rooms while some doors were locked for patient safety reasons, for example, the main entrance to the service, and the staff areas. 

The service had a blanket restriction register in place; however, the kitchen areas were locked, with patients needing to request access from a member of staff. This was not recorded in the blanket restriction register and is overly restrictive for a rehabilitation setting. Other items on the blanket restriction register included a rationale, potential for individual risk assessments who authorised the item, and how often the restriction was to be reviewed. 

Mental Capacity Act

Staff received and kept up to date with training in the Mental Capacity Act, had a good understanding of the five principles and were able to give examples of when capacity had been assessed. Staff received mandatory training on the Mental Capacity Act and Deprivation of Liberty Safeguards, and the compliance rate was 100%.

Staff took all practical steps to enable patients to make their own decisions. There was evidence in care records that staff had involved patients in decision making and supported them to understand their care and treatment. 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. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it. Through the provider, staff could access advice regarding the Mental Capacity Act, they also monitored adherence and completed audits. Learning from audits was shared and actioned. 

There was no deprivation of liberty safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care.

We scored the service as 1. The evidence showed significant shortfalls.  The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During the inspection we reviewed 9 patient records. The service had a new electronic record system in place, which had been rolled out across the provider and was in its first phase of implementation. In its current form, the system was difficult to navigate, and information was not always saved in the same place between different patient’s records. The system also lacked archiving, which meant it was not clear when items had been updated, who had updated them or how they differed from previous versions. Staff raised this as a concern as they felt they were not always assured when and if changes had been made. This meant there was a risk that staff could not easily access records, and changes to records were not clear. Managers confirmed that they were able to request information on changes to care records from a central location. 

We found that most records contained comprehensive risk assessments that considered historic risk as well as current, and covered social, physical and mental health. The service used the START tool to clinically assess patients. However, we found that there was a lack of crisis plans in place for patients who required them due to identified risks, which meant there was no clear process for staff to support patients. We also found that one risk assessment had not been completed, despite the risk being identified in the patient’s multidisciplinary team (MDT) meeting 4 weeks previously. This meant that staff could not address the risk safely, which put the patient, other patients and staff at risk of harm. This was raised during the inspection, and a risk assessment was completed. 

In 4 out of the 9 records, we found a lack of consistency with the use of the National Early Warning System 2 (NEWS2) to record patients’ physical observations, for example they were not completed at regular intervals, or were discontinued without a clear clinical explanation. This meant that we could not be assured that physical health checks were being completed appropriately.

In 7 out of 9 records, we found that there was a lack of crisis plans in place for patients who required them due to identified risks, which meant there was no clear process for staff to support patients. We also found a risk assessment had not been completed for a patient when the risk had been identified 4 weeks before during an MDT meeting. This was raised during the inspection, and a risk management plan was completed at the time. 

Patient involvement in care planning and risk assessments was not always clear or consistent in the records we reviewed. For example, 3 did not have evidence of patient involvement, 2 had partial involvement and 4 had full involvement. This meant there was no clear assurance that care plans had been developed with patients. Due to the concerns around the records system, management of patient risk and lack of consistent patient involvement in care planning we identified a breach of Regulation 12: safe care and treatment. 

However, leaders in the service were aware that improvements in care records were required, and a quality improvement plan was in process to address this. 

During the inspection we spoke with 4 patients who felt they were involved in developing their care plan, they attended MDT meetings and had a copy of their care plans. Patients felt that they could speak with staff about their care and treatment and could raise any concerns, particularly with support staff and nursing staff. During an MDT meeting we observed, we saw how patient’s views and preferences were considered, for example, a patient had raised concerns about the side effects of their medication. The responsible clinician had encouraged them to trial the medication for a period, and if the patient still had concerns, they would change the medication. 

Staff enabled patients to give feedback on the service they received, patients had morning meetings to discuss options for activities, and they had a weekly community meeting. Patients could access advocacy, patients we spoke with where aware of advocacy, and there was an information board by the entrance of the unit that gave details on how to access one of the named advocates. 

In the 12 months before the inspection there had been no incidents of rapid tranquilisation and 2 incidents of restraint. The service did not have a seclusion room and there had been not incidents of long term segregation. Each incident had been reported in detail, with consideration of whether observations needed to be increased, section 17 leave needed to change, and the outcome for patients and staff involved. 

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There were some shortfalls regarding the environmental ligature risk assessment for the service . All risks identified in the bedrooms were grouped together, which meant that differences between rooms were not identified. For example, some rooms had been recently refurbished with beds that had legs while other rooms still had the older box frame beds. The mitigation for identified risks was through observations, but the assessment did not establish how often observations were to be completed and whether it was through patient observations or security room checks. There had been no ligature incident relating to the beds in the 12 months prior to inspection. Following the inspection, the ligature assessment had been updated to reflect the individual differences between bedrooms. 

There were areas of the environment that needed repair, such as the floor sealant coming off the floor in one corridor, and damage to the walls. However, the service had an environmental action plan in place, some of which was being addressed while we were on site. This included improved fire alarms being installed into the service. 

The ward layout allowed staff to observe all parts of the ward and where vision was obstructed, this was mitigated through CCTV and regular security checks throughout the day. 

The service was mixed sex, but all bedrooms were ensuite, and the layout of the ward had one side with female rooms with their own lounge, laundry, kitchen and bathroom, and the other side male rooms. The bedsits had ensuite, cooking and laundry facilities within them. 

All staff wore personal alarms, and patients had access to call alarms. 

The clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We scored the service as 1. The evidence showed significant shortfalls.  The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staff had received appropriate mandatory training, the service had a training target of 95%. However, there were 2 training modules where the completion rate was below 75%. The Oliver McGowan tier 2 training (nationally recommended training on meeting the needs of people with a learning disability and autistic people) was at 54%.  This training was introduced in 2022 to improve the knowledge, skills, and culture of staff when providing care for patient with learning disabilities and autism. As the service supports people with learning disabilities, there was limited assurance of how the needs of patients with a learning disability were being met. This was a breach of Regulation 12: Safe Care and Treatment.

Restraint training was at 68%. The low compliance in these modules was due to difficulties in accessing training sessions, as they had been booked and then cancelled. The manager confirmed that all staff who had outstanding restraint training had been booked onto a course, and the service was working closely with the provider’s Learning and Development team to ensure staff had access to the course where possible. Managers ensured that there were always enough staff trained in physical restraint on shift to provide safe restraint.

There were no current vacancies within the service, there was one full-time support worker completing onboarding, as well as a new full-time senior nurse practitioner. The service had had several months without a dedicated occupational therapist (OT). Regular cover was provided by an OT from the provider’s other services, which ensured that assessments were still completed. The service now had a permanent OT in post, who was re-establishing the occupational therapy offer within the service. This included the creation of the activity planner, getting support workers involved in the daily activities and starting to develop individual activity plans for the patients. 

The establishment levels at the service were 0.4 Whole Time Equivalent (WTE) consultant psychiatrist, 2 WTE senior nurse practitioners, 1 WTE occupational therapist, 8 WTE nurses, and 14 support workers. 

Within the 12 months before the inspection, 319 shifts had been covered by bank or agency staff, and there were no shifts during this period which had not been covered. The service had a robust system for ensuring shifts were covered, first offering the shift to substantive and casual staff, then escalating at the provider’s daily morning meeting or between managers throughout the day. If the shift could not be resourced, the service had access to approved agency staff, whose training compliance was managed through a third party, which would be reviewed before the agency member was booked. The service had a workplace orientation to be completed by bank and agency staff to orientate themselves to the ward and the patients. 

Staffing requirements in the service had been calculated, with 2 nursing staff and 3 support workers in the day, and 1 nurse and 2 support workers at night. Managers were able to adjust these when required, for example, when one to one enhanced observations were required, or there were additional operational demands such as mandatory training. 

Patients we spoke with felt there were enough staff in the service and they were able to have regular one to one time with their named nurse. Managers ensured that there were always enough staff trained in physical restraint on shift to provide safe restraint. 

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. The provider had an out of hours medical cover rota between 4 services within the provider.  

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas of the service were clean and tidy, and the furnishings were well maintained and in good condition. In one corridor, the floor had stains, and the mastic sealant had come away from the floor and the wall which meant that the area could not be thoroughly cleaned. The service had an environmental action plan in place for refurbishment of the ward. 

Staff maintained equipment well and kept it clean. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. The clinic rooms were cleaned daily. Staff adhered to infection control principles, including handwashing.

The service completed regular infection prevention audits and had a yearly schedule which focused on different areas or items, for example, September audits included bathrooms, personal protective equipment and mattresses. Overall, the audits found a good standard of cleanliness and staff compliance, most concerns related to the environment such as worn flooring, and damaged paintwork, which were added to the service’s maintenance plan. 

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

During the inspection we reviewed 9 care records.

Within 4 out of 9 care records we found a lack of consistency with the use of the National Early Warning System 2 (NEWS2) to record patients’ physical observations, for example they were not completed at regular intervals, or were discontinued without a clear clinical explanation. This meant that we could not be assured that physical health checks were being completed appropriately.

However, the service had a third-party pharmacist who completed regular audits of prescribed medicines. Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. Allergies and side effects of medicine were monitored for each patient, and all medication was prescribed within British National Formulary (BNF) guidelines. 

Appropriate consent to treatment and second opinions (T2 and T3) forms were in place, and all prescribed medication complied with these. Capacity to treatment had been completed for each patient. 

Medicines, including controlled drugs and related paperwork was stored securely and well organised. All medicines were in date and opened bottles were all labelled. Controlled drugs were stored securely according to legislation and policy. The emergency medications were stored safely and staff completed weekly checks of the emergency bags. 

Staff followed good practice in medicines management by following national guidance and prescribing in line with legal authorisations. Medicine records were completed accurately. Doctors were available to review and prescribe medicines, ensuring it was in line with national guidance. 

Staff completed medicine management training, the compliance rate was 100%. The service had a controlled drug policy and a medication management policy in place. The medication management policy also contained self-medication assessment forms.