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St Andrew's Healthcare - Nottinghamshire Good

We are carrying out checks at St Andrew's Healthcare - Nottinghamshire. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Good

Updated 13 January 2016

We rated St Andrew’s Healthcare Nottingham as good because:

  • Our previous inspection raised concerns and a compliance action regarding the number of staff and the skill mix on the wards. On this inspection, we found the provider had systems in place to address this which were effective.
  • Comprehensive assessment of needs were undertaken prior to admission. These were updated during the initial weeks of admission to ensure all care needs were met. Patients told us that they felt they were involved in decisions regarding their care and in the care planning process. They also told us that they were involved in discharge planning
  • Each ward had a ligature risk audit and resultant action plan.
  • The clinic rooms were clean, tidy and well equipped.
  • A safety nurse role operated on all wards. There are two registered adult nurses who were employed to undertake physical healthcare assessments.
  • Risk assessments were undertaken on all patients following admission and through regular multidisciplinary team meetings.
  • Restraint was only used as a last resort when verbal de-escalation and other interventions failed to reduce the risk presenting within the situation.
  • The number of seclusions used was low.
  • There was a daily review meeting carried out by hospital coordinators to look at staffing, safeguarding, seclusion and incidents and where wards or staff needed support.
  • We found good medication management which was consistent with the provider’s policy and procedural guidance.
  • Under the Reporting of incidents, diseases and dangerous occurrence regulations, there were no incidents in the period March 2015 to May 2015.

  • There was information available for patients around how to complain, their rights and information about treatments. A log of local complaints was kept. Local resolution of complaints occurred generally. Patients were encouraged to contribute and problem solves issues with support from each other and staff.

  • A psychologist was based on the wards who offered one to one sessions to patients. Group’s sessions such as assertiveness, risk, and communication were also facilitated by the psychologist. Outcomes were identified and monitored.
  • Staff had undertaken induction on the ward.
  • Annual mandatory training figures for May 2015 showed that over 96 % of staff had completed training. 100 % of personal development reviews had been completed. Monthly managerial supervision was provided.
  • The clinical team met weekly.
  • Each patient was seen by the clinical team every four weeks.
  • Information about treatments available was given following assessments.

  • Staff were observed to behave in a respectful manner.
  • A full range of rooms was available to support treatment and care.
  • Patients had access to outside space.
  • Patients could access a small kitchen on the wards during the day to make drinks and snacks.
  • Patients were able to personalise their room if they choose and we could see that some had chosen to do this..
  • Staff worked with patients to meet their cultural needs. The site had a multi faith room for people of all faiths to use.
  • Hospital directors and senior management were visible to staff and the patients.
  • Staff appeared to understand and own the values of the organisation.
  • Governance procedures were in place for monitoring the progress and functioning of the hospital. Results were produced monthly and disseminated to ward managers via the dashboard. Staff said they were confident about using the whistleblowing, grievance and bullying and harassment policies.

However:

  • The ward layouts were not conducive to observation of patients at all times. Each ward had acknowledged this and staff were seen to be in the communal areas and undertaking regular checks of the ward environment.
  • Rufford ward seclusion room had blind spots where observation of patients was not possible. This was a concern on our last visit.
  • The de-escalation areas on the wards were in differing states of repair.
  • The de-escalation environments were unclean with a lack of furniture, stained carpets and a lack of ventilation. This was of particular concern on Newstead ward.
  • Concerns were raised by staff and patients about the length of time maintenance repairs took to be rectified.
  • We had concerns from our intelligence and ongoing monitoring of the service over the inter-agency working with regard to safeguarding concerns. There were reported difficulties in St Andrew’s making appropriate referrals, providing timely and good quality information, and making reports to the Multi-Agency Safeguarding Hub (MASH) and the Community Learning Disability Team (CLDT). It is not clear what consideration was given to providing interim updates to patients where there are delays in the safeguarding process

  • We had concerns with care plans and found inconsistent evidence that plans were regularly reviewed and evaluated.
  • Care records were stored on an electronic system accessed by substantive staff across the hospital. We found that agency staff were unable to access this system meaning they did not have access to the latest accurate information around care and risk.

  • Our previous visit raised concerns about the use of inappropriate language by staff on Rufford ward. During this inspection, we noted improvement in the approach on Rufford ward. We were concerned about behaviour of four members of staff we witnessed on Wollaton ward.
  • Two patients were identified as having significant delays in their transfer of care to a more appropriate setting.
  • On Rufford ward, there was a lack of easy read literature available.
Inspection areas

Safe

Good

Updated 13 January 2016

We rated safe as good because:

  • On this inspection, we found the provider had systems in place to address staffing and skill mix that were effective. Staff we spoke with told us the staffing situation had improved compared to our last visit.
  • Agency staff were booked on three monthly block booking arrangements to ensure continuity of care and were provided with an induction on the ward.
  • There are two registered adult nurses employed to undertake physical healthcare assessments.
  • Each ward had a ligature risk audit and resultant action plan.
  • The clinic rooms were clean, tidy and well equipped. Cleaning records for the general ward areas were being carried out daily and were up to date. Environmental risk and fire checks were being carried out on an annual basis. Every shift had one member of staff allocated to the role of ‘safety nurse’. A safety nurse role operates on all wards.
  • There were no reportable RIDDOR incidents in the period March 2015 to May 2015.
  • Daily reviewing of incidents was carried out as part of site wide hospital coordinators meeting. Lessons learnt emails were sent to all staff and discussed in reflective practice groups and team meetings.
  • Risk assessments were undertaken on all patients on admission and through regular multidisciplinary team meetings. The historical clinical risk management 20 and the Short Term Assessment of Risk and Treatability were the recognised risk assessment tools used for all patients.
  • Restraint was only used as a last resort when verbal de-escalation and other interventions failed to reduce the risk presenting within the situation. The number of times that the seclusion rooms were used was low. One ward manger told us that restrictive practice discussions are held once a month within the senior management team and the multi-disciplinary team (MDT).
  • The safeguarding policy was on the intranet and was regularly emailed out. Staff we spoke with appeared to have a good understanding of issues that should be reported.
  • We found good medication management as per the provider’s policy and procedure
  • We observed on all wards there were staff in the communal areas at all times.

.

However;-

  • The ward layouts were not conducive to observation of patients at all times. Each ward had acknowledged this and staff were seen to be in the communal areas and undertaking regular checks of the ward environment.
  • The seclusion room on Rufford ward had blind spots where observation of patients was not possible. This was also a concern that we observed on our last visit.
  • The de-escalation areas on the wards were in differing states of repair. The environments were unclean with a lack of furniture, stained carpets and a lack of ventilation. This was of particular concern on Newstead ward.
  • Concerns were raised by staff and patients about the length of time maintenance repairs took to be rectified.

Effective

Good

Updated 13 January 2016

We rated effective as good because:

  • Comprehensive assessment of needs were undertaken prior to admission and updated during the initial weeks of admission to ensure all care needs were met.
  • There were two registered adult nurses who undertook physical assessments on admission and managed long-term conditions.
  • A psychologist was based on the wards who offered one to one sessions to patients as well as the facilitation of groups sessions such as assertiveness, risk, and communication.
  • Outcomes were identified through one to one sessions, care coordinator sessions, evaluation of activities. Outcomes following periods of aggression were monitored with risk assessments and care plans reviewed and updated. Patients had graphs which showed the levels of safeguarding, incidents. health of the nation outcome scores that were being recorded in patient’s notes.
  • Monthly performance reports showed what percentage of patient’s conditions had improved according to outcome measuring scales for speciality and security level.
  • Guidance around the prescription and monitoring of Clozapine was being followed accurately. .
  • Records showed that staff had undertaken induction on the ward in relation to fire, contraband items, safeguarding, hygiene, observations, key security, safe staffing, mobile phones, and management of aggressive incidents, security and emergency equipment. Annual mandatory training figures for May 2015 showed that over 96 % of staff had completed training. 100 % of PDRs had been completed. Monthly managerial supervision was being provided.
  • The clinical team met weekly.
  • Each patient was seen by the clinical team every four weeks.
  • The clinical teams had business meetings prior to ward rounds. Relational security was discussed in these meetings.

However:

  • We had concerns from our intelligence and ongoing monitoring of the service regarding inter-agency working with around safeguarding concerns. There were reported difficulties in St Andrew’s making appropriate referrals, providing timely and good quality information, and making reports to the Multi-Agency Safeguading Hub (MASH) and Community Learning Disabiity Team (CLDT). It is not clear what consideration was given to providing interim updates to patients where there are delays in the safeguarding process
  • We found inconsistent evidence that care plans were regularly reviewed and evaluated.
  • Care records were stored on an electronic system accessed by substantive staff across the hospital. We found that agency staff were unable to access this system meaning they did not have access to the latest accurate information around care plans and risk.

Caring

Good

Updated 13 January 2016

We rated caring as good because:

Information about treatments available was given to patients following assessments. Patients received an induction pack prior to being admitted to the ward which the staff went through. Patients we spoke to told us that they felt they were well involved in their care and in the care planning process.

  • Staff were observed to knock on bedroom doors before entering and to speak respectfully to patients and other staff.

However:

  • Our previous visit raised concerns about the use of inappropriate language by staff on Rufford ward. During this inspection, we noted much improvement in the approach on Rufford ward but were concerned about behaviour of staff we witnessed on Wollaton ward.

Responsive

Good

Updated 13 January 2016

We rated responsive as good because:

  • There was a letter of welcome and a ward induction pack for patients which was detailed and in an easy read format. It could be produced in different languages if required.
  • Beds remained available when patients return from S17 leave.
  • Patients were involved in their discharge plans.
  • A full range of rooms were available to support treatment and care. There were quiet rooms for patients to use when they wished to have some time away from the immediate ward environment. Therapy rooms were available for the use of patients and a sensory or relaxation room was available on every ward. Patients also had access to outside space.
  • Visitors rooms were available to be used and the ward also had an accessible and private room with a telephone for patients to use.
  • Protected meal times were in place. Patients could access a small kitchen on the wards during the day to make drinks and snacks.
  • Patients were able to personalise their room if they choose and we could see that some had chosen to do this.

  • Wards had disabled access and patients we spoke with told us that the environment was easy to navigate for them and staff knew how to assist them when they needed it. Staff worked with patients to meet their cultural needs. The site had a multi faith room for people of all faiths to use.
  • There was information available for patients around how to complain, their rights and information about treatments. A log of local complaints was kept. Local resolution of complaints occurred generally. Patients told us they knew how to complain. Patients were encouraged to contribute and problem solve issues with support from each other and staff.

However;-

  • Two patients were identified as having significant delays in their transfer of care to a more appropriate setting.
  • On Rufford ward, there was a lack of easy read literature available.

Well-led

Good

Updated 13 January 2016

We rated well led as good because:

  • The Chief executive had recently visited the hospital to engage with staff. The hospital director and senior management were visible to staff and the patients. Staff appeared to understand and own the values of the organisation.
  • Each ward had documented operational policies which included the longer term vision for that ward.
  • There was a daily review meeting carried out by hospital coordinators to look at staffing, safeguarding, seclusions and incidents and where wards or staff needed support. Team meetings occurred monthly and discussed relational security, boundaries, finances, ward rules and staffing.
  • Governance procedures were in place for monitoring the progress and functioning of the hospital. Results were produced monthly and disseminated to ward managers via the dashboard. We saw minutes of senior staff meetings which included consideration of both the local and provider wide risk register.
  • Staff said they were confident about using the whistleblowing, grievance and bullying and harassment policies.
  • Staff told us they were able to give suggestions about the care provided through team meetings or individually to managers.
Checks on specific services

Wards for people with learning disabilities or autism

Requires improvement

Updated 10 February 2015

There were systems and processes to monitor staffing, incidents and safeguarding, which were summarised in a ward dashboard. Up to date environmental audits and plans were not available on the wards. Resuscitation equipment was not checked on a weekly basis. We found staffing skill mix and deployment affected the patient experience. Patients were concerned about the turnover of medical staff. Staff and patients understood and applied the safeguarding processes well.

The hospital provided data for the first quarter of the year that showed almost one third of activities planned were not taken up by patients. However the patients we spoke with told us that there were not enough nurse led activities for them to do.

Thorsby ward had introduced the concept of a therapeutic community which was being embedded. There was an initiative called “meaningful conversations” which had been introduced to facilitate dialogue between nurses and patients which patients were positive about. There was a mixed picture about the way patients felt were treated by staff. We observed some staff to be caring and compassionate; we also observed one staff member swearing in the office and heard that there had been problems with staff attitude on Rufford ward.

There was an active patient representative group “our voice” who had formulated an action plan for changes that they felt were required.

We found that patients knew how to make complaints. Patients told us their complaints were rarely fully addressed and often do not receive clear responses. Out of 25 formal complaints only one had been fully upheld.

Patients did not consider that ward leaders were visible. Staff supervision was provided, however not consistently.

Mental Health Act responsibilities

Updated 10 February 2015

We do not rate responsibilities under the Mental Health Act 1983. We use our findings as a determiner in reaching an overall judgement about the Provider.

There were systems in place to scrutinise detention papers to make sure they followed the MHA and we found the detention papers appeared to be in order.

Patients were given their rights in relation to their detention every six months. We found no evidence of repeated attempts when patients refused or were unable to understand their rights. Patients had access to an Independent Mental Health Advocate (IMHA) and used them.

Case notes demonstrated and patients confirmed that hospital manager’s hearings and mental health review tribunals took place.

We found some good documentation confirming mental capacity assessments in relation to medication and consent. However some of the records did not adhere to the MHA Code of Practice because they had not been completed by the current responsible clinician (RC).

In accordance with the Code of Practice Mental Health Act 1983 not all case notes confirmed that patients had been informed by the responsible clinician of the outcome of a SOAD nor had the statutory consultees recorded their discussion with the SOAD, this means that patients were not aware of the outcome of the independent review of their treatment plan.

Patients were granted section 17 leave. Patients, staff and records confirmed that this was not always facilitated. Internal leave in the hospital was recorded alongside external leave which is not in accordance with the Code of Practice. There was no record of patients being given copies of section 17 leave forms and patients said they had not received copies.

Seclusion rooms were on main corridors and had observation panels on the doors which were not covered, so limiting privacy. We observed a blind spot in the seclusion room which would necessitate the observing staff member moving from the observation room to the corridor.

We were informed by staff that patients were routinely searched when coming back from leave. The hospital needs to demonstrate they were adhering to the Code of Practice by ensuring that consent, and the rights of the individuals were explained and searches were proportionate to individualised risk.

We observed that staff had access to the copies of the Mental Health Act and Code of Practice.