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Maple House Rehabilitation Unit Good

Inspection Summary


Overall summary & rating

Good

Updated 16 April 2018

We undertook this focussed, unannounced inspection to find if Ash House had made improvements to their service since our last unannounced comprehensive inspection in July 2017.

When we last inspected Ash House, we found that two of the five key domains, effective and well-led, were deemed to require improvement, whilst the other three domains were rated as good. In completing this latest inspection, we considered that, based on information gathered during the period between inspections, caring and responsive domains remained rated as good. We reviewed three domains on this inspection: safe, effective and well-led.

We rated Ash House Rehabilitation Unit as good because:

  • The service had met requirements with regard to breaches of regulation found in the inspection, report published in July 2017.

  • The building had blind spots that were adequately mitigated by mirrors and equipment to reduce risk of harm to staff and patients. The service had an environmental ligature risk assessment in place, as well as individual risk assessments for each patient. Induction training was deemed appropriate and was completed across the service by all staff. Leave documentation for patients was audited. Patient risk assessments were holistic and up to date. Safeguarding was in place and audited. Medication management was in place and audited. All staff had a disclosure and barring service check that was electronically maintained and a copy kept in personnel files.

  • Care plans were up to date, personalised and holistic. There was documented evidence that patients were being given a copy of their care plan, or offered a copy. Physical health monitoring was on-going at the service. There were comprehensive pre-admission criteria in place that was being followed. Patients were given time to access the internet by computer, as well as having access to their own mobile telephones after individual assessment. Mandatory training was taking place, and was audited by the service. Mental Health Act documentation was in order, and the new Mental Health Act administrator for the service was clearly knowledgeable about the subject. Ash House had five lay hospital managers who were involved with the service. Mental capacity of patients was being monitored and considered across the service.

  • Policies and procedures that had not been tested on the previous inspection were embedded and seen to be working. Senior management oversight was present and noticeable at the service. There was a full and comprehensive risk register at Ash House. Policies at Ash House were in place and were relevant to the service. Key performance indicators were in place, and we saw evidence in minutes of meetings that these were used to gauge and enhance performance. Staff felt that morale was much higher, and felt that they had a voice in the service.

However:

  • while staff told us supervision was regularly taking place, data supplied by the service was not up to date.
  • Proactive referral to the independent mental health advocate was not being recorded when patients did not understand their rights.
Inspection areas

Safe

Good

Updated 16 April 2018

We rated safe as good because:

  • The building had blind spots that were adequately mitigated by mirrors and equipment to reduce risk of harm to staff and patients.

  • The service had an environmental ligature risk assessment in place, as well as individual risk assessments for each patient.

  • Induction training was deemed appropriate and was completed across the service by all staff.

  • Leave documentation for patients was audited.

  • Patient risk assessments were holistic and up to date.

  • Safeguarding was in place and audited.

  • Medication management was in place and audited.

  • All staff had a disclosure and barring service check that was electronically maintained and a copy kept in personnel files.

Effective

Good

Updated 16 April 2018

We rated effective as good because:

  • Care plans were up to date, personalised and holistic. There was documented evidence that patients were being given a copy of their care plan, or offered a copy.

  • Physical health monitoring was on-going at the service.

  • There were comprehensive pre-admission criteria in place that was being followed.

  • Patients were given time to access the internet by computer, and had access to their own telephones after individual assessment.

  • Mandatory training was taking place, and was audited by the service.

  • Mental Health Act documentation was in order, and the Mental Health Act administrator for the service was clearly knowledgeable about the subject.

  • Ash House had five lay hospital managers who were involved with the service.

  • Mental capacity of patients was being monitored and considered across the service.

However,

  • Whilst staff told us supervision was regularly taking place, data supplied by the service was not updated.

  • Proactive referral to the independent mental health advocate was not being recorded when patients did not understand their rights.

Caring

Good

Updated 16 April 2018

This domain was not inspected as it had been rated as good in the previous inspection in July 2017.

Responsive

Good

Updated 16 April 2018

This domain was not inspected as it had been rated as good in the previous inspection in July 2017.

Well-led

Good

Updated 16 April 2018

We rated well-led as good because:

  • Policies and procedures that had not been tested on the previous inspection were embedded and seen to be working.

  • Senior management oversight was present and noticeable at the service.

  • There was a full and comprehensive risk register at Ash House.

  • Policies at Ash House were in place and were relevant to the service.

  • Key performance indicators were in place, and we saw evidence in minutes of meetings that these were used to gauge and enhance performance.

  • Staff felt that morale was much higher, and felt that they had a voice in the service.

Checks on specific services

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 16 April 2018