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Archived: Brook House Requires improvement

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 September 2016

We rated Brook House as requires improvement because:

  • The hospital was not compliant with the Mental Health Act Code of Practice, published 2015. The required policies within the Code of Practice were not written and available. One prescription card had medication prescribed for a patient as required (PRN) which was not authorised on their T3 form. Staff had not received training in the revised Code of Practice. The responsible clinician frequently changed the days of the ward rounds at very short notice, meaning patients were not prepared for their meeting, the advocate was not present and if family or external professionals were due to attend they would not have been aware of the change.
  • Staff did not consider the Mental Capacity Act in their everyday practice. Capacity assessments were not taking place in accordance with the Mental Capacity Act and there was no consideration of best interest processes.
  • The hospital could compromise the safety of patients. The environmental risk assessment was not fit for purpose and did not identify the ligature points within the building or advise staff of how to mitigate the risks. The hospital manager was not following the ligature and self-harm policy. There was a sign on the clinic room door to inform staff that oxygen was stored there, however the oxygen was stored in the staff office. There was no emergency medication available for the overdose of benzodiazepines. The prescription cards were illegible. This posed a risk of staff administering the wrong medication to patients. There were no care plans in place for patients prescribed antipsychotic medication above the British National Formulary limits.
  • Staff did not receive the training relevant to their role. Mandatory training attendance levels were below 75% for the majority of courses, including emergency first aid and safeguarding adults. Staff did not receive training on the Human Rights Act. Specific training for the needs of the patients were low, including diabetes awareness at 21% and drug and alcohol awareness at 53%
  • The provider was not complying with the Duty of Candour Regulation. The policy did not specify that people should receive a written apology. Staff we spoke with were not aware of the duty of candour.
  • Care was not patient centred. Restrictive practices were in place including locking the cutlery away and not allowing detained patients to hold their own lighters. A patient had been deskilled, who was previously cooking independently and living in the annex. They had to move back into Brook House due to building works, had all meals cooked for them, and were in a hospital with locked doors. Care plans were nurse led and it was not clear what actions patients needed to take to progress from the service. Staff had not referred a patient identified as requiring psychology. There was no written information provided to patients upon admission to assist with orientation within the environment. Community meetings had a disproportionate amount of staff present compared to patients and actions from previous meetings were not always completed.
  • The hospital was not well led. There was no evidence of learning from incidents at a hospital or provider level. Policies at the hospital were all out of date, mainly from 2013. However, the provider had more recent versions in place, which the hospital had not made available to staff. Staff felt unable to progress within the organisation with limited opportunity for development including no opportunity to complete National Vocational Qualifications. There were no examples of staff surveys or any other methods or forums for staff to give feedback about the service.

However:

  • The hospital was homely and welcoming and provided the facilities to promote patients' recovery including access to drinks and snacks at all times and areas to spend in quiet. Patients had keys to their bedrooms and had their own mobile phones. The majority of patients had progressed within their time at Brook House and were pursuing activities in their local community independently. The occupational therapy assistant had created a plan to show times of activities available in the local community.
  • We observed warm, positive and nurturing interactions between staff and patients. All patients reported staff were friendly, caring and respectful. Patients had access to advocacy. Families were involved in ward rounds and care programme approach meetings if patients wished. Patients gave feedback about the service via service user questionnaires and community meetings.
  • The hospital manager was following the complaints policy and investigations were completed in a timely manner. Information was on display to inform patients how to complain.
  • Staff had appraisals and supervisions. Regular team meetings took place. Debriefs were taking place following incidents.
  • The provider’s recruitment and selection policy, dated July 2015, complied with the Health and Social Care Act 2008(Regulated activities) Regulations 2014 in relation to recruiting staff that are fit and proper.
Inspection areas

Safe

Requires improvement

Updated 27 September 2016

We rated safe as requires improvement because:

  • The hospital manager was not following the ligature and self-harm policy and the daily environmental risk register did not identify ligature points and risks within the building or advise staff of how to mitigate the risks.

  • There was no flumazenil stocked which is used for the reversal of the central sedative effects of benzodiazepines. Patients were prescribed benzodiazepines and would not have emergency medication available to them if they reacted to the medicine or were given an incorrect dose.

  • Medicines for the patients in the service next door were stored in Brook House fridge including opened eye drops from Jan 2016, insulin pens from March 2015. Staff were not following the provider’s medicine policy, by not discarding eye drops 28 days after opening.

  • The doctor who had completed the prescription cards had poor handwriting and it was difficult to decipher. This posed a risk of staff administering the wrong medication to patients.

  • Oxygen was marked as being in the clinic however; it was stored in the office.

  • Staff mandatory training attendance levels were below 75% for a number of courses, including emergency first aid and safeguarding adults.

  • The provider’s policy on duty of candour was not compliant with the regulation and staff were not aware of the duty of candour.

  • Restrictive practices were in place including locking the cutlery away and not allowing detained patients to hold their own lighters.

  • The observation policy in place only focused on enhanced observations and did not provide guidance to staff on how to complete and record observations of patients on general observations.

  • The medicine management policy did not reflect current practice including Controlled Drugs (Supervision of Management and Use) Regulations 2013.

  • The flooring in the laundry room had missing sections and the seating in the dining room was torn on some seat pads, which increased the infection control risk.

  • Risk assessments did not include risk mitigation plans for patients.

  • There was not a formal process within the organisation by which important lessons to be learnt from incidents could be disseminated to staff.

However:

  • Debriefs took place following incidents.

  • Staff understood how to safeguard vulnerable adults and how to escalate safeguarding concerns.

  • The hospital was very clean.

Effective

Requires improvement

Updated 27 September 2016

We rated effective as requires improvement because:

  • The hospital did not have the specified policies in place as required under the Mental Health Act Code of Practice, published 2015.

  • Patients were not always offered a copy of their section 17 leave form.

  • The responsible clinician frequently changed the days of the ward rounds at very short notice, meaning patients were not prepared for their meeting, the advocate was not present and if family or external professionals were due to attend they would not have been aware of the change.

  • Capacity assessments were not taking place in accordance with the Mental Capacity Act, there was no consideration of best interest processes.

  • Staff had variable knowledge of the Mental Capacity Act. The hospital manager could not explain the five statutory principles of the Act or that you assume capacity until proven otherwise. However, five of the nine other staff we spoke with were able to explain the principles and that capacity is decision specific.

  • The provider had a Mental Capacity Act policy, dated March 2016. There were a few typographical errors within the policy, which could cause confusion. The policy stated that health and social care staff could conduct capacity assessments however; the hospital manager advised that they would refer capacity assessments to the patient’s home team. The updated policies were not present at the hospital and available to staff.

  • Care plans were nurse led and it was not clear what actions patients needed to take to progress from the service.

  • There were no care plans in place for patients prescribed antipsychotic medication above the British National Formulary limits.

  • Daily records for patients did not include information about support provided by staff or the activities that patients had pursued.

  • There was little evidence of physical health promotion, especially in relation to patients reducing or stopping smoking and the impact this may have on their medicines.

  • There were low levels of staff completion of training courses in a number of areas including diabetes awareness and drug and alcohol awareness. Staff reported a lack of development opportunities.

  • Staff had not referred a patient identified as requiring psychology.

However:

  • Patients were actively involved in the planning of their section 17 leave including completing part of the form prior to the responsible clinician’s authorisation.

  • The independent mental health advocate was visible in the hospital, details were on display of how to make contact with them and we observed patients had a positive relationship with them and would approach them for support.

  • Detention paperwork was accessible to all clinical staff.

  • We saw evidence of the regular attempts to explain to patients what their rights were whilst detained.

  • Staff we spoke with understood their role in relation to the Mental Health Act.

  • Detailed care plans were in place for patients with diabetes.

  • There was a good range of multidisciplinary professionals within the hospital including a Mental Health Act administrator, occupational therapist and occupational therapy assistant and social worker.

  • The provider had a policy on the Deprivation of Liberty safeguards, dated May 2016. The policy explained how to apply for a Deprivation of Liberty safeguard.

Caring

Good

Updated 27 September 2016

We rated caring as good because:

  • We observed warm, positive and nurturing interactions between staff and patients.

  • Staff knew patients well including their future plans.

  • All patients reported staff were friendly, caring and respectful.

  • Patients had access to advocacy.

  • Families were involved in ward rounds and care programme approach meetings if patients wished.

  • Patients gave feedback about the service via service user questionnaires and community meetings.

However:

  • There was no written information provided to patients upon admission to assist with orientation within the environment.

  • Care plans were nursing focused. Patients’ perspectives were included in some of the care plans however they did not include unique support needs of patients, including how best to support them and what their coping strategies were.

  • One patient had a care plan in place for shadowed local leave, he was not aware that he was being shadowed whilst on unescorted community leave.

  • Community meetings had a disproportionate amount of staff present compared to patients and actions from previous meetings were not always completed.

Responsive

Requires improvement

Updated 27 September 2016

We rated responsive as requires improvement because:

  • The service was not moving patients on in a timely manner. The aim of the hospital was to move patients on within twelve to eighteen months. Several patients had been at the hospital for more than eighteen months, one patient over two years and another over five years.

  • In five of the six files examined, a discharge care plan was in place; such plans were non-specific in their approach and did not specify the potential timing or location of eventual discharge.

  • Staff had not updated or reviewed discharge plans. The registered manager told us this was because patients were not ready for discharge.

  • Care plans were also unclear as to what patients needed to do to achieve step down or discharge from the unit.

  • The provider had made the decision to close the service as a hospital and reconfigure the service to join the service next door and offer nursing care. Staff were going through the consultation process and commissioners had been contacted regarding the future of the six remaining patients. However, the provider had not discussed this with patients or the advocate.

  • A patient had been de skilled; they were previously living in the annex and had to move back into Brook House due to building work. They were previously cooking independently, however, at Brook house they had all meals cooked for them, and were in a hospital with locked doors.

  • Information on display regarding activities within the hospital was out of date and did not reflect activities available.

  • There were limited activities available in the hospital, especially at weekends. Patient surveys identified the need to improve activities on offer.

  • There was no computer available for patients to use.

However:

  • The hospital was homely and welcoming and provided the facilities to promote patients' recovery including access to drinks and snacks at all times and areas to spend in quiet.

  • Patients had keys to their bedrooms and had their own mobile phones.

  • The majority of patients had progressed within their time at Brook House and were pursuing activities in their local community independently. The occupational therapy assistant had created a plan to show times of activities available in the local community.

  • Patients reported the food was good and that the chef had made changes to the menu from feedback from patients via the feedback questionnaire and community meetings.

  • The service had supported patients to explore their faith. The quiet lounge was available for use to pray. There was a multi faith calendar on display in the hospital to assist with planning.

  • A variety of information was on display for patients including how to complain, how to contact the CQC and the role of the advocate and how to contact them.

  • The hospital was following the complaints and compliments policy and resolving investigations in a timely manner.

Well-led

Requires improvement

Updated 27 September 2016

We rated well-led as requires improvement because:

  • Staff attendance at mandatory training was low, with the majority of the courses completed attendance at below 75%.

  • There were a variety of clinical audits in place, however they were not always meaningful and did not feed into any meetings or follow best practice.

  • There was no dedicated administration support for the hospital; the hospital manager seemed to delegate administration tasks to support workers.

  • Policies at the hospital were all out of date, mainly from 2013. However, the provider had more recent versions in place, which the hospital had not made available to staff.

  • The policies required by the Mental Health Act Code of Practice, published in 2015 were not available. There was no written information available for patients upon admission to the hospital to orientate them to the hospital and provide important information.

  • Staff turnover rates were 20% from January to July 2016.

  • The culture of the hospital was not inclusive. Interactions observed and minutes reviewed showed a culture of informing and telling staff what to do, not acknowledging the contribution staff could give.

  • Staff felt unable to progress within the organisation with limited opportunity for development including no opportunity to complete National Vocational Qualifications.

  • There was very limited understanding of the duty of candour within the service and the policy did not comply with the regulations.

However:

  • Staff were knowledgeable in relation to safeguarding vulnerable adults and understood the process for escalating concerns.

  • Sickness rates were low at one per cent.

  • Staff meetings, appraisals and supervisions took place.

Checks on specific services

Long stay or rehabilitation mental health wards for working age adults

Requires improvement

Updated 27 September 2016