255 Lichfield Road

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

Responsive

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

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

Good: This meant people’s needs were met through good organisation and delivery.

Good: The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as work, education and family relationships. The service met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We make sure people are at the centre of their care and treatment choices and we decide, in partnership with them, how to respond to any relevant changes in their needs.

The service made sure people were at the centre of their care and treatment choices and decide, in partnership with them, how to respond to any relevant changes in their needs. Staff regularly met with patients to understand their views on care and treatment. These discussions took place in one-to-one meetings with nurses and in multidisciplinary team meetings. Staff monitored patients’ conditions and discussed any changes at handover meetings.

Staff developed care plans around patients’ individual needs and preferences. Care plans were personalised based on each individuals’ well-being. However, the patient voice was not evident consistently throughout the plans. Not all patients said they had copies of their care plans but said they could speak to staff about them.

The service provided therapeutic and recreational activities to meet the needs and personal interests of patients. A timetable of therapeutic activities was displayed on the ward. The Occupational Therapy team delivered planned sessions that were personalised to each individual and although groups sessions were held these were always adapted to each individual's needs or risk. We saw examples of care being adapted to the individual needs and wishes. For example, a patient felt that a planned group cooking session was too ambitious for their needs so this was adapted by the team to offer more detailed 1-2-1 support to build on confidence.

We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.

Staff ensured that patients had access to external opportunities to support their recovery, for example support to access accommodation and continuing treatment for those moving into the community.

Staff told us that they supported, informed and involved families or carers. Families and carers were informed about the service prior to admission. Where consent was given by the patient, family members were involved in their relative’s care. Families and carers who were actively involved told us they were invited to multi disciplinary meetings and kept informed of key information. Some staff told us more could be done to engage families and carers to promote involvement.

Staff supported patients to access their chosen place of worship within the community, where this was appropriate. Leaders told us plans were in place to renovate the downstairs toilet areas to create more space for a multi faith room.

We provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs. We do not always make notifications to external bodies as needed.

Staff did not always make notifications to external bodies as needed. The hospital did not inform the Care Quality Commission of the change in registered manager which took place in November 2024. When it was highlighted that changes did not appear to have been effectively communicated to CQC this was rectified immediately. During our inspection we were assured that the position of manager had always been filled during this period.

The hospital had made other notifications to external bodies during this period.

The service submitted all other notifications to the Care Quality Commission in accordance with the requirements of their registration. The service also submitted safeguarding referrals to the local authority.

The service could support and make adjustments for disabled people and those with communication needs or other specific needs. We saw examples of posters written in an easy read and accessible formats.

Staff made sure patients could access information on treatment, local service, their rights and how to complain. Key information was displayed on noticeboards throughout the ward including community opportunities, patient rights, safeguarding processes and therapies and activities available at the hospital. Patient information leaflets were written in an accessible format and the service could access the leaflets in different languages when needed. Managers made sure staff and patients could get help from interpreters or signers when needed.

We make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result.

The hospital had processes in place to manage complaints. All patients said they knew how to complain and were confident in doing so. No patients or carers we spoke to had made a formal complaint. Patients told us that where there had been issues staff had ensured these were rectified.

Staff said they knew how to handle complaints appropriately and efficiently and managers provided feedback on the outcome of investigations and acted on any findings

The provider told us that there had been 0 complaints in the 6 months prior to our inspection. We saw that the hospital audited complaints and reviewed themes within clinical governance meetings. Managers shared themes with staff to improve practice.

Patients had access to several forums to raise concerns about the service. For example, through the patient representative or keyworker, community meetings and patient surveys.

The community meetings and recent appointment of new patient representative evidenced ways in which the hospital were starting to involve patients more in decisions about the service. Weekly meetings were an opportunity for patients to get together with staff to discuss issues such as maintenance, giving feedback on the service and making plans for future activities.

The hospital had also recently introduced the employee of the month which was a chance for patients to nominate a staff member who they felt stood out in the care they had given.

We make sure that everyone can access the care, support and treatment they need when they need it.

The service ensured patients could expect their care and treatment to be accessible and timely. Managers told us that they would always assess whether it could meet a patient's needs safely on admission. The service met the needs of its patients, ensuring reasonable adjustments were made for disabled people and communication barriers were addressed. For example, upstairs living areas could be accessed by a lift if required and all bungalows were accessible on the ground floor.

Staff ensured patients had access to post-discharge care – for example, S117 aftercare, community mental health services and crisis services.

Staff carefully planned patients’ discharge and worked with care managers and coordinators to make sure this went well. We saw evidence of discharge planning within care plans, multi-disciplinary meetings and patient ward rounds. Staff supported patients when they were referred or transferred between services. Staff supported patients with transitions into future services and placements. Staff told us that their priority was always the wellbeing of the patient and wanted to ensure that discharges were as safe as possible.

We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. Patient and carers feedback was collated through community meetings, patient and carer satisfaction surveys, compliments and complaints.

The service admitted patients from diverse religious and cultural backgrounds. Staff asked patients about their religious and cultural needs when they were admitted to the ward.

Staff shared that adjustments were made to accommodate patients with diverse needs. Information was also made available in various formats and languages upon request to ensure accessibility. Translation services had also been made available.

All staff were trained in equality, diversity and inclusion with a compliance rate of 100% at the time of the inspection.

We support people to plan for important life changes, so they can have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients to make informed choices about their care and plan their future. We found evidence of discharge planning in care records reviewed. The multidisciplinary team worked in partnership with external agencies including local mental health teams to ensure a safe discharge.

Patients told us that discharge plans were regularly discussed. One patient told us that progress felt slow and that little action had been taken. One carer told us that their family member regularly discussed their discharge but this information had not been shared with them by the hospital staff.