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Mental Health Unit, Lincoln County Hospital Site

All reports

Inspection report

Date of Inspection: 24 July 2012
Date of Publication: 15 August 2012
Inspection Report published 15 August 2012 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

The provider was not fully meeting this standard.

The provider had a system to regularly assess and monitor the quality of service that people receive. However, at times, patients may be put at risk due to the lack of risk assessment and contingency planning for the times when there is a lack of acute admission beds.

User experience

We spoke to a number of patients within both units about this outcome. They told us that staff listened to them and helped to sort out any problems they had. A patient satisfaction survey carried out in Peter Hodgkinson Centre showed that 80% of patients said that staff were willing to listen to their views.

In Peter Hodgkinson Centre one patient told us that they had made a complaint and said “I know they (staff) will sort it out.” In Francis Willis Unit a patient said they had experienced problems with trying to make a complaint as not all staff were familiar with the procedure. They and the manager told us that the issue had been resolved and staff had been retrained about how to manage complaints.

Other evidence

We know from our records, and records that we saw in both units, that the trust had a quality assurance programme. The programme included regular audits of things like health and safety arrangements, ligature points, the environment, infection control and staff training.

We saw that both units carried out a trust wide programme called ‘The Productive Ward’ which regularly measures things like the frequency of individual patient meetings and therapeutic input. Outcomes of the productive ward programme were clearly displayed for patients and visitors to see. Records also showed that things like care plans, activity plans and risk assessments were audited on each unit.

Records showed that patients were encouraged to be involved in planning and improving services in both units. We saw minutes of in-patient meetings in which they discussed things like activities and catering. We also minutes of a service user involvement group which included in-patients and ex-patients. Issues discussed ranged from providing pet therapy, reviewing policies and developing a day ward booklet.

The productive ward surveys and minutes of patients meetings also highlighted the issue of the number of available beds for admission into Peter Hodgkinson Centre. During our visit one ward in the unit had 22 available beds and 29 in-patients listed, and another ward had 20 beds available and 22 in-patients listed. Staff told us that when they were fully occupied, any newly admitted patients were admitted into beds of patients that were on leave from the ward. They said that there was a particular pressure on male beds. We did not find any evidence of risk assessments or contingency arrangements in place to deal with these situations.

We saw one patient who had returned from leave during our visit, and their bed had been allocated to a newly admitted patient. This situation was resolved through other patients being discharged on the same day. However, staff told us that at times they needed to make risk assessments of patients who were on leave, with a view to extending their leave, so that they could accommodate more acutely ill patients.

Information was available to patients and visitors about how to make a complaint. Staff we spoke to described how they would deal with a complaint in the right way. During the visit we saw how staff in Peter Hodgkinson Centre responded calmly and appropriately to a patient who wanted to make a complaint.

Our records showed that the trust investigated any untoward incidents, and completed a report with recommendations for improvements. We saw minutes of staff meetings which showed that the reports and recommendations were used within the units to help staff learn lessons for the future.