You are here

Archived: Olive Mount Hospital

All reports

Inspection report

Date of Inspection: 17 December 2013
Date of Publication: 17 January 2014

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

Meeting 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 17 December 2013, checked how people were cared for at each stage of their treatment and care and talked with carers and / or family members. We talked with staff.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that patients received.

Reasons for our judgement

We included this outcome in our inspection to see if effective systems were in place to regularly assess and monitor the quality of the service patients were receiving.

In relation to this outcome, we spoke with three managers of the service. Patients were not available on the day of our inspection so we contacted six relatives by telephone to seek their views of the service.

Mersey Care NHS Trust comprises seven clinical business units (CBU). A CBU is a distinct area of care provision based on service speciality and/or geographical location. Wavertree Bungalow is part of the ‘Rebuild’ CBU, which provides services for patients with learning disabilities, including community residential services, community teams, in-patient services, respite services, on call service and the Asperger’s service.

Prior to the inspection we had access to information which identified that an integrated Trust-wide governance committee was in place, supported by specific groups or committees. These included an adverse incidents group, clinical audit group, infection control committee and safeguarding strategy group. We also looked at the Trust-wide performance report for June 2013. It took into account the performance assurance framework, external assessments, financial performance and workforce matters. We noted it addressed any areas of underperformance; identified from both internal and external performance assessments, including recent regulatory visits and inspections.

We asked the manager how the service linked with the wider CBU for the purposes of sharing information about quality and risk. The manager advised that they attended the risk meetings for the CBU. The risk register for the CBU was reviewed at these meetings. We were informed that Wavertree Bungalow was on the risk register because of limitations with the building. Updates regarding plans to develop the building were shared at each meeting. The manager also attended the weekly CBU meetings for service managers. This was described as a quality meeting which supported the sharing of quality practice alerts and the general sharing of good practice. Other meetings the manager attended included the dementia care meetings, physical health meetings and meetings regarding the self-administration of medication.

We asked the manager how incidents were managed and reported within the CBU. We were informed that incidents were recorded electronically and forwarded to the operational management team. The manager generally investigated the incident and informed the operation management team of the outcome, including any recommendations regarding the action required. For example, if an incident involved a fall and there were concerns about flooring then a referral would be made to the maintenance team. If the incident involved medication then the service would seek support from the pharmacy team. The manager advised that support services responded in a timely way.

We asked about the arrangements for addressing complaints from patients or families. A process was established for managing complaints within the Trust. However, the manager highlighted that the last complaint was received approximately 18 months ago and was resolved to the satisfaction of the complainant.

A range of audits or checks were established for the service. Information we were provided with confirmed that environmental and fire risk assessments took place. A ‘workplace’ inspection was conducted by the manager on a regular basis and we noted that it identified the developments to the building had been submitted to the Trust as a ‘business case’. Infection control checks took place each month.

Arrangements were in place to seek feedback from families about the service. The manager informed us that a carers group had been set up about three months ago. The aim of the group was to provide support for families and to share ideas about how the service could be improved upon. The family members we spoke with confirmed they h