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Inspection summaries and ratings from previous provider

Overall summary & rating

Updated 6 August 2018

We rated Breightmet Centre for Autism as good because:

• Patients received comprehensive care assessments which involved input from a multidisciplinary team which including psychiatry, nursing, clinical psychology, occupational therapy. Care plans showed evidence of patient involvement in care planning, risk assessment and management and activity planning. There were sufficient nursing and support staff available to ensure patients were cared for in accordance to their care plans.

• Patients had access to physical healthcare and the service ensured their physical health needs were assessed and monitored on a regular basis. Patients with underlying physical health conditions had appropriate health action plans to monitor and manage these.

• We observed kind and respectful interactions between staff and patients. Both patients and carers gave positive feedback about how staff treated them. Staff knew the patients well and their needs.

• Patients could access telephone facilities within each apartment by either using their own mobile phone if this had been risk assessed or the cordless office telephone which could be used in their own bedrooms or in the quiet rooms.

• Patients had access to drinks and snacks throughout the day, with drink facilities kept on each apartment and snacks stored in the main kitchen.

• Patients had personalised activity planners, which were person-centred and designed to support their individual rehabilitation needs. Activities were available seven days a week both on and off site.

• There was an effective governance structure in place, which included systems and processes to ensure monitoring of the service. The provider was committed to service improvement. As well as having a comprehensive internal audit programme in place, the provider had commissioned a number of service specific reviews to ensure approaches and strategies were most appropriate for the patients within their care.


• Although staff were aware of the processes in place for raising safeguarding concerns, the service manager did not immediately demonstrate that the threshold for these were understood when a concern was raised during the inspection.

•         Though the service had psychiatry provision provided by a part time locum psychiatrist with the support from an assistant psychiatrist, there was no assurance to ensure all patients had received regular psychiatry assessments and reviews.           

Inspection areas


Updated 6 August 2018

We rated the safe as good because:

  • The service provided a safe environment for the care and treatment of patients in which access was controlled throughout the centre.

  • There were sufficient nursing and support staff in place to deliver care appropriately.

  • Staff had completed the training requirements to enable them to safely work at the service.

  • The service followed a least restrictive approach to managing violence and aggression with staff using de-escalation strategies and when required the use of physical restraint was documented and care plans updated accordingly.

  • Staff could identify signs of abuse and knew who to contact regarding safeguarding concerns.

  • The service had systems in place for recording and analysing safety concerns.

  • There were processes in place for the management team to review safety.

  • The service had systems and processes in place for logging incidents.

  • Number of Incidents between patients was low due to early staff intervention.

  • Staff were debriefed after safety incidents and complaints.

  • Managers were proactive in discussing findings from outside the organisation.

  • Most staff were up to date with their mandatory training requirements.


  • Not all medication was appropriately labelled.

  • Systems for recording and sharing lessons learned from investigations were limited.

  • The communal bathroom had a non-anti ligature compliant shower which the service mitigated against by only allowing unsupervised access to patients who were well enough. All other patients were supervised if they required access and it was locked when not in use.

  • Domestic and clerical staff working only in communal areas were not provided with portable alarms.

  • Though processes existed for daily cleaning across patient areas, outside these designated times cleaning did not appear to be done and there were no processes in place to ensure patient areas were deep cleaned when required

  • The threshold for escalating safeguarding concerns and the processes for reviewing allegations were not clearly understood and fully demonstrated by the service manager.


Updated 6 August 2018

We rated effective as good because:

  • Care and treatment of patients involved a multidisciplinary team approach with the service having good links with other agencies and organisations.

  • Care plans and assessments looked at strategies for positive behavioural support. They were personalised, relevant, regularly used and up to date.

  • Patients had access to a variety of therapies, interventions, assessments and support.

  • There was a provision of activities made available for patients including individualised activities.

  • There was a focus on identifying and following best practice in autism care.

  • There were systems in place to ensure all employees had to complete an induction after their details had been checked and verified.

  • Staff handovers were detailed and covered each patient.

  • Staff showed good understanding of the Mental Health Act and capacity, with good systems and processes in place to support the service with these and detailed records kept for each patient.

  • Information about individual rights was developed in a way that could be understood by patients.

  • The service demonstrated good compliance of the Mental Capacity Act.


  • The style in which care plans were written was inconsistent and did not always use patient friendly terminology.

  • Team meetings and reflective practice sessions were infrequent with staff meetings held every two months and nursing meetings not a regular occurrence with minutes not available for any of these.


Updated 6 August 2018

We rated caring as good because:

  • Patients and carers felt the service offered a supported, kind and caring approach.

  • Staff demonstrated detailed knowledge about the patients in their care and showed a genuine concern about patient under their care.

  • Staff interactions were mostly positive and person centred in accordance to care preferences documented in the care plans.

  • Activities were not rushed and were based around the patient and their individual needs.

  • Collaboration and partnership working formed a central part of the services care pathway.

  • Patients had access to support from an advocacy service.

  • Patient choice was respected, understood and facilitated, which was seen in care plans which documented patient wishes.


Updated 6 August 2018

We rated responsive as good because:

  • There were systems and processes in place for triaging and assessing patients before admission to ensure the service could best facilitate their care and treatment.

  • Personalisation of bedrooms was encouraged and strategies were in place to develop this with each patient.

  • Activities for patients were personalised depending on their rehabilitation needs and interests.

  • Information for patients was available in a number of formats.

  • Patients had their communication needs assessed and communication plans were developed how best to communicate with each patient which staff understood.

  • Individual patient preferences were documented and the service attempted to facilitate these.


  • Discharge planning and care plans were not always target and timeline focused to achieve intended goals.


Updated 6 August 2018

We rated well-led as good because:

  • The executive team had oversight of the running of the service.

  • There were clear processes to review key areas and themes to ensure the management team had oversight.

  • There was a clear commitment towards continual improvement and innovation.

  • The service was responsive to feedback from patients, staff and external agencies.

  • Shortcomings in the recruitment and induction process had been identified and new systems introduced to improve this.

  • The service had been proactive in capturing and responding to patients concerns and complaints. There were creative attempts to involve patients in all aspects of the service.


  • Learning from incidents and sharing of this was not clearly defined.

  • Team meetings were not regular and varied in their format and detail.

Checks on specific services

Wards for people with a learning disability or autism

Updated 6 August 2018