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Inspection report

Date of Inspection: 11 January 2011
Date of Publication: 9 February 2011
Inspection Report published 9 February 2011 PDF

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People should be cared for in safe and accessible surroundings that support their health and welfare (outcome 10)

Not met this standard

We checked that people who use this service

  • Are in safe, accessible surroundings that promote their wellbeing.

How this check was done

Our judgement

We found not all areas of this outcome were being met, though we found the building had a positive atmosphere on the day of our visit, and was generally clean and tidy. We are concerned that clear glazing to the link corridor doors and fire exit door may be affecting the privacy and dignity of patients who are residing in the female area of Rowan ward. We are concerned that inadequate heating is being provided in various areas of the Longley Centre and in a number of patient bedrooms.

User experience

The provider stated that people who use services had participated in the PEAT assessments. The provider explained that the ‘partners in improving quality group’, which consists of a group of people who use services, had begun to do site visits to identify any areas for improvement at the various locations.

Additional evidence was sought from the provider in the form of an annual team governance report for Rowan ward covering the period April 2009 to March 2010. The report included a section on ‘estates’ and explained that last year gardeners did a “makeover” of the ward’s enclosed garden area which received positive feedback from people who use services.

On the site visit conducted 11 January we sought the views of patients about this outcome. Most are captured under outcome eight. Patients did raise concerns over some of the cold patient bedrooms.

Other evidence

The provider declared compliance with this outcome at this location at registration with CQC in April 2010. Our provider level QRP for this outcome contained positive information, including a number of location specific positive information from PEAT assessments of the environment such as décor, furnishings, outdoor recreational facilities and access for people with disabilities. None of the external stakeholders referred to within outcome one who responded raised any areas of concern specifically relating to this location or outcome.

The MHA Commissioner visits have noted positive commentary and matters of good practice regarding the last visit 19 July 2010 at the Maple Ward and Rowan ward. On Maple ward it was noted that this 24 bedded ward (including one section 136 bed) was large and provided quiet areas for patients within its boundaries. The commissioner also found that levers for the observation blinds on most doors of patient rooms had been replaced with a key operated system. On Rowan ward it was noted the ward was large and spacious with quiet areas for patients. The commissioner commended the change in use of the former smoke room into an activities room and noted that dormitories were longer being used and being adapted for other purposes. All levers for the observation blinds had been converted to a key operated system.

The MHA commissioner visits to Rowan and Maple ward had noted some environmental recommendations for improvement, including that a door to the passage at the bottom far right side of the garden posed a ligature risk and the decking fence in the garden area could also pose a ligature risk. On Rowan ward, though overall the ward is clean and tidy, grouting to tiles in the patients en-suite areas needed attention.

As part of the assessment of this location the provider submitted a detailed provider compliance assessment which explained how the provider was meeting the outcome. We found the provider had appropriate systems and processes in place that are required to meet this outcome with no identified gaps in assurance when this self assessment was reviewed. To provide a few examples, the provider reported that a “red box” system had been implemented at all locations, which contain a suite of essential maintenance and safety related information. The provider has ensured that there is 24 hour on call response available to cover estates related emergencies.

People who use services have access to a range of facilities and equipment to support assisted use and meet requirements of the Disability Discrimination Act. All provider locations are reported to have a range of spaces for social, therapeutic, cultural and educational needs including lounges, quiet rooms, women only lounges, craft areas, gymnasiums, multi-faith rooms and clinical rooms to meet the needs of people who use services, including access to outdoor spaces.

Additional evidence was sought from the provider in the form of an annual team governance report for Rowan ward covering the period April 2009 to March 2010. The report explained that weekly health and safety checks are performed on the ward using a checklist and where necessary this had resulted in requests for repairs being made. The report also explained that the lounges had received new settee’s, chairs and new televisions along with some other improvements.

As we had identified areas of concern in relation to outcome four that required a site visit to gain additional evidence we decided to include this outcome to review those areas recommended by the MHA commissioner for consideration by the ward.

On the site visit performed 11 January 2011 we found that Maple and Rowan wards along with the ITS, despite them being fully occupied, had a positive, calm and welcoming atmosphere. We observed that the building was generally clean and tidy and relatively spacious though ‘bland’ in terms of décor in places. We specifically reviewed the seclusion rooms on Maple ward and the ITS and