Review of compliance. Waterloo Manor Limited Waterloo Manor Independent Hospital. Yorkshire & Humberside. Region:

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1 Review of compliance Waterloo Manor Limited Waterloo Manor Independent Hospital Region: Location address: Type of service: Yorkshire & Humberside Selby Road Garforth Leeds West Yorkshire LS25 1NA Long term conditions services Date of Publication: June 2014 Hospital services for people with mental health needs, learning disabilities and problems with substance misuse Rehabilitation services Overview of the service: Waterloo Manor is an independent low secure facility for women. The hospital has recently been explanded and redeveloped to a high standard. The Maple suite has 13 beds for the Page 1 of 19

2 assessment and treatment of mental illness. The Cedar suite consists of 12 beds for the assessment and treatment of personality disorder. The Lodge is a four bedded rehabilitation unit. Waterloo Manor is situated within large landscaped grounds in the village of Garforth near Leeds and is close to motorway links. Page 2 of 19

3 Summary of our findings for the essential standards of quality and safety Our current overall judgement ##Report Error## The summary below describes why we carried out this review, what we found and any action required. Why we carried out this review We carried out this review as part of our routine schedule of planned reviews. How we carried out this review We reviewed all the information we hold about this provider and carried out a visit on 23 October What people told us We spoke with three patients who told us they knew about the care and support that was planned for them and said they were consulted about this. They also told us they attended meetings to review their care plan and progress and were given the opportunity to share their own views about this. Patients told us they were kept informed about the planned changes for the future service delivery at Waterloo Manor. One patient said; "I like it a lot here. I get chance to go out and can now use public transport. Staff listen and generally care about your mental heath. Staff are very friendly and approachable and we have a laugh. I have not found this in other places where I have been." Another patient said; "Staff are very helpful, especially the manager." Another patient told us the food was "fantastic" and they had the opportunity to have takeaway meals each week. Patients were able to explain why they were taking certain medications and said that the medical team had explained to them about the possible side-effects from the medication prescribed and had sought their consent about taking the treatment. Each patient spoken with said that there had never been any shortfalls in staffing levels that had resulted in cancellation of their section 17 leave. Patients spoken with told us they felt able to make comments or complaints and believed they would be listened to and their concerns acted on, without the fear that they would be discriminated against for making a complaint. Page 3 of 19

4 One patient told us, "I think it is alright here. I am relaxed and know if I have any concerns I can go to the staff. What we found about the standards we reviewed and how well Waterloo Manor Independent Hospital was meeting them Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run Patient's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. The provider was meeting the standard. Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights Patients experienced care, treatment and support that met their needs and protected their rights. The provider was meeting this standard. Outcome 09: People should be given the medicines they need when they need them, and in a safe way Patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. The provider was meeting this standard. Outcome 14: Staff should be properly trained and supervised, and have the chance to develop and improve their skills Patients were cared for by staff that were supported to deliver care and treatment safely and to an appropriate standard. The provider was meeting this standard. Outcome 17: People should have their complaints listened to and acted on properly There was an effective complaints system in place. Comments and complaints people made were responded to appropriately. The provider was meeting this standard. Other information Please see previous reports for more information about previous reviews. Page 4 of 19

5 What we found for each essential standard of quality and safety we reviewed Page 5 of 19

6 The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. Where we judge that a provider is non-compliant with a standard, we make a judgement about whether the impact on people who use the service (or others) is minor, moderate or major: A minor impact means that people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. A moderate impact means that people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. A major impact means that people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary changes are made. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety Page 6 of 19

7 Outcome 01: Respecting and involving people who use services What the outcome says This is what people who use services should expect. People who use services: * Understand the care, treatment and support choices available to them. * Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support. * Have their privacy, dignity and independence respected. * Have their views and experiences taken into account in the way the service is provided and delivered. What we found The provider is compliant with Outcome 01: Respecting and involving people who use services Our findings What people who use the service experienced and told us We spoke with three patients who told us they knew about the care and support that was planned for them and said they were consulted about this. They also told us they attended meetings to review their care and progress and were given the opportunity to share their own views about this. Patients told us they were encouraged to attend weekly community meetings. One person said; "I prefer not to attend these," and staff respected the person's decision. Patients knew about the planned changes for the future service delivery at Waterloo Manor. Other evidence Patients expressed their views and were involved in making decisions about their care and treatment. All of the patient records we looked at had evidence to show that their legal rights in relation to their detention had been explained regularly and had been periodically reviewed with them. Staff told us how they provided patients with the information and support to make sure they were fully informed and aware of the decisions made. Page 7 of 19

8 An independent advocate attended weekly community meetings and was qualified to act on behalf of patients as an Independent Mental Capacity Advocate (IMHA) in situations where the patient may lack capacity to make their own decisions. This meant that people were properly supported with their legal rights. We looked at the care records of patients and saw that the information included a record of their consent to their involvement in their therapeutic programme. This included their individual commitments around behaviour and involvement in activities. We also saw that documents were signed by the individual to confirm their agreement with what had been written in them. Consent issues were regularly considered within the regularly held ward rounds. We were told that patients were asked about who they would like to be present within care review meetings. This included family members and professionals who were involved in the patient's care and treatment. This was important in making sure patients were fully involved in decision making about their care and treatment. We looked at how patient's privacy and dignity were protected. Patients said they had blinds on their bedroom door to maintain their privacy and these were only opened by staff when carrying out observations to check the patient's welfare and whereabouts. Patients received personal care and support in private and there were designated rooms where visiting health professionals saw patients. The Maple and Cedar Units have only recently been built and contained very modern furnishings and décor which patients liked very much. We were told that further expansion work which will lead to an increase in the number of places available is due for completion by early The Lodge had been flooded earlier on in the year and because of this had to be redecorated and refurbished. Patients told us this had made the environment more "homely." Patients also said they had been involved in decisions about the new décor and furnishings. Patient's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. The provider was meeting the standard. Page 8 of 19

9 Outcome 04: Care and welfare of people who use services What the outcome says This is what people who use services should expect. People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. What we found The provider is compliant with Outcome 04: Care and welfare of people who use services Our findings What people who use the service experienced and told us One patient said; "I like it a lot here. I get chance to go out and can now use public transport. Staff listen and generally care about your mental heath. I used to harm myself but no longer do this. Staff are very friendly and approachable and we have a laugh. I have not found this in other places where I have been." Another patient told us the food was "fantastic" and they were offered the opportunity to have takeaway meals each week. Other evidence Care and treatment was delivered in a way that ensured patient's safety and welfare and protected them from unlawful discrimination. We saw that each patient had care programme approach (CPA) meetings and regular multidisciplinary meetings (MDT) to review their needs, treatment and progress. Specialist therapy sessions were also held such as psychological therapies and dialectical behaviour therapy for patients with specific needs. The multi-disciplinary team who were all employed to solely work at the hospital included the nursing team, health care support workers, psychiatrists, psychologists and occupational therapists. This was important to make sure that each patient's care was consistent and their care plan was regularly reviewed by everyone involved in delivering their care. We also saw evidence to show that patients had regular checks on their physical health. A GP visited the hospital weekly and saw patients within a private clinic area. Page 9 of 19

10 When we spoke with staff and looked in patient's care records we found there was a commitment to positive risk taking so that decision making about risks considered developing the patient's independence and skills as well as their and other people's safety needs. Staff explained the circumstances and actions taken to keep patients safe and we saw this had been recorded appropriately. We saw risk assessments and review systems were in place and these were regularly updated. We looked at patient's behavioural management plans which were clear, detailed and specific. Where restraint and seclusion had been used this was documented. Some patients when becoming unsettled requested to have private time in an Enhanced Nursing Area (ENA). This was also documented so that it was clearly detailed why ENA had been used and how this had been managed to ensure the patient's rights were protected and their and other people's health and safety needs were met. However, some of the information was located in different areas so this made it more difficult to link information together. The provider may find it useful to note that when restraint had taken place, the restraint records did not include any information to show that the patient had been checked for any injuries afterwards. We also found that when rapid tranquilisation had been administered, there was no documentation to show that the patient's vital signs were checked following this in order to monitor the patient's physical wellbeing. Staff explained that families could visit the service at different times of the day and at weekends. Because of the security in the hospital, there were restrictions in the way visits took place. For instance, patients met their family and friends in a special visitor's room, so they did not enter the ward. There was a designated area which visitors reported to. Patients were compulsorily detained under the Mental Health Act 1983 (amended 2007) and we saw they had section 17 leave arrangements in place. We looked at the section 17 leave forms and found these clearly stated the agreed conditions of leave, such as where the leave could be taken, the duration of this and the number of staff that were needed to escort the patient during this time. Patients were offered a copy of their leave entitlements. Staff recorded when detained patients left the unit to have section 17 leave and patient's leave was regularly reviewed within ward round meetings. Audit information showed that patient's leave had only been cancelled where there were concerns about the patient's or other people's safety. All staff had received training about the Mental Health Act and the Mental Capacity Act. This helped their understanding in making sure they followed correct procedures to protect the rights of detained patients. Patients were complimentary about the quality of food provided. Once a week they had the opportunity to have a takeaway meal, although there were no restrictions on this. The registered manager explained that some patients did not have enough money to purchase a takeaway meal for whatever reason. In order to accommodate these patients, the chef was asked to cook a meal similar to the choice of takeaway meal and this was delivered to the patient in a takeaway box. This practice helped in making sure none of the patients were excluded and that care was planned in a patient centred manner. There were a large range of activities that were on offer such as education groups, mental health awareness, and cookery and technical skills. Within the hospital patients Page 10 of 19

11 could also attend a gym and swimming pool but were also encouraged to have involvement with these facilities within the local community. There were trips out to the local shops and some patients were involved in a local community group and went off for day trips. The hospital had links with voluntary services such as Age UK (previously Help the Aged) and charities and helped supported patients to find voluntary work where possible. This gave patients a sense of social inclusion and belonging and helped to improve their levels of confidence and self-esteem. Some patients enjoyed smoking. As part of the new building programme there were very modern smoking shelters with roofing to protect patients in bad weather. Patients were able to access the courtyard to have a cigarette at least every hour. The opening of the new build had significantly improved the living environment for the patients at the hospital and had led to a reduction in the number of incidents. However, the provider may find it useful to note that temperatures throughout the hospital fluctuated with some areas being very warm. Excessive heat can cause irritability and agitation and affect mood and behaviour which could potentially lead to serious incidents. A review of the current heating arrangements would help in minimising any potential risks from this. Patients experienced care, treatment and support that met their needs and protected their rights. The provider was meeting this standard. Page 11 of 19

12 Outcome 09: Management of medicines What the outcome says This is what people who use services should expect. People who use services: * Will have their medicines at the times they need them, and in a safe way. * Wherever possible will have information about the medicine being prescribed made available to them or others acting on their behalf. What we found The provider is compliant with Outcome 09: Management of medicines Our findings What people who use the service experienced and told us Patients were able to explain why they were taking certain medications and said that the medical team had explained to them about the possible side-effects from the medication prescribed and had sought their consent about taking the treatment. Other evidence We found that medications were prescribed and given to patients appropriately. We looked at the medication arrangements and spoke with a nurse about the medication procedures. We saw that medication was stored safely and securely within a designated area. Daily temperature checks were undertaken and recorded within the medication room and fridges used to store medication, to make sure all medication was being stored at suitable and safe temperatures. Medication Administration Records (MAR) were written by the psychiatrist who undertook monthly medication reviews to make sure the treatment was still appropriate in meeting the patient's needs. We saw records to show that staff regularly reminded patients about their rights whilst under detention. Patients were told about the reasons for the use of any medication they were prescribed and about any potential side-effects from taking it. There were also records to show that the patient consented to continue having their treatment. Page 12 of 19

13 When we looked in patients' care records we saw that in some cases emergency treatment had to be administered under section 62 of the Mental Health Act 1983 (amended 2007). We were told that when this happened this triggered a request for a Second Appointed Opinion Doctor (SOAD) to be informed in case the patient was no longer consenting to having their treatment. The provider may find it useful to note that when looking through one patient's records, on one occasion this had not happened. The registered manager explained this had occurred whilst the hospital's approved clinician was on leave and their replacement had not followed the proper procedure. We saw written evidence that the manager had sent information out to all responsible medical staff about the need to notify SOAD's whenever section 62 was used. The manager assured us they would be addressing this matter with the person in question. When we looked at the medication records we saw that the majority of medication records were satisfactory. On two occasions staff had not signed the records to confirm they had administered medication. A pharmacist visited the hospital weekly to audit the medication systems and used a communication book to record any discrepancies. They had identified the two omissions within the medication records and the clinical nurse manager told us she was following up the signature omissions with the staff on duty on the days in question to clarify the shortfalls and to take any necessary actions. There were appropriate storage facilities for controlled drugs although at the time of our visit none of the patients were prescribed this type of medication. Staff checked the controlled drugs supplies during staff handover periods between the day and night shifts. Some patients needed to have regular blood tests to monitor potential side-effects from the medication they were taking. There was a list of dates to remind staff as to when these tests were due. Staff who administered medication received the appropriate training and received regular updates. There was also drug information available which staff could refer to if they had any queries. Patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. The provider was meeting this standard. Page 13 of 19

14 Outcome 14: Supporting workers What the outcome says This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by competent staff. What we found The provider is compliant with Outcome 14: Supporting workers Our findings What people who use the service experienced and told us One patient said; "Staff are very helpful, especially the manager." Each patient spoken with said that there had never been any shortfalls in staffing levels that had resulted in cancellation of their section 17 leave. Other evidence We found that staff received appropriate professional development. The staff training matrix provided details about staff training and planned future training. The information showed that all staff undertook a good range of training. As well as mandatory training, staff had other training that was relevant to the patient group, for example; training about the Mental Capacity Act and Mental Health Act. The hospital employed a training co-ordinator to organise and provide in-house training. An external training provider was being used to provide training about the use of physical interventions. Staff told us that there was good training provided to help maintain and develop their knowledge and skills in meeting the needs of the patients in their care. One member of staff said; "The training is very good and we feel well supported as a staff team." Staff turnover was low and the atmosphere within the units visited was relaxed. Supervision arrangements were in place. Staff said they received supervision twice a month and a staff member described these as "very useful." There were also reviews following any serious incidents to support staff and to look at ways incidents had been Page 14 of 19

15 managed and any improvements that could be made to avoid a repeat of the incident. Staff took part in reflective practice sessions where they were able think about their working practices and reflect on their strengths and areas for development. There was a comprehensive induction programme for new staff who had a six-month probationary period before their employment is confirmed. New workers had a mentor who provided guidance and support to them. Patients were cared for by staff that were supported to deliver care and treatment safely and to an appropriate standard. The provider was meeting this standard. Page 15 of 19

16 Outcome 17: Complaints What the outcome says This is what people should expect. People who use services or others acting on their behalf: * Are sure that their comments and complaints are listened to and acted on effectively. * Know that they will not be discriminated against for making a complaint. What we found The provider is compliant with Outcome 17: Complaints Our findings What people who use the service experienced and told us Patients spoken with told us they felt able to make comments or complaints and believed they would be listened to and their concerns acted on, without the fear that they would be discriminated against for making a complaint. One patient told us, "I think it is alright here. I am relaxed and know if I have any concerns I can go to the staff. The patient said when they did not feel well they could tell the staff and they would suggest things for her to do to relax her. This included having a bath and listening to music. Other evidence We found that patient's complaints were fully investigated and resolved where possible and to their satisfaction. There was a complaints procedure which included the timescales in which complaints would be responded to. The manger kept a record of complaints received and we looked at the records from the previous six months. We saw that there had been 17 complaints made, six of which had been withdrawn. Each complaint had been properly investigated and the complainant received written feedback about the outcomes from the investigation and details of the action taken. We also saw that a letter of apology had been sent out if there had been a delay in the response time. Staff spoken with were aware of the procedure to follow should someone wish to make a complaint. There was also a copy of the complaints procedure available in each unit. Page 16 of 19

17 This included contact details for external agencies such as the local authority and CQC so that patients could contact these agencies if they did not want to raise concerns directly with the management team at Waterloo Manor. Patients who had attended arts and crafts sessions organised by the occupational team had previously commented that the sessions were often "basic." Because of this a 'technical design' group had been developed to provide more sophisticated arts and crafts activities. This provided an example of how patients' views and wishes were taken seriously and acted on. There was an effective complaints system in place. Comments and complaints people made were responded to appropriately. The provider was meeting this standard. Page 17 of 19

18 What is a review of compliance? By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. Where we judge that providers are not meeting essential standards, we may set compliance actions or take enforcement action: Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. We ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 18 of 19

19 Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public / Copyright (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Quality Commission Website Telephone address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 19 of 19