Review of compliance. Adult Mental Health Services Tower Hamlets Directorate. East London NHS Foundation Trust. London. Region:

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1 Review of compliance East London NHS Foundation Trust Adult Mental Health Services Tower Hamlets Directorate Region: Location address: Type of service: London Tower Hamlets Centre for Mental Health Bancroft Road Mile End London E1 4DG Hospital services for people with mental health needs, learning disabilities and problems with substance misuse. Rehabilitation services. Community based services for people with mental health needs. Date the review was completed: November & December 2010 Overview of the service: Adult Mental Health Services Tower Hamlets Directorate is part of East London Foundation NHS Trust. Page 1 of 42

2 The Tower Hamlets Centre for Mental Health provides inpatient care to people with mental health problems who live in Tower Hamlets. Outpatient follow up and community mental health services are provided through four Community Mental Health Teams, situated throughout the borough. The trust also provides specialist mental health services within Tower Hamlets including an Early Intervention Psychosis Team and a crisis service that includes a Home Treatment Team. There are also psychotherapy, occupational therapy and psychological services provided to people receiving a service either as an inpatient or in the community. Page 2 of 42

3 Summary of our findings for the essential standards of quality and safety What we found overall We found that Adult Mental Health Services Tower Hamlets Directorate was not meeting one or more essential standards. Improvements are needed. The summary below describes why we carried out the 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. On the 25 th November 2010 we visited six inpatient wards at the Tower Hamlets Centre for Mental Health. A team of four Inspectors visited Globe, Millharbour, Rosebank and Brick Lane wards. Two specialist Pharmacy Inspectors visited Lea ward where they focused on medication practices. A Mental Health Act Commissioner visited Roman ward. During these visits we observed how people were being cared for, talked to people who use services and talked to staff. We also checked records maintained by the provider, including some personal records for people using the service. On the 1st December a Compliance Inspector and a Compliance Manager visited a Community Mental Health Team in Tower Hamlets where outpatient and community mental health services are provided. During our community visits we talked to people who use the service, to relatives and carers of people using the service and to staff. We also examined relevant records. What people told us People using the service in the community spoke highly of the staff working with them. People using inpatient services told us that they received a welcome pack when they arrived on the ward and had their rights explained to them by staff. During our visit we observed good relationships between staff and people using the inpatient service. Some of the people we spoke to told us that their treatment had been explained to them. Page 3 of 42

4 We spoke with people using inpatient and community services, they told us they were supported to engage in a range of activities. People using inpatient services gave mixed views about the meals provided. During our visits the wards we visited were clean and hygienic. What we found about the standards we reviewed and how well Adult Mental Health Services Tower Hamlets Directorate was meeting them Outcome 1: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run In our judgement people who use the service understand the care, treatment and support choices available to them, and have their views taken into account. The provider recognises diversity and values the human rights of people using the service, and the trusts decision to end sleeping out further promotes positive outcomes in this area for people using the service. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 2: Before people are given any examination, care, treatment or support, they should be asked if they agree to it In our judgement the provider is not effectively implementing its systems to ensure that it obtains the consent of people using the service. Where people are detained under the Mental Health Act 1983 the provider must ensure that all required documentation is completed. The provider should also ensure that everyone who uses the service is aware of advocacy services and how to access them. Overall, we found that improvements are needed for this essential standard. Outcome 4: People should get safe and appropriate care that meets their needs and supports their rights In our judgement the majority of people using the service experience effective, safe and appropriate care, treatment and support. However, the provider should review its practice of accommodating acutely unwell people with those nearing the end of their admission. Potential risks and physical health needs should be appropriately addressed and recorded. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard but, to maintain this, we have suggested that some improvements are made. Outcome 5: Food and drink should meet people s individual dietary needs Page 4 of 42

5 On balance, people who use the service have access to adequate nutrition and have choices that meet their diverse needs. To promote choice, the provider could consider providing toasters on each inpatient ward. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 6: People should get safe and coordinated care when they move between different services In our judgement people receive a service that is safe and co-ordinated. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 7: People should be protected from abuse and staff should respect their human rights In our judgement despite efforts already made by the trust, some people using inpatient services are at potential risk of harm. The provider should also ensure that where needed there are suitable means for people using the service to be able to call for assistance from their bedrooms. The provider should ensure clearly evidence that all staff receive safeguarding adults training. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard but, to maintain this, we have suggested that some improvements are made. Outcome 8: People should be cared for in a clean environment and protected from the risk of infection In our judgement people who use the service benefit from a clean and hygienic environment. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 9: People should be given the medicines they need when they need them, and in a safe way In our judgement people are protected by systems which ensure they receive the correct medication and have access to a pharmacist for advice and guidance on their medication. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 10: People should be cared for in safe and accessible surroundings that support their health and welfare Page 5 of 42

6 In our judgement people who use services benefit from safe, accessible surroundings. However the provider should ensure that the temperature on all inpatient units can be maintained at comfortable levels. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard but, to maintain this, we have suggested that some improvements are made. Outcome 11: People should be safe from harm from unsafe or unsuitable equipment In our judgement people who use the service are not at risk of harm from unsafe equipment. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 12: People should be cared for by staff who are properly qualified and able to do their job The trust has an effective system in place to check the suitability of staff before they are employed. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs In our judgement people who use the service are safe, and their health and welfare needs are met by sufficient number of appropriate staff. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 14: Staff should be properly trained and supervised, and have the chance to develop and improve their skills In our judgement people who use the service have their health and welfare needs met by competent staff that are appropriately trained Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care People receive a service that is carefully monitored with robust governance arrangements in place. The trust investigates and learns from incidents to further improve outcomes for the people who use their services. Page 6 of 42

7 Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 17: People should have their complaints listened to and acted on properly In our judgement the provider has systems in place to deal with comments and complaints from people who use the service. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Outcome 21: People s personal records, including medical records, should be accurate and kept safe and confidential In our judgement the inpatient personal records we saw were accurate and fit for purpose. Overall, we found that Adult Mental Health Services Tower Hamlets Directorate was meeting this essential standard. Action we have asked the service to take We have asked the provider to send us a report within 28 days of them receiving this report, setting out the action they will take to improve. We will check to make sure that the improvements have been made. Other information This was the services first review since registration under the Health and Social Care Act 2008 Page 7 of 42

8 What we found for each essential standard of quality and safety we reviewed Page 8 of 42

9 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. A minor concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard. A moderate concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard and there is an impact on their health and wellbeing because of this. A major concern means that people who use services are not experiencing the outcomes relating to this essential standard and are not protected from unsafe or inappropriate care, treatment and support. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary improvements are made. Where there are a number of concerns, we may look at them together to decide the level of action to take. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety. Page 9 of 42

10 Outcome 1: 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 1: Respecting and involving people who use services. Our findings What people who use the service experienced and told us People using the service in the community told us that staff are very approachable and helpful, the service is fantastic, and I really get the help I need. Some people using the inpatient service told us that they received support with medication and spoke to the nurses if they needed anything. On some wards people using the service did not appear to know who their named nurse was. Other people using the inpatient service reported that they did not have regular one to one meetings with staff. There seemed to be variations across wards regarding access to talking therapies. On some wards people told us they were receiving these services, whilst on other wards people told us that there were delays in accessing these services. During our visit we observed good relationships between staff and people using the service People using inpatient services told us that they received a welcome pack when they arrived on the ward. People who were detained under section of the Mental Page 10 of 42

11 Health Act knew their rights. Staff told us that they explain these rights regularly to people who are detained under section and record this in their personal file. Discussion with people who use the service and sampling of care plans showed that on balance, people who use the service are involved in care planning, and that staff use a this is me tool with people using inpatient services to identify and include their perspective and wishes in care plans. We looked at the personal files of several people using the service. These showed that a full needs assessment had been carried out, and that this included information from other agencies involved in the persons care. Staff in the community told us that new referrals are discussed at weekly multi disciplinary meetings. The referral is allocated to the most appropriate discipline for initial assessment. Staff across inpatient and community services told us that people using the service are encouraged to participate in ward reviews, Care Program Approach meetings and one to one meetings to ensure their wishes and needs are heard and included in the decision making process. The staff we spoke to told us that all disciplines were included in the decision making process. On some of the wards we visited people have their own private bedrooms with ensuite facilities. People using the inpatient service commented that they received as much privacy as they need. Some people using told us that they did not have keys to their bedrooms and had to ask staff to lock and unlock their rooms. Some wards we visited were mixed gender, and people using the service told us that they would prefer to have single sex accommodation. During our visit we observed that public telephones were situated in very busy communal areas of the ward and did not afford any privacy. This was commented on by several people using the service. In addition, people on some wards told us that they did not know how to access a public telephone. Our discussions with staff demonstrated a good understanding of privacy and sensitivity when observing someone using inpatient services on a one to one basis. People we spoke to who use the service told us that their dignity and privacy was respected by their care team. We noted that on the day of our visit to inpatient services, there were issues regarding over occupancy. One of the wards we visited had nineteen beds. However, twenty six people were receiving care on the ward. Seven of the people were sleeping out on other wards at the unit. We spoke with three people who were using the service who were sleeping out on another ward. They told us that they had limited access to their named nurse as a result of moving between wards, and also commented that they were not able to speak to someone about their personal problems. Staff told us that they also felt concerned about the sleeping out arrangements as they thought it was bad practice. We approached the trust about this practice, and they told us that this practice on Globe ward was stopped by the end of November Page 11 of 42

12 We spoke to staff in the community who told us that despite bed pressures, they were still able to access inpatient services where an assessment had indicated this was appropriate. People using the service told us that staff respect their wishes with regards to gender of worker, for example some women using the service only want their medication injections administered by a female nurse. Prayer rooms are available on some wards. Staff also told us how one person wishing to observe Ramadan had had their medication and meal timings adjusted. Staff in the community told us that they can access the Cultural Consultation Service attached to Queen Marys University which promotes the understanding of different cultures. We were told by staff that they can readily access interpreting services and have received training in the use of interpreters. Other evidence We looked at the reports of Mental Health Act Commissioners who had visited the inpatient wards over the last year. This indicated that at other times in the year over occupancy had been an issue. In the period 2009/2010 trust records indicate that bed occupancy over the whole trust, including Tower Hamlets Centre for Mental Health, were at 97.3%. The trust stated that it aimed to reduce this to 85% in the 2010/2011 period. As already stated, the trust has told us that it has now ended the practice of people sleeping out on other wards from Globe ward, and that people using the inpatient service were now only admitted to wards with vacant beds. Prior to our visit we saw a leaflet the trust had prepared for informal patients that explained their rights. We found this to be easy to read and understand. In our judgement people who use the service understand the care, treatment and support choices available to them, and have their views taken into account. The provider recognises diversity and values the human rights of people using the service, and the trusts decision to end sleeping out further promotes positive outcomes in this area for people using the service. Page 12 of 42

13 Outcome 2: Consent to care and treatment What the outcome says This is what people who use services should expect. People who use services: Where they are able, give valid consent to the examination, care, treatment and support they receive. Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed. Can be confident that their human rights are respected and taken into account. What we found There are moderate concerns with outcome 2: Consent to care and treatment. Our findings What people who use the service experienced and told us One person we spoke to who was using inpatient services told us that they had been taking their medication for a long time. They said that it had been explained to them why they needed to take it, but that they thought it was too strong. People receiving a service in the community told us that their treatment had been explained to them, and that they had been able to give their informed consent. On some wards we visited people using the service told us that they did not know about advocacy services or how to contact them. Some people in the community had accessed advocacy services and they told us that they were very helpful. On one of the wards we visited we looked at the personal files of people using the service. On some of the files we could not find any evidence that the capacity of people using the service was being assessed. We were also unable to find evidence that some peoples consent to treatment was being sought. Other evidence When the trust applied for registration it told us that it was not compliant with some Page 13 of 42

14 areas of this outcome. The trust told us that its own audit regarding compliance with the Mental Health Act 1983 had identified that 12% of people receiving treatment as an inpatient across all directorates, including at the Tower Hamlets Centre for Mental Health, were being treated with at least one medication for which there was no legal authority. The trust told us that each in each case the person receiving treatment had been informed and the situation rectified. The trust also told us about of range of measures it had put in place to ensure future compliance, including weekly spot checks on personal files. As part of the planned review process we reviewed the findings of Mental Health Act Commissioners who had visited wards at the Tower Hamlets Centre for Mental Health over the last year. These reports indicated that there were shortcomings in the recording and documentation relating to people consenting to their treatment. The Commissioners also noted that some discussions required under the Mental Health Act 1983, for example with a Second Opinion Appointed Doctor were also not appropriately documented. In our judgement the provider is not effectively implementing its systems to ensure that it obtains the consent of people using the service. Where people are detained under the Mental Health Act 1983 the provider must ensure that all required documentation is completed. The provider should also ensure that everyone who uses the service is aware of advocacy services and how to access them. Page 14 of 42

15 Outcome 4: 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 4: Care and welfare of people who use services. Our findings What people who use the service experienced and told us People using inpatient services told us that there is a range of activities available for them to access on the wards. These include arts, dance and movement therapy, reading, music therapy and gym sessions. There are notice boards displaying information about activities on the wards and in the local community. During our visit we observed staff and people using the service chatting and playing board games. People in the community had been supported to access a range of activities including gym membership. Some had received support to access college courses and others were being supported into employment. One of the wards we visited had a seclusion room. We spoke to staff who told us it was used as a last resort. We saw the seclusion room and noted that it was clean and well maintained. We also looked at records which showed that its use varied from several hours to several days. We noted that people using the seclusion room were regularly observed by staff and that an authorisation to use seclusion was completed and held in the personal file. Another ward we visited accommodates people who are both acutely unwell and Page 15 of 42

16 those who are at the point of moving back into the community. We raised some concerns about this mix of needs and some of the staff did agree that it could at times be detrimental to the progress of some people when those who were acutely unwell displayed episodes of disruptive or challenging behaviour. We looked at a number of personal files. These showed that for one person using the service a history of severe physical assaults had been recorded. However, we could not see that this potential risk had been appropriately addressed in the persons risk assessment. In other personal files we looked at there we did see that potential risks had been appropriately addressed in the risk assessment, however these potential risks had not been included in the persons care plan, so it was not clear how these issues would be addressed and worked on with them. Staff also told us that there is a GP service on site that people using inpatient services can access. However, two people who we spoke with told us that they were experiencing minor health problems. We looked at their personal files and it was not clear how these issues were being addressed. One person using the service was pregnant. Staff told us that they check in with this person during every shift, and have made contact with local midwifery services who visit regularly. Staff also told us that dental services visit the inpatient unit twice weekly. People using the service in the community told us that they had been given details of out of hours and emergency mental health services. One person we spoke to had used these services. They commented that they had been very helpful. Other evidence As part of the planned review process we reviewed the findings of Mental Health Act Commissioners who had visited wards at the Tower Hamlets Centre for Mental Health over the last year. In these reports the Mental Health Act Commissioners raised some concerns about this mix of needs and some of the staff did agree that it could at times be detrimental to the progress of some people when those who were acutely unwell displayed episodes of disruptive or challenging behaviour. In our judgement the majority of people using the service experience effective, safe and appropriate care, treatment and support. However, the provider should review its practice of accommodating acutely unwell people with those nearing the end of their admission. Potential risks and physical health needs should be appropriately addressed and recorded. Page 16 of 42

17 Outcome 5: Meeting nutritional needs What the outcome says This is what people who use services should expect. People who use services: Are supported to have adequate nutrition and hydration. What we found The provider is compliant with outcome 5: Meeting nutritional needs. Our findings What people who use the service experienced and told us People who use the service gave us mixed reviews regarding food. One person told us that the halal food here isn t tasty. We did observe meal time on one ward, and we found that the food was hot, served in good portions and looked healthy and appetising. We looked at the menus on other wards, and noted that a variety of choices including kosher, halal and vegetarian were available, and that the choices seemed varied. People we spoke to told us that snacks and drinks are available on wards in between meal times. However food was locked away so people using the service had to ask staff to access. Several people complained that there was no toaster on the ward, and that this meant they could not have toast for breakfast or as a snack. On balance, people who use the service have access to adequate nutrition and have choices that meet their diverse needs. To promote choice, the provider could consider providing toasters on each inpatient ward. Page 17 of 42

18 Outcome 6: Cooperating with other providers What the outcome says This is what people who use services should expect. People who use services: Receive safe and coordinated care, treatment and support where more than one provider is involved, or they are moved between services. What we found The provider is compliant with outcome 6: Cooperating with other providers. Our findings What people who use the service experienced and told us People using the service in the community told us that they knew who was involved in their care and the name and contact details of their Care Co-ordinator. Discussion with inpatient and community staff showed that large numbers of people using inpatient and community services have complex social issues, and that problems such as housing can cause delays in discharge. We were told that there is a weekly bed meeting to address any social issues and how these might be addressed to free up inpatient beds. We were also told that the trust has developed links with other agencies and were able to refer people using the service for a community support worker. Some people using the service in the community commented that the handover between the Home Treatment Team and the Community Mental Health Team was not always smooth. We were given examples of confusion over visit times and medication changes. However, the people we spoke to said that these issues had been raised at the time and all had been dealt with quickly and appropriately. Staff we spoke to told us that there were good links between the Community Mental Health Teams and the inpatient wards. We were also told that community workers attend ward reviews and discharge planning meetings. Page 18 of 42

19 In our judgement people receive a service that is safe and co-ordinated. Page 19 of 42

20 Outcome 7: Safeguarding people who use services from abuse What the outcome says This is what people who use services should expect. People who use services: Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld. What we found The provider is compliant with outcome 7: Safeguarding people who use services from abuse. Our findings What people who use the service experienced and told us Some people using inpatient services on one ward raised concerns about bullying. They told us that they had been subjected to threats and intimidation from other people using the service. One person using the service told us that they had been moved between wards as they had not felt safe. We discussed this with staff who told us that they were aware of these issues and gave instances where police had been called to the unit to deal with allegations of bullying. They also told us that there is a zero tolerance approach to this issue, and that increased observations are used to monitor the situation when bullying is reported or suspected We spoke to one person using inpatient services who was using a peg feed. They told us that they must lie down whilst receiving the peg feed, and that a possible complication of the peg feed is choking. This person told us that they were concerned as there was no call alarm in their room should they need assistance when using the peg feed. Staff we spoke to had received safeguarding training and gave examples of safeguarding incidents involving children that they had been involved with. Some staff we spoke to told us that they had not received safeguarding adults training. Page 20 of 42

21 Other evidence The trust produced a Safeguarding Children Annual Report This identified providing safeguarding children training to all staff as a priority. In December 2009 the trust reviewed its progress in this area and there was an improvement in the numbers of staff completing this training. In its application for registration, the trust stated that it was compliant with this outcome and that 88% of all trust staff had completed safeguarding children training. In our judgement despite efforts already made by the trust, some people using inpatient services are at potential risk of harm. The provider should also ensure that where needed there are suitable means for people using the service to be able to call for assistance from their bedrooms. The provider should ensure clearly evidence that all staff receive safeguarding adults training. Page 21 of 42

22 Outcome 8: Cleanliness and infection control What the outcome says Providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. What we found The provider is compliant with outcome 8: Cleanliness and infection control. Our findings What people who use the service experienced and told us People who use the service told us that the wards were clean and hygienic, and we found this to be the case during our visit. Other evidence As part of the planned review process we reviewed the findings of Mental Health Act Commissioners who had visited wards at the Tower Hamlets Centre for Mental Health over the last year. These reports indicated that the wards visited were clean and hygienic. In our judgement people who use the service benefit from a clean and hygienic environment. Page 22 of 42

23 Outcome 9: 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 9: Management of medicines. Our findings What people who use the service experienced and told us We met with people using inpatient services. They told us my view is considered and I can refuse medicines if I want to". This person said that they had seen the pharmacist but they did not know the names or possible side effects of the medicines they were currently taking. Another person told us that they were happy with their treatment and had no concerns. Other evidence Staff explained to us how care is taken to get an accurate record of the medicines a person is already taking when they are admitted to the ward. The pharmacist will check this record when felt necessary to make sure medicines are given safely. The pharmacist visits the ward every day and talks to staff and people using the service, as well as checking medicine charts. Patients can ask the ward staff or pharmacist for written information about their medicines, including side-effects. We looked at medicine charts and found that these were completed accurately and any known allergies were written on the front of each person's chart. Medicines prescribed on charts corresponded with information about people's medicines that was recorded on forms that had been completed to meet legal requirements. We watched medicines being given to people and saw that the system used was appropriate. Page 23 of 42

24 In our judgement people are protected by systems which ensure they receive the correct medication and have access to a pharmacist for advice and guidance on their medication. Page 24 of 42

25 Outcome 10: Safety and suitability of premises What the outcome says This is what people should expect. People who use services and people who work in or visit the premises: Are in safe, accessible surroundings that promote their wellbeing. What we found The provider is compliant with outcome 10: Safety and suitability of premises. Our findings What people who use the service experienced and told us Each ward we visited had a range of communal areas that were appropriately furnished. Several people using the service complained that the beds were very hard. Inpatient wards located on the ground floor have their own gardens. Wards located on the first floor have access to garden facilities on the ground floor. We were told that staff will escort people to the garden area if required. On several of the wards we visited there were issues regarding the storage of valuables belonging to people using the service. Items were being held in storage boxes in consultation rooms on the wards. Staff told us that refurbishment works were underway, and that proper storage would be provided as part of these works. We were also told that CCTV is being fitted on some wards to improve staffs ability to see what is happening outside of communal areas. Staff told us that they carry personal alarms, On mixed gender wards the bedroom and bathroom areas are segregated. During our visit to Roman ward we noted that the ward was extremely hot. We were told by staff that there were issues in regulating temperature on the ward, and that often the environment was either too hot or too cold. One of the wards we visited had locked doors. There was a sign on the door Page 25 of 42

26 advising voluntary patients of their right to leave. People who use the service in the community told us that appropriate rooms are always available for their meetings. Staff told us that the centre would be moving to new accommodation in the near future. Other evidence As part of the planned review process we reviewed the findings of Mental Health Act Commissioners who had visited wards at the Tower Hamlets Centre for Mental Health over the last year. These reports indicated that potential ligature points had been identified on a number of wards. In September 2010 a report regarding this issue was presented to the board trust. This report stated that a trust wide audit of ligature points was taking place. On the wards we visited there we did not see ligature points that people could use to harm themselves. The Mental Health Act Commissioners will continue to monitor this outcome as part of their regular visits. In our judgement people who use services benefit from safe, accessible surroundings. However the provider should ensure that the temperature on all inpatient units can be maintained at comfortable levels. Page 26 of 42

27 Outcome 11: Safety, availability and suitability of equipment What the outcome says This is what people should expect. People who use services and people who work in or visit the premises: Are not at risk of harm from unsafe or unsuitable equipment (medical and nonmedical equipment, furnishings or fittings). Benefit from equipment that is comfortable and meets their needs. What we found The provider is compliant with outcome 11: Safety, availability and suitability of equipment. Our findings What people who use the service experienced and told us When we visited the wards there was no obvious broken equipment. In our judgement people who use the service are not at risk of harm from unsafe equipment. Page 27 of 42

28 Outcome 12: Requirements relating to 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 staff who are fit, appropriately qualified and are physically and mentally able to do their job. What we found The provider is compliant with outcome 12: Requirements relating to workers. Our findings What people who use the service experienced and told us Staff told us that they had undergone pre employment checks. These included taking up references, applying for a Criminal Records Bureau checks and providing proof of professional registration. The trust has an effective system in place to check the suitability of staff before they are employed. Page 28 of 42

29 Outcome 13: Staffing 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 sufficient numbers of appropriate staff. What we found The provider is compliant with outcome 13: Staffing. Our findings What people who use the service experienced and told us One patient commented that staff sometimes appeared stretched and didn t always have time to just sit with you and find out how you are. However during our visit we observed that the unit appeared well staffed, with staff interacting well with people using the service. We spoke with staff employed within inpatient services. They told us that there were staffing vacancies on the ward, and that these are covered by regular bank staff. We were also told that there had been an increase in staffing levels on the inpatient unit. Staff we spoke to both in the community and hospital told us that there was the right mix of skills to meet the needs of people using the service Other evidence As part of the planned review process we reviewed the findings of Mental Health Act Commissioners who had visited wards at the Tower Hamlets Centre for Mental Health over the last year. These reports indicated that on some wards it had been observed that there were insufficient staff this was noted as having occurred when the ward was over occupied. As previously stated, during our visit we found that wards appeared to be appropriately staffed, however Mental Health Act Commissioners will continue to monitor this outcome as part of their regular visits. Page 29 of 42

30 As a result of investigations into serious untoward incidents that had occurred across all directorates, the trust had reviewed and increased staffing levels. Our discussions with staff and people using the service showed that these increases had been implemented. In our judgement people who use the service are safe, and their health and welfare needs are met by sufficient number of appropriate staff. Page 30 of 42

31 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 Staff we spoke to told us that they receive regular supervision and have access to practice groups facilitated by psychology staff and clinical improvement groups. Staff also said that they attend regular staff meetings. We also saw records that showed staff performance was being monitored with training and support being provided to improve practice. The staff we spoke to told us that they received regular training. We were also told that that senior staff are seen regularly on the wards, and are easily accessible. Other evidence At the time of registration the provider declared non compliance against this outcome. They told us that that their records showed that statutory and mandatory training had not been regularly provided to all staff. The trust said that to address this issue it had recruited additional training staff and purchased new training materials. In addition the trust was planning to update its training records and improve staff access to these so that they could easily book training. In July 2010 training information presented to the trust board showed that improvements in the numbers of staff attending mandatory training had been achieved. The trust told us that it had introduced initiatives to ensure that all staff receive Page 31 of 42

32 monthly supervision and that there are protected time slots for case presentation and increased visibility of senior staff on wards. Our discussions with staff showed that these initiatives had been implemented. We noted that from the Trusts figures incidents involving violence and aggression and steadily risen from April 2009 to March The trust responded by organising a 5 day training for all staff on preventing and managing violence and aggression, with regular refresher days to follow up. By July 2010 the trust reported that 80% of all staff had completed this training. We noted that the trusts incident report for October 2010 identified that whilst violence and aggression were still the most commonly reported incidents, the overall number of incidents had fallen. In our judgement people who use the service have their health and welfare needs met by competent staff that are appropriately trained Page 32 of 42

33 Outcome 16: Assessing and monitoring the quality of service provision What the outcome says This is what people who use services should expect. People who use services: Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety. What we found The provider is compliant with outcome 16: Assessing and monitoring the quality of service provision. Our findings What people who use the service experienced and told us Some staff we spoke to told us that they had reported incidents using the trusts procedure. They told us that the incidents had been properly investigated, and that they had received follow up support. Other evidence We have information about the trust which tells us about their quality assurance and governance arrangements. The trust has a stable executive and non-executive team, with just a few changes over the past year. Attendance at board meetings is good and it appears that the board are very aware of key issues around bed occupancy, serious untoward incidents and the need to provide separate gender care on wards. Board members have also undertaken visits to specific wards. The trust has a wide number of measures in place to monitor its own performance. This has included undertaking patient surveys and a number of specific audits looking at case notes, consent to treatment recording and Care Program Approach. The trust has monitored itself against targets set by the Royal College of Page 33 of 42

34 Psychiatrists Centre, Acute Inpatient Mental Health Services and was also a member of the Audit Commissions Mental Health Benchmarking Club. This is overseen by the Information Governance Steering Group. The trust holds regular meetings with the Primary Care Trust Commissioners, who have also made monitoring visits to the trust. In the past year and a half there have been serious incidents, some of which have occurred within this directorate. These have resulted in very in depth investigations with a trust wide project board ensuring that the recommendations that have come out of these investigations are being put into practice. Our visit has found a number of examples of these new measures being successfully implemented. People receive a service that is carefully monitored with robust governance arrangements in place. The trust investigates and learns from incidents to further improve outcomes for the people who use their services Page 34 of 42

35 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 One person who used inpatient services told us that they had made a complaint, but that they had not felt listened to. On some of the wards we visited the people we spoke to told us that they did not know how to make a complaint and had not been given any information about this. However, during our visit we noted that complaints information was displayed on notice boards in communal areas. Other evidence The Trust have told us that they have appointed a complaints manager in July They have also monitored and ensured they have responded to complaints within the target times. Staff training has been offered on customer care, but this is not mandatory and has had a low uptake. In our judgement the provider has systems in place to deal with comments and complaints from people who use the service. Page 35 of 42

36 Outcome 21: Records What the outcome says This is what people who use services should expect. People who use services can be confident that: Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential. Other records required to be kept to protect their safety and well being are maintained and held securely where required. What we found The provider is compliant with outcome 21: Records. Our findings What people who use the service experienced and told us We scrutinized a number of personal files. The files we looked at were generally in good order. Some people who were detained under section of the Mental Health Act 1983 told us that they did receive copies of their leave forms, as required by the Code of Practice. Other evidence As part of the planned review process we reviewed the findings of Mental Health Act Commissioners who had visited wards at the Tower Hamlets Centre for Mental Health over the last year. These reports indicated that on some wards there were multiple copies of documents in personal records, making them unwieldy or difficult to find things in. The files we looked were in good order, however, Mental Health Act Commissioners will continue to monitor this outcome as part of their regular visits. In our judgement the inpatient personal files we saw were accurate and fit for Page 36 of 42

37 purpose. Page 37 of 42

38 Action we have asked the provider to take Improvement actions The table below shows where improvements should be made so that the service provider maintains compliance with the essential standards of quality and safety. Regulated activity Regulation Outcome Treatment of disease, disorder or injury & assessment of medical treatment for persons detained under the Mental Health Act 1983 Treatment of disease, disorder or injury & assessment of medical treatment for persons detained under the Mental Health Act Outcome 4: People should get safe and appropriate care that meets their needs and supports their rights Why we have concerns: In our judgement the majority of people using the service experience effective, safe and appropriate care, treatment and support. However, the provider should review its practice of accommodating acutely unwell people with those nearing the end of their admission. Potential risks and physical health needs should be appropriately addressed and recorded. 11 Outcome 7: People should be protected from abuse and staff should respect their human rights In our judgement despite efforts already made by the trust, some people using inpatient services are at potential risk of harm. The provider should also ensure that where needed there are suitable means for people using the service to be able to call for assistance from their bedrooms. The provider should ensure clearly evidence that all staff receive safeguarding adults training. Treatment of disease, disorder or injury & assessment of medical 15 Outcome 10: People should be cared for in safe and accessible Page 38 of 42

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