Report Parklands Hospital Hawthorns 1 Psychiatric Intensive Care Unit (PICU) 11 th December 2012 Overall Impression Parklands Hawthorn 1 PICU was bright, clean, tidy and spacious. The unit appeared relaxed and calm. Staff were welcoming, introduced themselves to visitors and service users. The ward had flexible visiting times for relatives due to the possible distance for visitors to travel. The ward also had protected meal times. Building work was planned to improve the size of the PICU enclosed garden and would include a small running track. There were also plans to provide a dedicated bed space for three female service users. There was a female only lounge and a communal lounge, service users also had the use of the gymnasium, had their own dining room and craft room. Page 1 of 12
Type of Service A PICU is a safe, secure and low stimulus ward environment, separate to the rest of an inpatient unit. A PICU has a greater number of staff per patient (staff ratio), which allows us to provide more intensive care and treatment. Hawthorns 1 is an Adult Mental Health ward (PICU) and has 24 beds. The inpatients services are staffed by psychiatrists, clinical psychologists, nurse practitioners, mental health nurses, occupational therapists, support workers and support time recovery workers. The service provides psychiatric intensive care unit for patients who need treatment in a safer or more restricted environment. What We Did We reviewed information relating to incidents, complaints, clinical audits, risks, compliments and litigation prior to visiting the site. We undertook an unannounced inspection on Tuesday 11 th December 2012 which focussed on: Outcome 1 involving people who use services; Outcome 4 care and welfare; Outcome 16 assessing and monitoring quality; We spoke to staff, service users, made observations and reviewed documentation. What the Outcomes Say Outcome 1: Involving people who use services People who use services understand the choices available to them, can express their views and have their privacy, dignity and independence respected. Outcome 4: Care and Welfare People who use services experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. Outcome 16: Assessing and monitoring quality People who use services benefit from safe quality care due to effective decision making and the management of risks to their health, welfare and safety. Overall Impression Parklands Hawthorn 1 PICU was bright, clean, tidy and spacious. The unit appeared relaxed and calm. Staff were welcoming, introduced themselves to visitors and service users. The ward had flexible visiting times for relatives due to the possible distance for visitors to travel. The ward also had protected meal times. Building work was planned to improve the size of the PICU enclosed garden and would include a small running track. There were also plans to provide a dedicated bed space for three female service users. There was a female only lounge and a communal lounge, service users also had the use of the gymnasium, had their own dining room and craft room. Page 2 of 12
What We Found Outcome 1: Involving people who use services People who use services understand the choices available to them, can express their views and have their privacy, dignity and independence respected. Staff The team spoke to four members of staff; the ward manager, a staff nurse, health care support worker and a housekeeper and the following points were identified: The ward telephone had no hand set. This had been removed following an incident in another unit. The team were awaiting a handset with a short lead. Service users were able to use an alternative phone in the meantime. During the multidisciplinary team (MDT) meeting service user were given a full explanation of treatment and offered a copy of the care plan and medication leaflets. Carers were involved in service user care with the permission from the service user. If so, carers were invited to the MDT meeting if requested by the service user or they could speak with staff outside of the meeting if more suitable. Care Programme Approach (CPA) meetings were held prior to transfer or discharge. Service users had weekly meetings and were chaired by a local service user project worker. Carer support workers were able to attend the unit if requested. Staff tried to maintain service user privacy and dignity. Staff explained there was a fine between maintaining service user s privacy and reducing risks through undertaking one-to-one or 15 minute observations. One-to-one discussions were always held in private with the service user. IMHA advocates were available to all service users. Staff were able to close part of the ward off if service users behaviour deteriorated to protect their privacy and dignity. The ward tried to have staff present of both sexes so that staff undertaking searches were of the same gender as the service user. Staff felt that the ward had very limited psychological input. The ward manager had an open door policy on the unit and service users, relatives and staff were able to seek advice and support. Service Users The team spoke to one service user and the following points were identified. The service user felt that the doctor had not listened to their wishes. Page 3 of 12
The service user spoken to thought that staff did their best during the time allocated. The service user commented that their care coordinator from the Assertive Outreach Team (AOT) had not visited over the last two weeks. Documentation The team did not review any documentation in relation to this outcome. Observation The team had a tour of the unit and facilities and observed the gymnasium, the ward and the menu and the following points were identified: The inspectors viewed a Mind and medication leaflet displayed on the unit. Service users had access to a computer where they could access information online around their health issues. Weekly activity programmes were being developed by the staff with active input from service users to find out what they would like provided. The gymnasium was available to service users; however there was currently only one member of staff trained in the use of the equipment. Page 4 of 12
Outcome 4: Care and Welfare People who use services experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. Staff The team spoke to four members of staff; the ward manager, a staff nurse, health care support worker and a housekeeper and the following points were identified: The team would shortly be producing MDT outcome sheets which would be given to service users. There was a weekly ward round template that was used for each service user who could attend the meeting. The template recorded risks, safeguarding issues, capacity, medication, plan of care; any leave and service user views. Risks were reviewed weekly at the MDT meetings, care plans were reviewed two weekly with the service user or more frequently if circumstances changed. Service users were encouraged to sign their care plans. Section 17 leave was used to maintain links in the community. The occupational therapy post was vacant at the time of the inspection; however the post was due to be advertised shortly. The ward was flexible with visiting times for relatives due to the potential distance of travel. Service users from Hawthorn 2 ward were able to be brought down for two to three hours to be in a lower stimulus area if needed. Service users from PICU could spend time on Hawthorn 2 if this had been indicated in their discharge plan. This helped the service user get used to the staff and routine of the ward. Staff had not noticed any change in demand for beds since the acute beds closed. Visitors reported to the main hospital reception desk and staff would escort them to the unit. Visitors could be restricted if there were any potential risks to service users. Daily menu choices were offered, service users received a hot meal in the evenings and were offered several choices; however this did not change over the year so this could become repetitive. The ward manager was unclear when the next ligature assessment was due and this needed to be clarified. Service Users The team spoke to one service user and the following points were identified. The service user had the opportunity to discuss their care with the staff and medical team. The service user had used the advocacy service in the past. The service user asked to see the inspector and stated that they should not be in hospital and did not want to have a blood test. This information was passed on to the medical team. Page 5 of 12
The service user was aware of their plan of care and knew they had a tribunal soon and felt able to put their case forward. Service user stated they were able to access the internet to gain information and were not worried about the current lack of activities on the ward (while the occupational therapist post was vacant). Documentation The team reviewed five RiO notes, secondary files, seclusion register, the major incident file; rapid tranquiliser file and menu choice, the LEaD records and the following points were identified: The five RiO and secondary files were reviewed, care plans were not always signed or a reason stated why the service user had declined. One out of five consent to share forms had not been signed and no reason had been stated why. Risk assessments and care plans had been completed. Not all progress notes had been validated. The rapid tranquilisation forms had been completed for past incidents. The seclusion room process was in place and this was observed in use for one service user. An emergency action plan was in place; however there was no evidence to state that this had been reviewed. The last entry was 2009 and the paperwork still had the old Hampshire Partnership FT logo. RiO files evidenced MDT review plans in place and stated who had carried out the actions. Three out of 23 members of staff were out of date with care and responsibility training; so were not qualified to perform physical restraints. Observation The team had a tour of the unit and facilities and observed the gymnasium, the ward and the menu and the following points were identified: Cold drinks were available all day - there was open access to the dining area. The hot drinks area was kept locked; service users had to request access to the area; usually staff were situated in the service user lounge so this was not an issue. Caffeine-free hot drinks were also available. Service users were given one-to-one time with staff. Staff were respectful in manner, calm and helpful. All staff wore their identity badges. Staff names were also displayed on the noticeboard in the main corridor of staff on duty on that day/shift. The ward had a prayer request flyer on the service user noticeboard. Special dietary requests could be facilitated and service users could be given extra portions if required. Page 6 of 12
Outcome 16: Assessing and monitoring quality People who use services benefit from safe quality care due to effective decision making and the management of risks to their health, welfare and safety. Staff The team spoke to four members of staff; the ward manager, a staff nurse, health care support worker and a housekeeper and the following points were identified: Staff were aware of CQC and how this related to their working. Staff were aware of how to access the CQC evidence folder which was in the staff office. Risks were assessed by staff daily during interaction with service users and reviewed weekly by the MDT. The team last received a complaint ten months ago. Complaints would be investigated fully and discussed with staff at meetings. PALS and Complaints leaflets were available and displayed on the ward. A female bedroom area was being developed following a recommendation from a Quality Turnaround Team (QTT) inspection. Service Users The team spoke to one service user and the following points were identified. Service users were aware of PALS, complaints and advocacy. Documentation The team reviewed the team LEaD records and the following points were identified: 22 out 23 members of staff were out of date or had not undertaken governance and risk training. Few staff had governance and risk or customer care listed as a requirement and so few staff had completed this. Observation The team had a tour of the unit and facilities and observed the gymnasium, the ward and the menu and the following points were identified: PALS and complaints leaflets were displayed. A fire action poster was displayed. Two thank you cards were observed on the ward. Page 7 of 12
Additional information relating to other Outcomes In addition to the information gathered relating to the outcomes listed above, the following points were identified: Outcome 11: Safety, availability and suitability of equipment The unit had a medical device inventory which listed the devices and training provided. The medical device folder was kept in the ward office. The unit did not appear to have a medical device service schedule in place; the inspectors were advised this was located with the hospital services manager. It appeared that the hospital did not have a central service contract however the inspectors were advised that this was being looked in to. Soft furnishings in the main lounge were becoming threadbare and required replacement. Outcome 14: Supporting workers The team LEaD records were reviewed following the inspection. The inspectors updated the team member list for the manager and updated the team members LEaD records to reflect statutory and mandatory requirements for the service as the records were not correct. Overall prior to the individual training requirements being updated, training was at 60% compliant. Following the review of the team s training requirements training was at 44% compliant. 22 out of 23 members of staff were out of date of had not undertaken slips, trips and falls training though many records did not have this listed as a requirement. 14 out of 23 members of staff were out of date with fire training. 18 out of 23 members of staff were out of date or had not undertaken patient handling training. Eight of 23 members of staff were out of date with health and safety training and eight were out of date with respect and values training. 14 out 23 members of staff were out of date infection prevention control training. 13 out of 23 members of staff were out of date with the appropriate resuscitation (BLS or ILS) required for their role. Three out of 12 members of staff were out of date with required medicine management training. 14 out of 23 members of staff were out of date or had not undertaken safeguarding adults level two training. Page 8 of 12
Eight out of 23 members of staff were out of date of had not undertaken safeguarding children level two training. Four out of 12 members of staff were out of date or had not undertaken Mental Health Act training for inpatient nurses or MHPs. Nine out of 12 members of staff were out of date or had not undertaken assessment and positive risk taking. Eight of 30 staff members were out of date with information governance (IG) training. Page 9 of 12
Recommendations Outcome 1: Involving people who use services There were no recommendations relating to this outcome. Outcome 4: Care and Welfare We recommend that the ward manager clarifies the ligature assessments process and ensures updates to the risk assessments are documented. Outcome 11: Safety, suitability and availability of equipment We recommend that soft furnishings in the main lounge are replaced as soon as possible. Outcome 14: Supporting workers We recommend that the manager speaks to all members of the team in relation to statutory and mandatory training to ensure staff book, attend and remain up to date as a matter of urgency. Outcome 16: Assessing and monitoring quality We recommend that a formal process is implemented to capture both positive and negative comments from service users and visitors. Page 10 of 12
Best Practice The following points have been highlighted: Parklands Hawthorn 1 PICU was bright, clean, tidy and spacious. The unit appeared relaxed and calm. Staff were welcoming, introduced themselves to visitors and service users. The ward had flexible visiting times for relatives due to the possible distance for them travelling. The ward also had protected meal times. Carers were involved in their care with the permission from the service user. Carers were able to speak with staff if the service user had given permission for them to do so. IMHA advocates were available to all service users. The ward manager had an open door policy on the unit so service users, relatives and staff were able to seek advice and support. There was a weekly ward round template that was used for each service user who could attend the meeting. Daily menu choices were offered; service users received a hot meal in the evenings and were offered several choices. Staff interacted with service users and were respectful in manner, calm and helpful. Risks were assessed by staff daily during interaction with service users and reviewed weekly by the MDT. A female bedroom area was being developed following a recommendation from a Quality Turnaround Team (QTT) inspection. Risk assessments and care plans had been completed. The service user had the opportunity to discuss their care with the staff and medical team. The service user had used the advocacy service in the past. Page 11 of 12
CQC Outcome Outcome 1 Involving people who use services Outcome 2 Consent to treatment Outcome 4 Care and welfare Outcome 5 Nutrition Outcome 6 Cooperating with other providers Outcome 7 Safeguarding people Outcome 8 Cleanliness and infection control Outcome 9 Managing medicines Outcome 10 Safety and suitability of premises Outcome 11 Safety, suitability and availability of equipment. Outcome 12 Requirements relating to workers Outcome 13 Staffing Outcome 14 Supporting workers Outcome 16 Assessing and monitoring quality Outcome 17 Complaints Outcome 21 Records Judgement of compliance based on evidence seen during inspection As of the date of the inspection the service was deemed: Compliant As of the date of the inspection the service was deemed: Compliant This outcome was not fully reviewed during this inspection. however the service was deemed: Non-compliant Issues raised could have a moderate impact on service users As of the date of the inspection the service was deemed: Compliant Report Date: 20.12.12 Page 12 of 12