Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Luton & Central Bedfordshire Mental Health Unit Lime Trees, Off Calnwood Road, Luton, LU4 0FB Tel: 03001230808 Date of Inspection: 30 July 2013 Date of Publication: September 2013 We inspected the following standards as part of a routine inspection. This is what we found: Consent to care and treatment Care and welfare of people who use services Safeguarding people who use services from abuse Supporting workers Assessing and monitoring the quality of service provision Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 1
Details about this location Registered Provider Overview of the service Type of services Regulated activities South Essex Partnership University NHS Foundation Trust South Essex Partnership University Trust provides this service at Luton & Central Bedfordshire Mental Health Unit. They are able to assess and or give medical treatment to people detained under the Mental Health Act (MHA) 1983. This location has five separate wards. These are Coral, Onyx, Jade, Robin Pinto and Crystal. Both Coral ward and Onyx ward provide admission and treatment facilities to mixed gender adults for detained and informal inpatients. Jade ward is an assessment unit that is short stay, usually for no more than five days unless specific reasons have been agreed for the benefit of the person. Robin Pinto is a 14 bedded all male low secure rehabilitation ward. Crystal is an assessment inpatient ward for older people with a functional or organic mental illness. On this inspection we did not inspect Robin Pinto and Crystal. Hospital services for people with mental health needs, learning disabilities and problems with substance misuse Rehabilitation services Assessment or medical treatment for persons detained under the Mental Health Act 1983 Treatment of disease, disorder or injury Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 2
Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 4 Our judgements for each standard inspected: Consent to care and treatment 6 Care and welfare of people who use services 8 Safeguarding people who use services from abuse 10 Supporting workers 12 Assessing and monitoring the quality of service provision 14 About CQC Inspections 16 How we define our judgements 17 Glossary of terms we use in this report 19 Contact us 21 Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 3
Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 30 July 2013, observed how people were being cared for and talked with people who use the service. We talked with staff, reviewed information given to us by the provider and were accompanied by a specialist advisor. We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service. What people told us and what we found During this inspection we spoke with 17 people that used the service specifically on Coral, Jade and Onyx wards. People had a good experience of care that respected their dignity and human rights. One person said the care and support they received was, "Very good, compassionate." People told us they felt that staffing levels could be improved. We found evidence that actions were being taken to improve this. At this inspection we found a well led service. One that had an effective leadership that was approachable and responsive to what was brought to their attention. We saw good examples of development and change when things could be improved. This was a safe service. There were systems in place to ensure a safe service such as safeguarding vulnerable people from abuse and learning from adverse events. We found that staff were well supported to provide safe care. The provider had systems to take account of people's views about the service, and to monitor the quality of the service. You can see our judgements on the front page of this report. More information about the provider Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 4
we use in the report. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 5
Our judgements for each standard inspected Consent to care and treatment Before people are given any examination, care, treatment or support, they should be asked if they agree to it Our judgement The provider was meeting this standard. Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. Reasons for our judgement Overall people who had used the service were satisfied with the support they received. One person said, "They have treated me very well, in fact I do not know where I would have been without the staff." A typical response said by one person was, "So far the staff have treated me with respect and observed my dignity and I feel quite safe here." Five people told us that they got up when they wanted to do so and also retired to bed when they wished. They could access their own room accommodation at any time during the day or night. This meant that people could spend time on their own when they wished to do so, while not becoming isolated. We saw that people were supported to take part in a wide range of activities. There were two courtyard gardens, which contained exercise equipment and table tennis. We observed these spaces being well used by the people. People at the service had access to laundry facilities and were encouraged to do their own laundry. People could take a bath or shower when they wanted. One person told us, "I like to eat at different times and there is food available outside of the main meal times." Other people we spoke with complimented the choice of food available. They also told us that there was a choice of foods available each day and enough to eat. Two people told us they had been out of the unit a few times with family, friends or staff supporting them. One person was making plans with staff to arrange their return to the community. Another person was engaged with the activities coordinator in Jade ward with art work. This person told us that they enjoyed joining in with the activities such as drawing, exercise, relaxation and Kama. One person in Jade told us there was not much to do other than watch television. However, staff on Jade viewed this time as specific time for assessment and that activities would be provided on other units if so required. One person on Coral ward told us that they took part in activities, enjoyed being outside, liked playing pinball, painting and drawing. They said that they had a really good psychology session today. This meant that staff were seeking people's consent to provide choices in the way they spent their time. We spoke to a person who complained that staff had twice broken the confidentiality rule Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 6
by speaking about their illness in front of their relative. The person told us they had made a written complaint and had received an acknowledgement pending further investigation. This showed the service was taking action to address the concerns. The provider may wish to note that one person told us that as far as they knew they had no care plan. They said that no-one had yet spoken about a care plan and they were given no explanation of risk assessments. They also said that no therapy or counselling had been offered to them, and that medication or possible side effects had not been explained by staff. This person was new to Onyx ward but had been assessed in Jade ward before moving there. The provider may like to note that four people in Jade ward were asked about accessing advocacy services. People did not know what an advocate was or how to contact them even though there were plenty of notices on the ward notice board. We examined paperwork that related to consent matters. During the inspection we saw, an Approved Mental Health Professional (AMHP) completed a detention authorisation document with reference to section 3 of the Mental Health Act 1983 as amended in 2007, for one of the informal people whose care we reviewed. (Section 3 is for admission and treatment). We observed the AMHP and the nurse in charge of the shift checking more than one set of authorisation for detention paperwork and they both agreed that these were correct. In Coral ward, we saw that people were informed in writing of their rights under MHA. This document explained the right to a tribunal, the admission to Coral ward, and what would take place in terms of assessment. This meant that legally required documents were in place and information was provided so that people understood their rights and care package We saw that people were assessed for mental capacity to make particular decisions. We saw that one person who lacked capacity had a mental capacity assessment completed. The details of their assessment were included in the ward round report so that all staff were aware of the person's needs. This meant that where people did not have the capacity to consent, the provider acted in accordance with legal requirements. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 7
Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Reasons for our judgement People told us that their treatment had been explained to them by their doctor. All but one person said they felt their views and opinions were taken into account with regards to their treatment. People generally said that they did have a care plan in place completed with a qualified nurse, when admitted. Another person told us that they had completed a care plan on a one to one basis with a staff member during their first week of being in the ward. They felt they discussed each issue and were really happy with the care plan in place. People on Coral ward confirmed they had been asked about health matters and knew what medication was prescribed and why they were taking it, this was not always confirmed as the case by people on Onyx ward. One person on Coral ward told us that the care and support they received was, "Very good, compassionate." On Jade ward, people had detailed assessments, including baseline physical observations. They also had risk assessments completed on admission. However, this level of detailed assessment and documentation was not consistent on Onyx ward. We observed that some of the assessment documents were incomplete for a person who had been transferred from Jade ward to Onyx ward. They were transferred on a Friday afternoon and from speaking with staff and people who used the service, no assessments were completed over the weekend, until the consultant was back on Monday. The ward round was in progress during the inspection and we were told the person's care was being reviewed the following day. On Coral ward most people had detailed assessments in place. One person had an additional occupational therapy assessment in place to determine any support they needed with their daily living skills. One person however had an assessment that was incomplete with sections left blank such as; 'what is important in terms of daily living, issues that are worrying you, what helps you manage your own mental health needs, what things in your life are important such as your faith'. This meant that there was inconsistency across wards in the thoroughness of people's risk assessments. On Jade ward the lead nurse told us that as an assessment unit everyone admitted had a review every 24 hours. This included looking at their health and wellbeing and discussing what would be happening next whether being discharged or moving onto one of the treatment wards at the service. During our inspection we saw one person being supported to leave the service and another being updated on how their care would be continuing. We Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 8
saw that staff displayed understanding and were helpful when asked questions. We saw evidence that people had signed their care plans. In the case of one detained person they had been informed about the content and had refused to sign. This meant that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. The provider may like to note that some staff behaviours could contribute to anxieties of people using the service. For example on Jade ward several staff stood in a row watching people eating lunch. There was no information to show that there were any risk factors around the lunch time meal or plans to manage potential risks in a more effective way. On Jade ward people told us that they had had been frightened by their condition, behaviour or circumstances in which they found themselves. Once on the ward and having got to know the staff they felt safe and secure. People had care plans in place, relating to their mental health needs and treatment and other important information. People had been consulted about their health, future needs and involved in their care planning. We saw that daily notes were kept by the staff about the person and the progress they were making towards their agreed care plan goals. All records reviewed had risk assessments in place and we saw evidence that they were being reviewed during ward rounds. This meant that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. On Coral ward the provider may wish to note that in two cases people had a care plan template in place with headings; 'recovery, goal, need'. Although care plans identified people's needs there was no description or guidance for staff (as described in the care plan guidance) on how these were to be met. Also on Onyx ward the care plans we saw were not consistently completed to address people's varied needs to include their social, psychological and occupational needs. The provider may wish to note that people's privacy and dignity were not always respected on Onyx ward. When we were being shown around the ward, we noted that the bedroom observation windows were open. This meant that anyone walking past could see into the bedrooms. We were told people were not able to close the observation windows as the levers inside the bedrooms were deemed a ligature risk and they had all been removed. Staff had a key to open the windows, but it appears that they did not routinely close them after each check. This was not the case on other wards at this location as they had been refurbished at a later date. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 9
Safeguarding people who use services from abuse People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Reasons for our judgement All staff we spoke with were able to explain how they reported any concerns about people's safety. Staff spoken with were clear about safeguarding processes, had received training and were aware of the provider's safeguarding and whistleblowing policy and procedures. They were clear about the process of raising safeguard concerns or alerts. Staff who had received training were clear on what constituted abuse. One of the staff provided examples of alerts they had raised to the local authority as part of their role working within the crisis team. The service liaised with local authorities and other stakeholders to report and resolve issues. We had evidence to show that the service does respond appropriately to safeguarding concerns as they have systems in place to refer or investigate where needed, and had taken action to protect people and learn from incidents that were known to them. In Onyx ward we observed the door to the male bedroom corridor had been removed and we were told that it had been broken by one person when they were angry. The female corridor door was intact and we were told that only the female patients and staff can access that corridor. The male entry fobs did not allow them access to the female bedroom area. In Coral ward we were advised that patients do not have key fobs to the bedroom corridor areas due to patients having used these to self-harm previously. Individual assessments of risk and subsequent risk management were not taking place. We saw that the entrance to both bedroom wings was open for anyone to wander into the bedroom areas. The provider may wish to note that people did not have individual risk assessment regarding key fobs which meant that their privacy was not fully protected. People's rights and choices were not protected if they were smokers. We saw that the service was aware of the issue and actively spoke with people to ensure they understood the limits in place. People could only smoke if they had unescorted leave. Those with escorted leave were not always able to do so, as staff were not always available to leave the service. People with no leave did not smoke at all, although staff told us that smoking cessation therapy was offered to them. We were told that those who were being admitted informally were told about the service's smoking arrangements and therefore had a choice not to stay. However, those admitted on a section or subsequently sectioned, had no choice at all. We were also told about the practice not to allow people to smoke until they Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 10
had a medical assessment. This meant that people admitted informally on Friday afternoon, were not allowed to smoke over the weekend until they had been assessed on Monday. People told us they found this frustrating and an infringement of their human rights, as they felt they had a right to choose whether they smoked or not. There was no clear rational for this other than to ensure that the no smoking policy was strictly adhered to. The provider may find it useful to note that whilst this may be appropriate for some people who may be vulnerable to exploitation or present a fire risk it is not appropriate to manage all people in this manner. On Coral we were shown intensive care rooms on both female and male units. These were used to support people at times of crisis, but were not used as seclusion. Staff told us that at no time were people on their own or locked in these rooms. The rooms were used to help deescalate behaviour in periods of tension, aggression and anxiety. Staff told us that people were supported at all times and treated by staff where appropriate with prescribed medication. We saw that rooms could be locked and unlocked from the inside and out. When we spoke with staff on Coral ward three staff were aware of the seclusion policy. They were very clear that seclusion did not take place on the ward. There was always a member of staff supporting people using the intensive care rooms, to check health and administer sedatives to help calm people when they were agitated. One member of staff positively stated that they had also, used the room for therapy to minimise the risk of harm to people using the service, staff and others. This meant that people were supported appropriately when they were anxious, agitated or showing extreme behaviour. On Onyx ward staff were not familiar with the procedure for the use of the extra care room. One person was in the extra care room on our arrival to the ward and staff told us the person asked to go to the room. The provider may wish to note that when we reviewed their records later, their use of the room had not been recorded. We asked staff about this and they told us they did not need to record it as the person had asked to go in the room. We asked if there was a form they needed to complete and they told us there was no such form. We were later shown by a senior manager, the procedure and the form to be completed when people used this room. This meant that good practice was not consistent throughout the service and therefore some people may be placed at potential risk. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 11
Supporting workers Staff should be properly trained and supervised, and have the chance to develop and improve their skills Our judgement The provider was meeting this standard. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Reasons for our judgement We spoke with 17 people and they spoke favourably about the service. One person told us they appreciated the staff and felt the staff had the skills to support them with their Individual concerns and difficulties. People on Coral and Onyx wards did express that there was on occasion a lack of staff to meet their needs. One person said, "I feel the staff have the correct skills to care for me but I often need to tell them that I am still here." Another person said, "When staff are present, it makes me feel safe. I feel that the ward does struggle with staffing, you can tell when the ward is short staffed, tea and fag breaks are later and when there is not enough staff there is more anxiety on the ward." Another person said, "I do feel safe, but was terrified when I first arrived. I now feel this is the best unit I have been in, it's really friendly, all the staff are lovely. It is a stressful job for staff and they can be short staffed." A fourth person told us, "I do struggle with staff on the ward, it's frustrating when you have to wait, especially with my illness, if I am feeling extremely anxious and angry, part of my treatment plan is to speak with a nurse, however when they are short staffed, they say, 'Give me a minute, give me a minute', then I lose it. If I could change one thing about Coral ward, I would have more staff." This meant that people considered that there were not enough staff to provide support they felt they needed. The expert by experience observed two patients on Onyx ward sitting at tables in the communal lounge looking exceedingly miserable and in despair. In the couple of hours plus they were on the ward they did not see a single member of staff approach them. Apart from the activities co-ordinator the expert by experience saw no meaningful interaction between staff and people in Onyx ward. This meant that people were not always given appropriate support. We were told by nursing staff that there were ten staff vacancies on Coral ward. One staff member told us that there were some issues accessing training. If the ward was short staffed, then it was impossible to attend important training. The staff member expressed concerns regarding large number of vacancies and the impact on the team. They stated that the heavy and regular use of bank staff along with when staff left they were not replaced, had impacted upon staff morale. We were informed that Coral ward only had five regular qualified nursing staff currently employed and that two of these were on regular nights. We received confirmation and evidence that this matter had been resolved through very recent recruitment and links with a local training course for suitably qualified nurses. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 12
Through this contact the service had received 35 expressions of interest from potential staff to complete their six month confirmation which is a time to guide and support all newly qualified practitioners (known as preceptorship). The provider may like to note that whilst this reaction had solved the matter, proactive planning may have avoided this issue. In Jade ward staff informed us that the rota was well organised so that their days off were usually together and they had regular weekends off duty. Overtime was available but not too much and there was no pressure applied to do extra hours. The staff we spoke with felt well supported and that the unit was sufficiently staffed. One person told us the unit functioned well because they worked as a team. We asked how it was they worked as a good team and were told; "Because we are trained, enjoy our job and have clear goals to work towards, which is helping the person to get better and be discharged." This meant that the staff were working as team to support the people in their care. We spoke to 14 staff who had differing roles during our inspection. Staff confirmed their training was up to date and the Matron on Coral ward was aware of who had completed what training. Three staff members confirmed that they had training on dealing with any violence or aggression, this included, de-escalation, prevention and physical interventions. One staff member told us that the organisation did provide good training and that they could book their own training that was all funded by the organisation. Staff stated they had requested to attend alcohol and drug abuse training and they awaited confirmation. One staff member told us that they had attended training on immediate life support, mental health illness and medication, therapeutic engagement and the mental health code of practice and ethics learning. They were pleased that this had been via both theory and practical training sessions. In Jade ward each staff member we asked informed us that they had attended mandatory training. One staff member had attended additional training of their choice which they considered would improve their knowledge and in turn the care they provided. All staff had continual professional development and mandatory training. There was a computer system to alert staff to outstanding training and reminders to attend training sessions. We were sent evidence of staff training completed. This meant that staff received appropriate professional development to enable them to perform their role. The majority of staff we spoke with were positive about team work and the availability of senior managers at the trust. One person told us that the chief executive was 'Open and approachable' and that they received updates and emails regularly about the trust. Another told us that there was a 'Culture of senior managers visiting' and that they were asked for their views about changes. Three people said that they were able to attend debrief sessions after incidents and said this helped them to understand and support people better. However two other staff on a different ward said that they did not always have access to debriefing sessions. The provider may like to note there is inconsistency of staff support through debriefing. Staff on Coral ward said that they thought the ward matron was approachable. Staff confirmed they received regular supervision and yearly appraisals. One person said they thought the service was supportive of them and interested in helping them to develop their career. This was because the service had arranged different work placed experiences from working in different departments. This meant that staff received appropriate professional development. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 13
Assessing and monitoring the quality of service provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. Reasons for our judgement People on Coral ward told us that ward meetings were facilitated by staff every Sunday. This was to discuss issues on the ward, what people want to do, and plan activities. A relative on Onyx ward told us they were happy with the care their relative had received. They told us they found staff helpful and responsive to people's needs. They were fully involved in their relative's care and they had just attended a ward round review. This meant that people who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. We spoke with the person who was responsible for monitoring quality and serious incidents. They spoke about how they used information reported to them via a computerised system, how this was reported to external agencies or bodies and investigated if needed. Outcomes were recorded and lessons learnt were prepared in an informative way for the attention of staff. Staff could access the learning from reports on the internal intranet system. We were shown recent examples that allowed others within the wider organisation to learn from incidents and investigations. This meant there was evidence to improve the service from adverse events. Staff were also aware of the complaints procedure and one staff member said, "If you help the person, get to know them, and try to understand, then it is rare you will have a complaint." The majority of people we spoke with were satisfied with the service offered to them. We had an example of one person who had used the service and made a complaint. They felt they were listened to and taken seriously. The matter had yet to be concluded. We examined the electronic log in place to monitor complaints and saw a clear system with timescales in place. Neither the provider nor CQC had received any whistle blowing information and concerns from staff within the last year. There was however a potentially serious matter that came to the attention of the provider and we saw evidence that this was being addressed in a robust manner with changes made in the service provision. This meant the provider took account of complaints and comments to improve the service. A manager of the service told us about developments to increase the physical activity and improve nutrition for people using the service. The service had invested in a programme entitled 'Mental health working your way to a better diet'. This formed work books for Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 14
people to keep and take with them. There was also an increase in physical activity on offer through development of plans with risk assessments and purchase of exercise equipment. We were sent documentary evidence to support the programme we heard about at inspection. During the inspection we saw that people had a 'weekly therapy programme' that included relaxation sessions, art, self-awareness, health and wellbeing. On a notice board in a dining area, we saw a list of activities planned activities and we saw the occupational therapy (OT) staff engage people with board games and art activities. We also saw OT staff take some people to the gymnasium, for a game of basketball. This meant that people benefitted from exercise and nutrition developments and changes made within the service. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 15
About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social 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 essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 16
How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 17
How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact - 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. Moderate impact - 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. Major impact - 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 We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 18
Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 19
Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 20
Contact us Phone: 03000 616161 Email: enquiries@cqc.org.uk Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: www.cqc.org.uk Copyright Copyright (2011) 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. Inspection Report Luton & Central Bedfordshire Mental Health Unit September 2013 www.cqc.org.uk 21