2 Review of compliance Healthlinc Individual Care Limited Bradley Woodlands Low Secure Hospital Region: Location address: Yorkshire and Humberside Bradley Woodlands Low Secure Hospital 1 Bradley Road Bradley Grimsby Lincolnshire DN37 0AA Type of service: Independent healthcare organisation Hospital services for people with mental health needs, learning disabilities and problems with substance misuse. Date the review was completed: November 2011 Overview of the service: Bradley Woodlands Low Secure Hospital is run by Healthlinc Individual Care Limited. The hospital is a 37 bedded, rehabilitation facility for people with a learning disability. The hospital is Page 1 of 18
a purpose built and comprises of several small apartments with kitchen and living areas, separate activity areas and a sports hall. Patients have free access to their own apartments and supervised access is available beyond the apartments, due to the low secure nature of the hospital. The hospital is located in extensive grounds on the outskirts of the village of Bradley, which is on the south western edge of Grimsby. Care is provided for people detained under the Mental Health Act 1983. It is registered to provide the following regulated activities: Accommodation for persons who require nursing or personal care Treatment of disease, disorder or injury Assessment and medical treatment for persons detained under the Mental Health Act 1983 Page 2 of 18
Summary of our findings for the essential standards of quality and safety What we found overall We found that Bradley Woodlands Low Secure Hospital was meeting all the essential standards of quality and safety we reviewed but, to maintain this, we have suggested that some improvements are made. The summary below describes why we carried out the review, what we found and any action required. Why we carried out this review This review is part of a targeted inspection programme to services that care for people with learning disabilities to assess how well they experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights; and whether they are protected from abuse. How we carried out this review The inspection teams are led by Care Quality Commission (CQC) inspectors joined by two experts by experience, people who have experience of using services (either first hand or as a family carer) and who can provide that perspective. A professional advisor is also a member of the team. We reviewed all the information we hold about this provider, then carried out a visit on 28 and 29 November 2011. We observed how people were being cared for, talked with patients, talked with relatives and staff, checked the provider s records and looked at records of patients. As part of our inspection, discussions were also held with relatives. Their comments are included within this report. To help us to understand the experiences people have we can use our Short Observational Framework for Inspection (SOFI) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how patients spend their time, the type of support they get and whether they have positive Page 3 of 18
experiences. We did not use SOFI on this occasion. It would have been obtrusive, because patients were living in small, two and three bedroom apartments. Because the service is a hospital we use the term patients in this report. What people told us At the time of the inspection visit, there were 24 patients present. Twelve female patients were living in four apartments in Willow unit. Eight male patients were living in three apartments in Maple and three female patients were living in an apartment in Beech unit. We met and introduced ourselves to 11 patients and spoke with six patients in more depth to get their views of the service. Overall, patients told us they were satisfied with the care and treatment at Bradley Woodlands. Activities that patients said they were involved in included: going to the supermarket, budgeting and cooking for themselves. Patients told us the staff supported them to be involved in putting their care plans together and going to review meetings and that they had access to independent advocates. Patients said that they could have a copy of their care plan and copies were kept in a cupboard in their apartment. Everyone mentioned that they had advocates. That was someone from outside of Bradley Woodlands who came in and spoke up for them. We spoke with the relatives of four patients about how they felt about the care, treatment and support provided. Two relatives gave generally positive feedback about the service, saying that their relatives were happy, well cared for and had made good progress. One comment was, Communication always very good about the important things. One relative told us that, although the staff were very good and that the patient always looked well cared for, they did not think that the patient was happy at Bradley Woodlands. This patient s relative said they would like the patient to move closer to their family. The expert by experience who was part of our inspection team said that they thought that the apartments were a good idea for patients to live in. The professional advisor thought that the way the apartments were set up helped in providing individualised personal care, especially for those patients who were likely to find it difficult living with others. What we found about the standards we reviewed and how well Bradley Woodlands Low Secure Hospital was meeting them Outcome 4: People should get safe and appropriate care that meets their needs and supports their rights Overall, patients care and welfare was protected. Staff were caring, good at engaging with patients and had developed positive relationships with them. Patients diversity was recognised and respected. Patients needs were assessed; care plans and risk assessments were in place, and patients health needs were met. Page 4 of 18
However, care plans were not always devised using person centred principles and most were not always in a format that was accessible to patients. Referrals were not always made to Independent Mental Capacity Advocates (IMCA) when necessary, to make sure patients were not subject to inappropriate restrictions. This did not encourage full patient involvement and did not show that patients rights were always protected. Overall, we found that Bradley Woodlands was meeting this essential standard but to maintain this, we have suggested that some improvements are made. Outcome 7: People should be protected from abuse and staff should respect their human rights Overall, patients were protected from abuse, or the risk of abuse and their human rights were respected and upheld. There were effective policies and procedures in place to safeguard patients against abuse and there was evidence the staff team had a good understanding of the procedures. There were systems in place to prevent and identify abuse. Overall, we found that Bradley Woodlands 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. Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. Any regulatory decision that CQC takes is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken. Page 5 of 18
What we found for each essential standard of quality and safety we reviewed Page 6 of 18
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 7 of 18
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 Our judgement There are Minor concerns with Outcome 4: Care and welfare of people who use services Our findings What people who use the service experienced and told us Most patients told us that they had a named nurse and that staff followed their care plans and they felt well supported. One patient said, I m happy here, I ve been here a long time and know everyone really well. Another said, We have a care programme approach. The activities patients told us that they were involved in and enjoyed included: going to the pub, sing along, baking, bingo, brunch club, gardening, using the gym, going for walks, going to the local shops, and the, Pets as Therapy (P.A.T) dogs. One patient told us that they had a timetable of about 26 hours of activities a week. Another patient told us that they were doing a night class to help them read. Comments included: We have a meeting to choose activities. I enjoy all of the activities. I work with tutors and I m doing personal hygiene. We go apartment shopping. We have a certain amount of money for food throughout the week. We have a menu plan, we do shopping and sometimes I cook. I m doing life skills, cooking, money and fire hazards. Everyone said they got on well with day staff and felt that staff respected them. Page 8 of 18
One patient said they were not very happy about some of the rules, like having set bedtimes. Others said they thought the rules about bedtimes were reasonable. Everyone told us that, overall they were happy at Bradley Woodlands. Most said they do get out in to the local area, depending on their care plans. Everyone we spoke with said that they had contact with a relative or someone close to them. One patient said they were working towards moving out to a more independent setting. Two patients mentioned that they had an advocate. That was someone from outside of Bradley Woodlands who came in and spoke up for them. One patient showed the expert by experience, who was part of our inspection team, their life story. The expert by experience thought that it was a good idea for patients to have these, as was a good way for staff to get to know the patients. We spoke with three patients relatives about how they felt about the care, treatment and support provided. They gave positive feedback about the service. They felt involved as the staff kept them up to date. They confirmed that their family members had advocates and that they had care plans. Two relatives mentioned that there had been some staff shortages and staff changes over the year, but that it seemed to have settled a bit. One relative said, One bugbear is that on Sundays it sometimes takes the staff up to 10 minutes to answer the bell, I ve phoned from outside before now. Another said, Only one negative side, a few staff don t seem to be as dedicated as lots of the others. One relative told us that, although the staff were very good and that the patient always looked well cared for, they did not think that the patient was happy at Bradley Woodlands. This patient s relative said they would like the patient to move closer to their family. Other evidence Assessing people s needs We saw copies of the referral and admissions policies for the service. These gave staff clear instructions to follow when assessing and admitting a patient. We were told that there had not been any recent admissions. We looked at three patients files to see how they had been referred and admitted to Bradley Woodlands. Their records clearly showed their individual needs and reason for admission. Most patients had family members who were involved in their admission and regularly came to their review meetings. Community nurses and social workers had made the referrals to support placement at Bradley Woodlands. Two patients told us about what had happened when they moved into Bradley Woodlands. They said that before they moved in staff came to see them to talk about whether the service was right for them. They visited Bradley Woodlands to see what it was like and were asked about their needs before they moved in. The manager told us that most patients stayed in the hospital for about two and a half years. The records we saw showed that there was planning in place for patients around discharge. One patient was ready to move on, but we were told by staff that suitable alternative accommodation had not yet been found for them. The patient Page 9 of 18
told us that they were not going to be there long, as they were working towards moving into a more independent setting, in the community. Care planning We looked at four patient s care plans. We did this to see what their needs were and how they were to be met. The staff we spoke with told us that plans were put together from pre-admission assessments and further assessments following admission, involving the patient and family where possible. Patient s plans and risk assessments were discussed at the patient s Multi-disciplinary team (MDT) meeting and were agreed with the health professionals involved. The care plans we saw were based on individual needs. Some parts of the care plans we checked were put together using person centred principles, but they were mostly written for the staff to follow rather than from the patients perspective. They did not always take patient s individual communication needs in to account. This meant that for some patients, who did not read, the care plans were not accessible. Staff told us that they try and develop the care plans with the patients, sitting down with them, discussing their aims and asking them what they want. Reviews and updates were done with the patient where possible. Regular MDT and Care Programme Approach (CPA) meetings were held. Patients were encouraged to attend and discussed their plans and risk assessments. Patients confirmed that they attended MDT meetings and the medical and nursing staff talked with them about their care and any changes. The records we saw for one patient showed that they attended meetings and discussed things such as their requests for leave for walks to the supermarket and other activities. The four relatives we spoke with confirmed that they were invited to meetings to discuss the care and any changes, both positive and negative. All stated that this aspect of involvement was good. However, two said that they would welcome more regular, informal updates. Although patients and their relatives told us that they were involved in decision making about patients care, there was not much evidence of this in patient s files. The service had recently done their own quality audit and all of the above issues had been identified as areas that needed to be improved. We saw that work had been started to make sure that patients had more person centred care plans. The manager told us that a care planning system called My future plan was being introduced. The new plans were in a format that better suited patients individual communication needs and showed how patients were involved in putting the plan together. We found two instances where patient s interests would have been better protected with the support of an Independent Mental Capacity Advocate (IMCA). However, we were told that no patients had an IMCA at the time of our visit. One patient had gloves put on their hands to prevent them from harming themselves. There was no care plan for this and the intervention was not subject to regular review by the MDT. There was no programme of treatment to address this issue and no plan in place to reduce the need for the intervention. Another patient had been prescribed a particular form of contraception prior to being admitted to the service and had continued with its use while staying at the hospital. The records we saw showed Page 10 of 18
different professionals involved had different opinions about the patient s ability to consent to this particular treatment, but it had not been subject to review by the MDT. Meeting people s health needs Two patients relatives commented that patients had put on weight since being admitted. We looked at three patient s Health Action Plans (HAP). These identified their health needs. The health action plans were in an accessible format. We saw evidence that patients received regular health reviews and attend appointments with other health professionals. One patient said, They know about me wanting to lose weight. If I lose weight the doctor said my diabetes might go away and that would be good. I go on my Nintendo Wii and I have exercise DVD s. I want to be able to walk on my own to Cleethorpes and to do the big sponsored walk. Patients had annual health checks with a doctor. This helped to make sure that their health care needs were met. Delivering care There were a lot of activities going on, such as education courses, art therapy, house meetings and trips out for shopping. There was a poster about the activity programme on the notice board, which detailed pampering sessions, pool, bingo, P.A.T. dog, brunch club and coffee afternoons. We spoke with the Occupational Therapist (OT) who told us about individual activities that were set up for small numbers of patients, one patient was going out to Zumba sessions and another was going horse riding. The OT said that this was an area that was being developed. More therapy sessions were being set up, such as music and woodwork and they also intended to have more exercise programmes. More meetings had been arranged such as anti-bullying, a befriending-buddying group, and involvement forums. Visitor records showed that family, friends and professionals visited patients at the service at different times of the day and at weekends. The relatives we spoke to felt they were made welcome when they visited. However, they usually saw their relatives in the visitor s room rather than in their apartments. Patients had access to independent advocates. Records showed the advocates attended the patients community meetings. Staff and patients told us that the advocate visited all of the patients to check if they want to see her. The advocate had an office in the hospital and the patients also put letters under the door if they want to talk to the advocate. One male patient told us that, because of some people s behaviour, patients had been given set times throughout the day for going out to the smoking area. The patient said that male and female patients were not able to smoke together and that they had liked talking to females, so they were disappointed that they could no longer mix. We discussed this issue with the manager and it was evident that the approach had been introduced to protect female patients from bullying. It was discussed with patients, with the input of the advocacy service and was reviewed on a regular basis. Page 11 of 18
Managing behaviour that challenges We looked at the written records for three patients and saw that work had been done to prevent patients behaviour from having a negative effect on each other. Consideration had been given to how and where patients were accommodated in the units. Patients had behavioural management plans. They were clear and detailed, specific, to keep everyone safe. A risk assessment and review system was in place and all the risk assessments we checked had been regularly reviewed. One of the patients told us they had regular contact with a psychologist. We saw the summaries of weekly ward rounds. This was when the psychiatrists spent time with, and reviewed each patient. The records we saw showed that patients behaviour management plans were reviewed when they needed to be. When we spoke with staff about how they managed incidents of challenging behaviour, they were knowledgeable about patients specific needs and were able to describe the support they should offer to different patients. This showed that patients individual needs were understood by staff and this enabled patients to be supported consistently by the staff team. Our judgement Overall, patients care and welfare was protected. Staff were caring, good at engaging with patients and had developed positive relationships with them. Patients diversity was recognised and respected. Patients needs were assessed; care plans and risk assessments were in place, and patients health needs were met. However, not everyone had a care plan that was put together using person centred principles and most plans were not accessible to patients. This did not encourage full patient involvement and did not protect patients rights. Referrals were not always made to Independent Mental Capacity Advocates (IMCA) when necessary, to make sure patients were not subject to inappropriate restrictions. Page 12 of 18
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 Our judgement 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 We spoke with six patients. Most of the patients we spoke with said they usually got on with the staff. When asked if they had an opportunity to see the advocate they said that they did and one patient said, Once a week. I knock on her office door. Go and see her. She s nice, we talk about different things. One patient said, It s OK living here. Another patient was asked if they felt safe enough to speak to a member of staff if they were worried about abuse and they said, I can go to day staff and talk to them and they care. Staff will try to cheer me up. We spoke with four patients relatives, they told us, they felt the patients were safe at the unit and would take any concerns they had to the manager. Page 13 of 18
Other evidence Preventing abuse We observed good relationships between the staff and patients. We saw that staff engaged well with patients and had warm, informal relationships with them. The manager told us that systems were in place to both prevent and identify abuse. We saw a copy of the safeguarding policy. This included clear definitions of abuse and the aim of the policy. We were told these were available to all staff. We spoke with five members of staff, during our two day visit. They all showed a good understanding of the policy and procedures. They were able to tell us the correct procedures to follow if they suspected abuse, or if abuse had been disclosed to them. All of the staff we spoke with said they were confident abuse was not taking place at Bradley Woodlands. One nurse said there were a number of different ways that patients could raise concerns. These include one-to-one sessions, ward rounds, multi-disciplinary meetings, the hospital complaints process and by talking to the independent advocates. The patients had regular meetings. One patient told us that they were a representative at the patient council meeting saying: I am a rep and stick up for people here and make things better for people. We saw a copy of the whistleblowing policy. This was clear and the members of staff we spoke with were aware of whistle blowing procedures. They were able to explain to us what they would do if they needed to raise concerns. We looked at how the service implemented the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). One staff member told us about a recent example of a patient needing dental surgery under general anaesthetic and being unable to consent. The staff member told us that a best interests meeting was held, which had been attended by representatives from the patient s family, the dental surgeon, psychiatrist and named nurse. The outcome of the meeting was that the persons agreed the surgery was to be undertaken. Responding to allegations of abuse When incidents had taken place where one patient had harmed another, or if a patient made an allegation that they had been harmed by staff, the service had made referrals to the Adult Protection unit of the local council and accurate records had been kept. The manager told us that following an incident, there were debriefings about what had happened. We saw the records of de-briefings for a number of incidents. The de-briefing showed that reflection had taken place about what had happened and what could be done differently in the future, to avoid the same thing happening again. All untoward incidents were reviewed by the manager to make sure that any lessons were learned and a copy sent to their head office. This included when patients had been restrained. The reports were analysed and audited and any patterns or themes were noticed and acted upon, to make sure patients were kept safe. We spoke to five staff. All were able to tell us the correct procedures to follow if they suspected abuse or if abuse had been disclosed to them. Page 14 of 18
All of the patients we spoke with said they usually got on with the staff. Several patients said that staff were nice. One patient told us that the night staff did not care as much as the day staff. This patient told us about concerns they had about particular night staff. Speaking to the manager, it became clear that the patient was telling us about some serious incidents that had happened the previous year. These issues had been dealt with through the safeguarding process and the staff involved had been dismissed. However, what the patient told us highlighted that there may be a need for some remedial work with patients. Spending time de-briefing those who had been affected by the incidents of the previous year. The manager told us that this was one of the reasons that the Bullying group had been set up. Using restraint Staff told us, restraint was used on some occasions, but the preferred option was to use de-escalation techniques to prevent challenging behaviour. We saw evidence of this in patients daily records. When speaking with staff we found they had clear techniques to avoid using restraint. We found they were knowledgeable and confident about using restraint techniques in a way that was not harmful or punitive to patients. We looked at the written records of 12 incidents where restraint had been used, along with the daily notes and other written records for those dates and there was a clear audit trail of the events and actions taken by staff to support the patients in most cases. As previously mentioned, the manager monitored incident reports, to see whether staff were responding to and reporting incidents effectively. This protected patients welfare and rights. Our judgement Overall, patients were protected from abuse, or the risk of abuse and their human rights were respected and upheld. There were effective policies and procedures in place to safeguard patients against abuse and there was evidence the staff team had a good understanding of the procedures. There were systems in place to prevent and identify abuse.. Page 15 of 18
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 Accommodation for persons who require nursing or personal care Treatment of disease, disorder or injury Assessment or medical treatment for persons detained under the Mental Health Act 1983 Regulation 9 Why we have concerns: Outcome 4: Care and welfare of people who use services Care plans were not routinely devised using person centred principles and most were inaccessible to patients. This did not encourage full patient involvement and did not protect their rights. The service needs to show more how patients and people close to them are involved in their care planning, and this includes patients risk assessments and risk management plans. Referrals were not always made to Independent Mental Capacity Advocates to make sure patients were not subject to inappropriate restrictions and to protect patients human rights. The provider must send CQC a report about how they are going to maintain compliance with these essential standards. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The provider s report should be sent within 28 days of this report being received. CQC should be informed in writing when these improvement actions are complete. Page 16 of 18
What is a review of compliance? By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. When making our judgements about whether services are meeting essential standards, we decide whether we need to take further regulatory action. This might include discussions with the provider about how they could improve. We only use this approach where issues can be resolved quickly, easily and where there is no immediate risk of serious harm to people. Where we have concerns that providers are not meeting essential standards, or where we judge that they are not going to keep meeting them, we may also set improvement actions or compliance actions, or take enforcement action: Improvement actions: These are actions a provider should take so that they maintain continuous compliance with essential standards. Where a provider is complying with essential standards, but we are concerned that they will not be able to maintain this, we ask them to send us a report describing the improvements they will make to enable them to do so. Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. Where a provider is not meeting the essential standards but people are not at immediate risk of serious harm, we ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Adult Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 17 of 18
Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public 03000 616161 / www.cqc.org.uk Copyright (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Quality Commission Website www.cqc.org.uk Telephone 03000 616161 Email address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 18 of 18