Archived: Compstall House

We rated Park Lodge Independent Hospital as Inadequate because:

• staff did not ensure that the ward environments were safe and clean. Some emergency equipment had passed its expiry date. A number of fridge and freezer temperatures were outside the recommended range and staff had not acted on this. Staff had not completed clinic room audits in line with hospital policy or acted on the outcomes of infection control audits. Some areas of the hospital were dirty
• staff did not assess or monitor the physical health of patients well. There was no evidence in the care records that staff had undertaken a physical health examination when patients were admitted. Staff had not developed care plans to monitor side effects for patients prescribed clozapine nor did they know whether patients prescribed antipsychotic medication above the British National Formulary guidance limit had monitoring plans. Staff did not provide therapeutic activities to promote recovery and rehabilitation
• the service stored patient records in paper and electronic format and records were not complete and contemporaneous. Staff did not routinely seek and share information related to patient care with commissioners
• staff did not understand the Mental Capacity Act. Staff did not consider patients’ capacity to make decisions about their care in planning and delivering care
• some staff had minimal meaningful interactions with patients and were dismissive of patients. Some staff did not respond to patients’ requests in a timely manner. Patients told us that some staff were not good listeners. Relatives told us that some staff were insensitive and abrupt. Some staff coerced patients to carry out tasks

• eight out of nine patients did not have discharge plans in place

• monitoring systems did not identify when audits had not been completed correctly and were not effective in ensuring outcomes of audits were acted upon. The service’s risk register was an assessment of potential risks and did not include actual risks.

However:

• there was an up-to-date risk assessment of ligature points (places where someone intent on self-harm could tie something to strangle themselves). Staff conducted risk assessments of patients that were detailed and thorough. Staff knew how to report incidents of harm or risk of harm and learning from incidents was shared

• there was an action plan in place to ensure all staff received an appraisal. New starters and agency staff went through an induction process and staff received regular managerial and clinical supervision

• patients were involved in the care they received and told us their needs were being met. Regular community meetings took place where patients were encouraged to give feedback

• food was of a good quality and patients could have hot drinks and snacks at any time. Patients could make telephone calls in private. Bedrooms were personalised with patients’ belongings

• action plans were in place to implement a governance structure as part of the transition process. Staff felt supported and were offered opportunities for professional development. Staff told us improvements had been made since the transition to Partnerships in Care.