08 - 22 March 2023
During an inspection looking at part of the service
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
People’s experience of using this service and what we found
The service was not able to show how they met some of the principles of right support, right care, right culture all the time.
Right Support
The Model of Care and treatment setting maximised people’s choice, control and independence for people who were settled. It prepared people to take the final steps of their rehabilitation before going to community placements. However, the Model of care and setting did not meet the needs of people who were also experiencing acute mental ill health or people with limited mobility. Staff were clear that if a person with limited mobility was referred to the service, they would not be able to meet their needs. Managers accepted that this would limit their quality of life as they would find it difficult to access the garden and the cobbled stones in the car park would limit their opportunity to use the salon and access the meeting room.
People told us staff supported them to take part in activities and to pursue their interests in their local area when the hospital was settled. One person said they liked to go out for walks and could go out when they wanted to with staff. People had opportunities to use local facilities for learning, education, and voluntary work. Permanent staff supported people whenever possible to play an active role in maintaining their own health and wellbeing. Staff gave people information about accessing well woman checks and supported people to attend these. The service provided care and support in a safe, clean, and well-furnished, environment. Although space was limited, the service prided itself on providing a homely environment in which people could develop their skills and knowledge, to help them move onto community settings. However, some people said they did not always know staff because they did not wear clear name badges and there was no photo board of staff they could refer to.
Right Care
Care is person-centred and promotes people’s dignity, privacy, and human rights. However, not all staff knew of, or understood all peoples care needs. Some staff did not always meet the individual care needs identified or treated people in a way that encouraged them to achieve their potential. While care plans were person centred and showed people’s goals for treatment and hopes for their future not all staff were following the care plans, risk management plans or positive behavioural support plans. Risk management plans, while appropriate for the person they were intended for, did not always consider the impact they would have on other people using the service.
The service worked well with other agencies such as the local authority and the police to manage safeguarding. They had worked hard to strengthen their links with their Integrated Care Board. Staff had training on how to recognise and report abuse and they knew how to apply it.
Right Culture
The ethos, values, attitudes and behaviours of leaders and most care staff ensured people using services led confident, inclusive, and empowered lives. Most staff placed people's wishes, needs, and rights at the heart of everything they did. The registered manager and all staff understood the importance of family to people. However, one relative said communication could be better, they were unable to attend their relative’s last review and did not receive notes from it. However, another relative told us that because they lived a long way away and did not drive the provider had paid for them to travel to Matlock and stay overnight so they could see their relative. The relative also told us the doctor rearranged their relative’s care and treatment review to coincide with their visit, so they could be present. People, and those important to them, were involved in planning their care. People said they liked going out but due to the remote location many outings had to completed using the hospital minibus. One person thought having the hospital minibus was a good thing as they could go further afield with their friends and in safety. People's quality of life was enhanced by the service's culture of improvement and inclusivity.
The service had policies and systems in place to support people in the least restrictive way. Although staff used these to support people who had acute mental health needs, the restrictive practices negatively impacted on other people who did not have these needs. However, leaders in the service had worked hard to create a learning culture. Most permanent staff we spoke with said they felt valued and empowered to suggest improvements and question poor practice. There was a transparent, open, and honest culture between people, those important to them, staff, and leaders. They all felt confident to raise concerns and complaints.
SUMMARY
Our rating of this service went down. We rated it as requires improvement because:
Not all temporary staff knew the people they were looking after, this prevented staff from interacting with people in a way that encouraged people to achieve their potential and ensure all peoples individual needs were met.
People using the service did not always know who the staff were. Staff did not wear clear name badges and there was no staff photograph board in the communal area. This could have prevented people from feeling comfortable enough around staff to exercise their autonomy.
People could not always access support from independent advocacy. The advocate was not able to be in the communal areas when people were distressed.
Some staff were not always aware of individual risk. Some support staff were not always following individual risk management plans. While risk management plans were adequate for the person they were intended for, they did not always consider the impact of a person’s actions on other people and visitors.
There was no evidence to show how staff monitored people’s physical health if the person declined physical observations. We reviewed two people’s records; one person was on high dose anti-psychotic medicine and the other person required intra-muscular rapid tranquilisation.
Staff were not always following handwashing procedures. There was risk of cross contamination from people’s laundry. Staff had not separated out people’s laundry and there no process for keeping dirty laundry separate from clean laundry.
Staff had not cleaned the splashback around the sink in the therapy kitchen. Staff had not cleaned a medicines trolley or inside a clinic room cupboard properly.
Due to the design and layout of the hospital the environment was not suitable for people who were experiencing acute mental ill health or who had a history of using ligatures. Staff could not control the heating in the communal areas of the hospital. On the day of our inspection the communal areas were uncomfortably hot.
Although audits and governance were in place some of the systems and processes had not been used to full effect.
Apart from the new manager and new Head of Care the registered nurses did not have a learning disability background. Registered nurses were not always present in communal areas and were not providing leadership or positive role modelling for healthcare support workers.
Managers were not monitoring support staff’s competency or understanding following completion of their online learning disability training. Therefore, some staff were not always confident when working with people with a learning disability and autistic people.
The admission policy did not identify what measures should be in place if a newly admitted person was later found to be too acute for the service to manage safely. Due to its design and layout the hospital environment was not suitable for acutely unwell people. We judged that the provider should address this issue.
Staff did not always follow the new protocol for administering medicines ‘when needed’. We judged that the provider should address this issue. Staff had not ensured that the glucose monitors taken in by people using the service were all calibrated.
However:
There was a full multidisciplinary team of staff working in the hospital. Their specialist assessments were thorough and comprehensive.
Information about people who use the service was easily accessible in both electronic and hard copy format. Positive behaviour support plans, and risk management plans were available in easy read and grab sheet format.
There were enough staff to meet people’s needs.
Although the registered manager and new Head of Care were new to the service, having only been in post five weeks, both were experienced in hospital management and caring for people with learning disability and autistic people.
Managers at the hospital were responsive and keen to learn from our inspection findings. Within two weeks of our onsite visit, they had already sent an action plan and evidence of having addressed the issues we raised in our initial feedback.