Archived: Tesito House

We rated Tesito House as Inadequate because:

• In 2018, we placed the service into special measures because the provider did not ensure patient care was being delivered to the highest standard possible, patient assessments were not complete, shortcomings were not promptly identified and rectified. At this re-inspection we found a number of areas of concern raised in our previous inspection had not improved.
• Safety was not a sufficient priority. Measurement and monitoring of safety performance with regards to the use of restrictive practices and the safe proper management of patient medication was poor.
• Systems, processes and standard operating procedures were not robust and regularly reviewed to keep patients safe.
• Staff did not have access to training and development to enable them to meet the needs of patients. The learning needs of staff were not understood. Staff were not supported to participate in training and development or the opportunities that were offered did not meet their learning needs.
• Patients were not supported to understand information they were given about their care and condition. Staff did not consistently provide clear information to patients or give them time to respond.
• Discharge and transition planning was not timely, was not done in partnership with patients and did not consider all of the patient’s needs.
• Governance systems and processes were not effective and did not give the service oversight to ensure the standard of care and treatment was maintained. There was no process in place to review key items such as the strategy, values, objectives, plans or the governance framework. The impact of service changes on the quality of care was not understood.
• Notifications were not submitted to external organisations in a timely manner.
• There was no evidence of learning and reflective practice. When concerns were raised or things did go wrong, the approach to reviewing and investigating causes was insufficient or too slow. There was no evidence of learning from events or action taken to improve safety.
• The service operated with a number of blanket restrictions in place which were not individually risk assessed or care planned.

However:

• Patients were regularly being assessed and their individual strengths, problems and needs were being identified and documented.
• The service kept detailed risk assessments and management plans which were updated when patients’ presentations changed and actions taken accordingly.
• Comprehensive physical health provision was available to patients to monitor and review their physical health and wellbeing.

We rated Tesito House as Inadequate because:

• Patients receiving treatment at this service are a high-risk group, they have a history of high risk behaviours and self-harm. Therefore, it is a concern that not all patients had written risk assessments. Those risk assessments that were in place were poorly written and individual risks to the patients and others were not sufficiently mitigated. This means that opportunities to prevent or minimise harm could be missed.
• The need for a personal emergency evacuation plan for one patient was not identified before a fire drill. The personal emergency evacuation plan put in place for this patient following the drill was not sufficient to mitigate the risk of the patient refusing to leave the room.
• Staff had not undertaken comprehensive, holistic or recovery orientated assessments of patients’ needs.
• Physical health examinations were not routinely carried out on admission and reviewed thereafter.
• Tesito house is a rehabilitation unit which admitted patients from other wards. Despite this care plans were not recovery focused and not what is expected from a ward that provided intensive rehabilitation.
• There was no discharge planning in place for any patients.
• Patients and staff agreed that meals provided to patients were not of good quality.
• Patient activities and leave were cancelled at the service due to a shortage of staff.
• There was no evidence to demonstrate the outcome of audits had led to improvements in the quality of the service provided.
• The service had identified key risks and developed an action plan to address theses. However, there was no immediate mitigation for these risks while the action plan was being completed.

However:

• The ward areas had an open layout and were clean and appropriately furnished.
• Patients were able to personalise their own rooms to their taste.
• Managers had undertaken a comprehensive ligature assessment for the building.
• The service had an occupational therapist.
• There were a good range of therapies available at the service.
• We observed respectful and polite interactions between patients and staff.
• There were daily meetings for patients to discuss their activities and any concerns they may have.
• The service had recently implemented a values based recruitment process.