Frank Lloyd Unit

• This was a second follow up inspection to an unannounced focussed inspection on 18 and 19 January 2016. During the inspection in January, CQC found the trust had breached regulations 11, 12, 13 and 18 of the Health and Social Care Act 2008. CQC issued a warning notice to the trust on 8 February 2016 for significant improvement in these areas.
• The warning notice stated that the trust must take action within six weeks regarding risk assessments, the use of Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), the safe management of medicines and reporting and recording safeguarding incidents.
• The warning notice stated that the trust must complete a comprehensive review of patient assessment and care planning and to review staffing levels and skill mix within three months of the date of the warning notice.
• This inspection was to ensure that the trust had completed all actions set out in the warning notice and was delivering a safe, effective and caring service for patients.

This was a follow up inspection to an unannounced inspection on 18 and 19 January 2016 where we found the trust had breached regulations 11, 12, 13 and 18 of the Health and Social Care Act 2008. We issued a warning notice to the trust on 8 February 2016 for significant improvement in these areas.

The warning notice stated that the trust must take action to address concerns within six weeks regarding risk assessments, the use of Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), the safe management of medicines and reporting and recording safeguarding incidents. This inspection was to ensure that the trust had completed these actions, met the requirements of the warning notice, and was delivering a safe and effective service for patients.

Following our inspection of the Frank Lloyd unit, we issued the trust with a warning notice on 8 February 2016 having found them to be in breach of the following Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:

Regulation 12 (1) (2) Safe care and treatment.

Regulation 13 (1) Safeguarding service users from abuse and improper treatment.

Regulation 18(1) Staffing.

Regulation 11(1), (2), (3) Need for consent

We found the following problems that the trust needed to improve:

We identified serious concerns regarding the care and welfare of patients. There were a number of issues relating to compliance and practice regarding use of the Mental Capacity Act 2005 (MCA) Code of Practice and Deprivation of Liberty Safeguards (DoLS). Staff had made standard and urgent DoLS applications for all 39 patients. Staff had completed thirty six applications prior to assessing the patient’s capacity and only five had been authorised. Principle one of The MCA 2005 Code of Practice (CoP) states ‘A person must be assumed to have capacity unless it is established that he lacks capacity.’ Section 6.50 of the MCA states ‘Sometimes there is no alternative way to provide care or treatment other than depriving the person of their liberty. In this situation, some people may be detained in hospital under the Mental Health Act 1983– but this only applies to people who require hospital treatment for a mental disorder. Otherwise, actions that amount to a deprivation of liberty will not be lawful unless formal authorisation is obtained’. None of the patients on the ward had been detained under the Mental Health Act.

Staff told us that they would stop a patient who did not have an authorised DoLS from leaving the ward and complete a new DoLS application. This contravened the MCA, which states that a deprivation of liberty will not be lawful unless formal authorisation is obtained.

Staff did not manage medicines safely. There were missing signatures on medicine administration records (MARs), transcribing of medicines and missing information concerning allergies. A medication trolley was left unattended and unattached to a wall in the staff office between 10.10am and 11.25am during our inspection.

The MAR charts were mostly computer generated by the pharmacy. We saw that staff had handwritten some MAR charts, which had not been signed by a doctor. Staff had photocopied MAR charts, which meant that the boxes were very faint and it was unclear whether medicine was given and signed for.

Staff were restricting patients in their movements and using restraints for personal care, for which there was no record or assessment in the patients care plans.

Pull cords in the en suite toilets had been cut out of reach of patients and call bells next the patient beds had been disabled. Staff told us this was a precautionary measure to stop patients from deliberately harming themselves.

There were inconsistent thresholds and timeliness of reporting of safeguarding incidents. Risk assessments and risk management plans were variable in their detail and did not reflect patients’ risks in some areas.

There was insufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure they could meet patients care and treatment needs. The quality of care provided on each ward was inconsistent. Staff on Woodstock ward demonstrated care that was compassionate and engaged well with patients. Staff on Hearts Delight ward spoke of having little time to engage with patients and often being unable to provide personal care required by patients due to lack of staff. Staff told us that there was often insufficient staff available to ensure the safety and wellbeing of the patients. We observed that staff were unable to give patients sufficient time and attention. For instance, we saw that there was little interaction between staff and patients during a mealtime because there was too few staff. One staff member reported feeling stressed and fearful of the potential consequences of insufficient staff on Hearts Delight ward.

All patient bedrooms were furnished with appropriate beds and mobility armchairs where required. However, the trust had not replaced chairs for two patients that had been removed several months prior to the inspection because of damage. This meant that these patients remained in bed with little or no interaction with staff and other patients.

However, we also found:

All bedrooms had an e-suite toilet and basin. Rooms were spacious and patients were able to personalise their bedrooms. There were covered display boards in each bedroom which contained information including the patient’s named nurse, moving and handling information, personal care information, photographs and activities enjoyed.

On Woodstock ward, we were shown a care planning booklet, which contained information regarding the individual patient’s physical needs, diet, mental health, medication, mobility, personal care, religious and cultural needs, communication skills and relationships.  However, we were told that these may not be in every patient’s room due to being removed or ‘lost’ by the patient.

Dedicated rooms had been created to create a non-institutionalised environment. Rooms included a parlour, pampering room, barbers, a gentleman’s club and a pub. Staff had created life story boxes to stimulate memories such as school days or transport. The trust had recently purchased two therapy dolls to promote comfort and calming for patients. There was a variety of activities available for patients including pet therapy, music therapy, a you and me group delivered by the chaplain, music and memories and a weekly church service. The ‘daily sparkle’ newspaper was available which included ‘this day in history’, ‘do you remember’, history and quizzes.

Corridors had been decorated to suggest that the entrance to bedrooms was through the patient’s own colour coded front door with a photograph of the patient’s younger self next to the door handle to encourage recognition of their room. Staff told us that the use of the photograph also encouraged staff to see the ‘person behind the patient’.