Review of compliance. Florence Nightingale Hospitals Limited Capio Nightingale Hospital. London. Region: Lisson Grove Marylebone London NW1 6SH

Transcription

1 Review of compliance Florence Nightingale Hospitals Limited Capio Nightingale Hospital Region: Location address: Type of service: London Lisson Grove Marylebone London NW1 6SH Diagnostic and/or screening service Date of Publication: January 2012 Overview of the service: Capio Nightingale Hospital provides mental health care and treatment for up to 80 people who may or may not be detained under the Mental Health Act The hospital offers general psychiatry, eating disorder and addiction treatment to adults; and general psychiatry and eating disorder treatment to adolescents. Page 1 of 16

2 Summary of our findings for the essential standards of quality and safety Our current overall judgement Capio Nightingale Hospital was not meeting one or more essential standards. Improvements are needed. The summary below describes why we carried out this review, what we found and any action required. Why we carried out this review We carried out this review as part of our routine schedule of planned reviews. How we carried out this review We reviewed all the information we hold about this provider, carried out a visit on 9 December 2011, talked to staff and talked to people who use services. What people told us People were given adequate information about what to expect and were satisfied with their care and treatment. People felt safe in the hospital, had their privacy and dignity respected and felt involved in their treatment. What we found about the standards we reviewed and how well Capio Nightingale Hospital was meeting them Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run People who use the service understand the care, treatment and support choices available to them. They are involved in their treatment and care and have their privacy and dignity respected. Overall, Capio Nightingale Hospital was meeting this essential standard. Outcome 02: Before people are given any examination, care, treatment or support, they should be asked if they agree to it People who use the service have their mental capacity assessed to make specific decisions, and where appropriate, give valid consent to their care and treatment. However, there was no documented evidence that people using the service were informed by staff that they could withdraw their consent to treatment at any time. Overall, Capio Nightingale Hospital was meeting this essential standard, however to maintain this, we have suggested improvements. Outcome 04: People should get safe and appropriate care that meets their needs Page 2 of 16

3 and supports their rights People using the service experience safe and appropriate care, treatment and support that meets their needs and protects their rights. Overall, Capio Nightingale Hospital was meeting this essential standard. Outcome 07: People should be protected from abuse and staff should respect their human rights People using the service are protected from abuse, or the risk of abuse. However, staff working with adolescents had not attended child protection training in the past year. Overall, we found that improvements were needed with this essential standard. Outcome 14: Staff should be properly trained and supervised, and have the chance to develop and improve their skills People using the service have their health and welfare needs met by competent staff. Overall, Capio Nightingale Hospital was meeting this essential standard. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care People who use the service benefit from safe, quality care, treatment and support, due to the management of risks to their health, welfare and safety. Overall, Capio Nightingale Hospital was meeting this essential standard. Actions 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. When we propose to take enforcement action, our decision 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. Other information Please see previous reports for more information about previous reviews. Page 3 of 16

4 What we found for each essential standard of quality and safety we reviewed Page 4 of 16

5 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 5 of 16

6 Outcome 01: Respecting and involving people who use services What the outcome says This is what people who use services should expect. People who use services: * Understand the care, treatment and support choices available to them. * Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support. * Have their privacy, dignity and independence respected. * Have their views and experiences taken into account in the way the service is provided and delivered. What we found The provider is compliant with Outcome 01: Respecting and involving people who use services Our findings What people who use the service experienced and told us People we spoke with told us that they were given adequate information about what to expect and were given information packs on admission, which described the services available. People using the service told us that their privacy and dignity was respected and they felt involved in their treatment and care. Other evidence We observed that people using the service were provided with information about the aims, objectives and purpose of the service. People were involved in their care where appropriate and signed care plans as necessary. We saw staff interacting with people using the service in a polite manner and treating them dignity and respect. People who use the service understand the care, treatment and support choices available to them. They are involved in their treatment and care and have their privacy and dignity respected. Overall, Capio Nightingale Hospital was meeting this essential standard. Page 6 of 16

7 Outcome 02: Consent to care and treatment What the outcome says This is what people who use services should expect. People who use services: * Where they are able, give valid consent to the examination, care, treatment and support they receive. * Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed. * Can be confident that their human rights are respected and taken into account. What we found The provider is compliant with Outcome 02: Consent to care and treatment Our findings What people who use the service experienced and told us We did not speak to people using the service about this outcome on this occasion. Other evidence We saw evidence that staff had completed training on the Mental Capacity Act Records reviewed indicated that people using the service were initially assessed as to whether they had the capacity to make specific decisions or required a detailed assessment. Medical staff carry out decision-specific capacity assessments for treatment. The wards were unlocked and people using the service who were informal, could leave if they desired. However, there was restricted access to the hospital entrance, and people using the service, would require permission to leave the building. We did not see evidence that people using the service were informed by staff that they could withdraw their consent to treatment at any time. People who use the service have their mental capacity assessed to make specific decisions, and where appropriate, give valid consent to their care and treatment. However, there was no documented evidence that people using the service were informed by staff that they could withdraw their consent to treatment at any time. Page 7 of 16

8 Overall, Capio Nightingale Hospital was meeting this essential standard, however to maintain this, we have suggested improvements. Page 8 of 16

9 Outcome 04: 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 The provider is compliant with Outcome 04: Care and welfare of people who use services Our findings What people who use the service experienced and told us People we spoke with told us that they were satisfied with their care and treatment. We were told by people using the service that they knew who their key worker was and most had signed their care plans in agreement. Other evidence We saw evidence that each person using the service had a named key worker on each ward. People using the service had initial risk assessments upon their admission. Brief risk assessments were also carried out on a daily basis by registered nurses. The records we reviewed showed that people using the service had individual care plans and signed in agreement. Notes on peoples' progress were recorded in a chronological order in their personal file. Where people were detained under the Mental Health Act, a leaflet on their rights was given to them and documented in their file. We observed that staff wore name badges and kept the people using the service under an appropriate level of observation. A community meeting for people using the service was held on each ward on a regular basis, where issued were discussed and resolved. Adolescents were cared for in a separate unit to that of adults. The treatment programme for adolescents included educational activities. People using the service experience safe and appropriate care, treatment and support that meets their needs and protects their rights. Overall, Capio Nightingale Hospital was meeting this essential standard. Page 9 of 16

10 Outcome 07: 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 There are minor concerns with Outcome 07: Safeguarding people who use services from abuse Our findings What people who use the service experienced and told us People using the service told us that they felt safe in the hospital. Other evidence Staff told us that they would discuss any safeguarding concerns they had with the relevant person and report it their manager. We were told by staff that there was a safeguarding officer based at the hospital, who they would refer suspected cases of abuse. We saw evidence that staff had attended training on safeguarding vulnerable adults, which included training on the deprivation of liberty. We did not see evidence that staff working with adolescents had attended child protection training in the past year. People using the service are protected from abuse, or the risk of abuse. However, staff working with adolescents had not attended child protection training in the past year. Overall, we found that improvements were needed with this essential standard. Page 10 of 16

11 Outcome 14: Supporting staff What the outcome says This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by competent staff. What we found The provider is compliant with Outcome 14: Supporting staff Our findings What people who use the service experienced and told us We did not speak to people using the service about this outcome on this occasion. Other evidence Staff told us that they received supervision either individually or in a group and were appraised on their performance on an annual basis. There were monthly meetings on each ward and staff told us that they felt supported and managers were approachable. We saw records that staff had attended training on fire safety, breakaway techniques and basic life support. People using the service have their health and welfare needs met by competent staff. Overall, Capio Nightingale Hospital was meeting this essential standard. Page 11 of 16

12 Outcome 16: Assessing and monitoring the quality of service provision What the outcome says This is what people who use services should expect. People who use services: * Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety. What we found The provider is compliant with Outcome 16: Assessing and monitoring the quality of service provision Our findings What people who use the service experienced and told us We did not speak to people using the service about this outcome on this occasion. Other evidence We saw evidence that staff carried out routine environmental checks on a weekly basis. There are monthly clinical governance meetings that monitor compliance with essential standards. These meetings were attended by doctors, nurses, managers and pharmacists. There are clinical advisory committee meetings and clinical audits were carried out on therapy files and people detained under the Mental Health Act. Records of people's satisfaction and feedback are kept and analysed on a monthly basis. There was a staff satisfaction survey in 2010, where most staff were satisfied with the service provided. People who use the service benefit from safe, quality care, treatment and support, due to the management of risks to their health, welfare and safety. Overall, Capio Nightingale Hospital was meeting this essential standard. Page 12 of 16

13 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 Treatment of disease, disorder or injury Regulation 18 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 02: Consent to care and treatment Why we have concerns: There was no documented evidence that people using the service were informed by staff that they could withdraw their consent to treatment at any time. 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 The provider's report should be sent to us within 28 days of the date that the final review of compliance report is sent to them. CQC should be informed in writing when these improvement actions are complete. Page 13 of 16

14 Compliance actions The table below shows the essential standards of quality and safety that are not being met. Action must be taken to achieve compliance. Regulated activity Regulation Outcome Treatment of disease, disorder or injury Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 07: Safeguarding people who use services from abuse How the regulation is not being met: Staff working with adolescents had not attended child protection training in the past year. The provider must send CQC a report that says what action they are going to take to achieve compliance with these essential standards. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The provider's report should be sent to us within 28 days of the date that the final review of compliance report is sent to them. Where a provider has already sent us a report about any of the above compliance actions, they do not need to include them in any new report sent to us after this review of compliance. CQC should be informed in writing when these compliance actions are complete. Page 14 of 16

15 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 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 15 of 16

16 Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public / 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 Telephone address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 16 of 16