MENTAL HEALTH AND LEARNING DISABILITY ANNOUNCED INSPECTION. Downe Acute Inpatient Unit. South Eastern Health and Social Care Trust

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1 MENTAL HEALTH AND LEARNING DISABILITY ANNOUNCED INSPECTION Downe Acute Inpatient Unit South Eastern Health and Social Care Trust 9 and 10 May

2 Table of Contents 1.0 Introduction Ward Profile Inspection Summary Stakeholder Engagement Additional concerns noted by Inspectors RQIA Compliance Scale Guidance Summary of Compliance RQIA Assessment Appendix 2 Inspection Findings... 17

3 1.0 Introduction The Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Northern Ireland s health and social care services. RQIA was established under the Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003, to drive improvements for everyone using health and social care services. On 24 October 2011 RQIA informed the South Eastern Health and Social Care Trust of the inspection date and forwarded the associated inspection documentation. RQIA adopted the approach of self-assessment, which allowed the ward the opportunity to demonstrate its ability to deliver a service against best practice indicators. This included the assessment of the trust s performance against an RQIA compliance scale, as outlined in Section 6. The inspection process included an analysis of the ward s self-assessment, other associated information, and discussions with ward staff, patients and relatives. A range of multidisciplinary records, policies and procedures were also examined as part of the inspection. The recommendations made during the previous inspection on 8 February 2011 were also assessed during this inspection to determine the trust s progress towards compliance. The inspector found compliance in all areas where recommendations were made. The minutes of the patient forum recorded that the patient advocate had attended a number of meetings. It was reported by the ward manager that they attend the multidisciplinary assessment meeting of those patients who have made this request in keeping with the previous inspection recommendations. Patients now have unrestricted access to bedroom and the smoking areas throughout the day. A South Eastern Trust policy for the entry and exit to acute inpatients units has been developed and was available for inspection. Information was also displayed informing patients and relatives that the door to the unit is locked and entry and exit can be gained by request to a member of staff. In addition the policy and the displayed information included that requests for exit will be monitored to ensure there is no delay for those patients who are voluntary and should not have their liberty restricted. All patients reported that they were familiar with the complaints process and this information was displayed around the ward, leaflets were also available. Information about how to make a complaint was also included in the admission documentation. Inspectors examined the complaints log and found that staff record all informal complaints. Patients reported that they are given 3

4 an information booklet on admission and inspector found that extra copies of these were made available at the patient forum. The ward manager reported that all nursing staff now have improved access to online records on Maximus, the trusts computerised record keeping system, where social work entries can be found and that staff on the ward will access these records on a regular basis. An example of this was shown to inspectors. Patients reported that they have one to one time with their primary nurse. Inspectors reviewed evidence of an audit which monitores patient access to individual time as part of the releasing time to care project. Ashtrays are now available in the smoking area of the unit and laundry facilities were available for use. None of the previously stated recommendations were outstanding. Inspectors wish to thank the ward manager and the staff for their efforts in achieving these recommendations. An overall summary of the ward s performance against the human rights theme of protection is in Section 3 and full details of the inspection findings are outlined in Appendix 2. 4

5 2.0 Ward Profile Trust Name of hospital/facility Address South Eastern Health and Social Care Trust Downe Acute Inpatient Unit, Downe Hospital 2 Struell Wells Road Downpatrick BT30 6R1 Telephone number Person in charge on day of inspection Mr Neil Morgan Nature of service - MH/LD Mental Health Name of ward/s and category of care Acute Mental Health Number of patients and occupancy level on days of inspection 23 patients full occupancy level plus one Number of detained patients on days of inspection 6 detained Date of last inspection 8 and 9 February 2011 Name of Inspector Janet McCusker 5

6 The Downe Acute Inpatient Unit (MHIPU) is located in the Downe Hospital which opened in July It is one of three mental health acute inpatient admission wards in the South Eastern Trust area. The MHIPU is a mixed adult ward of male and female patients and can accommodate patient s younger than 18 and over 65 years if required. There are ongoing plans to centralise acute inpatient facilities and this may result in this ward being relocated. The number of beds available in this unit has been reduced from 25 to 22 due to plans to reconfigure mental health services within the South Eastern Trust area. Nursing staff levels have been reduced in accordance with the number of inpatients There were six patients detained under the Mental Health (NI) Order There was one vacant bed and one patient was considered as a delayed discharge due to difficulty in finding a suitable placement for their complex needs. There was also one patient on observation on the first day of the inspection. The patient areas were accommodated on two corridors which were divided into female and male areas. All patients had ensuite single bedrooms and access to single gender day rooms. The patient's rooms consisted of a bathroom with shower, cupboards and nurse call system. The ward also included several interview rooms, an occupational therapy room and an assessment kitchen. A laundry room was also available with washing machine and ironing facilities. The patients had access to an outside smoking area and enclosed grounds around the unit. Medical cover was provided through one consultant psychiatrist and senior house officers. A consultant was also available for patients over 65 with functional mental illness. Patients on the ward have weekday access to occupational therapy. A daily programme of activities is available in the morning and afternoon which include a range of age appropriate activities developed from suggestions made by patients involved in the groups. In addition patients have access to ward based social workers. The ward is involved in an initiative Releasing Time to Care (RTTC) aimed at helping staff on acute mental health wards to improve the amount of nursing time spent with patients rather than time on other duties. 6

7 3.0 Inspection Summary An announced inspection of Downe Acute Inpatient Unit was undertaken on 9 and 10 May The purpose of this inspection was to assess the ward s arrangements and procedures for safeguarding vulnerable adults. The following is a summary of the inspection findings of the arrangements for safeguarding vulnerable adults on this ward. Information on safeguarding vulnerable adults was available on the ward and was found in policies, guidance documents and flowcharts outlining the trust procedure for safeguarding referral. Leaflets informing staff of the definitions and different types of abuse were also displayed on the ward and contained in a safeguarding folder maintained by the ward manager. Not all staff had mandatory training in protection of vulnerable adults, child protection or management of violence and aggression (care and responsibility). It is recommended that this is made available to all staff. At the time of the inspection the ward did not have any ongoing vulnerable adult referrals or investigations. Staff interviewed during the inspection were familiar with signs of abuse and the name of the nominated designated officer to contact if they wished to raise concerns. Inspectors examined two incident books recording the last six months incidents, and patient notes. The incidents reviewed did not identify concerns which would instigate protection of vulnerable adult referrals. However, in one set of notes reviewed inspectors found a record made that a patient had been deemed as a vulnerable adult and a protection plan had been put in place in March There was no further information or documentation regarding the type of abuse or the protection plan. Inspectors identified that this information was relevant to the staff currently providing care and treatment and a recommendation is made. Four sets of patient notes reviewed included a brief risk screen and a comprehensive risk screen. Other risk assessments found in patient notes included falls risk assessment and Braden risk assessments. In most instances this was signed by the patient and staff. One set of notes did not have any patient signature and did not indicate why the patient had not been involved in the care plan. Evidence in patient notes highlighted that the risks identified are reviewed and updated in the documentation on a weekly basis. Care plans for the risks identified were available. 7

8 Staff reported that they have regular access to supervision. and yearly appraisal. Templates for the recording of these were examined. Inspectors found that local induction to the ward was of a high standard and included information on safeguarding; a completed induction was examined and was found to be signed by the staff mentor and the member of staff. The content of the corporate induction does not include information on trust s vulnerable adult procedures and a recommendation is made. Patient s money can be stored in the trust s cash office and lodged into the Trust client s monies bank account. Inspectors examined the paperwork of a patient who had lodged money into the trust s bank account. This was recorded satisfactory and had been signed by members of staff and the patient. A policy was available for the safeguarding of patient property however it does not include the recording of returned items which had been given to staff for safekeeping. Inspectors noted that the policy had not been followed in a number of instances where two staff signatures were required and when they had recorded patient clothing on admission. Inspectors found that staff report and record incidents and accidents in accordance with trust policy and that learning from serious adverse incidents (SAIs) are discussed at ward manager level and that that this is included in the agenda for staff meetings. Information contained in the incident reporting form did not include evidence that relatives were informed of incidents or accidents. In addition, patient notes did not provide evidence that a relative had been contacted or any reason why staff did not inform relatives of the incident. Staff reported that they would often inform relatives verbally when they visited the ward however documentation of this did not occur on every occasion. Recommendations are made in relation to this. The regional policy for the use of observation of patients at risk was in operation on the ward. This guidance directs staff to record observations on an hourly basis and provides patients with written and verbal information regarding the reasons for the use of observation level. Inspectors found compliance with the regional policy and templates from the policy document. The ward does not have a policy for the use of restraint. Not all staff had full training in the management of violence and aggression (care and responsibility). A number of recommendations have been made in relation to this. 8

9 The ward had a copy of the trust s child visiting policy, but this was not easily accessible on the day of inspection. Staff reported that child visiting was accommodated in an office outside of the main ward. Despite this, inspectors identified that the office which is used is austere and clinical in manner and not suitable for children visiting, in addition, the ward do not display the child visiting policy / arrangements. Recommendations are made in respect of these matters. Inspectors would like to thank the patients and staff for their cooperation throughout the inspection process. 9

10 4.0 Stakeholder Engagement Questionnaires were issued to staff, patients, relatives/ carers and visiting professionals in advance of the inspection. The responses from the questionnaires were used to inform the inspection process. Questionnaires issued to Number Number issued returned Patients 23 9 Carers/Relatives 23 0 Visiting Professional 3 0 Staff 10 4 During the inspection the inspector has the opportunity to meet with staff, patients, relatives/ carers, visiting professionals or advocates. Below are the details of the number of discussions held during the inspection. Additional discussions during inspection Number Patients 4 Carers/Relatives 0 Visiting Professionals 0 Staff 3 Advocates 0 The following information is a summary of feedback received from those who returned a questionnaire or met with an inspector during the inspection. Patients: One detained patient and eight voluntary patients returned the questionnaires. Most patients were familiar with the term risk assessment and the safeguarding vulnerable adult policy. One patient reported that they had been upset and distressed as a result of an incident that had occurred on the ward. In response to this the patient was happy that they had been supported and appropriate action had been taken by staff on the ward. One patient raised issues relating to the noise level in the ward and this was discussed at feedback. A number of positive comments were made about the staff. This included: first class and sympathetic, very good, staff at all levels lovely, Carers/ Relatives: None of the relatives returned questionnaires and none were available during the times of inspection 10

11 Staff: Staff returning questionnaires commented positively about teamwork and the quality of care they are able to provide on the ward. A few staff reported that they had not received training in the protection of vulnerable adults and this was also identified during inspection. Three staff indicated that they had concerns about the lack of visiting space in the ward and identified this as a potential difficulty for those patients who do receive visitors. This was discussed with the ward manager and senior managers at feedback. Advocates: Inspectors did not meet with the patient advocate during this inspection. 11

12 5.0 Additional Concerns Noted by Inspectors 5.1 Gym facilities on the ward Inspectors examined the gym which is situated in the ward and includes exercise equipment and includes a treadmill and bike. The ward manager reported that patients can use the gym when supervised by a member of staff. However, inspectors noted that staff do not have training in the use of the equipment or in assisting patients to use the equipment. In addition medical checks prior to using this facility was not routinely sought. It was agreed that none of the patients should use this facility until staff members have training in the use and monitoring of patients using this type of equipment. 5.2 Serious Adverse Incident (SAI) Review Inspectors noted that there have been a number of SAIs involving patients from this ward within the last number of months. It was reported to the ward manager and clinical services manager that part of this inspection was to review if any links between the incidents could be made and the staff support in place following these incidents. It was reported that initial review of the three incidents identified that that no links could be found between the circumstances of these cases, and no immediate changes to practice or the environment have been made. Staff advised that support from management had been in place and that they were assisted to manage the other patients on the ward along with their own reactions to the events. In addition, one member of staff was supported to attend occupational health. No further recommendations are made at this time and RQIA awaits the reports of the investigations into the incidents. 12

13 6.0 RQIA Compliance Scale Guidance Guidance - Compliance statements Compliance statement 0 - Not applicable 1 - Unlikely to become compliant 2 - Not compliant 3 - Moving towards compliance Definition Compliance with this criterion does not apply to this ward. Compliance will not be demonstrated by the date of the inspection. Compliance could not be demonstrated by the date of the inspection. Compliance could not be demonstrated by the date of the inspection. However, the service could demonstrate a convincing plan for full compliance by the end of the inspection year. Resulting Action in Inspection Report A reason must be clearly stated in the assessment contained within the inspection report A reason must be clearly stated in the assessment contained within the inspection report In most situations this will result in a requirement or recommendation being made within the inspection report In most situations this will result in a recommendation being made within the inspection report 4 - Substantially Compliant Arrangements for compliance were demonstrated during the inspection. However, appropriate systems for regular monitoring, review and revision are not yet in place. In most situations this will result in a recommendation, or in some circumstances a recommendation, being made within the Inspection Report 5 - Compliant Arrangements for compliance were demonstrated during the inspection. There are appropriate systems in place for regular monitoring, review and any necessary revisions to be undertaken. In most situations this will result in an area of good practice being identified and being made within the inspection report. 13

14 7.0 Summary of Compliance RQIA Assessment No. Question Compliant Substantially Compliant Moving Towards Compliance Not Compliant Unlikely to become compliant Not Applicable How do you ensure that everyone involved with the ward is aware of and understands the safeguarding vulnerable adult policy? List the additional procedures and guidelines that you use to support the safeguarding vulnerable adult policy. List the additional procedures and guidelines, aimed at promoting safe and healthy working practices, which you use to support the safeguarding vulnerable adult policy. Outline how the ward is involved in the review of the Trust s safeguarding vulnerable adult policy, the code of behaviour and the other associated procedures and guidelines. Outline how new staff are appropriately inducted into the ward. Describe how staff training needs, appropriate to the post/ role, are identified. Outline the arrangements in place for: (i) the support and supervision of all staff (ii) the annual appraisal of staff and the review of volunteers Describe the arrangements in place for maintaining written records of: training completed; support and supervision; and annual appraisals and reviews. Describe how the ward ensures staff and volunteers comply with the Safeguarding Vulnerable Adults Standard 4. Outline the steps the ward has taken to ensure that staff and volunteers are competent to recognise signs of abuse. 14

15 11 Describe how the ward identifies and manages risks for individual patients. 12 Outline the mechanisms used by the ward to ensure that vulnerable adults have the right to take risks in relation to their care Describe how the reporting, recording and reviewing accidents, incidents and near misses informs and influences ward practice and the risk assessment and management procedures. Describe how the ward promotes and communicates the Trust s ethos of inclusion, transparency and openness to vulnerable adults, carers, advocates, family members, staff and volunteers. Describe the procedures in place for carers, advocates and vulnerable adults to share concerns they may have or to make complaints about the organisation. Outline the steps the ward has taken to encourage carers, advocates and vulnerable adults to raise concerns or make a complaint following an incident. Outline how the ward ensures that staff know and comply with the records management policy. Outline the mechanisms the trust has in place to inform vulnerable adults about their right to access to information held about them. Describe how the ward ensures that staff, volunteers and visitors know about and adhere to the Code of Behaviour. outline how the ward safeguards patients rights in relation to the use of: (i) restrictions on the ward (ii) isolation/ seclusion (iii) close observation (iv) restraint Outline the mechanisms for the handling of vulnerable adults money Outline how the ward ensures the safety of patients property while on the ward. Describe what arrangements the ward has in place for children visiting the ward. 15

16 24 Outline the safeguarding arrangements the ward has in place for the admission of an under 18 year old. 16

17 Appendix 1 Quality Improvement Plan QUALITY IMPROVEMENT PLAN ANNOUNCED INSPECTION Downe Acute Inpatient Unit 9 and 10 May 2012 The issue(s) identified during this inspection are detailed in the Quality Improvement Plan. The details of the Quality Improvement Plan were discussed with the Ward Manager and Senior Manager 1

18 2. RECOMMENDATIONS MADE FOLLOWING INSPECTION OF SAFEGUARDING VULNERABLE ADULTS AND CHILDREN HUMAN RIGHTS THEME OF PROTECTION RECOMMENDATIONS DETAILS OF ACTION TO BE TAKEN TIMESCALE 1. Staff induction, training, supervision and appraisal. It is recommended that all staff have mandatory training and this includes training in protection of vulnerable adults, child protection and care and responsibility It is recommended that all staff sign that they have read and understood policies relating to the protection of vulnerable adults It is recommended that the ward manager ensures that all staff receive mandatory training It is recommended that Vulnerable Adult Procedures are included in the corporate induction The Charge Nurse will facilitate attendance at mandatory training programmes to promote full compliance. Staff will continue attendance in training as set out in the recommendations. Documentation has been introduced for staff to sign to evidence that policies have been read and understood. We will continue to facilitate staff attendance at mandatory training. December 2012 July 2012 Immediate and ongoing Immediate 2

19 2. Awareness and implementation of procedures for the protection of vulnerable adults. It is recommended that any records made of a previous referral to the protection of vulnerable adult procedures should provide details of the nature of the referral. In addition, if a protection plan has been put in place previously, this information must also be available to staff currently involved in the patients care and treatment. The Ward Charge Nurse has linked with the designated officer to ensure such information is available to staff. Immediate 3. Incident reporting and risk management. It is recommended that any additional assessment of risk (such as a falls risk assessment) are discussed at the next multidisciplinary team meeting. However, if the outcome of assessment identifies that immediate prevention interventions should be put in place such as increasing the level of supervision required then this should be discussed immediately with the consultant and the nurse in charge. It is recommended that patients should be involved in the risk assessment or it should be indicated why the patient was unable to sign the documentation. This has been addressed and agreed that any changes to risk assessments are reviewed at the team assessment meeting. The Charge Nurse has reinforced to staff the need to ensure that any new identified risks that require immediate attention are addressed at that point in the Risk Assessment. It has been highlighted to all staff that we need to be clear if someone is unwilling or unable to sign documentation; this should be recorded in the patient s file. Immediate Immediate and ongoing It is recommended that relatives should be informed of incidents / accidents with patient This has been highlighted at a Immediate and ongoing 3

20 consent. Where patient lack capacity the relatives should be informed of all incidents ward meeting. Relatives/Carers will be informed of incident/accidents with appropriate consent. 4. Policies It is recommended that the admission and discharge policy draft is finalised. It is recommended that the trust develop a policy on restraint in mental health inpatient units. The Service has a planned programme for reviewing policies/procedures. The Trust Policy is currently out for consultation. September 2012 September 2012 It is recommended that other policies requiring renewal, as identified in the report, are updated. 5. Patients money and property. It is recommended that it is recorded when patient property which has been given to staff for safe keeping has been returned. As above. September 2012 The Service is currently reviewing policy and practice to address this recommendation. Immediate and ongoing It is recommended that two staff signatures are evident in keeping with the policy when dealing with patient monies or property It is recommended that guidance for staff is reissued regarding safeguarding of patient property and monies Has been implementated. This has been highlighted at a recent ward meeting to ensure staff are aware of need for dual signatures. Immediate and ongoing September Child Protection. 4

21 It is recommended that the trust child visiting policy is easily accessible on the ward and that all staff indicate that they have read and understood the policy It is recommended that the child visiting policy is displayed for visitors. It is recommended that the area used for children visiting is made child friendly The policy is available for all staff to consider and a sign off sheet is available to confirm same. The policy is now on display on the ward. The Charge Nurse will review how this can be accomplished. Immediate Immediate September Additional Recommendations. It is recommended that patient s do not use the gym until staff have been trained to supervise and induct patients how to use the equipment safely The Service, in conjunction with Estates and the Physiotherapy Departments; are reviewing the protocol for the use of gym equipment. This equipment will not be used until this review is satisfactorily concluded. Immediate 5

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