Inspection Report - Care Quality Commission · |Inspection Report | Alpha Hospital - Woking | February 2015 3 Contents When you read this report, you may find it …

| Inspection Report | Alpha Hospital - Woking | February 2015 www.cqc.org.uk 1

Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Alpha Hospital - Woking

Redding Way, Knaphill, Woking, GU21 2QS Tel: 01483795100

Date of Inspections: 21 November 201418 November 2014

Date of Publication: February 2015

We inspected the following standards in response to concerns that standards weren'tbeing met. This is what we found:

Care and welfare of people who use services Action needed

Safeguarding people who use services from abuse

Met this standard

Cleanliness and infection control Action needed

Management of medicines Met this standard

Safety and suitability of premises Action needed

Assessing and monitoring the quality of service provision

Met this standard


Details about this location

Registered Provider Alpha Hospitals Limited

Registered Manager Mr Sampson Antwi-Marful

Overview of the service

Alpha Hospital Woking is a mental health hospital that is owned and managed by Alpha Hospitals Limited. The service provides low secure services for adult and female patients and PICU services for adolescent male and female patients.

Type of service Hospital services for people with mental health needs, learning disabilities and problems with substance misuse

Regulated activities Assessment or medical treatment for persons detained under the Mental Health Act 1983

Diagnostic and screening procedures

Treatment of disease, disorder or injury


Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page

Summary of this inspection:

Why we carried out this inspection 4

How we carried out this inspection 4

What people told us and what we found 4

What we have told the provider to do 5

More information about the provider 5

Our judgements for each standard inspected:

Care and welfare of people who use services 6

Safeguarding people who use services from abuse 9

Cleanliness and infection control 11

Management of medicines 13

Safety and suitability of premises 14

Assessing and monitoring the quality of service provision 16

Information primarily for the provider:

Action we have told the provider to take 19

About CQC Inspections 21

How we define our judgements 22

Glossary of terms we use in this report 24

Contact us 26


Summary of this inspection

Why we carried out this inspection

We carried out this inspection in response to concerns that one or more of the essential standards of quality and safety were not being met.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, carried out a visit on 18 November 2014 and 21 November 2014, observed how people were being cared for and talked with people who use the service. We talked with staff, reviewed information given to us by the provider, were accompanied by a pharmacist and were accompanied by a specialist advisor.

We were accompanied by a Mental Health Act commissioner who met with patients who are detained or receiving supervised community treatment under the Mental Health Act 1983.

What people told us and what we found

Is the service safe?

The safeguarding policies and procedures were up to date. Staff demonstrated a clear understanding of the types of abuse and the responsibilities they had to report safeguarding concerns. Medicines were prescribed, administered and stored appropriately. The risk of cross contamination was increased due to poor infection control practices.

Is the service effective?

There was a multi-disciplinary team of staff working within the service. Audits had been carried out and some changes implemented as a result.

Is the service caring?

Some of the care we observed was positive. Capacity to consent to decisions was routinely assessed and recorded. Care plans showed involvement and acknowledgement of the person's needs and what action was needed to support them. Blanket rules and restrictions were implemented on some wards.

Is the service responsive?

All the people using the service had a care plan. In some cases this was tailored to the needs of the person, but in others it did not reflect their individual needs or risk assessment.


Is the service well led?

The service had up to date policies and these were accessible to all staff. There were processes in place for monitoring the service. However, there was limited evidence to demonstrate action taken or required, and timescales when this would be achieved.

You can see our judgements on the front page of this report.

What we have told the provider to do

We have asked the provider to send us a report by 20 February 2015, setting out the action they will take to meet the standards. We will check to make sure that this action is taken.

Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service(and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions.

There is a glossary at the back of this report which has definitions for words and phrases we use in the report.


Our judgements for each standard inspected

Care and welfare of people who use services Action needed

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement

The provider was not meeting this standard.

People did not always experience care, treatment and support that met their needs and protected their rights.

We have judged that this has a moderate impact on people who use the service, and havetold the provider to take action. Please see the 'Action' section within this report.

Reasons for our judgement

We reviewed 11 patients' care records across the service. Prior to admission, patients had been assessed by a consultant and a nurse and information from their previous placementwas reviewed. A 72 hour care plan and risk assessment had been implemented on admission.

The sample of care records we looked at included care plans, risk assessments and care programme approach (CPA) documents. Most of these were fully completed and showed involvement and acknowledgement of the person's needs and what action was needed to support them. For example, on Greenacre ward we saw detailed recording of support plans, evaluation and review at multi-disciplinary team (MDT) meetings for a patient in longterm, self-imposed segregation. However, on Park View Ground ward we found that a patient's risk assessment had rated them at high risk of self-neglect and vulnerability. We could not find a care plan with detailed interventions for staff to support the patient and hadno further information as to what the risks were.

Some patients on Park View Ground ward were on enhanced observations, where they had a member of staff with them at all times. The care records did not have care plans or risk assessments to demonstrate why enhanced observations were required, what concerning behaviour staff should be aware of, and how care should be provided. We asked staff and managers to tell us the reasons that specific patients were on enhanced observations, but the information we were given was contradictory.

We saw that individual support plans had been developed for patients to ensure that staff had information about their individual needs and wishes. This information included personal preferences and goals to make sure patients' wishes and needs were respected. We saw evidence of recent MDT and CPA meetings that had been held to review the


support that was provided. This had involved patients, their representatives and various health and social care professionals.

Patients had their capacity to consent to decisions routinely assessed and recorded. The sample of records we looked at showed that people's capacity had been assessed and recorded, both on admission and in weekly MDT meetings.

We reviewed a sample of seclusion and segregation records and found they had been completed correctly. We saw that information about the use of seclusion was recorded andmonitored across the service.

The service had policies about the management of challenging behaviour. However, detailed information about challenging behaviour, the action taken and its effectiveness was not consistently recorded. The service had a policy entitled "De-escalation and management of challenging behaviour", which stated: "A record of the post incident debriefing for staff and young people will be recorded on the incident form and included in the ward electronic report". Staff told us that after an incident a debriefing meeting sometimes took place. This included all the staff involved in the incident and gave them time to ask questions and reflect on their practice. However, we could not find evidence of these having been recorded. The same policy stated that, "The de-escalation form is to be used when a young person responds to de-escalation interventions/techniques and returnsto mix with peers. These interventions also need to be recorded on an incident form (if used) and in the MDT notes". Although incident forms stated "de-escalation techniques used" it was not clear what these techniques were and we could not find evidence of a de-escalation form being used. The care records did not include the recording of patient debriefing.

Staff and management were kept up to date about any changes to patients' needs. Handover meetings were held each morning between the nurse in charge of the night shift and all staff arriving for the day shift. Senior nurses attended a daily management meeting and information was further discussed with consultants and managers. Changes to patients care needs were made accordingly.

Blanket rules and restrictions were implemented on some of the wards, which were not based on individual patients' needs. On Greenacre and Oak Tree low secure wards we found that patients were individually risk assessed to have their own bedroom door key. However, on Acorn ward and Park View Ground ward we found several 'blanket rules' in place. For example, no patients were allowed a key to access their bedroom. There was no free access to hot or cold drinks and staff told us this was because patients would throw the water at other patients and staff. However, each patient was provided with a named plastic water bottle, which staff refilled as necessary. The corridors on Park View Ground ward were locked off as were the communal toilets. Patients had to ask staff to be able to access their bedroom or the communal toilets.

There were arrangements in place to deal with foreseeable emergencies. Staff told us that if a patient became unwell they informed the nurse in charge. Staff told us that if a patient became unwell suddenly and needed urgent medical treatment they would call the emergency services.

We saw positive interactions between patients and staff. We saw staff engaging with patients. The staff were talking with patients and supporting them to participate in groups and undertake daily activities.


The provider may find it useful to note that people were not always given appropriate information. For example, on Acorn ward and Park View Ground ward, information about informal patients' rights, or other bodies that people could contact, such as the local authority or the Care Quality Commission, was not displayed. Information was clearly displayed on Oak Tree ward and Greenacre ward. However, it was not always provided in a clear, easy to read format which may have been helpful to people with a learning disability, complex needs or people who lack capacity.


Safeguarding people who use services from abuse Met this standard

People should be protected from abuse and staff should respect their human rights

Our judgement

The provider was meeting this standard.

Patients who used the service were protected from the risk of abuse, because the providerhad taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.


The service had an organisational policy and procedure for protecting and safeguarding vulnerable adults and children, and a whistle blowing policy. Staff were aware of both policies. We saw that the policies were accessible for staff in the ward office and containedup to date information to guide and support staff.

We spoke with several staff during our inspection about safeguarding procedures and practices. They all demonstrated a clear understanding of the types of abuse and the responsibilities they had to report safeguarding issues and raise concerns.

Most staff had completed safeguarding training. Records showed that new staff had an induction programme which included safeguarding and management of violence and aggressive behaviour. Staff working on the wards did not directly report safeguarding concerns. However, staff did record potential safeguarding concerns through the daily handover records and through the incident management system.

Patients and staff told us that independent advocates were provided and regularly visited the ward. Patients were able to request a visit from an advocate and could contact them bytelephone when they wanted.

The provider was working with stakeholders to address and manage situations where repeated safeguarding concerns had been raised. The registered manager told us that they had regular meetings with the local authority safeguarding team to discuss incidents and safeguarding concerns.

There was a safeguarding tracker which included details of reported safeguarding concerns, the action taken, and investigations and outcomes. This was reviewed regularly within the local service. The provider may find it useful to note that the details of the immediate action taken to ensure a patient's safety following an alert, and the rationale for this, were not always recorded.

We reviewed patients' notes and could not find evidence that the outcome from


safeguarding alerts had been fed back to the patient and/or their relatives.


Cleanliness and infection control Action needed

People should be cared for in a clean environment and protected from the risk of infection

Our judgement


There were not effective systems in place to reduce the risk and spread of infection.

We have judged that this has a minor impact on people who use the service, and have toldthe provider to take action. Please see the 'Action' section within this report.


The service had an infection control policy. This outlined the strategy and responsibilities for infection control, which included the provision of an infection control nurse. There were clinical waste bins on each ward. However, one of the wards had a used incontinence pad in an open bin outside a bathroom. Staff agreed that the bin should not be kept there.

The kitchen on Greenacre ward was in need of a deep clean. For example, there was black mould around the back of the sink, areas of the room had ingrained dirt, and there were gaps between the skirting board and floor which made it difficult to clean effectively. Staff told us that food was handled in the room.

Clean, dirty and soiled items were not effectively separated, which increased the risk of cross-contamination. We saw a bin that contained mixed waste also included a red soiled laundry bag. Staff confirmed that this was not appropriate disposable of the items. The manager confirmed that they used the red plastic bags for soiled laundry. When asked why there was a torn red bag in the bin, staff told us that they took the soiled laundry out ofthe red bag to put it in the washing machine. The purpose of the red bags is that they dissolve in the washing machine, so that the soiled items do not contaminate non-soiled items, and do not have to be re-handled after they have been put in the bag. In the laundryroom on Greenacre ward we saw that there was a red soiled laundry bag on top of a pile of dry clothes on top of the washing machine. Staff were not aware that the bags should not be mixed with other items where there was the potential for cross contamination. We saw that the washing machines did have a sluice cycle for the effective washing of soiled laundry.

Staff told us that people were encouraged and supported to do their own laundry, and there was a laundry rota. On Oaktree and Greenacre wards there were clothes piled on top of the washing machines. It was not clear who the clothes belonged to or if they were clean or dirty. Staff told us that patients often took other people's clothes out of the machines, to put their own in. However, patients were always supervised by staff in the laundry.


We saw that there were mops in the washing machine on Greenacre ward. Staff confirmedthat they did not have a dedicated machine for washing mops, so this was the same machine used by patients. Staff told us they were not aware of a policy for managing this to ensure that patients' clothing was not contaminated by dirty mops.

The infection control nurse carried out audits of the service. The most recent infection control audit had been carried out on all five wards in October and November 2014. We saw that a number of problems had been highlighted on all the wards. These mainly involved cleaning and tidying, with repainting or replacement of some items. The audits looked at the laundry facilities, but did not refer to the use of mops or soiled laundry bags. They did identify that there were piles of clothing on top of the washing machines that needed to be tidied away. Many of the issues identified had a timescale for "immediate" action. However, the progress against this was not recorded and during our inspection we saw that actions had not been completed. For example, an audit had been carried out on Greenacre ward on the 23 October 2014. The actions included that the kitchen needed a deep clean and had marked the timescale as "immediate". However, this had not been implemented by the time of our inspection more than three weeks later.


Management of medicines Met this standard

People should be given the medicines they need when they need them, and in a safe way

Our judgement


People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.


The medicine management systems in this service were safe. Medicines were prescribed and administered to patients appropriately. There was support from an external pharmacistand a general practitioner. The pharmacist attended weekly and performed checks and completed audits. This meant that there were clear processes in place to ensure a person's medicines prescription was reviewed as their needs or conditions change in relation to their medicine.

There were systems in place to ensure safe practices and that latest guidance was cascaded to all healthcare staff within the hospital. This meant that there were clear processes to take account of new guidance and alerts relating to the safe handling and use of medicines.

Medicines were stored safely in locked treatment rooms on the wards. Access to these rooms was via a door key held by staff working in the area. Within these rooms medicines were stored in locked cupboards, refrigerators or controlled drugs safes. Access to medicines was restricted to appropriate staff.

Some of the patients were on high doses of medication, which required additional monitoring of their physical health. We saw one example where a patient was on high dose anti-psychotic medication and had refused a monitoring blood test on four consecutive occasions. The provider may find it useful to note that there was no clear policy or guidance on what action staff should take to ensure the patient's physical healthcare needs were met.


Safety and suitability of premises Action needed

People should be cared for in safe and accessible surroundings that support their health and welfare

Our judgement


Patients and staff were not protected against the risks of unsafe or unsuitable premises.

We have judged that this has a minor impact on people who use the service, and have toldthe provider to take action. Please see the 'Action' section within this report.


All patients had a single room with an ensuite shower and toilet. Some patients had their own key to their room, which staff told us was determined by a risk assessment of the person. There was an inbuilt blind in the window of each door, which could be opened by staff with a key, or from the inside with a knob. This gave patients privacy, whilst allowing staff to check on people when necessary. There was a communal bathroom available for people who preferred a bath to a shower.

Each ward had a communal lounge, television and dining areas; a laundry and kitchen. There was dedicated outdoor space for each ward, and activity rooms for crafts and computer usage. Food was prepared in the main hospital kitchen, and served to patients on their ward.

The building was designed to reduce the environmental risks to patients and others, and most of the fittings in the bedrooms were anti-ligature. However, there were some areas where environmental risks had not been addressed. For example, on at least one of the wards there was a communal toilet which did not have an anti-barricade door. We were able to hold the latch on the inside whilst a member of staff tried unsuccessfully to open the door with a key from the outside.

On Greenacre ward the upstairs rooms had freestanding wardrobes and lockers. Staff told us that patients who had been assessed as at a higher risk had bedrooms on the lower floor. However, all patients were able to access the upper floor, and not all of the rooms there were locked. One room was suitable for a person with a physical disability and had an adjoining accessible bathroom. Staff told us that the bathroom was kept locked because of the potential ligature risks. However, the bedroom also had ligature risks and was left unlocked and open. In one room we saw that there was a supply of healthcare products in their original plastic bags and rolls of plastic waste bags. Staff confirmed that plastic bags were classed as contraband in the service and that this had not been considered in relation to these products. The room was unlocked, and the door was open during our inspection so the items were accessible to all patients on the ward, regardless of their level of risk.


There was a cutlery checking folder used on each of the wards. However, this was not consistently completed by staff.

The garden of Oaktree ward was only accessible by leaving the ward and walking through the building. An area of the outdoor space was fenced off from the rest of the garden, because there was a large tree which may present a risk to patients. Staff told us the gate to the area was always locked but it was open when we inspected the garden. Staff told usthat patients would always be supervised in the garden and that they were unable to get into the garden area without staff to give them access. We saw that there was CCTV and assistance alarm points but there was a blind spot on route to the garden which may put staff and patients at risk. There were anti-climb fences surrounding the gardens. We saw that CCTV was used throughout the building and that there were monitors for this on the wards and in reception.

A ligature audit tool had been completed for the building. It covered most rooms, but bedrooms were assessed as a type of room, rather than individually. The audit tool identified potential ligature risks, rated the likelihood and seriousness of the risk, and identified any action that was required. We saw that common risks had been highlighted, such as doors and windows, and that for most areas there was no action required. The forms stated that the risks were mitigated by good observation, patient risk assessment, staff awareness, environmental checks and regular searches. These terms were used on most of the forms as mitigating actions, and referred to general rather than specific risks. For example, the assessment of Oaktree ward's garden highlighted the risks presented by the tree but did not state that this was partially mitigated by fencing off the tree, or when the gate should be locked or unlocked.

The ligature audit included an assessment of the communal toilets, but not that they did not have an anti-barricade door. Risks were identified in the disabled bedroom and toilet on Greenacre ward. The "bedroom" and disabled bedroom risks were identified. However, the audit did not identify that patients assessed as at a higher level of risk of harm could still access the "lower" risk upstairs rooms, which included the disabled bedroom

We saw that some areas of the building were in need of maintenance. For example on Parkview Ground ward there was an electrical socket with broken plaster around it. Each of the wards had a payphone on a trolley, and a private room for this. Some of the trolleys were unsteady, and the "private" rooms on Greenacre ward had a missing glass brick fromthe wall.

There were airlocks onto each of the wards. There were rooms for visitors on each of the wards. These rooms were also used as places to search patients when they returned to the ward from leave. There was a family room for children visiting the unit and a multi-faith room.


Assessing and monitoring the quality of service provision

Met this standard

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care

Our judgement


The provider had an effective system to regularly assess and monitor the quality of servicethat people receive.


The registered manager told us that any issues that occurred in the service were summarised each day in the senior nurses' report. This was reviewed by the registered manager and discussed at the daily handover meeting. We saw the notes of the daily handover meetings for October 2014. These showed that care issues such as incidents, possible safeguarding concerns and seclusion were discussed and actions identified. The findings of audits and other meetings within the service were also discussed, although the outcomes were not always recorded.

The service had a monthly clinical governance meeting. This was chaired by the registeredmanager and the medical director, and attended by a range of staff which included nurses and an external pharmacist. We saw the minutes of the three most recent meetings in August, September and October 2014. There was a standing agenda which included care,records, staffing, and the environment. There was some discussion of specific patient and ward issues. Completed audits were discussed, and the need for further audits identified. For example, a medication audit was discussed and the need to look at the use of "PRN", or as necessary, medication was identified. Training needs were identified following audits and incidents. For example, following incidents, the need for staff to have further training on carrying out observations, and about relational security were highlighted. Actions were identified and these were followed through at subsequent meetings.

The registered manager told us they compiled a monthly report on incidents, and the use of seclusion and restraint, and the monthly reports were summarised quarterly. The reports were discussed in the local governance meetings and also in the quarterly corporate governance meeting attended by staff from all the hospitals in the group.

Staff told us that they had used a paper-based incident recording system, but this had changed to a computer system the week before the inspection. Staff told us that any member of staff could record and log incidents. These were reviewed by the ward manager and then discussed in the service-wide handover meeting. The minutes of the daily handover meeting confirmed that incidents were discussed, and they signposted any further action that needed to be taken.


Information about incidents was collected and analysed for trends. This included analysis of types of incident, and looked for any particular times or days of the week when they occurred. Where patterns were identified, possible reasons for this were suggested. For example, the analysis showed that there was an increase in incidents on the days that ward rounds took place. To address this issue, staff were encouraged to involve people more in their care and use "have my say" forms. However, the action required or taken was not always recorded within the incident analysis.

The incident trends report for August 2014 suggested that an increase in incidents was due to over reporting when "standard nursing interventions" were incorrectly recorded as incidents. Staff training was planned to address this. However, the incidents referred to were regarding self-harm, staff assaults and security related incidents which would typically be expected to be recorded as incidents, even if elements of these were included in a patient's care management plan. The most recent quarterly incident report showed thenumber of incidents had reduced. However, there was no reference to the "over reporting" identified in previous months, and whether this was part of the reason for the reduction.

The August audit report included a detailed summary of incidents. The audit found that there was a number of poor recording issues such as no action recorded, insufficient detailabout the severity of and items used for self harm, and times of incidents and when they had been recorded. The service hoped to address this with the introduction of an electronic recording system which had been introduced the week before our inspection.

The service had identified that Park View Ground ward had a significantly higher level of incidents than the other wards. Over half of these incidents involved self harm, and about a quarter involved harm to others. The service had included the key areas of concern from the incidents on its risk register. These included staff shortages, staff confidence in managing challenging behaviour, and lack of effective communication with staff. The action required to address these concerns and the people responsible had been identified,but there were no timescales for when this would be achieved.

The registered manager told us that there was a monthly clinical audit and effectiveness meeting where they reviewed audits. The service had staff who carried out clinical audits and produced a monthly audit report. We saw the most recent audit reports for August, September and October 2014. These showed that audits were carried out across the wards and included risk assessments, medication (by an external pharmacist), and care records. The level of impact and progress following the audits was variable. For example, in August a number of gaps in the STAR risk assessment tool were found. During further audits in August, September and October the adult wards improved. However, the child and adolescent mental health services (CAMHS) services saw limited if any improvement and limited action had also been taken following gaps in specific CAMHS audits carried out over the same period.

Audits of clinical files were carried out on admission and at care programme approach (CPA) meetings. The registered manager told us that where gaps were highlighted, this information was sent to the ward to be addressed. The files were not checked again until the next CPA meeting, which could be several months later. However, records confirmed that any gaps in the audit were reviewed in the daily handover meetings.

The registered manager told us that a patient satisfaction survey had been carried out of the adolescent service in 2014, but not of the adult service. The survey was compiled in August 2014, but did not state over what time period it had been completed. There were


13 responses. Most patients (11 out of 13) said they felt safe, and most people understoodtheir care plans, had an activity timetable, and were involved in their care planning. Other areas were less positive, for example how useful they found meetings, how often they met their named nurse, and the number of agency staff used. The action from this was to review the named nurse system. They also highlighted that people did not have access to a social worker, which highlighted work to "investigate [young person's] understanding of the supportive disciplines." The questionnaires were sent to all people using the service, but the response rate varied. The registered manager told us that they had not carried out a carers' survey for the last quarter, or a staff survey.

The service kept a log of enhanced observations, segregation and seclusion. The log recorded how long each person had been subject to the intervention, and how many staff they had with them. The log showed that observation, segregation and seclusion were used across the service. Staff told us that "segregation" referred to ECA (extra care facility) or a person being cared for in a closed-off "zone" of the ward. For the three monthsof August, September and October 2014 they were mostly used on Parkview Ground and Acorn wards. The registered manager told us that individual patient's observation levels were reviewed every morning.

All seclusion records were audited and any gaps were identified and addressed. We saw the seclusion audit records for September and October 2014. The seclusion records were picked up twice a day and reviewed by the audit coordinator. They identified any gaps on the forms, which went back to the ward staff to complete them. The completion of the forms was discussed at the daily handover meeting, and any identified themes were raisedin the governance meeting. For example, gaps were found in the seclusion record. This was identified as being due to a member of staff who was unfamiliar with the seclusion process. This was identified as a training need, and the risk manager carried out training with the member of staff. Segregation was also monitored, and the audits for August, September and October 2014 showed that the service was monitoring, and reviewing the reasons for increases and decreases in its use.

We saw the complaints log for August, September and October 2014. The complaints were on a variety of issues, and included staff attitude and behaviour, care issues, other patients' behaviour and food. The log included a summary of each complaint, when it was received and responded to, who had investigated it, and whether it was upheld. Most complaints were from patients, and were responded to within three weeks. There was a mix of outcomes which showed that complaints were fully, partially or not upheld. There was space on the log to record action taken following the complaint, but this was not recorded. The registered manager told us that they produced a complaints report each month, and when complaints were upheld they discussed the lessons learnt in the local governance meeting.

This section is primarily information for the provider


Action we have told the provider to take

Compliance actions

The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activities Regulation

Assessment or medical treatment forpersons detained under the Mental Health Act 1983



Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010

Care and welfare of people who use services

How the regulation was not being met:

Regulation 9 (1)(b)(i)(ii)




Treatment of disease, disorder or

Regulation 12 HSCA 2008 (Regulated Activities) Regulations2010

Cleanliness and infection control


Regulation 12(1)(a)(b)(c)(2)(a)(c)(i)

This section is primarily information for the provider


injury





Regulation 15 HSCA 2008 (Regulated Activities) Regulations2010

Safety and suitability of premises


Regulation15(1)

This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The provider's report should be sent to us by 20 February 2015.

CQC should be informed when compliance actions are complete.

We will check to make sure that action has been taken to meet the standards and will report on our judgements.


About CQC inspections

We are the regulator of health and social care in England.

All providers of regulated health and social 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 essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "governmentstandards".

We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming.

There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times.

When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place.

We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it.

Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re-inspect a service if new concerns emerge about it before the next routine inspection.

In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers.

You can tell us about your experience of this provider on our website.


How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection.

We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action.We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement action taken

If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.


How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact.

Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.


Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17)

Consent to care and treatment - Outcome 2 (Regulation 18)

Care and welfare of people who use services - Outcome 4 (Regulation 9)

Meeting Nutritional Needs - Outcome 5 (Regulation 14)

Cooperating with other providers - Outcome 6 (Regulation 24)

Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)

Cleanliness and infection control - Outcome 8 (Regulation 12)

Management of medicines - Outcome 9 (Regulation 13)

Safety and suitability of premises - Outcome 10 (Regulation 15)

Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)

Requirements relating to workers - Outcome 12 (Regulation 21)

Staffing - Outcome 13 (Regulation 22)

Supporting Staff - Outcome 14 (Regulation 23)

Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)

Complaints - Outcome 17 (Regulation 19)

Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.


Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.


Contact us

Phone: 03000 616161

Email: [email protected]

Write to us at:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

Website: www.cqc.org.uk

Copyright Copyright © (2011) 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 thetitle and date of publication of the document specified.

Documents

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