Inspected but not rated

We inspected Garrow House on 12 and13 June 2017. This was an unannounced, focused inspection looking at the well led and safe domain to find out whether the hospital had made the required improvements since our last focused inspection on the 09 November 2016.

Following our inspection in June 2017 we did not rate the safe and the well led domains we found:

• Staff used a safe staffing tool to ensure there was always enough staff to provide 1:1 time. Planned activities both on and off the unit were rarely postponed as the occupational therapist and activities co-ordinator were not counted in the staffing numbers.
• Staff compliance with their mandatory training was at 97% overall. This was above the mandatory training compliance target of 80%. Managers ensured staff received regular and comprehensive supervision.
• We reviewed weekly and monthly medication audits and found the provider had detected some gaps in administration records. Staff documented clear actions to make improvements where there were identified shortfalls. The hospital had made improvements to staff compliance with the recording of physical health checks for patients who received rapid tranquilisation and monitoring side effects for patients who received high doses of anti-psychotic medication.
• The hospital had maintained improvements needed to ensure that the equipment used for providing care and treatment was safe for use.

However:

• There was no record of an initial risk assessment for patients who administered their own medicines. Although this had not affected patient’s safety, it meant staff had not fully followed the hospital policy for self-administration of medicine.
• Following the administration of rapid tranquilisation Staff had not consistently recorded the level of consciousness in particular when a patient had refused to have their observations taken. Although this had not affected patient safety, it did mean that staff had not always followed the hospital policy for the recording of observations.
• During inspection we found that two of the five medicine records we reviewed had gaps in administration signatures. This meant that staff had not always maintained an accurate record of the treatment patients had received.
• The hospital had an environmental ligature risk assessment completed in February 2017; this risk assessment did not include the study room on the second floor. This meant that not all potential ligature points within the hospital had a completed risk assessment. The hospital had a separate environmental risk assessment that included cables and wires. We were concerned that having two separate risk assessments addressing ligature risks could be confusing for staff.
• The hospital emergency ‘grab bag’ was cluttered and felt heavy to lift. Although this was accessible in the clinic room the equipment in the bag included an oxygen cylinder, we were concerned that staff might have difficulty finding and carrying equipment they needed in an emergency.
• Patients we spoke with felt agency staff did not always respect their privacy and sometimes sat reading or using their personal phones in communal areas.
• The hospital did not have an identified seclusion room and had when necessary used the ‘chill out’ room to seclude patients. The hospital had considered if a dedicated seclusion room was necessary for the hospital in the future, as the ‘chill out’ room does not comply with the Mental Health Act 1983 and it’s code of practice which states what the specifications of a seclusion room should be.  

We inspected Garrow House on 09 November 2016. This was an unannounced, focused inspection to find out whether the hospital had made the required improvements since our last comprehensive inspection on 4-5 January 2016.

Following our inspection in November 2016 we have not changed the rating in the safe domain but have changed the overall rating from good to not rated because:

• The hospital had not made all the improvements needed to ensure that staff followed the hospital policies and procedures for the safe management of medication.

• The hospital did not carry out checks on the quality of staff compliance with the policies and procedures for the safe management of medicines. This included checks regarding staff administration of medication, records for patients prescribed ‘when required’ medication and records for patients who administered their own medication.

• The hospital did not carry out checks regarding staff compliance with monitoring physical health checks for patients who received medication for rapid tranquillisation and side effect monitoring for patients who received anti-psychotic medication.

• Because of what we found, we issued the hospital with a warning notice in November 2016 in relation to regulation breaches in the governance arrangements.

• In the warning notices, we told the hospital they needed to take action to improve staff compliance with hospital policies and procedures for the safe management of medication and improve the management and quality assurance of the service by 28 February 2017.

• We will be returning to the service after this date to check the hospital has made the improvements.

However;

• The hospital had made some improvements following our last inspection in January 2016. This included action that ensured that all equipment used for providing care and treatment was safe for use, reviewed policies, and procedures about their medicines practices and arranged for most staff to attend additional medicines management training.

• The physical health lead ensured staff carried out regular and comprehensive checks on patients’ physical health

• Staff reported medicine related incidents and apologised to patients when errors occurred. Staff acted quickly to ensure the impact of any errors did not cause any harm to patients.

The service had consent policies and procedures in place which reflected current guidance on informal and formal consent. This enabled patients, their relatives or representatives, to give appropriate consent to care and treatment.

We spoke with four people who used the service and the staff working in the hospital. People told us they felt involved and included in decision making within the service. They made comments like, "I have regular meetings with the staff" and "Staff sit and talk through my support with me." We saw care records were person centred and reflected individual choice in their rehabilitation.

We found regular assessments were undertaken and care plans were in place We also saw that the care was reviewed regularly with the individual.

We confirmed that staff were well supported and confident in their role with good training and developments plans in place.

We saw that there were good systems in place to listen to people’s concerns about their support and that everyone was supported to access advocacy services. However people were not fully aware of the formal complaints process. This meant that their rights may not be fully protected

We found that since the previous inspection the care records and auditing had improved and information was more accessible. We also found that management of medication and the cleanliness of the hospital had improved.

We spoke with four people who used the service and the staff working in the hospital. People felt involved and included in decision making within the service. We saw care records were person centred and reflected individual choice in their rehabilitation.

People told us they thought staff were ‘excellent’. They said they were ‘treated well’ and their experiences were positive. People also told us if they had a complaint they would talk to the staff and they were confident any issues would be dealt with properly. They explained they felt 'safe' and 'protected'. The patients explained how the staff involved them in assessing any risks, and agreed with them the best approach for staff to take to protect them from harm.

We found the service was well managed and looked at ways to improve the quality of service it delivered.

Patients told us they were informed about and involved in their care and treatment. They met regularly with their named nurse to discuss and agree their treatment plans. Patients made positive comments about the care and treatment they received at Garrow House. They explained they felt “safe” and “protected”. The patients explained how the staff involved them in assessing any risks, and agreed with them the best approach for staff to take to protect them from harm.

They explained they have regular house meetings where they could make their views known about the care and treatment provided. One explained any issues are “sorted out” at these meetings and this provides for a calmer and more supportive atmosphere.

Patients told us they could make choices about their day to day activities, for example all have a weekly budget and carry out their own food shopping and cooking. They could rise and retire to their rooms when they want.

We had a mixed response when we asked about activities; some patients went to various community activities such as shopping in a nearby shopping centre, volunteering at a local café. But others who remained in the house told us “Not very much to do here, all sit in the atrium, listen to music, and have a laugh and we can do arts and crafts in social space”. For therapeutic activities we were told that they have recently commenced a ‘Living in your own gaffe skills’ group, which was named by the patients.

Patients made positive comments about the staff they said the staff helped to “motivate” them and fully “supported them”. They “listened” and are always “on hand to provide support and help”. They said the staff helped them to “feel safe”.

We rated Garrow House as good because:

• Garrow House had a strong, visible person centred culture and staff offered care that was kind. Women using the service were truly respected and valued as individuals and empowered as partners in their care.
• The service had a full range of rooms and equipment to support treatment and care. It was welcoming, clean and had pleasant furnishings. Equipment was checked regularly and well maintained. Although there were blind spots on the ward the service had clear, well communicated protocols that staff followed to lessen risk.
• The service used a recognised staffing tool to calculate staff numbers and skill mix. The service adjusted staffing levels to take account of case mix and ensured that service users could take leave and have access to an extensive range of activities seven days a week.
• The service had a proactive approach to anticipating and managing risks to women that used the service. Risks were clearly communicated and considered prior to, throughout and following admission. Risk management was integral to the service users’ care and treatment.
• The service cared and treated the service user’s physical and mental health needs and most care plans and risk assessment were completed collaboratively with service users and staff.
• The service had a thorough incident monitoring program and staff met regularly to discuss feedback. Staff visibly understood their responsibilities and acted accordingly.
• Staff induction included a range of training that helped them to understand the service users’ needs. Staff were encouraged and supported to develop professionally and acquire new skills. Staff had regular access to supervision, team meetings and reflective practice sessions.
• Staff understood and applied the principles of the Mental Health Act, the Mental Health Act Code of Practice and the Mental Capacity Act. Staff knew who to contact for additional advice and support. Staff could clearly explain their understanding of seclusion in line with the Mental Health Code of Practice definition and it was recorded and completed in accordance with the code.
• All of the service users described staff as caring, supportive, respectful and interested in their wellbeing. The women told us that the service promoted independence. Staff were fully committed to working in partnership with the women and we saw this happening in all aspects of their care. Feedback from people who used the service, those who were close to them and stakeholders was continually positive about the way staff treated the service users.
• Garrow House had a clear admissions process that informed and orientated the women to the ward and the service. Women had multiple ways to feedback about the service and the service fully encouraged and supported the women to do so. The service implemented changes based on service user feedback.
• All patients and staff knew the senior managers at Garrow House and described them as available and approachable. They said they were able to speak up without fear of victimisation, felt fully supported and that managers listened.
• Staff morale on the unit was high. There was strong collaboration and support across all functions and a common focus on improving quality of care and people’s experiences. Staff worked as an effective multidisciplinary team that focused on the recovery of the service users. There were no barriers between any of the disciplines and staff respected each other’s contribution.
• Garrow House had good systems in place to run the service effectively. Governance and performance management arrangements were proactively reviewed.

However;

• Some Mental Health Act and ‘use as required’ medications care plans were generic and had not been updated to reflect the individual service users’ needs. The service had not completed a risk assessment to determine the emergency medicines stock held in line with best practice guidance and daily checks had not identified defibrillation pads that had recently gone out of date.
• Medicines reconciliation was completed for all new admissions by the pharmacy service but this was not recorded in the care notes due to the pharmacy team not having authorised access to the provider’s system.
• The service’s environmental ligature assessment did not include the garden and outside environment where there were ligature risks.
• Informal patients’ fob access did not include the front door so women in the service had to ask staff to leave the ward.
• There was limited evidence of discharge planning visibly recorded on the electronic records system and care plans did not reference section 117 aftercare.
• There was no process to review patterns and trends over time for informal concerns and the complaints policy did not provide clear timelines for investigation or time points to feedback to the complainant for formal complaints.
• Staff were unclear who the Freedom to Speak Up Guardian was within the Turning Point organisation.