We inspected the Oxford Centre for Enablement (OCE) on 8 November 2017; this was an unannounced inspection following up on the previous inspection on 9 August 2017. The previous inspection followed a RIDDOR notification concerning a safety incident that occurred on the 8 July 2017.

During this inspection concerns previously identified were followed up to ensure that the previous risks identified had been addressed. There was also an additional focus on the safe and well led domains. This was to ensure patient care was safe and to review the organisation and leadership of the unit.

The CQC inspected and gathered evidence relating to the safe care of patients and the organisation and leadership of the inpatient ward and to some degree the wider unit. This evidence was collected through observation, staff interviews and document review.

This was a focused inspection with only two domains being reviewed therefore there is no overall rating for this service. This was because this inspection was to follow up on concerns identified at the previous inspection. The two domains safe and well led have been rated as requires improvement.

There were areas of poor practice where the trust needs to make improvements:

• There was variation in the cleanliness of the ward; clinical cleaning at the weekend was inconsistent and hand hygiene audits were not submitted monthly as required by the trust.

• The work to update and change existing door locks, to ensure patients using the service were safe, was still not complete even though the completion date for the work was October 2017.

• The leak in the conservatory roof had not been fixed properly; although in recognition of the risk, during our inspection it was closed to patients.

• There was not an effective system to manage and monitor maintenance issues. There were some outstanding safety tests for equipment from 2016.

• There were some items stored alongside, but not part of the emergency equipment, that were out of date presenting a potential risk.

• Staff were not routinely trained in all key areas of safety. Mandatory training rates were low in some key areas for medical staff and some areas of safety were not deemed essential for staff working in the unit. The unit had started to use a new electronic patient observation and escalation system without staff receiving the full training.

• There was a potential for patients to be placed at risk because staff were not familiar with the trust sepsis pathway.

• There were no personal evacuation plans for patients and there had been no reassessment of the fire evacuation risks following the decision to change the security arrangements for the unit.

• The nurse staffing vacancies were still significant with little improvement since the last visit despite recruitment efforts. The trust had mitigated the risk by reducing the number of beds in October 2017.

• Although the organisation of patient paper records were found to have improved overall, it was still difficult to link them with the electronic system, and therefore a contemporaneous record was not available.

• Pre-printed care plans had not been reviewed to ensure they were reflective of the latest local and national guidance; there was also inconsistency in the staff evaluations and signatures of these documents.

• There had been no opportunity for a multidisciplinary team event for the promotion of unit working and team development for the last two years, in a department were multidisciplinary working was a key component of providing a quality service for their patients.

• A philosophy and vision paper was produced in November 2017, but there was no evidence who had been engaged in agreeing it or who wrote it. There were no shared values or strategy displayed.

• We were not assured that the monitoring of the service was effective, as the team had not recognised the risks we identified. The rating of risks was not consistent, with some rated lower than the impact would indicate, for example the nurse staffing vacancies, which had led to bed closures. Therefore, where high levels of risk existed there were not recognised and escalated appropriately for consideration.

• There was no local mechanism for patient and relative feedback.

• Staff were not all familiar with the term Duty of Candour and its formal requirements

However:

• There had been good progress in developing a more effective method of tracking and managing the patients’ pathway via the use of daily quality board reviews.

• Staff followed the trust policy and assessed their patient’s capacity using the Mental Capacity Act. There was documentary evidence to support this.

• Some work on the environment had been completed to help protect the patients from harm. The ward kitchen doors were shut securely for safety. The garden area was now secured with keypad locked gates; the codes were restricted to OCE staff

• There had been changes and development in the way unit managed and considered patient’s safety.The patient tagging system, used to alert staff if patients assessed to be at risk, leave the ward area, had been repaired and there was a 24hour helpline in case of breakdown. Patients were risk assessed for their suitability to use bedside rails on their initial admission to the unit.

• Staff were complimentary of the unit’s local leadership and the general team.

• Staff were clear about their responsibilities to report incidents and how to do this. There was a process for feedback on incidents, actions and learning.

• Staff managed and administered medicines safely.

• The leadership team were involved in various research projects for improving patient outcomes.

Importantly, the trust must:

• Ensure that all staff are able to describe and apply their responsibilities in relation to the Duty of Candour.

• Review the standard of record keeping ensuring each patient has a multi-disciplinary contemporaneous plan and record of care, which reflects their individual needs taking into account the assessment of safety risks associated with delivering the required level of care.

• Continue to monitor and review the staffing levels on the inpatient ward to ensure they are at the required level with the correct skill mix to meet the assessed needs of the patients.

• Ensure planned work to improve the safety of the ward and the unit in general is completed or escalated, as not completed in the agreed time scales.

• Review staff education on the sepsis pathway and ensure that staff have received the required training on the use of the new electronic observation and escalation system.

• Review the content of staff mandatory training ensuring it reflects the needs of the unit using feedback from training needs analysis, local and national developments.

• Take action to improve the compliance with completion of mandatory training.

• Review the use of the risk register ensuring staff understand the scoring system so that risks are recognised and escalated in a timely way.

• Review the monitoring of the quality of the service to ensure it is effective.

In addition the trust should:

• Ensure that the new system to monitor application for Deprivation of Liberty Safeguards is understood by staff. Including the need for staff to understand they should track both the application, and the expiry dates of any such applications to ensure they do not unlawfully deprive patients of their liberty.

• Ensure the new process for mental capacity assessments is embedded with completed and documented assessments for all patients considered not to have capacity. Where a patient lacks capacity, consideration must be given to what would be in the patient’s best interest and if they are to be deprived of their liberty, safeguards required by legislation must be put in place.

• Ensure regular reviews of all plans of care and immediate reviews when there is a change to the patients’ needs to ensure they remain current and relevant to the needs of the individual patient.

• Take action to ensure the conservatory is always a safe area for patients to use.

• Ensure all staff are aware of the importance of closing and securing all doors assessed as needing to be shut for patient safety reasons.

• Ensure the unit is secure and safe out of hours and a local fire risk assessment is carried out to reflect the changes in door security.

• Monitor and sustain the clear guidance as to when patients have the tagging system applied for their own safety.

• Monitor staff compliance with the use of the new guidance and criteria that must to be followed when considering placing patients under one to one supervision.

• Review the effectiveness of the service monitoring and reporting arrangements to ensure risks are identified and mitigated.

• Review the process that the senior teams are expected to follow when they are considering local risks to ensure ownership and oversite of risks is achieved.

• Review the ward’s cleaning schedule including the monitoring of cleaning to ensure it is fit for purpose.

• Ensure that clinical cleaning is taking place and monitored.

• Review the use of the pre-printed care plans ensuring they are current and monitor how staff evaluate them and provide evidence that evaluation has occurred.

Professor Edward Baker

Chief Inspector of Hospitals

We inspected the  Oxford Centre For Enablement inpatient ward on 9 August 2017; this was an unannounced focused responsive inspection in response to a Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) notification concerning an incident that occurred on the 8 July 2017.

The rationale for this inspection was to follow up on the RIDDOR, which gave details of possible avoidable harm that had occurred to an inpatient, and to ensure care was being provided in a safe way for the current patients.

Therefore, CQC only inspected and gathered evidence relating to the safe care of patients through observation, staff interviews and evidence gathering.

We have not rated this service as this was an inspection, which focused on safe care in one area.

• Areas of the ward were not secure placing patient at risk as some patients would be able to leave the ward and grounds without being witnessed. The trust has put plans in place to address the issues identified with entry and exit points and the main unlocked gate.
• Patients’ records were predominantly electronic, however these were difficult to integrate and there was not a clear contemporaneous record of care.
• Risk assessments were being completed on admission; however, these were not consistently being reviewed and updated particularly when there was a change with the patient’s conditions. Neither were risk assessments being used to ensure plans of care reflected the patient’s needs.
• Deprivation of Liberty safeguard applications were being submitted in response to some recognised occurrences where people were being deprived of their liberty such as the use of pen release lap belts and unit’s tagging system. However, patients were on occasion being deprived of their liberty without due consideration being given to the need to submit an application to gain consent to deprive a person of their liberty such as the use of bedside rails.
• There was a lack of evidence that formal mental capacity assessments were being completed and documented when a patient was considered to lack capacity.
• Staff were working flexibly to try to ensure there were sufficient staff to meet the patients’ needs, however to achieve this skill mix of staff was being impacted on.
• Medical staff would place people under formal one to one supervision if they assessed them to be at risk. Other staff would place patients under intermittent one to one supervision if they felt the patient’s behaviour was placing them or others at risk. There was no clear process for this and no criteria therefore staff were at risk of unintentionally depriving patients of their liberty.

However:

• Staff were clear about their responsibility to report incidents and how to do this. There was also a process to feed back the outcomes and required actions from any investigations.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Review the standard of record keeping ensuring each patient has a contemporaneous record of care, with a plan of care which reflects their needs, taking into account the assessment of risk associated with delivering the required level of care.
• Ensure plans of care are reviewed on a regular basis and when there is a change to the patients’ needs to ensure they remain current and relevant to the needs of the individual patient.
• Ensure mental capacity assessments are completed and documented for all patients considered not to have capacity. Where a patient lacks capacity, consideration must be given to what would be in the patient’s best interest and if they are to be deprived of their liberty, safeguards required by legislation must be put in place.
• Monitor and review the staffing levels on the inpatients ward to ensure they are at the required level with the correct skill mix to meet the assessed needs of the patients.
• Ensure planned work to improve the safety of the unit is completed in a timely way.
• Implement clear guidance and criteria for staff to follow when considering placing patients under one to one supervision.
• Ensure that all aspects of the duty of candour regulations are adhered to and conversations are clearly documented.

In addition the trust should:

• Ensure there is a clear system in place which is understood by staff to monitor application for Deprivation of Liberty safeguards to track both the application and the expiry dates of any such applications to ensure patients are not unlawfully deprived of their liberty.
• Ensure the work to change control systems or the entrance and exit points of the unit, is completed in the agreed time scale.
• Review the security control measures in place for all the gates that lead from the inpatient ward garden area to help ensure it is a safe place for patients to roam.
• Take action to ensure the conservatory is a safe area for patients to use when it is raining.
• Take account to ensure all staff are aware of the importance of closing and securing all doors assessed as needing to be shut for patient safety reasons.
• Implement a system to ensure the unit is secure and safe out of hours.
• Ensure staff are up to date with their mandatory training.
• Consider the introduction of clear guidance as to when a patient becomes a risk and the use of the tagging system should be used for their own safety.
• Ensure there is sufficient medical cover to provide a safe service.

Professor Edward Baker

Chief Inspector of Hospitals

Our rating of services stayed the same. We rated it as good because:

• People were protected from harm. Lessons were learned and communicated widely to support improvement in other areas where relevant, as well as services that are directly affected.

• People have good outcomes because they received effective care and treatment that met their needs. Up to date information about effectiveness was shared, and used to improve care and treatment and people’s outcomes.
• When people received care from a range of different staff, teams or services, it was co-ordinated. All relevant teams were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
• Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005. People were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.
• People were supported, treated with dignity and respect and were involved as partners in their care. People were treated with dignity, respect and kindness during all interactions with staff and relationships with staff were positive.
• People’s needs were met through the way services were organised and delivered. Reasonable adjustments were made and action taken to remove barriers when people find it hard to access or use services.
• Leaders were visible and approachable. Leaders modelled and encouraged compassionate, inclusive and supportive relationships among staff so that they felt respected, valued and supported.
• There was an effective and comprehensive process to identify, understand, monitor and address future and current risk.

However

• The service provided mandatory training in key skills to all staff but not everyone had completed it. Nursing staff compliance was significantly higher than medical staff.
• There was a gap in the management and support arrangements for staff. Appraisals were significantly below the trust target of 90% for all staff groups with the exception of medical staff. The medicine division had developed actions to address the gap in compliance, and action plans were in place at directorate level.

• The trust’s responses to complaints were not always completed in a timely manner. The trust did not have a target for closing complex complaints, which some of these complaints may have been.

• A proportion of patients did experience a delay when medically fit with their transfer from hospital.
• To keep patients safe, eight beds were closed which had impacted on the waiting list and finances. There was an average wait of two weeks for admission to the Oxford Centre for Enablement (OCE).