The Royal Hospital for Neuro-Disability (RHN) is an independent medical charity which provides neurological services to the entire adult population of England. The hospital specialises in the care and management of adults with a wide range of neurological problems, including those with highly dependent and complex care needs, people in a minimally aware state, people with challenging behaviour, and people needing mechanical ventilation.

At our last inspection in March and April 2017, this provider was rated as Good overall. Safe was rated as Requires Improvement. All other key questions were rated as Good. This is a report of a focused inspection of the long-term conditions service we carried out on 16 July 2018. We carried out this inspection in response to concerns about some incidents the provider had notified us of. These were concerns about assessing and responding to patient risk, including care for deteriorating patients, prevention of pressure ulcers and learning from incidents, in the long-term conditions core service. As this inspection was focused on specific areas of concern, we did not look at all aspects of all key questions, and we have not re-rated this service.

On our last inspection, we found areas where the provider needed to improve. We issued the provider with a requirement notice, telling the provider to make improvements, in order to meet legal requirements. Therefore, we also followed up on these areas during this inspection. These were as follows:

The provider must:

• Ensure ward staff have more training both on the different degrees of decision-making ability among patients and residents, and the types of decisions each can make, and on the risks to patients and residents of not following the guidance for eating and drinking.

• Ensure all staff have an annual appraisal.

Our key findings from this inspection were:

• The hospital had completed the actions of the requirement notice we issued on our last inspection. Ward staff had improved training on the risks to patients and residents of not following guidance for eating and drinking. Ward staff had more training on the different degrees of decision-making ability amongst patients and residents, and the types of decisions each could make.

• All staff received an annual appraisal.

• Staff knew how to assess and respond to patient risk, and could explain the processes for doing so.

• Prevention, identification and management of pressure ulcers was generally well managed.

• Residents of the specialist nursing home had all aspects of their care plans reviewed in line with national practice.

• Staff understood their responsibilities to raise concerns, record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate. Learning from incidents was shared amongst staff.

• Staff awareness of the need for reasonable adjustments to help patient decision-making had improved.

• The complaints handling process had improved, with a more structured approach and measures to determine whether complainants were satisfied with the outcome.

• Leaders understood the challenges to quality and sustainability and could identify actions needed to address them.

However:

• Patient records were not always consistently detailed or complete. Recording of key clinical interventions such as completing turning charts, and escalation of NEWS scores, were inconsistent. This meant there was a risk that patient care records were not always accurate, which could result in patients not having their care needs met, particularly by new or temporary staff who were not familiar with the patient. Staff told us that they did not always have time to complete care records thoroughly. Senior leaders were aware of this, and had introduced some pilot mitigating actions, but these were not yet embedded.

• Hand hygiene audits showed mixed results, although they had improved since our last inspection.

• We found one instance of where a patient’s fluid balances were not monitored systematically, as they had not been totalled. Totalling fluid balances is important to ensure that patients are optimally hydrated. This was an action we told the provider they should take to improve at our last inspection. We highlighted this to staff during inspection, who corrected the lack of totals. However, it should be noted that this was an improvement on our last inspection, where we found we did not find any charts where scores had been added up.

• Sections of care plans covering the Mental Capacity Act (MCA) were not always sufficiently detailed, and senior leaders did not always robustly monitor this. These sections, referred to as MCA care plans, contained details as to whether a patient could make some, none or all decisions for themselves. Where a patient could make ‘some’ decisions for themselves, details of what this meant were not listed. MCA care plans were reviewed as part of the hospital’s programme of mock inspections, but there was no formal audit programme for MCA care plans. Senior leaders told us they tried to set aside time monthly to look at MCA specific care plans, templates and data, but this was not always possible.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals

We carried out this inspection to monitor the standards that we had judged to be non-compliant at our inspection of November 2013.

We found that there had been improvements in caring for people using the service. Care plans were up to date and more focused on people's individual needs, and there was professional and respectful staff interaction with people they were caring for. Everyone living in the hospital had individual passports that gave simple information about important things to know about the person's relationships, medical, nursing and social needs.

Medications were now accurately recorded in people’s daily medication charts, including dosage and frequency. Emergency medicines were accessible and up to date.

Ward environments had been improved by using off ward storage for some equipment and making all areas tidier. Andrew Reed Ward, Wolfson and Wellesley wards had been fully refurbished since our last visit.

Records were organised and medical and care records were stored together, and securely. The records we sampled were up to date and had completed forms relating to the person's resuscitation wishes and Deprivation of Liberty safeguards where appropriate

During our visit we visited Glyn Ward, the Jack Emerson Centre, Andrew Reed Ward, Wellesley Unit and we reviewed the pharmacy system in place at the hospital. We spoke with people using the service, relatives, staff and senior managers.

A member of housekeeping staff we spoke with said “I feel part of the staff, we are important to the patients”.

The relative of a person using the service said “They couldn’t be anywhere better”, “This is the best of both worlds” and “They are very happy, they laugh a lot. The nursing care is very good and there are plenty of activities off the ward to join in with. They can attend church each week and the priest visits the ward”.

When asked about staffing levels on their ward most said their felt there was enough staff but one nurse said “You need more time on the ward to talk to people and the HCA, to watch them and train them”.

During the visit we identified issues with person-centred care plans and staff interaction with people using the service, the suitability of the premises, medication management, staffing levels and record keeping.

During our inspection we visited Chatsworth Ward, the Jack Emmerson Ward, Evitt Ward and Coombs Ward. We spoke with a number of patients, relatives and staff during our visit and by telephone shortly afterwards.

We asked people about the care that was being provided and one person said "I am happy here, staff are very nice". Another person said "It's good here, staff are considerate, understanding and have a good sense of humour but caring".

Two relatives we spoke with felt the care their family member received was good and they were confident that they could speak to the senior nurse if they had any concerns about the care provided. One person did comment that "some days there is good care and the next not so good as it depends who is on duty".

The staff members we spoke with were happy with the training they received and they felt that the dignity of the patients was respected. A member of staff commented that where they worked was "a small, happy unit with long term patients you get to know well and understand their likes and dislikes". Some of the staff felt that they would like more time to spend with the patients that could be achieved with additional staff or volunteers.

The Royal Hospital for Neuro-disability is an independent medical charity which provides neurological services to the entire adult population of England.

The hospital specialises in the care and management of adults with a wide range of neurological problems including those with highly dependent and complex care needs, people in a minimally aware state, people with challenging behaviour and people needing mechanical ventilation.

The hospital was inspected in June 2015 and not rated as that was a pilot inspection. This inspection has followed up on issues identified in the June 2015 inspection and the hospital is now rated.

Our key findings are as follows:

• We found improvements in all the areas of concern that we had identified in the previous inspection, such as staff understanding of the mental capacity act and lack of patients and residents with authorisations for deprivation of liberty safeguards, staff understanding of aspects of duty of candour and safeguarding. Medical cover had improved and efforts were being made to make the environment for long term residents more homely, and the quality and presentation of food was better.
• There were systems to report and investigate incidents, to control the spread of infection, to manage medicines in line with legislation and current guidelines and to report and investigate suspected abuse
• We saw good use of audit to assess progress of patients
• There were enough staff to care for patients and residents.
• Patient records in the BIS and the specialist unit reflected a multi-disciplinary approach to care with individual outcome goals that were regularly reviewed.
• Research was beginning to influence patient care.

We found some outstanding practice, particularly the wide availability of a range of advanced communication aids such as eye gaze technology customised to the needs of the individual, and the support to patients, residents, families and staff by the chaplaincy service. .

However, we also found areas where that the provider needs to improve.

Importantly the provider must:

• Ensure ward staff have more training both on the different degrees of decision-making ability among patients and residents, and the types of decisions each is able to make, and also on the risks to patients and residents of not following the guidance for eating and drinking.
• Ensure all staff have an annual appraisal

In addition the provider should;

• Ensure staff are encouraged to record patient notes contemporaneously, and have time to do this.
• Improve standards of hand hygiene.
• Ensure that all residents in the specialist nursing home have all aspects of their care plans reviewed at intervals in line with national practice.
• Adopt a more structured process for handling complaints, working with the complainant as a far as possible to ensure both sides were satisfied with the outcome.
• Ensure that patients’ fluid balances are monitored systematically by adding up fluid balances on charts.

​Professor Edward Baker

Chief Inspector of Hospitals