The Raphael Hospital is operated by Raphael Medical Centre Limited (The), an organisation that also provides social care services for people with acquired brain injuries. The Raphael Hospital is an independent hospital specialising in neuro-rehabilitation of adults with complex neurological disabilities with cognitive and behavioural impairment.

The long-term conditions service at the hospital focuses on the care, treatment and rehabilitation of people with acquired brain injuries. There are facilities to accommodate a total of 60 patients. There is space for 31 patients in two wards in the main building and 21 patients in Tobias House which is designated as an area for the treatment of prolonged disorders of consciousness. There is a further capacity to treat eight patients in the special care unit for neurobehavioral rehabilitation and this unit also accommodates patients admitted under the Mental Health Act. Facilities available at the hospital included a physiotherapy gymnasium, a hydrotherapy pool, therapy rooms, consultant rooms and common areas.

We inspected this service using our comprehensive inspection methodology. We carried out the inspection on 15 January 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

Our rating of this hospital/service stayed the same. We rated it as Requires improvement overall.

• The service did not have managers at all levels with the necessary experience, knowledge and skills to lead effectively. The main house was managed by an experienced ward manager who had been in post since 2015. However, during inspection it was identified that three out of four of the wards did not have a ward manager.

• Managers could not demonstrate adequate systems and processes that assured us they had full oversight of the service in terms of risk, quality, safety, and performance.

• The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care, but there were areas that were not fully effective.

• The systems used to identify risks, and eliminate them, were not always carried out in a timely manner. Although there was a risk register, there was no robust way of ensuring effective risk reduction strategies had been undertaken, or potential risks not fully recognised.

• The service provided mandatory training in key skills to all staff; however, not all staff were up to date with their training.

• Infection control issues identified in the last report remained. Although there was a plan to make changes, the pace of making sure compliance with infection control regulations was slow.

• The service generally had suitable premises, but the design, maintenance and use of facilities and premises did not always keep people safe.

• The service audit programme was not robust; although audits were undertaken, non-compliances were not always rectified and we saw the same non-compliances repeated on multiple audits.

• Staff and patients did not always have access to call-bells to get help. Communal areas such as the lounge, activity room and corridors did not have call points available

• Emergency buzzers were available, but staff we spoke with were unaware if these had been tested or whose responsibility this was.

• Staff on the special care unit were not able to communicate effectively, particularly in an emergency. Two-way radios were available, but we found only two were working and of the two working radios, only one could make and receive calls.

• Best interest meeting notes, were not completed consistently, and the least restrictive option was not always clearly identified.

However:

• Staff in different roles worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide care. Staff respected their colleague’s opinions.

• Staff cared for patients with compassion. Feedback from patients confirmed staff treated them well and with kindness.

• Staff provided emotional support to patients to minimise distress. Staff were on hand to offer emotional support to patients and those close to them. Patients told us they felt able to approach staff if they felt they needed any aspect of support.

• Staff involved patients and those close to them in decisions about their care and treatment. We saw effective interactions between staff and patients.

• There were systems and processes to assess, plan and review staffing levels at the location, including staff skill mix.

• There were systems and processes to protect people from abuse and harm. Staff understood their responsibilities and the process to take in the event of any safeguarding concerns.

• The service gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.

• Staff gave patients enough food and drink to meet their needs. Nutritional assessments were completed on admission.

• Staff monitored and assessed patients regularly to see if they were in pain.

• The service took account of patient’s individual needs.

Nigel Acheson

Deputy Chief Inspector of Hospitals

( London and South Regions)

People using the service had their capacity to consent assessed. Where they were able to make decisions for themselves, people had signed their consent to treatment. We saw that people were able to make choices and refuse care if they wished. Where people were not always able to make decisions for themselves, we saw that this had been discussed with relatives where possible, and the correct procedures were followed to ensure that people were cared for in their ‘best interest’ and their rights were protected under the legislation such as the Mental Capacity Act.

People had their needs assessed, and care plans and therapy timetables developed and implemented. There was a seven day a week therapy programme. Most of the people we spoke with, or their relatives, were positive about the service. One relative told us that “on the whole” they were “very happy with the care”. Another relative told us it was an “amazing place”, and others that the service was “brilliant, fantastic!”

We found that there were processes in place for the management and handling of medication. There were sufficient numbers of staff employed.

We saw that there was a process in place for managing complaints. People or their relatives that we spoke with told us that they felt able to raise concerns, and that these were usually addressed. Some people told us they had had problems, but these had been resolved.

We visited the main centre and the other two residential units. The cancer care clinic was not open on the day that we visited. We spoke with some people living at the hospital either individually or whilst they were with others.

We observed that people were comfortable in the presence of staff, and that staff were respectful towards them. One person using the service told us that staff worked together as a team to make sure that people received holistic care and treatment. A relative said that the hospital communicated well, that “I think the people here (staff) are fantastic” and “communication is brilliant”.

We saw on people’s personal records that their needs had been fully assessed by the service before they were admitted. One person we spoke with commented that that the staff who had completed the assessments were thorough and helpful in giving information about the service.

People said that staff were kind and understood their needs. One person using the service said “There is so much team work here “.They said that staff respected and listened to them, and that they were given choices. They told us that staff understood that on some days they may not feel up to attending therapy sessions, and staff always gave the encouragement that people needed.

Raphael Medical Centre is operated by Raphael Medical Centre Limited, an organisation which also provides social care services for people with acquired brain injuries. The Raphael Medical Centre is an independent hospital mainly specialising in the neuro-rehabilitation of adults suffering from complex neurological disabilities with cognitive and behavioural impairment.

The long term conditions service at the hospital focuses on the care, treatment and rehabilitation of people with acquired brain injuries. There are facilities to accommodate a total of 50 patients. There is space for 33 patients in two wards in the main building, and nine patients in Tobias House which is designated as an area for the treatment of prolonged disorders of consciousness. There is further capacity to treat eight patients in the special care unit for neurobehavioral rehabilitation and this unit also accommodates patients admitted under the Mental Health Act. Facilities available at the hospital included a physiotherapy gymnasium, a hydrotherapy pool, therapy rooms, consulting rooms and common areas.

We inspected the long term conditions service using our comprehensive inspection methodology. We carried out the inspection on 6 and 7 February 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Overall we rated the long term conditions services at Raphael Medical Centre as requires improvement because:

• We had concerns regarding some aspects of patient safety. This related to some areas in medicine storage, the environment and shortfalls in infection control procedures.

• Although there were suitable systems to report and investigate incidents and complaints received, staff did not consistently receive feedback on either. Additionally we saw no evidence of lessons learned.

• The provider did not provide assurances that doctors working under the rules of practising privileges had appropriate references and criminal checks as per their policy and best practice guidelines.

• The audit plan was not fully embedded and we were told it was in the process of being redesigned. This meant staff were unable to monitor performance and areas of risk.

• Risks and issues identified were not sufficiently monitored or documented. For example some audits were being carried out but the provider was unable to show the results of these were consistently acted upon or used to improve service.

• The management team had a lack of knowledge and no plan in place to implement the Workforce Race Equality Standard (WRES) requirement.

  However:

• We found treatment followed current national guidance. The hospital had policies and guidelines in place for most areas of the hospital.

• Patients were cared for by a multidisciplinary team working in a cohesive way and generally had access to service seven days a week.

• We found there were arrangements to ensure nursing, therapists and support staff were competent and confident to look after patients.

• Patients’ dietary and nutritional needs were met and were supported appropriately when problems occurred.

• Consent was obtained and recorded in patients’ notes in line with relevant guidance and legislation. Where patients lacked capacity to make decisions for themselves, staff acted in accordance with their obligation under the Mental Health Act.

• We observed compassionate care that promoted patients’ privacy and dignity. Patients and their relatives were involved in their care and treatment and were given the appropriate amount of information to support their decision making.

• Discharge planning was started upon a patient’s admission.The service encouraged and supported social reintegration from the point of admission. The provider acknowledged end of life care, advance care planning and the recognition for emotional support and spiritual needs of the patient.

• The arrangements and quality of leadership had improved. Committee meetings identified areas of concern and acted to address these. Delegation of duties had been passed to directors and managers to empower staff to make decisions for the good of the hospital and its patients.

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 three requirement notices that affected Raphael Medical Centre. Details are at the end of the report.

Professor Edward Baker

Deputy Chief Inspector of Hospitals