Care Standards Inspectorate Report Visit Sept 2002

ABP/4859/27/10/03/Final Report 1
NATIONAL ASSEMBLY FOR WALES
CARE STANDARDS INSPECTORATE FOR WALES
CARE STANDARDS ACT 2000
INSPECTION REPORT
PRIVATE AND VOLUNTARY HEALTH CARE ESTABLISHMENT
Beechwood House
Brain Injury Unit
Date: 27 October 2003
You may reproduce this Report in its entirety. You may not reproduce it
in part or in any abridged form and may only quote from it with the
consent in writing of the National Assembly for Wales.
ABP/4859/27/10/03/Final Report 2
CARE STANDARDS INSPECTORATE
FOR WALES
CARE STANDARDS INSPECTORATE FOR WALES
South East Regional Office, 6th Floor, Civic Centre, Pontypool, NP4 6YB
INSPECTION REPORT
For the period: April 2002 to March 2003
Establishment: Brain Injury Services
Contact telephone number: 01873 881200
Registered Provider: Partnerships in Care Ltd Kneesworth
House Hospital, Brassingbourn-Cwm-
Kneesworth, Hertfordshire, SG85JP.
Responsible individual: Mr John Barry Crosbie
Registered Manager: Mr Trevor Irwin
Number of overnight beds: Eighteen
Type of establishment: Private hospital registered to take
persons over the age of 18 years who
are liable to be detained under the
Mental Health Act 1983.
Date of first registration: 2001
Date of previous Announced visit:
Date/time of this Announced visit: 17th September 2002
Dates of unannounced and other
visits:
N/A.
Requirements outstanding since
the last report:
N/A
Date of publication of this report: 27 October 2003
Date next announced inspection
due:
To be confirmed.
Inspected by: Mr J Powell and Mrs A Price.
ABP/4859/27/10/03/Final Report 3
INTRODUCTION
This report has been compiled following an inspection of the establishment
undertaken by the Care Standards Inspectorate for Wales (CSIW) under the
provisions of the Care Standards Act 2000 and associated Regulations.
The primary focus of the report is –
• To comment on how the establishment performs against the National
Minimum Standards (NMS).
• To provide an assessment of the quality of treatment and care provided.
• To evaluate the standard of information given to the patients about the
treatment, care, and facilities provided at the setting.
The report contains information on the process of inspection and records its
outcomes. It is divided into at least two distinct parts, following the structure of
the NMS. All independent health care establishments, whatever the service
provided are required to meet the core standards for private and voluntary
health care. In addition, the NMS also set out standards governing specific
services. This report therefore contains the sections relevant to the services
provided at the establishment. It outlines the requirements of each of the
individual standards in each section and provides an overall conclusion of the
establishments compliance with National Minimum Standards.
The CSIW’s Inspectors are authorised to enter and inspect private and
voluntary health care settings at any time. The annual pattern of inspections
consists of a minimum of one announced inspection - for which prior
information on service users, staffing and other essential information is
obtained from the establishment - and one unannounced inspection, which
may be out of normal office hours. Visits are also made to investigate
complaints and in response to changes in the setting. Inspection enables the
CSIW to satisfy itself that continued registration is justified. It ensures
compliance with:
• Care Standards Act 2000 and Regulations;
• National Minimum Standards
• The care establishment’s own statement of aims and objectives
The National Assembly for Wales’s National Minimum Standards (core
standards) for private and voluntary health care services are based in safety
quality assured services, underpinned by a system of Clinical Governance.
They include topics such as information for patients, quality of treatment and
care, management and personnel, complaints and risk management.
Over a 12 month period inspectors will:
• spend time with patients and service users and seek to engage them in
conversation
• see all of the accommodation used by patients and service users
• talk to the manager and each group of staff
• satisfy themselves that all records are being properly maintained
ABP/4859/27/10/03/Final Report 4
The Care Standards Inspectorate for Wales is required to make reports on
registered facilities available to the public. The report is a public document
and following agreement with the registered provider on the contents, a
summary will be available on the National Assembly web site:
www.wales.gov.uk
Readers of this report will need to keep in mind that the Care Standards Act
2000 and its associated Regulations and National Minimum Standards for
Private and voluntary health care came into force on 1st April 2002. The
national minimum standards therefore are now being applied for the first time
to private and voluntary health care services throughout Wales. It will be
almost inevitable that on the first inspection of a private and voluntary
health care setting under the new framework, a number of new
requirements and recommendations will be listed which may not have been
identified during previous inspections. It is envisaged that these will reduce
on subsequent inspections, as providers by then will have had the opportunity
to address the necessary areas.
SUMMARY
Beechwood House is a residential rehabilitation unit that provides a
service for individuals with acquired brain injury. The unit is registered
to take eighteen patients over the age of 18 years old, who are liable to
be detained under the Mental Health Act 1983.
Each service user has their own care programme and treatment plan,
formalised after a comprehensive assessment period, produced by the
staff team who are experienced, and specialise in this service user
group.
A variety of interventions are provided depending on the individually
assessed requirements. These include cognitive behavioural therapy,
social skills training, group and individual therapies.
The Brain Injury Unit is situated in open countryside between the market
town of Abergavenny and valley town of Pontypool South Wales, yet is
close to the M50 and road net works North, and the M4 corridor. The
magnificent house, and adjacent cottage, provides the base for
therapeutic services, staff training facilities, and administration offices;
all of which has been extensively and tastefully renovated to a very high
standard, providing an environment conducive to delivery of quality
care.
The Inspection process included consideration of material sent to the
Care Standards Inspectorate for Wales prior to the date of the
inspection. Monitoring visits, and a tour of the premises on the day of
the inspection, discussions with service users, staff and Mr Irwin the
registered manager, all enabled the Inspector to consider whether the
ABP/4859/27/10/03/Final Report 5
home was complying with the recently introduced National Minimum
Standards for homes for Private and Voluntary Health Care Services and
comment accordingly. The inspector is of the opinion that when there
are more appropriate guidelines available, in the form of a National
Service Framework, specific to this service user group, individuals with
neurological conditions, then the process of audit will be easier to
facilitate.
The Inspectors would like to thank all concerned for making them
welcome and for co-operating with them throughout the inspection
process.
ABP/4859/27/10/03/Final Report 6
CORE STANDARDS (Standards C1 – C 34)
SECTION ONE - INFORMATION PROVISION
STANDARD C1 : INFORMATION FOR PATIENTS
REQUIRED OUTCOME
Patients receive clear and accurate information about their treatment
Standard partially met
INSPECTORS FINDINGS:
The hospital has a number of clearly written booklets in relation to the various
Sections of the Mental Health Act 1983. The booklets information for family
and friends and patient’s handbook is excellent productions also contain
information on the advocacy service in clear terminology. However there is
work to be undertaken in respect of the way information is communicated to
individuals with sensory impairment, and whose first language is other than
English.
Requirements:
The Company to produce a patient guide/other appropriate documentation to
contain all the information listed within the Statutory Instrument 2002 in a
format that is easily understood by the individuals. Reg 6
Timescales
3 Months
SECTION TWO – QUALITY OF TREATMENT AND CARE
STANDARD C 2 : Patient-Centred Care
OUTCOME
The treatment and care is patient-centred
Standard partially met
INSPECTORS FINDINGS:
The company has produced a comprehensive charter. During the visit a
number of patient care plans were examined and these contained patient
centred treatment plans.
Requirements:
The following policies/procedures to be produced:
Response to advance directives
Resuscitation
Diagnosis and evidence based treatment and care.
Reg 8(1)
Timescales
2 Weeks.
ABP/4859/27/10/03/Final Report 7
STANDARD C 3 : Quality of Care and Management of Patient Conditions
OUTCOME
Treatment provided to patients is in line with the relevant clinical guidelines
Standard almost fully met
INSPECTORS FINDINGS:
The company has produced a policy/procedure on the Clinical Governance
Strategy. This documentation identifies a number of areas that assist in the
provision of a quality service to patients. The National Institute for Clinical
Excellence (NICE) and reference to the relevant medical Royal Colleges are
still in draft form.
Requirements:
Validating of the policy or mechanism for taking account of NICE evaluations,
clinical and professional guidelines. Reg 8(1)
Timescales
2 Weeks.
STANDARD C : 4 Monitoring Quality
OUTCOME
Patients are assured that the monitoring of the quality of treatment and care
takes place
Standard fully met
INSPECTORS FINDINGS:
There is a policy on person in control visits and this is a useful mechanism in
the evaluation of quality monitoring and the hospital has a detailed flow chart
in relation to complaints. The Inspectors observed a number of documents
on the area of quality and it is felt that the hospital facilitates this process via a
professional and appropriate system. And this is to be commended.
STANDARD C : 5 Care of the Dying
OUTCOME
The terminal care and death of patients is handled appropriately and
sensitively
Standard not audited
STANDARD C : 6 Patients’ Views
OUTCOME
Patient’s views are obtained by the establishment and used to inform the
provision of treatment and care and prospective patients
ABP/4859/27/10/03/Final Report 8
Standard partially met
INSPECTORS FINDINGS:
Inspectors observed that there is a client questionnaire, in use, but only on
discharge. As previously noted, those patients that have brain injuries or
whose first language is, other than English were not specifically provided for,
and the process does not provide for an ongoing continuous audit.
Requirements:
That the system for consulting with patients is comparable with the National
Minimum Standard statement and compiles with regulation 16.
Timescales
3 Months
Good Practice Recommendations
There was no evidence that the results of the client questionnaires were used
to inform the provision of treatment. If this is facilitated it would, in the
inspectors’ opinion be a useful clinical and quality audit tool.
STANDARD C : 7 Policies and Procedures
OUTCOME
Appropriate policies and procedures are in place to help ensure the quality of
treatment and services
Standard partially met
INSPECTORS FINDINGS:
There was an array of policies and procedures, however information as to
whom had access to these, and who actually had actually read them was not
evident. Abilities of the staff team were not documented in a way that would
indicate their competencies and skills
Requirements:
All policies and procedures will need to be disseminated to the multidisciplinary
team and other key individuals, a documented reference made of
the individuals who has had access to, and read the documentation.
Staff competencies and skills must closely mirror the policies they are
expected to facilitate. This needs to be documented in a systematic and
easily audited manner. Reg 8(1)
Timescales
3 Months.
SECTION THREE - MANAGEMENT AND PERSONNEL
STANDARD C : 8 Role and Responsibility of the Registered Manager
OUTCOME
Patients are assured that the establishment or agency is run by a fit
person/organisation and that there is clear line of accountability for the
delivery of services.
ABP/4859/27/10/03/Final Report 9
Standard almost fully met
INSPECTORS FINDINGS:
The company has produced a clear organisational chart and the individual job
descriptions identify the lines of accountability. The manager is in the
process of being registered with the Care Standards Inspectorate for Wales.
Requirements:
There must be a policy/procedure that gives details of the mechanism for the
declaration of Continual Professional Development. Reg 8(1)
The reviews currently under way relating to the job descriptions for the
Executive Director and Registered manager needs to be completed. Reg
17(2)
Timescales
3 Months
Good Practice Recommendations
A copy of the performance management documentation should be made
available.
STANDARD C : 9 Human Resources Policies and Procedures
OUTCOME
Patients receive care from appropriately recruited, trained and qualified staff
Standard fully met
INSPECTORS FINDINGS:
There is a policy and procedure in relation to Recruitment Induction and
Retention and exit interviews are undertaken with staff that leave the
company. The company has also produced information in relation to Criminal
Records Bureau checks. However the recruitment process is not always fully
adhered too
STANDARD C : 10 Registered Nurses
OUTCOME
Patients receive care from appropriately registered nurses who have the
relevant skills, knowledge and expertise to deliver patient care safely and
effectively
Standard fully met
INSPECTORS FINDINGS:
There were a number of Registered Nurses holding a variety of qualifications
employed within the Brain Injury Unit. Inspectors felt that there was an
appropriate skill mix of staff. A copy of the application form was included
within the pre-inspection documentation.
ABP/4859/27/10/03/Final Report 10
STANDARD C : 11 Practising privileges
OUTCOME
Patients receive treatment from appropriately recruited, trained and qualified
practitioners
Standard N/A
INSPECTORS FINDINGS:
Inspectors were informed that there were no health care professionals with
practising privileges
STANDARD C : 12 Compliance with Professional Codes of Practice
OUTCOME
Patients are treated by health care professionals who comply with their
professional codes of practice
Standard fully met
INSPECTORS FINDINGS:
A range of job descriptions was made available within the pre-inspection
documentation; continuous revaluation of the requirements in line with the
changing needs of the service should be undertaken. Individual professional
codes of practice were made available. (Ref to standard 8 requirements)
Good Practice Recommendations
Written information for health care professionals that explicitly states that any
breach of such codes is regarded as a disciplinary offence. This is included
in the staff handbook;however to formally assertion that the employee has
understood the implications would be good practice
STANDARD C : 13 Health Care Workers and Blood Borne Viruses
OUTCOME
Patient and personnel are not infected with blood borne viruses
Standard partially met
INSPECTORS FINDINGS:
A policy/procedure on Blood Bourne Viruses and infection control was
available. However, the policy/procedures’ written instructions for health care
workers and practitioners on the steps required by the establishment in order
to ensure their compliance and notification of infection status in line with the
guidelines, needs to be elaborated upon.
Requiremets:
The policy/procedure on blood borne viruses/infection control must contain
written instructions for workers on the steps required by the establishment in
order to ensure their compliance and notification of infection status in line with
ABP/4859/27/10/03/Final Report 11
the guidelines. Policy must be up dated at a minimum of three yearly or in line
with changes/developments in this field. Reg 14(6) every three years.
Timescales
3 Months.
STANDARD C : 14 Child Protection Procedures
OUTCOME
N/A for Beechwood
STANDARD C : 15 Adult Protection Procedures
OUTCOME
Adults receiving care are protected effectively from abuse
Standard partially met
INSPECTORS FINDINGS:
The pre-inspection documentation contained a whistleblowing and protection
of vulnerable adults from abuse policy/procedure.
Requirements:
The policy/procedure on adult protection must reflect the current National
Assembly guidance and is consistent with up to date local vulnerable adult
protection procedures. In addition, staff need to be trained to understand the
principles, recognise symptoms and deal with allegations of abuse
appropriately. Reg 17(2)
Timescales
1 month.
SECTION FOUR - COMPLAINTS MANAGEMENT
STANDARD C : 16 Complaints Process
OUTCOME
Patients have access to an effective complaints procedure
Standard fully met
INSPECTORS FINDINGS:
Comprehensive policies and procedures relevant to the complaints process
has been formulated. The complaints process reflected the required
timescales within this standard.
STANDARD C : 17 Information for Patients About Complaints
OUTCOME
ABP/4859/27/10/03/Final Report 12
Patient receive appropriate information about how to make a complaint
Standard fully met
INSPECTORS FINDINGS:
The pre-inspection documentation reflected an easy to access
system/process. Patients also had access to an advocate The availability of
the advocate was advertised within the hospital, and regular visits were made,
this is to be commended.
STANDARD C : 18 Staff Concerns
OUTCOME
Staff and personnel have a duty to express concerns about questionable or
poor practice
Standard almost met
INSPECTORS FINDINGS:
Supporting the process are policies relating to the protection of vulnerable
adults, a policy/procedure for their employees disclosure of misconduct
(whistle blowing), and various other appropriate documents.
Requirements:
All staff must be made fully aware of the whistle blowing and other relevant
policies. Staff should sign to acknowledge that they have been made aware
and understand the policies. Regs. 17 & 21
Timescales
1 Month
SECTION FIVE - PREMISES, FACILITIES AND EQUIPMENT
STANDARD C : 19 Health Care Premises
OUTCOME
Patients receive care in premises that are safe and appropriate for that
treatment. Where children are admitted or attend for treatment, it is to a childfriendly
environment
Standard fully met
INSPECTORS FINDINGS:
Beechwood House is a well-maintained premise that provides an appropriate
environment for the patients. An emergency lighting system was in place and
this was tested on a regular basis. The South Wales Fire Authority inspects
fire precautions, and these were considered satisfactory. Portable Appliance
Testing is appropriately undertaken and environmental issues are
satisfactory.
Individuals’ private rooms allow appropriate levels of privacy, single sex toilet
facilities is available. Specialist contracts and relevant policies, under-pins the
ABP/4859/27/10/03/Final Report 13
hygiene, cleanliness and infection control procedures in the hospital, which
were adequately maintained. However at today’s inspection there was
immediate evidence of a very unpleasant odour in the main hall and back
corridor. The inspector was informed that this was emanating from a service
user’s private accommodation; it appears that there has been logistic
difficulties in accessing the room for long enough period of time to eradicate
the problem; the inspector has taken this issue into consideration when
setting the tariff timescale. The registered manger must urgently address the
issue.
Requirements:
All registered manager must ensure that the unpleasant odour is
eliminated.Regs.15.24 & 35
Timescales
1 week
STANDARD C : 20 Condition and Maintenance of Equipment and
Supplies
OUTCOME
Patients receive treatment using equipment and supplies that are safe and in
good condition
Standard fully met
INSPECTORS FINDINGS
The hospital had a number of records in relation to the maintenance and
servicing of equipment including: Portable Appliance Testing, Electrical
Inspections, Emergency Lighting, Oil Safety, Fire Extinguisher Testing and
Fire Alarm System Checking. Policies relating to the maintenance and use of
equipment are in place.
STANDARD C : 21 Catering Services for patients
OUTCOME
Patients receive appropriate catering services
Standard fully met
INSPECTORS FINDINGS:
The standard of catering at the hospital is to be commended. A four-week
menu plan was available and the choice available at each meal was very
good. A number of special diets were being catered for and the food was
presented in an attractive manner and there was the option of two cooked
meals each day. The dining room was pleasant, light and comfortable, more
than one sitting was facilitated to meet the needs of the patient group. The
inspectors were informed that staff that handle food, have food hygiene
training. the level of hygiene and general presentation of the kitchen is a
credit to all concerned.
ABP/4859/27/10/03/Final Report 14
SUB-SECTION SIX - RISK MANAGEMENT PROCEDURES
STANDARD C : 22 Risk Management Policy
OUTCOME
Patients, staff and anyone visiting the registered premises are assured that all
risks connected with the establishment; treatment and services are identified,
assessed and managed appropriately
Standard almost fully met
INSPECTORS FINDINGS:
The hospital has a comprehensive risk assessment policy, which
encompasses most of the elements required. There is also a comprehensive
risk register completed and a list of Health and Safety issues, which include
Pharmaceutical and Infection control measures.
Requirements:
A policy is required in relation to point 22.4. A named member of staff must
be identified to receive the information from the Medical Devices Agency.
These notices are badged as Safety Action Bulletins or MDA/NHS Estates
devices Alerts by the National Assembly. In addition, a named member of
staff is identified to receive information from the Medical Control Agency. Reg
8.
Timescales
2 weeks.
STANDARD C : 23 Health and Safety Measures
OUTCOME
The appropriate health and safety measures are in place
Standard fully met
INSPECTORS FINDINGS:
A risk assessment in relation to manual handling was available. There was a
comprehensive policy/procedure in relation to: Health & Safety, Manual
Handling, Control of Substances Hazardous to Health Regulations, HIV &
AIDS, Fire Safety, Contractors, Incidents & Near Misses, RIDDOR and Risk
Management. A Health & Safety audit is also undertaken.
STANDARD C : 24 Medicines Management
OUTCOME
Measures are in place to ensure to ensure the safe management and secure
handling of medicines
Standard almost fully met
ABP/4859/27/10/03/Final Report 15
INSPECTORS FINDINGS:
The Inspectors were informed that the responsibility for safe medicine
systems rests with the Registered Manager. The hospital had an up-to-date
British National Formulary and additional information about medicines. The
hospital has various procedures that include administration procedures. The
hospital has an appropriate relationship with the providing pharmacy, which
the staff teams use to advantage. The verbal prescription administration of
medication needs to be more tightly adhered too.
Requirements:
A policy/procedure on the National Service Frameworks and NICE guidance
should be formulated and facilitated as necessary. Reg 14 +8
Timescales
2 weeks.
STANDARD C : 25 Ordering, Storage, and Use of Medicines
OUTCOME
Medicines, dressings and medical gases are handled in a safe and secure
manner
Standard almost fully met
INSPECTORS FINDINGS:
The hospital has comprehensive policies/procedures in relation to the
administration, storage and administration of medicines; these under-pin safe
working practices; which from the evidence seen at this inspection were well
adhered too on the unit.
Requirements Timescales
The dispensing of verbal prescriptions need to be more tightly
adhered too.Reg.14
Immediate
STANDARD C : 26 Controlled Drugs
OUTCOME
Controlled drugs are stored, administered and destroyed appropriately.
Standard fully met
INSPECTORS FINDINGS:
The hospital maintains records in line with the Misuse of Drugs Regulations
1985 and the Controlled drugs are kept in an appropriately locked cupboard.
STANDARD C : 27 Infection Control
OUTCOME
The risk of patients, staff and visitors acquiring a hospital-acquired infection is
minimised
ABP/4859/27/10/03/Final Report 16
Standard fully met
INSPECTORS FINDINGS:
There is an infection control policy including infection with blood borne
viruses. Inspectors were informed that cleaning regimes were in place for all
patient areas; on the days that the inspection took place; this appeared to be
functioning to a satisfactory standard.
STANDARD C : 28 Medical Devices Decontamination
OUTCOME
Patients are not treated with contaminated medical devices
Standard fully met
INSPECTORS FINDINGS:
Inspectors were informed that medical devices intended for single use are
never reused.
STANDARD C : 29 Resuscitation
OUTCOME
Patents are resuscitated appropriately and effectively
Standard partially met
INSPECTORS FINDINGS:
There is a medical emergency policy, which in principle takes into account the
issues of resusitation, this needs to be more holistic and take into
consideration the wishes of patients, and all aspects of this standard. Staff
are trained to a basic first aid standard, however the situation needs to be
reviewed and the position fully established.
Requirements:
An audit as to the number of staff that are trained in basic resuscitation
techniques needs to be undertaken and adequate staff trained/provided so
that at least one member of the staff team is appropriately train is on shift at
all times. Reg 17 The wishes of patients need to be ascertained and
documented in their files. Reg 15 (1)
Timescales
1 Month.
STANDARD C : 30 Contracts
OUTCOME
Contracts ensure that patients receive goods and services of the appropriate
quality
Standard fully met
ABP/4859/27/10/03/Final Report 17
INSPECTORS FINDINGS:
There were written, dated and signed contracts between the hospital and
purchaser, and includes an auditing process.
SECTION SEVEN - RECORDS AND INFORMATION MANAGEMENT
STANDARD C : 31 Records management
OUTCOME
Records are created, maintained and stored to standards which meet legal
and regulatory compliance and professional practice recommendations
Standard fully met
INSPECTORS FINDINGS:
The hospital has a Data Protection Policy and health records are stored
securely. The health record management policy under-pins the process and
provides security and confidentiality
STANDARD C: 32 Completion of Health Records
OUTCOME
Patients are assured of appropriately completed health records
Standard almost met
INSPECTORS FINDINGS:
Comprehensive lists of individual documents are maintained. Entries in the
health records, reflected the signature and date, however, the time was not
always recorded. The process would benefit from being reviewed and
amended to enable compliance with this standard.
Requirements:
Health records need to comply with points 32.2 and 32.5 The transfer and
discharge policy needs to be reviewed to include the requirement indicated in
point 32.5 and 32.7 All aspects of this stand needs to be facilitated Reg.20 &
schedule 3
Timescales
2 Weeks.
STANDARD C : 33 Information Management
OUTCOME
Patients are assured that all information is managed within the regulated body
to ensure patient confidentiality
Standard fully met
INSPECTORS FINDINGS:
There are appropriate policies/procedures relating to the composite
ABP/4859/27/10/03/Final Report 18
requirements on confidentiality; these under-pin the relevant aspects of
documentation and confidentiality for the patients at Beachwood House
SECTION EIGHT – RESEARCH
STANDARD C : 34
OUTCOME
Any research conducted in the establishment/agency is carried out with the
appropriate consent and authorisation from any patients involved, in line with
published guidance on the conduct of research projects
This standard was not audited.
ABP/4859/27/10/03/Final Report 19
REGULATORY REQUIREMENTS TIME LIMITS (DAYS)
Section 1 – Information Provision
STANDARD C1 : INFORMATION FOR PATIENTS
Requirements:
The Company to produce a patient guide/other appropriate documentation to
contain all the information listed within the Statutory Instrument 2002 in a
format that is easily understood by the individuals. Reg 6
Timescales
3 Months
Section 2 – Quality of Treatment and Care
STANDARD C 2 : Patient-Centred Care
Requirements:
The following policies/procedures to be produced:
Response to advance directives
Resuscitation
Diagnosis and evidence based treatment and care.
Reg 8(1)
Timescales
2 Weeks.
STANDARD C 3 : Quality of Care and Management of Patient Conditions
Requirements:
Validating of the policy or mechanism for taking account of NICE evaluations,
clinical and professional guidelines. Reg 8(1)
Timescales
2 Weeks.
STANDARD C : 6 Patients’ Views
Requirements:
That the system for consulting with patients is comparable with the National
Minimum Standard statement and compiles with regulation 16.
Timescales
3 Months
STANDARD C : 7 Policies and Procedures
Requirements:
All policies and procedures will need to be disseminated to the multidisciplinary
team and other key individuals, a documented reference made of
the individuals who has had access to, and read the documentation.
Staff competencies and skills must closely mirror the policies they are
expected to facilitate. This needs to be documented in a systematic and
easily audited manner. Reg 8(1)
Timescales
3 Months.
ABP/4859/27/10/03/Final Report 20
Section 3- Management and Personal Care
STANDARD C : 8 Role and Responsibility of the Registered Manager
Requirements:
There must be a policy/procedure that gives details of the mechanism for the
declaration of Continual Professional Development. Reg 8(1)
The reviews currently under way relating to the job descriptions for the
Executive Director and Registered manager needs to be completed. Reg
17(2)
Timescales
3 Months
STANDARD C : 13 Health Care Workers and Blood Borne Viruses
Requiremets:
The policy/procedure on blood borne viruses/infection control must contain
written instructions for workers on the steps required by the establishment in
order to ensure their compliance and notification of infection status in line with
the guidelines. Policy must be up dated at a minimum of three yearly or in line
with changes/developments in this field. Reg 14(6) every three years.
Timescales
3 Months.
STANDARD C : 15 Adult Protection Procedures
Requirements:
The policy/procedure on adult protection must reflect the current National
Assembly guidance and is consistent with up to date local vulnerable adult
protection procedures. In addition, staff need to be trained to understand the
principles, recognise symptoms and deal with allegations of abuse
appropriately. Reg 17(2)
Timescales
1 month.
Section 4 – Complaints Management
STANDARD C : 18 Staff Concerns
Requirements:
All staff must be made fully aware of the whistle blowing and other relevant
policies. Staff should sign to acknowledge that they have been made aware
and understand the policies. Regs. 17 & 21
Timescales
1 Month
ABP/4859/27/10/03/Final Report 21
Section 5 – Premises, Facilities and Equipment
STANDARD C : 19 Health Care Premises
Requirements:
All registered manager must ensure that the unpleasant odour is
eliminated.Regs.15.24 & 35
Timescales
1 week
Sub-Section 6 – Risk Management Procedures
STANDARD C : 22 Risk Management Policy
Requirements:
A policy is required in relation to point 22.4. A named member of staff must
be identified to receive the information from the Medical Devices Agency.
These notices are badged as Safety Action Bulletins or MDA/NHS Estates
devices Alerts by the National Assembly. In addition, a named member of
staff is identified to receive information from the Medical Control Agency. Reg
8.
Timescales
2 weeks.
STANDARD C : 24 Medicines Management
Requirements:
A policy/procedure on the National Service Frameworks and NICE guidance
should be formulated and facilitated as necessary. Reg 14 +8
Timescales
2 weeks.
STANDARD C : 25 Ordering, Storage, and Use of Medicines
Requirements Timescales
The dispensing of verbal prescriptions need to be more tightly
adhered too.Reg.14
Immediate
STANDARD C : 29 Resuscitation
Requirements:
An audit as to the number of staff that are trained in basic resuscitation
techniques needs to be undertaken and adequate staff trained/provided so
that at least one member of the staff team is appropriately train is on shift at
all times. Reg 17 The wishes of patients need to be ascertained and
documented in their files. Reg 15 (1)
Timescales
1 Month.
ABP/4859/27/10/03/Final Report 22
Section 7_ Records and Information Management
STANDARD C: 32 Completion of Health Records
Requirements:
Health records need to comply with points 32.2 and 32.5 The transfer and
discharge policy needs to be reviewed to include the requirement indicated in
point 32.5 and 32.7 All aspects of this stand needs to be facilitated Reg.20 &
schedule 3
Timescales
2 Weeks.
SECTION EIGHT – RESEARCH
ABP/4859/27/10/03/Final Report 23
Good Practice Recommendations
SECTION ONE - INFORMATION PROVISION
SECTION TWO – QUALITY OF TREATMENT AND CARE
STANDARD C : 6 Patients’ Views
Good Practice Recommendations
There was no evidence that the results of the client questionnaires were used
to inform the provision of treatment. If this is facilitated it would, in the
inspectors’ opinion be a useful clinical and quality audit tool.
SECTION THREE - MANAGEMENT AND PERSONNEL
STANDARD C : 8 Role and Responsibility of the Registered Manager
Good Practice Recommendations
A copy of the performance management documentation should be made
available.
STANDARD C : 12 Compliance with Professional Codes of Practice
Good Practice Recommendations
Written information for health care professionals that explicitly states that any
breach of such codes is regarded as a disciplinary offence. This is included
in the staff handbook; however to formally assertion that the employee has
understood the implications would be good practice
SECTION FOUR - COMPLAINTS MANAGEMENT
SECTION FIVE - PREMISES, FACILITIES AND EQUIPMENT
SUB-SECTION SIX - RISK MANAGEMENT PROCEDURES
SECTION SEVEN - RECORDS AND INFORMATION MANAGEMENT
SECTION EIGHT – RESEARCH
ABP/4859/27/10/03/Final Report 24
MENTAL HEALTH (STANDARDS M1 – M47)
SECTION ONE – QUALITY OF TREATMENT AND CARE
STANDARD M1 : Working with the National Service Framework for
Mental Health in Wales (applies to adult mental health establishments
only)
REQUIRED OUTCOME
Patients receive treatment and care that reflects the National Service
Framework for Mental Health in Wales (NSFW) introduced in 2002.
Standard almost fully met
INSPECTORS FINDINGS:
Documentation in relation to the referencing of the National Service
Framework was available, as was a copy of the National Service
Framework (2002). The beautifully presented patients guide in an
easily understood format and this is to be commended. There were
numerous policies/procedures that reflected the area of joint
working with key organisations mentioned within M1.2.A policy, in
line with working within the National Service Framework for Mental
Health in Wales, is at the moment in draft form. Clear lines of
accountability and job descriptions, are in place, as is
communication systems.
Requirements:
An agreed and validated policy relevant to working within the
National Service Framework needs to be completed, and facilitated
as a working document Reg.6
Timescales
3 Months
Additional format for the patients guide needs to be available on
request. Reg 6
Good practise Recommendations:
3 months
A copy of the National Service Framework (2002) to be made available on the unit
STANDARD M2 : Communication Between Staff
REQUIRED OUTCOME
Patient treatment and care is informed by clear communication between staff.
Standard fully met
INSPECTORS FINDINGS:
The inspector was informed that the home has an independent advocate
service, which is to be commended. Appropriate policies/procedures,
underpins, the systems in place. The Care Management Approach is being
implemented, and links into such procedures as Mental Health Tribunals.
There was an internal communication strategy in place and there is also a
clinical government strategy in place. Quality, the inspector was informed is
ABP/4859/27/10/03/Final Report 25
taken forward by the Executive Director. Section 132 of the Mental Health
Act 1983 was being implemented. The comprehensive staff induction
programme is very detailed and includes on-going evaluations.
STANDARD M3 : Patient Confidentiality
REQUIRED OUTCOME
Patients are assured of confidentiality.
Standard almost fully met
INSPECTORS FINDINGS:
There was a policy on confidentiality and disclosure of
information, additional to which, there is a comprehensive range
of policies that underpins the confidentiality process
Requirements:
The inspector was informed that, training on the Date Protection
policy is included within the staff induction programme under the
heading of Medical records.
Up date/training, in relation to accountability, as a professional
practitioner, and as part of a multi-disciplinary team needs to be
formalised within the training matrix Reg 3
Timescales
1 month
STANDARD M4 : Clinical Audit
REQUIRED OUTCOME
Patients’ treatment and care is assured by clinical audit.
Standard partially met
INSPECTORS FINDINGS:
Inter-agency communication protocols have been established.
There is a clinical audit policy and programme, which is ongoing
and facilitative; the opinions from patients and families are taken
into account, within the restraints of the placement.
Requirements:
An improved patient satisfaction questionnaire is required; which
will need to link with the CPA and advocate systems
Timescales
3 Months
SECTION TWO – HUMAN RESOURCES
STANDARD M5 : Staff Numbers and Skill Mix
REQUIRED OUTCOME
The numbers, type and skills of health care professionals ensure that patients
are appropriately treated and cared for at all times.
Standard partially met
ABP/4859/27/10/03/Final Report 26
INSPECTORS FINDINGS:
The hospital was meeting the staffing notice issued that has
been issued. Due to a sustained recruitment programme there
are very few vacancies, and these were being covered with overtime.
The roles and responsibilities of each member of the team
were clearly defined and patients were allocated a named
Registered Nurse.
Requirements:
Formalised policy is required in relation to the provision of long
term primary nurse care
Formalised re-evaluation of staffing levels, on a daily/shift basis,
to meet the changing needs of the patient, are required.
Formalised supervision and appraisal systems need to be
consolidated. Reg 17 (2)+(3)
Timescales
1 month
STANDARD M6 : Staff Training
REQUIRED OUTCOME
Patients receive treatment and care from appropriately trained staff.
Standard almost fully met
INSPECTORS FINDINGS:
A number of training records were available for inspection and
these displayed various aspects of training undertaken by staff.
E.g. risk management and aggressive behaviour. However, the
training did not specifically address the area of the
implementation of the values, principles and broad standards of
the National Service Framework. Not all staff had specific training
in managing individuals that are liable to self-harming behaviours
or suicidal intent.
Requirements:
The training to address the specific values, principles and broad
standards of the National Service Framework.
Reg:17(2)
Timescales
1 month
Specifics training on managing individuals that are liable to selfharming
behaviours or suicidal intent.
Reg;17(2)
Timescales
1 month
SECTION THREE – RISK MANAGEMENT
STANDARD M7 : Risk Assessment and Management
REQUIRED OUTCOME
All potential environmental and clinical risks are assessed and managed to
ensure a safe environment is maintained for patients, staff and the general
public.
ABP/4859/27/10/03/Final Report 27
Standard almost fully met
INSPECTORS FINDINGS:
The hospital has a comprehensive risk management policy that
includes a major incident policy. Health and Safety audits were
undertaken and debriefing protocols had been formulated. The
inspector appreciates the issues and difficulties involved,
however there was little or no documentation in relation to
patient involvement in their own risk assessment. Risk
assessments are undertaken via the multi-disciplinary team
process and undertaken weekly, this is to be commended as very
good practice; however in response to serious untoward incident
or near miss involving a patient,(standardM7.3) the risk
assessment is not undertaken until the next multi-disciplinary
meeting, which could be in a weeks time.
Requirements:
When patients are involved in their own risk assessment this
must be documented. Reg (8) (1) f
Timescales
2 weeks
Key individuals need to be trained in understanding the
complexities of disabled individuals, including those with sensory
impairment. These can subsequently be utilised as a resource,
by all the units.
Timescales
1 month
Risk assessments must be reviewed as soon as possible
following an untoward incident.8 (1) e
Next
occurrence
STANDARD M8 : Suicide Prevention
REQUIRED OUTCOME
Patients are protected from self-harm, including risk of suicide.
Standard almost fully met
INSPECTORS FINDINGS:
There were care planning and risk assessments in place in
relation to patients being protected from self-harm. Various
levels of observation were documented within the individual care
plans. However specific policy and audit tools are required.
Annual health and safety reports are produced, which provide
additional and appropriate information.
Requirements:
Written policies, protocols and procedures on the prevention of
homicides and suicide, which takes account of the
recommendations of the Confidential Inquiry into Homicide and
Suicides (Safer Services Department of Health 1999; Safety First
Department of Health 2001) (Regulation 43 (2)
Timescales
2 Weeks
A strategy must be put in place that will routinely reviews the
physical environment to reduce access to means of self-harm
and suicide. Reg 43(1)
Timescales
2 weeks
ABP/4859/27/10/03/Final Report 28
STANDARD M9 : Resuscitation Procedures
REQUIRED OUTCOME
Patients are resuscitated appropriately and effectively.
Standard not fully met
Inspector’s Findings:
Beechwood House is not at this time, able to put first aid trained staff on duty,
on all shifts. They have appropriate policies relating to medical emergencies,
however, there no specific policy has been formulated, relating to
resuscitation.
Requirements:
The registered manager and the responsible individual must
ensure that enough staff is trained in first aid, and at least one
individual are on shift at all times.Registered Nurses can not
automatically be regarded as ‘first aiders’
Timescales
3 months
A policy specific to resuscitation must be formulated Reg 8(1)+
43(1)
Timescales
2weeks
STANDARD M10 : Responsibility for Pharmaceutical Services
REQUIRED OUTCOME
Responsibility for obtaining, prescribing, storing, use, handling, recording and
disposal of medicines is clear.
Standard almost fully met
INSPECTORS FINDINGS:
There were a number of in-home procedures in place including
storage and handling of medicines, the handling and storage of
controlled drugs, and self-medication.
Requirements: The registered manager must ensure that the
section related to verbal prescriptions is fully adhered too.
Reg 14(5)
Timescales
Next
occurrence
Good practise Recommendations:
A pharmacist should undertake a regular audit and provide a report .
SECTION FOUR – PATIENT TREATMENT AND CARE
STANDARD M11 : The Care Programme Approach
REQUIRED OUTCOME
Patients receive treatment and care in line with the Care Programme
Approach introduced in Wales in 2002 and supplemented by detailed
introductory guidance.
ABP/4859/27/10/03/Final Report 29
Standard fully met
INSPECTORS FINDINGS:
Fundamental elements and policies pertaining to the Care
Programme Approach were well established. The company has
formulated detailed guidance.
Good practice recommendation: A continuous, formalised
review of the systems in place, in line with a changing and
developing situation would be advantageous.
STANDARD M12 : Admission and Assessment
REQUIRED OUTCOME
Patients are admitted and assessed appropriately.
Standard fully met
INSPECTORS FINDINGS:
The statement of purpose included details in relation to admission
and assessment, as does the service user guide. There was a
policy/procedure in relation to admission and assessment of
patients, which took a holistic approach. Subsequent reviews are
undertaken appropriately so that the team can evaluate the initial
assessments and risk assessments.
STANDARD M13 : Care Programme Approach - Care Planning and
Review
REQUIRED OUTCOME
Each patient has a care plan that addresses their needs
appropriately in line with the Care Programme Approach
introduced in Wales in 2002.
Standard fully met
INSPECTORS FINDINGS:
The Care Programme Approach has been implemented for some
time, and appears to be working to a satisfactory level
comprehensive record of multi-professional in-put was available for
all patients including the involvement of the independent advocate.
STANDARD M14 : Information for Patients on their Treatment
REQUIRED OUTCOME
Patients are effectively involved in decisions about their treatment.
Standard almost fully met
ABP/4859/27/10/03/Final Report 30
INSPECTORS FINDINGS:
There was patient information on the various Sections of the Mental
Health Act 1983 and a client’s charter. The charter was easy to
read and facilitate understanding. The hospital benefits from the
advocate service, and patient participation in this process. An audit
is in place relating to high dose medication, the documentation of
this needs to be improved.
Requirements:
Care plans must reflect individual patients’ views about their care
plan and treatment, especially about the effects and side effects of
drugs, together with the response of the clinicians. (Standard 14.5)
Reg 15(1)(3)
Timescales
2 Weeks
STANDARD M15 : Patients with Developmental Disabilities
REQUIRED OUTCOME
The rights and needs of patients with developmental disabilities are
recognised and addressed
Standard partially fully met
INSPECTORS FINDINGS:
A copy of the Mental Handicap Strategy Guidance 1994 was
available within the hospital, as was an appropriate adult guidance.
Some of the patients records reflected that they were encouraged to
participate in decisions related to their care. It was not overtly
obvious to the inspectors, that information was provided in a variety
of formats to aid the individuals’ understanding.
Requirements:
Where patients are unable to participate in decisions related to care,
this should be clearly reflected within the care plan documentation.
Reg 8(2) c
Timescales
2 weeks
Individualised, assessed communication systems, need to be put in
place to meet the patients requirements. Training will need to be
provided for the staff team, as required.
Timescales
3 months
STANDARD M16 : Electro-convulsive Therapy (ECT)
REQUIRED OUTCOME
ECT is provided to patients safely and appropriately.
Standard M16 is not applicable to Beechwood House.
STANDARD M17 : Administration of Medicines
REQUIRED OUTCOME
Appropriately trained and qualified healthcare professionals administer all
medicines to patients.
Standard fully met
ABP/4859/27/10/03/Final Report 31
INSPECTORS FINDINGS:
Copies of current Certificates of Consent to Treatment (Form 38) or
Certificate of Second Opinion (Form 39) were available and had
been appropriately completed, and audited. There were
policies/procedures for a variety of areas, which under pinned the
systems, formalised process and enabled this standard to be met.
The inspector was informed that there are specimen signatures in
place; however this was not made evident to them, on the day of
inspection.
Good practise Recommendations:
Specimen signatures in relation to registered Nurses employed at the
Hospital, and all staff should be aware of their existence. Hazard notices should
be signed, dated and state what action is necessary when received.
STANDARD M18 : Self-administration of Medicines
REQUIRED OUTCOME
Patients are assessed, consulted and advised before they are enabled to
self-administer medicines.
Standard fully met
INSPECTORS FINDINGS:
There was an appropriate policy and procedure for self-medication,
however the Inspectors were informed that there were no patients
at the hospital who were self medicating.
STANDARD M19 : Treatment for Addictions
REQUIRED OUTCOME
Patients with addictions receive appropriate treatment and care.
Standard fully met
INSPECTORS FINDINGS:
The organisation has several policies/procedures in relation to the
management of patients who have had a history of abusing alcohol, illicit
drugs or other substances; and these under pin any requirements that
may become evident.
Good practice:
Those staff members, who have specific training, qualifications, and
interests in the subject of addictions, should be encouraged to participate
in training and facilitating of information to the staff team.
STANDARD M20 : Transfer of Patients
REQUIRED OUTCOME
The transfer of patients takes place safely and effectively.
ABP/4859/27/10/03/Final Report 32
Standard fully met
INSPECTORS FINDINGS:
There was a policy relating to the transfer of patients to other
hospitals for treatment, discharge and Section 117 meetings.
Communication systems are in place that indicated that the
discharge process was planned and well thought through.
STANDARD M21 : Patient Discharge
REQUIRED OUTCOME
The discharge of patients takes place appropriately and effectively.
Standard almost fully met
INSPECTORS FINDINGS:
Comprehensive policies, in relation to the transfer/discharge of
patients, are in place, which fundamentally covered all aspects
identified within Standard M21.2. The documentation examined
reflected that discharge was a systematic and planned event that
involved inter-agency working. A time scale is needed to ensure
that the formal exchange of information is speedy and consistent.
Requirements:
The discharge summaries must be completed and forwarded to the
appropriate GP and all stakeholders within 5 working days. Reg 8(1)
Timescales
Next
occurrence
STANDARD M22 : Patients’ Records
REQUIRED OUTCOME
Patients’ treatment and care is informed by accurate and comprehensive
records.
Standard almost fully met
INSPECTORS FINDINGS:
There is a policy on record keeping, however this requires additional
information relating to sharing/storage of notes, i.e. psychology, to
ensure that it complies with this standards M22. In addition, not all
the patients’ notes were available on the unit.
Requirements:
Additional information is required within the policy to ensure it meets
the standards.
M22.1 professional notes are integrated into a single multidisciplinary
record, which includes hospital and community records.
Reg 8(1)
Timescales
2weeks
ABP/4859/27/10/03/Final Report 33
STANDARD M23 : Empowerment
REQUIRED OUTCOME
Patients are informed about their rights, their treatment and how to obtain
independent advocacy.
Standard almost fully met
INSPECTORS FINDINGS:
Patient information leaflets were available in relation to detention
under the various sections of the Mental Health Act 1983. There
was also a comprehensive patient guide/charter. Information on
advocacy was available and the hospital provides an advocate on a
regular basis.
Requirements:
Should any patient request the services of an advocate who is
‘external’ to the one provided by the hospital; this should be
facilitated for them. This needs to be formalised and included in the
service users guide. Reg 6
Timescales
3 months
Good practise Recommendations:
Staff awareness in relation to patient empowerment should be included within the
induction programme.
STANDARD M24 : Arrangements for Visiting
REQUIRED OUTCOME
Appropriate visiting arrangements are in place, about which patients and their
visitors are clear.
Standard almost fully met
INSPECTORS FINDINGS:
There were a number of written policies for patients to have visits
from family and friends. These included children visiting; adequate
information is available to patients; however there was no reference
to staff interventions, should they be concerned at a visiting
practise, impacting negatively on a patient.
Requirements:
A policy on the observation of visitors must be formulated. Reg 45 Timescales
A policy/procedure/clear guidelines, is needed in respect of
assisting patients during any unwanted visits, and support at times
of unreasonable demands.
1 Month.
STANDARD M25 : Working with Carers and Family Members
REQUIRED OUTCOME
Staff involve patients’ carers and families as appropriate, in aspects of the
treatment and care provided.
ABP/4859/27/10/03/Final Report 34
Standard almost fully met
INSPECTORS FINDINGS:
There was a written policy about the arrangements for patient’s
family members, friends and carers. However, this was not
adequate to meet the requirements of this standard, and will need
to be reviewed and developed. There was reference to family
involvement in some of the individual patient care plan.. In addition,
written policies and procedures were not available in relation to the
various components of Standards M25.1 to M25.5. It is accepted
that this is a very complex and composite area of human rights,
safety and best practice.
Requirements:
Written policies and procedures must be devised in relation to the
arrangements to involve the patient’s family members, friends and
carers. In addition, written policies and procedures are required in
relation to the various components of Standards M25.1 and M25.5.
STANDARD M26 : Anti-Discriminatory Practice
REQUIRED OUTCOME
Patients are not discriminated against.
Standard fully met
INSPECTORS FINDINGS:
There was written information displayed in relation to patients’ rights
and patients spoken with were aware of their rights. The inspector
was informed that, where possible individuals were supported to
engage in religious and cultural preferences.
STANDARD M27 : Quality of Life for Patients
REQUIRED OUTCOME
The care provided recognises patients’ personal needs. Quality
can be compromised by inappropriate mix of patients cared for in
the same area.
Standard fully met
INSPECTORS FINDINGS:
Beechwood House has a responsive, facilitative and reflective
environment, conducive to meet the needs of one specific client
group.
STANDARD M28 : Patients’ Money
REQUIRED OUTCOME
Patients’ financial interests are safeguarded.
ABP/4859/27/10/03/Final Report 35
This Standard was not audited.
STANDARD M29 : Restrictions and Security for Patients
REQUIRED OUTCOME
Arrangements for the restriction and security of patients are clear and
effective.
Standard fully met
INSPECTORS FINDINGS:
There are clear policies and procedures in relation to this area. The
hospital uses the Risk Assessment, Management and Audit
System, which give a comprehensive risk to establish a client’s plan
of care. Additional restrictions and security arrangements are in
place, however a review of the maintenance of keys is required.
STANDARD M30 : Levels of Observation
REQUIRED OUTCOME
Appropriate arrangements are made for the observation of patients.
Standard fully met
INSPECTORS FINDINGS:
Policy and procedure reflects the need and actions required, as
does patients records, which generally, reflected the levels of
observation as defined within the observation policy. The
observation procedure is complex and comprehensive in that it
identifies the various appropriate levels of observation required in
relation to activities and locations.
STANDARD M31 : Managing Disturbed Behaviour
REQUIRED OUTCOME
Patients displaying aggressive and violent behaviour are managed
appropriately.
Standard partially met
INSPECTORS FINDINGS:
The Risk Assessment, Management and Audit System
documentation covered the area of managing disturbed behaviour.
Specific treatment plans were in place in relation to patients that
exhibited this behaviour. The levels of observation were agreed
within the multi-professional team meetings, or as appropriate in
situations of urgency. Communication strategies were in place to
manage disturbed behaviour.
ABP/4859/27/10/03/Final Report 36
STANDARD M32 : Management of Serious/Untoward Incidents
REQUIRED OUTCOME
Serious/untoward incidents are handled effectively and are learnt from.
Standard almost met
INSPECTORS FINDINGS:
There is a policy/procedure on serious/untoward incidents, however
the policy did not cover all the areas listed in Standard M32.2. The
multi-professional care team routinely reviews the reviewing of
serious incidents; however a wider range of incidents need to be
considered for inclusion in the policy Inspectors saw no evidence
that patients, carers and their families and any victims are involved
in the review at an early stage to ascertain their views and receive
information.
Requirements: Timescales
The policy/procedure must cover all the areas listed within Standard
M32.2. Early reviews should be undertaken to ascertain carers and
their families and any victims’ views following an incident. The areas
referred to as incidents need to be reviewed and expanded to be
more encompassing Reg 15 (1)
3 months
STANDARD M33 : Unexpected Patient Death
REQUIRED OUTCOME
The families and carers of patients who die unexpectedly, and the
staff who were involved in their care, are supported sensitively.
Standard fully met
INSPECTORS FINDINGS:
There was an appropriate policy/procedure in relation to this area
available for inspection; which provided for the necessary support of
individuals and processes required in this situation.
STANDARD M34 : Patients Absconding
REQUIRED OUTCOME
All attempts are made to prevent absconding. When patients do so,
Effective arrangements are in place to handle the absconsion
Standard fully met
INSPECTORS FINDINGS:
There was a policy on the area of patients absconding, which
included internal/external procedures that must be adhered too.
ABP/4859/27/10/03/Final Report 37
STANDARD M35 : Patient Restraint and Physical Interventions
REQUIRED OUTCOME
Patients are restrained appropriately and safely.
Standard partially met
INSPECTORS FINDINGS:
A policy/procedure on the area of restraint was available, however
additional, Individual prescriptions were not available for all patients,
nor was the documentation of technique to be used. The Inspectors
were informed that intervention procedures were reviewed within the
multi-disciplinary team framework.
There was evidence of training courses undertaken by staff team.
Requirements: Timescales
All patient restraint and physical interventions must be undertaken on
the basis of an individual prescription. This needs to be included in the
policy. 2 weeks
Reg 44
The use of rapid tranquillising/emergency medication procedure needs
to be Comprehensively detailed in the appropriate policy.
Post, full restraint, a physical examination should be undertaken; this
Element needs to be included in the policy/procedure Reg 44 2 weeks
SECTION FIVE – Child and Adolescent Mental Health Services
(additional standards)
Standards 36 to 40 are not applicable to Beechwood House Brain Injury
unit
SECTION SIX – Establishments in which Treatment or
Nursing (or both) are Provided for Persons Liable to be detained
STANDARD M41 : Information for Staff
REQUIRED OUTCOME
Detained patients receive treatment and care in line with the Mental Health
Act 1983, and regulations made under it, and its Code of Practice together
with the MHA Memorandum, and Mental Health Act Commission Practice
Notes.
Standard partially met
INSPECTORS FINDINGS:
The hospital has numerous policies/procedures in relation to
detained patients. However, not all of the policies and procedures
listed in Standard M41.3 were available. Existing policies and
procedures were reviewed on a regular basis. Applicable
ABP/4859/27/10/03/Final Report 38
information was strategically disseminated through out the units.
Requirements:
Copies of all the documents listed in Standard M41.2 must be
available within the clinical setting. Policies and procedures on all
the areas mentioned within Standard M41.3 must be formulated. An
audit system needs to be put in place. Reg 8(1) a
Timescales
2 weeks
STANDARD M42 : The Rights of Patients under the Mental Health Act
REQUIRED OUTCOME
Patients and their nearest relatives are able to exercise their rights and
entitlements under the Mental Health Act 1983 and its Code of Practice.
Standard fully met
INSPECTORS FINDINGS:
The hospital had a considerable amount of information in relation to
patients’ rights under the Mental Health Act 1983. This information
included the use of pictures. Patients had access to an advocate
and there was evidence that patients’ rights were being explained to
them on a regular basis under Section 132 of the Mental Health Act
1983. Legal advice was also made available to patients.
Information in relation to the role and function of the Mental Health
Act Commissioner was available
STANDARD M43: Seclusion of Patients
REQUIRED OUTCOME
Patients are secluded in accordance with the requirements of the 1983
Mental Health Act Code of Practice.
Standard almost met
INSPECTORS FINDINGS:
The inspector was informed that the hospital does not require
seclusion policy. Time out was utilised as a way of de-escalating
situations, however there is no reference to same sex staffing
requirements.
Requirements:
A policy/procedure to be devised in relation to time out, needs to
including staff preference.
Timescales
2 Weeks.
The need for the same sex-staffing requirement during periods of
seclusion/time out should be included in the policy, and facilitated
as required.
2 weeks
ABP/4859/27/10/03/Final Report 39
STANDARD M44 : Section 17 Leave
REQUIRED OUTCOME
Arrangements for Section 17 leave of absence are appropriate and clear, and
in accordance with the requirements of the 1983 Mental Health Act Code of
Practice and Mental Health Act Commission Guidance Note.
Standard fully met
INSPECTORS FINDINGS:
There was a policy/procedure available that addressed the majority
of areas listed in M44.2. Section 17 forms were utilised.
STANDARD M45 : Absence Without Leave Under Section 18
REQUIRED OUTCOME
Appropriate arrangements are made for missing and dead patients.
Standard fully met
INSPECTORS FINDINGS:
An appropriate policy/procedure on Absence Without Leave was
available; evidence showed that it is being well adhered to.
STANDARD M46 : Discharge of Detained Patients
REQUIRED OUTCOME
Arrangements for the discharge of detained patients are appropriate and
clear, and in accordance with the requirements of the 1983 Mental Health Act
Code of Practice.
Standard fully met
INSPECTORS FINDINGS:
Inspectors noted that the discharge of patients was
comprehensively documented, in line with the formalised
policy/procedure in relation to Section 117 and the Care Planning
Approach.
STANDARD M47 : Staff Training on the Mental Health Act
REQUIRED OUTCOME
Patients receive treatment and care from staff trained in, and conversant with,
the provisions of the Mental Health Act 1983.
Standard almost fully met
INSPECTORS FINDINGS:
Staff receives training on the Mental Health Act 1983 during their
induction programme; and additionally, individuals have extended
ABP/4859/27/10/03/Final Report 40
their knowledge in this area.
Requirements:
Training must include all the areas mentioned within Standard M47.
Reg 17(2)
Timescales
3 Months
ABP/4859/27/10/03/Final Report 41
REGULATORY REQUIREMENTS TIME LIMITS (DAYS)
Section 1 – Quality of Treatment and Care
STANDARD M1 : Working with the National Service Framework for
Mental Health in Wales (applies to adult mental health establishments
only)
Requirements:
An agreed and validated policy relevant to working within the
National Service Framework needs to be completed, and facilitated
as a working document Reg.6
Timescales
3 Months
Additional format for the patients guide needs to be available on
request. Reg 6
3 months
STANDARD M3 : Patient Confidentiality
Requirements:
The inspector was informed that, training on the Date Protection
policy is included within the staff induction programme under the
heading of Medical records.
Up date/training, in relation to accountability, as a professional
practitioner, and as part of a multi-disciplinary team needs to be
formalised within the training matrix Reg 3
Timescales
1 month
STANDARD M4 : Clinical Audit
Requirements:
An improved patient satisfaction questionnaire is required; which
will need to link with the CPA and advocate systems
Timescales
3 Months
SECTION TWO – HUMAN RESOURCES
STANDARD M5 : Staff Numbers and Skill Mix
Requirements:
Formalised policy is required in relation to the provision of long
term primary nurse care
Formalised re-evaluation of staffing levels, on a daily/shift basis,
to meet the changing needs of the patient, are required.
Formalised supervision and appraisal systems need to be
consolidated. Reg 17 (2)+(3)
Timescales
1 month
STANDARD M6 : Staff Training
Requirements:
The training to address the specific values, principles and broad
standards of the National Service Framework.
Reg:17(2)
Timescales
1 month
Specifics training on managing individuals that are liable to selfharming
behaviours or suicidal intent.
Reg;17(2)
Timescales
1 month
ABP/4859/27/10/03/Final Report 42
Section 3 – Risk Management
STANDARD M7 : Risk Assessment and Management
Requirements:
When patients are involved in their own risk assessment this
must be documented. Reg (8) (1) f
Timescales
2 weeks
Key individuals need to be trained in understanding the
complexities of disabled individuals, including those with sensory
impairment. These can subsequently be utilised as a resource,
by all the units.
Timescales
1 month
Risk assessments must be reviewed as soon as possible
following an untoward incident.8 (1) e
Next
occurrence
STANDARD M8 : Suicide Prevention
Requirements:
Written policies, protocols and procedures on the prevention of
homicides and suicide, which takes account of the
recommendations of the Confidential Inquiry into Homicide and
Suicides (Safer Services Department of Health 1999; Safety First
Department of Health 2001) (Regulation 43 (2)
Timescales
2 Weeks
A strategy must be put in place that will routinely reviews the
physical environment to reduce access to means of self-harm
and suicide. Reg 43(1)
Timescales
2 weeks
STANDARD M9 : Resuscitation Procedures
Requirements:
The registered manager and the responsible individual must
ensure that enough staff is trained in first aid, and at least one
individual are on shift at all times. Registered Nurses can not
automatically be regarded as ‘first aiders’
Timescales
3 months
A policy specific to resuscitation must be formulated Reg 8(1)+
43(1)
Timescales
2weeks
STANDARD M10 : Responsibility for Pharmaceutical Services
Requirements: The registered manager must ensure that the
section related to verbal prescriptions is fully adhered too.
Reg 14(5)
Timescales
Next
occurrence
SECTION FOUR – PATIENT TREATMENT AND CARE
STANDARD M14 : Information for Patients on their Treatment
Requirements:
Care plans must reflect individual patients’ views about their care
plan and treatment, especially about the effects and side effects of
drugs, together with the response of the clinicians. (Standard 14.5)
Reg 15(1)(3)
Timescales
2 Weeks
ABP/4859/27/10/03/Final Report 43
STANDARD M15 : Patients with Developmental Disabilities
Requirements:
Where patients are unable to participate in decisions related to care,
this should be clearly reflected within the care plan documentation.
Reg 8(2) c
Timescales
2 weeks
Individualised, assessed communication systems, need to be put in
place to meet the patients requirements. Training will need to be
provided for the staff team, as required.
Timescales
3 months
STANDARD M21 : Patient Discharge
Requirements:
The discharge summaries must be completed and forwarded to the
appropriate GP and all stakeholders within 5 working days. Reg 8(1)
Timescales
Next
occurrence
STANDARD M22 : Patients’ Records
Requirements:
Additional information is required within the policy to ensure it meets
the standards.
M22.1 professional notes are integrated into a single multidisciplinary
record, which includes hospital and community records.
Reg 8(1)
Timescales
2weeks
STANDARD M23 : Empowerment
Requirements:
Should any patient request the services of an advocate who is
‘external’ to the one provided by the hospital; this should be
facilitated for them. This needs to be formalised and included in the
service users guide. Reg 6
Timescales
3 months
STANDARD M24 : Arrangements for Visiting
Requirements:
A policy on the observation of visitors must be formulated. Reg 45 Timescales
A policy/procedure/clear guidelines, is needed in respect of
assisting patients during any unwanted visits, and support at times
of unreasonable demands.
1 Month.
STANDARD M25 : Working with Carers and Family Members
Requirements:
Written policies and procedures must be devised in relation to the
arrangements to involve the patient’s family members, friends and
carers. In addition, written policies and procedures are required in
relation to the various components of Standards M25.1 and M25.5.
STANDARD M32 : Management of Serious/Untoward Incidents
Requirements: Timescales
The policy/procedure must cover all the areas listed within Standard
M32.2. Early reviews should be undertaken to ascertain carers and
their families and any victims’ views following an incident. The areas
referred to as incidents need to be reviewed and expanded to be
3 months
ABP/4859/27/10/03/Final Report 44
more encompassing Reg 15 (1)
STANDARD M35 : Patient Restraint and Physical Interventions
Requirements: Timescales
All patient restraint and physical interventions must be undertaken on
the basis of an individual prescription. This needs to be included in the
policy. 2 weeks
Reg 44
The use of rapid tranquillising/emergency medication procedure needs
to be Comprehensively detailed in the appropriate policy.
Post, full restraint, a physical examination should be undertaken; this
Element needs to be included in the policy/procedure Reg 44 2 weeks
SECTION SIX – Establishments in which Treatment or
Nursing (or both) is Provided for Persons Liable to be detained
STANDARD M41 : Information for Staff
Requirements:
Copies of all the documents listed in Standard M41.2 must be
available within the clinical setting. Policies and procedures on all
the areas mentioned within Standard M41.3 must be formulated. An
audit system needs to be put in place. Reg 8(1) a
Timescales
2 weeks
STANDARD M43: Seclusion of Patients
Requirements:
A policy/procedure to be devised in relation to time out, needs to
including staff preference.
Timescales
2 Weeks.
The need for the same sex-staffing requirement during periods of
seclusion/time out should be included in the policy, and facilitated
as required.
2 weeks
STANDARD M47 : Staff Training on the Mental Health Act
Requirements:
Training must include all the areas mentioned within Standard M47.
Reg 17(2)
Timescales
3 Months
A written plan should be prepared, outlining the action that you will take
to implement the requirements listed (see above) within this report. Your
written plan should also confirm when each action will be (or has been)
completed. This ‘action plan’ should be sent to the CSIW office no later than
14 days after receipt of this report.
ABP/4859/27/10/03/Final Report 45
Good Practice recommendations
SECTION ONE – QUALITY OF TREATMENT AND CARE
STANDARD M1 : Working with the National Service Framework for
Mental Health in Wales (applies to adult mental health establishments
only)
Good practise Recommendations:
A copy of the National Service Framework (2002) to be made available on the unit
SECTION THREE – RISK MANAGEMENT
STANDARD M10 : Responsibility for Pharmaceutical Services
Good practise Recommendations:
A pharmacist should undertake a regular audit and provide a report .
SECTION FOUR – PATIENT TREATMENT AND CARE
STANDARD M11 : The Care Programme Approach
Good practice recommendation: A continuous, formalised review of the
systems in place, in line with a changing and developing situation would be
advantageous.
STANDARD M17 : Administration of Medicines
Good practise Recommendations:
Specimen signatures in relation to registered Nurses employed at the
Hospital, and all staff should be aware of their existence. Hazard notices should
be signed, dated and state what action is necessary when received.
STANDARD M23 : Empowerment
Good practise Recommendations:
Staff awareness in relation to patient empowerment should be included within the
induction programme.
SECTION SIX – Establishments in which Treatment or
Nursing (or both) are Provided for Persons Liable to be detained
ABP/4859/27/10/03/Final Report 46
Good Practice Comments
SECTION THREE – RISK MANAGEMENT
STANDARD M19 : Treatment for Addictions
Good practice:
Those staff members, who have specific training, qualifications, and
interests in the subject of addictions, should be encouraged to participate
in training and facilitating of information to the staff team.
ABP/4859/27/10/03/Final Report 47
Signed: Date:
Name:
Inspector:
Signed: Date:
Name:
Senior Inspector:
Signed: Date:
Name:
Lay Assessor: