Inver 3, Holywell Hospital - 31 July and 1 August 2012

MENTAL HEALTH AND
LEARNING DISABILITY
ANNOUNCED INSPECTION
Holywell Hospital
Inver 3
Northern Health and Social
Care Trust
31 July and 1 August
2012
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Table of Contents
1.0 Introduction ............................................................................................ 3
2.0 Ward Profile ........................................................................................... 4
3.0 Inspection Summary .............................................................................. 6
4.0 Stakeholder Engagement ....................................................................... 9
5.0 Additional Concerns Noted by Inspectors ............................................ 11
6.0 RQIA Compliance Scale Guidance ...................................................... 12
7.0 Summary of Compliance – RQIA Assessment ..................................... 13
Appendix 1 – Quality Improvement Plan ........................................................ 16

1.0 Introduction
The Regulation and Quality Improvement Authority (RQIA) is the independent
body responsible for regulating and inspecting the quality and availability of
Northern Ireland’s health and social care services. RQIA was established
under the Health and Personal Social Services (Quality, Improvement and
Regulation) (Northern Ireland) Order 2003, to drive improvements for
everyone using health and social care services.
On 24 October 2011 RQIA informed the Northern Health and Social Care
Trust of the inspection date and forwarded the associated inspection
documentation. RQIA adopted the approach of self-assessment, which
allowed the ward the opportunity to demonstrate its ability to deliver a service
against best practice indicators. This included the assessment of the trust’s
performance against an RQIA compliance scale, as outlined in Section 6.
The inspection process included an analysis of the ward’s self-assessment,
other associated information, discussions with ward staff, patients and a
visiting professional. A range of multidisciplinary records, policies and
procedures were also examined as part of the inspection.
An overall summary of the ward’s performance against the human rights
theme of protection is in Section 3 and full details of the inspection findings
are outlined in Appendix 2.
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2.0 Ward Profile
Trust
Name of hospital/facility
Northern Health and Social Care
Trust
Holywell Hospital
Address
60 Steeple Road
Antrim
Telephone number 02894413361
Person in charge on day of inspection
Mr R Luke
Nature of service - MH/LD
Long stay Mental Health
Name of ward/s and category of care Inver 3
Number of patients and occupancy
level on days of inspection
10
Number of detained patients on days
of inspection
Date of last inspection
Name of Inspector
2
Patient Experience Review - July
2011
Carolyn Maxwell
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The ward is situated off the main corridor in Holywell Hospital, it is locked and
can be accessed by ringing a bell at the entrance.
The ward has recently been refurbished and contains a mixture of double
rooms and four bedded dormitory accommodation. There are several patient
sitting areas including an activity room, a quiet room and seating along the
main ward area. A patient’s snack bar area with a vending machine and tea
making facilities is a recent addition to the ward accommodation. The toilets,
bathroom, shower are situated off the bedroom area, with one set of toilets
and the assisted bathroom accessed via the main corridor. The ward has a
spacious dining room which is shared with patients from Inver 1. Patients can
also access an enclosed landscaped garden. Seating is provided and shelter
for smokers is afforded on the veranda of a neighbouring ward.
The ward has input from support services daily and meals which are delivered
to the ward from the hospital kitchen are heated in the ward’s kitchen,
adjoining the dining room.
The ward currently has a locum psychiatrist with the new consultant due to
commence in September. Multidisciplinary meetings are held fortnightly.
Patients also have access to occupational therapy and social work services
on the ward.
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3.0 Inspection Summary
An announced inspection of Inver 3 Holywell Hospital was undertaken on 31
July 2012 from 9.30am – 5pm and 1 August 2012 from 9am – 1pm. The
inspectors were Carolyn Maxwell and Margaret Cullen. The purpose of this
inspection was to assess the ward’s arrangements and procedures for
safeguarding vulnerable adults.
The following is a summary of the inspection findings of the arrangements for
safeguarding vulnerable adults on this ward.
There were 10 patients on the ward at the time of the inspection, two of whom
were detained under the Mental Health (NI) Order, 1986. The average age of
the patients at time of inspection was 69 years. Two patients had been in the
hospital for over 50 years, with the average stay in Inver 3 being 10 years.
Although previously designated as continuing care the ward has recently
achieved several discharges to community facilities. Community resettlement
remains an aspiration for most of the patients. Two patients have no regular
visitors.
Patients were observed moving freely around the ward and availing of access
to the dining room, seating areas, the quiet room, activity room and their
bedrooms. Patients could access a snack bar for refreshments and snacks at
any time. One patient used a walking aid to assist mobility another patient
chooses not leave the ward on any occasions. Four patients have diabetes.
One has Parkinson’s disease and one is being assessed for dementia. One
patient was subject to restrictions due to potential MRSA. There was evidence
of allied health professional’s involvement with patients where indicated.
The ward maintains a range of policies, procedures and guidance documents
in relation to the safeguarding of vulnerable adults and children. Staff were
aware of safeguarding arrangements and a wide range of policies to support a
safe and healthy workplace.
A number of staff have undertaken training in safeguarding and there had
been referrals made by ward staff with regard to vulnerable adults concerns.
A recommendation was made for all staff to attend training.
Inver 3 ward’s vision statement was on display on the ward along with
information about complaints, hospital services, health promotion literature,
advocacy, activities and the ward routine.
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Several patients were experiencing restrictions on the ward at the time of the
inspection due to the locked environment. A care plan was in place which
referenced this restriction although it was not detailed or personalised
sufficiently. There was evidence of physical interventions being used to escort
a patient back to the ward and restrictions on spending money. A specific
recommendation was made with regard to one patient.
The wards procedures for safeguarding patient’s monies were examined. This
was complicated by a lack of clarity regarding existing competency
assessments. Patients were paying for communal toiletries and tuck.
Receipts, whilst provided to account for money, were not itemised. A
recommendation was made to change this practice and for review of all
patients capacity to handle their own money.
A patient complained about the quality of food offered. The inspector
observed the lunch being served on day one of the inspection and noted that
patients were given the opportunity to supplement from their chosen menu
choice and food appeared appetising and was plentiful. There was also fresh
fruit available in the snack bar.
The ward’s incident records reflected a number of incidents in which staff
were subject to physical and verbal aggression by one particular patient.
Inspectors also noted incidents in which staff were reported to have used
physical interventions to restrain patients. This was not documented fully in
records.
Staff training records were examined and reflected overdue updates in
training in the use of physical interventions, manual handling and fire safety.
Nursing staff were receiving supervision and some had undertaken an annual
appraisal. All staff confirmed they had had an induction process. The
corporate induction did not specify vulnerable adult policy. Recommendations
were made in relation to these issues.
Staff are referred to
HSC/MHDP – MHU 1/10 deprivation of liberty safeguards (DOLS) - Interim
guidance issued by the Department Health, Social Services and Public Safety
(DHSSPS)
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In relation to the use of restrictive practices and other issues identified in
respect of one patient, requested to be informed of the following
recommendations were made:
• assessment of patient's capacity (in relation to specific issues
particularly the decision to excessively consume sugary products in
light of the impact this has on diabetes and the decision not to
purchase clothing)
• consideration of the patient's legal status and use of force, restraint to
implement care, treatment plan
• provision of independent advocacy to safeguard the patient's rights and
to provide support
• provision of specialist input in relation to patient's apparent autism,
visual impairment, and need for psychological input.
• document any best interests discussions involving members of the
multi-disciplinary team and where possible the patients representatives
or advocate.
• outcome of best interests discussions, decisions made with clear
outline of actions to be taken and schedule for review of these
• consideration of necessity and proportionality of each restriction
• consideration of the patient's human rights in relation to restrictions and
in particular Article 5 and Article 8 rights
Inspectors would like to thank the patients, staff, relatives and visiting
professionals for their cooperation throughout the inspection process.
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4.0 Stakeholder Engagement
Questionnaires were issued to staff, patients, relatives, carers and visiting
professionals in advance of the inspection. The responses from the
questionnaires were used to inform the inspection process.
Questionnaires issued to Number issued
Number
returned
Patients 10 5
Carers/Relatives 10 1
Visiting Professional 5 0
Staff 10 5
During the inspection the inspector has the opportunity to meet with staff,
patients, relatives, carers, visiting professionals or advocates. Below are the
details of the number of discussions held during the inspection.
Additional discussions during inspection
Number
Patients 2
Carers/Relatives 0
Visiting Professionals 1
Staff 4
Advocates 0
The following information is a summary of feedback received from those who
returned a questionnaire or met with an inspector during the inspection.
Patients:
Patients had been assisted by the advocate to complete questionnaires.
Generally responses indicated that patients felt the care was good.
One patient indicated that they had been upset by another patient and
received no support from staff. Another reported that they had been upset by
not being allowed to buy clothing. Patients were not aware that they had the
right to access their records. None of the patients identified safeguarding
issues.
Carers/ Relatives:
Although the inspectors did not speak with any relatives individually. One
response made via questionnaire returned to RQIA stated:
“My brother is well cared for by all the staff. Staff will ring me up to tell me if
anything is happening”
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Visiting professionals:
Inspectors met with a podiatrist who attends the ward monthly. They were
aware of the safeguarding policy and considered that patients were well cared
for. Treatment that required to be continued was documented in patients
notes, otherwise records were maintained by the staff member.
Staff:
Staff who participated in the inspection were generally positive and outlined a
range of training and supervision undertaken. Staff were aware of the
safeguarding policy and could identify forms of abuse. They outlined
safeguarding arrangements for patient’s property and monies. Staff identified
that good knowledge of patients enables them to diffuse potential instances of
aggression between patients. One patient in particular had been violent and
emotionally abusive towards nursing staff. Measures were put in place to
protect staff; however there was some doubt around the effectiveness of a
zero tolerance in relation to abusive behavour policy in this setting.
Suggestions for improvements to the ward included; more occupational
therapy provision and increased availability of ward based activities.
Advocates:
No advocates attended the ward during the inspection.
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5.0 Additional Concerns Noted by Inspectors
Ward Environment
The staff toilets were accessed through the patients’ toilet and the windows
opened onto the patients’ garden area. This is unsuitable. Staff had requested
that a partition be erected to provide for privacy. Inspectors were informed that
plans have been agreed to relocate staff WCs to an area off the link corridor
to the ward.
Patient toilet had a strong odour of stale urine. The ward has recently been
refurbished with new flooring and plumbing installed. This had failed to solve
the problem. Inspectors were informed that the works docket had not been
signed off and contractors had been asked to return to find a permanent
solution to the problem. There was also evidence of a leak in the ceiling of the
main assisted bathroom.
There was ripped flooring at the doorway from the ward to the dining area.
This is hazardous particularly given the level of mobility impairment in several
of the patients.
Inappropriate usage of patients’ bathroom to store wheelchairs.
Four of the patients on the ward were diabetic and it was noted that the
vending machine had no low sugar options that would be suitable for those
patients. Staff had previously raised this issue with the suppliers.
Restrictions
In relation to one patient (discussed during inspection feedback) RQIA
suggested a range of safeguarding provisions and requested feedback once
completed.
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6.0 RQIA Compliance Scale Guidance
Guidance - Compliance statements
Compliance statement
0 - Not applicable
1 - Unlikely to become
compliant
2 - Not compliant
3 - Moving towards
compliance
Definition
Compliance with this criterion does
not apply to this ward.
Compliance will not be demonstrated
by the date of the inspection.
Compliance could not be
demonstrated by the date of the
inspection.
Compliance could not be
demonstrated by the date of the
inspection. However, the service
could demonstrate a convincing plan
for full compliance by the end of the
inspection year.
Resulting Action in
Inspection Report
A reason must be clearly stated in
the assessment contained within the
inspection report
A reason must be clearly stated in
the assessment contained within the
inspection report
In most situations this will result in a
requirement or recommendation
being made within the inspection
report
In most situations this will result in a
recommendation being made within
the inspection report
4 - Substantially
Compliant
Arrangements for compliance were
demonstrated during the inspection.
However, appropriate systems for
regular monitoring, review and
revision are not yet in place.
In most situations this will result in a
recommendation, or in some
circumstances a recommendation,
being made within the Inspection
Report
5 - Compliant
Arrangements for compliance were
demonstrated during the inspection.
There are appropriate systems in
place for regular monitoring, review
and any necessary revisions to be
undertaken.
In most situations this will result in
an area of good practice being
identified and being made within the
inspection report.
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7.0 Summary of Compliance – RQIA Assessment
No.
Question
Compliant
Substantially
Compliant
Moving
Towards
Compliance
Not Compliant
Unlikely to
become
compliant
Not Applicable
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2
3
4
5
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8
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How do you ensure that everyone
involved with the ward is aware of
and understands the safeguarding
vulnerable adult policy?
List the additional procedures and
guidelines that you use to support
the safeguarding vulnerable adult
policy.
List the additional procedures and
guidelines, aimed at promoting
safe and healthy working
practices, which you use to
support the safeguarding
vulnerable adult policy.
Outline how the ward is involved in
the review of the Trust’s
safeguarding vulnerable adult
policy, the code of behaviour and
the other associated procedures
and guidelines.
Outline how new staff are
appropriately inducted into the
ward.
Describe how staff training needs,
appropriate to the post/ role, are
identified.
Outline the arrangements in place for:
(i) the support and supervision of all
staff
(ii) the annual appraisal of staff and
the review of volunteers
Describe the arrangements in place
for maintaining written records of:
training completed; support and
supervision; and annual appraisals
and reviews.
Describe how the ward ensures staff
and volunteers comply with the
Safeguarding Vulnerable Adults
Standard 4.
Outline the steps the ward has taken
to ensure that staff and volunteers are
competent to recognise signs of
abuse.
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Describe how the ward identifies and
manages risks for individual patients.
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Outline the mechanisms used by the
ward to ensure that vulnerable adults
have the right to take risks in relation
to their care.
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Describe how the reporting, recording
and reviewing accidents, incidents
and near misses informs and
influences ward practice and the risk
assessment and management
procedures.
Describe how the ward promotes and
communicates the Trust’s ‘ethos of
inclusion, transparency and
openness’ to vulnerable adults,
carers, advocates, family members,
staff and volunteers.
Describe the procedures in place for
carers, advocates and vulnerable
adults to share concerns they may
have or to make complaints about the
organisation.
Outline the steps the ward has taken
to encourage carers, advocates and
vulnerable adults to raise concerns or
make a complaint following an
incident.
Outline how the ward ensures that
staff know and comply with the
records management policy.
Outline the mechanisms the trust has
in place to inform vulnerable adults
about their right to access to
information held about them.
Describe how the ward ensures that
staff, volunteers and visitors know
about and adhere to the Code of
Behaviour.
outline how the ward safeguards
patients’ rights in relation to the use
of:
(i) restrictions on the ward
(ii) isolation/ seclusion
(iii) close observation
(iv) restraint
Outline the mechanisms for the
handling of vulnerable adults’ money.
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Outline how the ward ensures the
safety of patients’ property while on
the ward.
Describe what arrangements the ward
has in place for children visiting the
ward.
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24
Outline the safeguarding
arrangements the ward has in place
for the admission of an under 18 year
old.
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