Brook Lodge, Lakeview Hospital - Regulation and Quality ...

MENTAL HEALTH AND
LEARNING DISABILITY
ANNOUNCED INSPECTION
Brook Lodge, Lakeview
Hospital
Western Health and Social
Care Trust
3 and 4 January 2012
1

Table of Contents
1.0 Introduction ............................................................................................ 3
2.0 Ward Profile ........................................................................................... 4
3.0 Inspection Summary .............................................................................. 6
4.0 Stakeholder Engagement ....................................................................... 8
5.0 Additional concerns noted by Inspectors (if applicable) ....................... 10
6.0 RQIA Compliance Scale Guidance ...................................................... 11
7.0 Summary of Compliance – RQIA Assessment ..................................... 12
Appendix 1 – Quality Improvement Plan ........................................................ 15

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 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
relatives. A range of multi-disciplinary records, policies and procedures were
also examined as part of the inspection.
The recommendations made during the previous inspection on 30 September
and 1 October 2010 were also assessed during this inspection to determine
the Trust‟s progress towards compliance. The inspector found compliance in
the following areas:
Admission documentation
Documentation in relation to patients‟ contact with their consultant
Provision of records management training
Replacement flooring
Bathroom repairs completed
Appropriate storage of linen and consumables.
However, in spite of assurances from the Trust, several recommendations
remained outstanding from the previous inspection. Any previously stated
recommendations that were outstanding were added to the Quality
Improvement Plan for action (reference Appendix 1).
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.
3

2.0 Ward Profile
Trust
Name of hospital/facility
Address
Western Health and Social Care Trust
Lakeview Hospital, Brook Lodge
Gransha Park
Clooney Road
Londonderry
BT47 6TF
Telephone number 028 71 382950
Person in charge on day of inspection
Lorraine Feeney
Email address
Nature of service - MH/LD
Learning disability
Name of ward/s and category of care
Brook Lodge, acute admissions
Number of patients and occupancy
level on days of inspection
10 bed ward, 9 beds occupied during
inspection period
Number of detained patients on days
of inspection
3
Date of last inspection 30 September and 1 October 2010
Ward Profile:
Brook Lodge is an inpatient facility for adults with a learning disability in
Lakeview Hospital. There are ten beds in the ward and it serves as the
hospital's admission facility and provides assessment and treatment services.
The ward provides single room accommodation to male and female patients
and there are two spacious sitting rooms, a quiet room, dining room and a
number of toilets accessible to patients. Two of the bedrooms have en suite
4

facilities and there is a bathroom and shower room available to patients. Two
of the bedrooms are located next to the nurse's station and are described as
assessment rooms.
The ward also contains a kitchen, a clinical room, sluice room, office and a
number of storage areas for linen etc.
At the time of the inspection there were nine patients being cared for on the
ward. There were three detained patients and several patients had been in
the hospital for a number of years and were awaiting community resettlement.
Inspectors were advised that regular meetings take place between hospital
senior management staff, medical staff and community teams to discuss the
resettlement needs of specific patients.
Patients have access to a consultant psychiatrist, psychologist and most
patients attend the Berryburn Centre which provides day time activities and is
within the Lakeview site.
5

3.0 Inspection Summary
An announced inspection of Brook Lodge was undertaken on 3 and 4 January
2012. The purpose of this inspection was to assess the ward‟s arrangements
and procedures for safeguarding vulnerable adults.
The ward‟s progress towards compliance with recommendations made during
the previous inspection was assessed and a number of recommendations
were restated as insufficient progress had been made. These areas for
quality improvement included:
the provision of advocacy services
staff training in restrictive interventions including physical restraint
staff training in the protection of vulnerable adults
staff training in handling complaints
development of the whistle blowing policy to include contact details of
external organisations and agencies.
patients‟ involvement in care planning, discharge planning and in the
multi-disciplinary meetings
the provision of complaints information in an appropriate format.
The following is a summary of the inspection findings of the arrangements for
safeguarding vulnerable adults on this ward.
Inspectors noted a significant number of incidents had occurred on the ward
involving patients assaulting each other and in some cases, sustaining injuries
such as breaks to skin and bruising. There was evidence of patients
experiencing repeated assaults from other individual patients and of a
patient‟s relatives raising concerns about patient safety on the ward.
Inspectors raised concerns that the Trust‟s protection of vulnerable adults
procedures were not being followed, adult protection concerns were not being
adequately reported or investigated and there was poor evidence of
documented protection arrangements.
In spite of assurances provided to RQIA from the Trust, following the previous
inspection (October 2010), a significant number of staff still had not received
training in the protection of vulnerable adults.
The staff induction records did not provide evidence that new staff had been
given guidance on the ward‟s procedures for safeguarding vulnerable adults.
Inspectors were of the opinion that insufficient action was taken to promote
the safety and wellbeing of patients on the ward and noted that patients had
suffered harm during their inpatient stay. Details of specific concerns were
shared with senior Trust staff following the inspection.
6

The needs assessments, care plans and other multi-disciplinary
documentation of a number of patients were examined. The Inspector noted
that several patients did not have up to date care plans and some of the care
plans were not dated.
Some care plans had been developed during previous admissions but did not
reflect current assessed needs.
The staff training records were examined and contained some evidence of
staff having received update training in the protection of vulnerable adults.
It was recommended in the previous inspection report that all staff would
receive this training. Inspectors were concerned to note that insufficient
progress towards compliance had been made in this area.
Inspectors were also very concerned to note that staff working in Brook Lodge
were caring for a patient who presented with significant challenging
behaviours, including violence and aggression. Staff were noted to have used
physical interventions in the management of the patient however only 4 have
staff received accredited training in the use of physical interventions.
Inspectors provided feedback in relation to the findings at the end of the
second day of the inspection. RQIA also wrote to the Trust on 9 January
2012 to seek assurances in relation to the issues identified during the
inspection.
The Trust have provided an action plan in relation to the specific issues raised
by RQIA and progress towards the satisfactory and timely compliance in these
areas will be closely monitored.
Inspectors would like to thank the patients, staff, relatives and visiting
professionals for their cooperation throughout the inspection process.
7

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.
Number Number
Questionnaires issued to
issued returned
Patients 10 3
Carers/Relatives 10 3
Visiting Professional 10 6
Staff 10 3
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 3
Carers/Relatives 0
Visiting Professionals 0
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:
The patients who participated in the inspection indicated that they didn‟t
always feel safe on the ward and two patients advised the inspector they were
unaware of the ward‟s complaints procedures.
Two patients referred to incidents in which they had been assaulted by other
patients and one patient advised the inspector that their personal property had
been damaged by another patient.
Suggestions for quality improvement made by patients included the provision
of a games room on the ward and more meetings about resettlement.
Carers/ Relatives:
Three relatives returned a questionnaire and the suggestions for quality
improvement made included the provision of more fresh fruit, games and
books to patients on the ward. One relative suggested that ward staff should
not use their mobile phones when working on the ward.
One relative suggested that they would like to be more informed about the
wellbeing of their relative.
8

Another relative referred to incidents on the ward in which their relative had
been assaulted by another patient and had sustained injuries. This relative
also referred to their relative‟s property going missing.
These issues and suggestions for quality improvement were discussed with
staff during the inpseciton and with hospital management during the feedback
session at the end of the inspection visit.
Visiting professionals:
The professionals who returned a questionnaire indicated they have regular
contact with the ward and one professional commented:
“I am happy with the care afforded to clients in Brook Lodge – there is good
disciplinary approaches to assessment, setting up care plans and
management”.
Suggestions for quality improvement made by visiting professionals included
the provision of „breakaway‟ training for visiting staff and the provision of more
staff and more staff induction for new staff.
Staff:
Staff who participated in the inspection made a number of suggestions for
quality improvement. These included the provision of training for unqualified
staff, more staff meetings and more support for staff when dealing with
patients who present with aggressive and violent behaviours.
9

5.0 Additional concerns noted by Inspectors
A female patient‟s bedroom curtains were noted to be missing on the first day
of the inspection and the inspector was advised these would be re-hung
before the end of the day.
The patient was described as having an intolerance of curtains and had a
history of pulling them down in her bedroom and in the living room. The
inspector visited the patients bedroom on the second day of the inspection
and noted that the curtains had not been rehung. Staff confirmed that the
curtains had not been in place since the patient pulled them down „several
days ago‟. The ward manager reported that the curtains were ripped and
would require sewing before they could be re-hung. The inspector was also
advised that the patient would not be afforded the option of washing or
changing in her bedroom when there were no curtains in place and that this
caused the patient a degree of agitation.
The Inspector raised concerns that the patient‟s privacy was being
unreasonably compromised and that her bedroom was overlooked by
administration buildings and a public pathway.
Inspectors requested that an alternative window covering be sought urgently
for this patient to promote her privacy.
10

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.
11

Compliant
Substantially
Compliant
Moving
Towards
Compliance
Not Compliant
Unlikely to
become
compliant
Not Applicable
7.0 Summary of Compliance – RQIA Assessment
No.
Question
1
2
3
4
5
6
7
8
9
10
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.
12

Compliant
Substantially
Compliant
Moving
Towards
Compliance
Not Compliant
Unlikely to
become
compliant
Not Applicable
No.
Question
11
Describe how the ward identifies and
manages risks for individual patients.
12
Outline the mechanisms used by the
ward to ensure that vulnerable adults
have the right to take risks in relation
to their care.
13
14
15
16
17
18
19
20
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
13

Compliant
Substantially
Compliant
Moving
Towards
Compliance
Not Compliant
Unlikely to
become
compliant
Not Applicable
No.
Question
21
Outline the mechanisms for the
handling of vulnerable adults‟ money.
22
23
24
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.
Outline the safeguarding
arrangements the ward has in place
for the admission of an under 18 year
old.
14

Appendix 1 – Quality Improvement Plan
QUALITY IMPROVEMENT PLAN
ANNOUNCED INSPECTION
Brook Lodge, Lakeview Hospital
3 and 4 January 2012
The issue(s) identified during this inspection are detailed in the Quality Improvement Plan.
The details of the Quality Improvement Plan were discussed at a feedback meeting which was attended by the Ward Manager,
Director of Mental Health and Learning Disability, Assistant Director of Learning Disability services, Head of Service, Head of
Hospital Services, Consultant Psychiatrist.
15

1. RECOMMENDATIONS RESTATED FROM PREVIOUS INSPECTION
RECOMMENDATIONS RESTATED FROM PREVIOUS
INSPECTIONS
It is recommended that the Trust review the arrangements to enable all
patients to access independent advocacy services.
It is recommended that information about patients‟ rights is produced in
a format suitable to the needs of individual patients.
NUMBER OF
TIMES
STATED
DETAILS OF ACTION TO
BE TAKEN
2 In Brook Lodge - all patients
who receive assessment and
treatment have good family
involvement - who, along with
staff will advocate on the
patients' behalf. The
programme has a small amount
of funding available and is
currently developing a service
specification to go to tender to
procure an advocacy service.
The procurement process will
progress in the third quarter of
this year 2012. However if a
need presents, the Trust will
source indpendent advocacy.
2 This is facilitated by
implementing augmentative
and alternative communication
systems such as interpreters
coming into the ward and
TIMESCALE
31 July 2012
Immediate and on-going
16

It is recommended that all staff receive training in dealing with
complaints.
colour picture cards, "A Guide
to the Human Rights Act" a
booklet for people with learning
disabilities, produced by
Ministry of Justice. WHSCT -
Equality Scheme - easy read
booklet & easy read "Ours to
Own Your Human Rights" by
Equality & Human Rights
Commission. Whereby a patient
lacks capacity, these rights are
explained to their relatives or
carers. A list of patient rights is
included in the Strule Lodge
information leaflet given to
patient and/or family on an
admission.
2 An education consultancy is
being facilitated by the
complaints department and
training will be provided on site
for all staff by end of October
2012 and discussed at
induction. A list of training
needs were identified and
balanced with care needs on
31 May 2012
17

It is recommended that information about the complaints procedures is
produced in a format suitable to the individual needs of the patinets.
It is recommended that protocols for restrictive practices including
physical interventions are clearly documented in care records and that
any such interventions are recorded accurately and in detail.
the ward. Mandatory training
was prioritised for example
MATHS 5 day training,
Vulnerable Adult training,
Record and Record Keeping and
others. Taking into account
staffing levels and summer
'peak' leave time, complaints
training will be provided on site
for all staff on 27th September,
2nd October and 26th October
2012. Complaints leaflets are
available on the ward and
complaints flow chart on wall.
2 WHSCT - Lakeview brochure
on ward in pictorial format, plus
posters on the wall and
information leaflets available.
This is incorporated during
admission process and included
in admission checklist under
patient's rights.
2 All patients who require
restrictive practices including
physical interventions will have
Immediate and on-going
Immediate and on-going
18

It is recommended that patients are reminded regularly of the ward‟s
policy on encouraging patients to attend the weekly multi-disciplinary
meeting and that patients‟ views are documented.
risk assessment for restrictive
interventions with a care plan.
All interventions recorded in
daily recordings after discussion
and decision. Staff have
received training in MATHS and
restrictive interventions training
will be rolled out commencing
24/09/12 throughout the Trust.
Staff in Brook have read the
Restrictive Interventions Policy
and signed that they have read
this.
2 All patients who have capacity
to understand are offered an
opportunity to attend weekly
MDT ward round. Patient views
are recorded during weekly
ward rounds or daily SHO
round. Patient views are
recorded by Consultant in
medical notes, nursing staff in
daily recording of nursing
process and by any other
members of the Multi-
Disciplinary Team attending the
Immediate and on-going
19

It is recommended that patients are involved in all aspects of the
discharge plan and that their views are sought and documented.
It is recommended that the arrangements for observing patients using
the assessment bedrooms are reviewed and that this is undertaken on
the basis of identified need. It is also recommended that when patients
do not requie this level of observation, they are afforded maximum
privacy.
It is recommended that all staff receive training in challenging
behaviour, to include the use of restrictive practices and physical
interventions.
weekly Multi-Disciplinary ward
round.
2 Discharge planning
commenced on admission - predischarge
meetings and
discussions with patient, MDT
and family are documented in
care plans/medical notes
2 Assessment bedrooms are only
used for 1:1 prescribed
observations. A velcro blind is
on the observation windows at
all other times.
2 All seventeen staff in Brook
Lodge have been offered
M.A.T.H.S training - 15 staff are
now trained and 2 staff have
been referred to occupational
health after being deemed
medically unfit to complete the
training. These two staff will be
trained when occupational
health declare them medically
fit. Staff have received training
Immediate and on-going
Immediate and on-going
31 May 2012
20

in MATHS and restrictive
interventions training will be
rolled out commencing
24/09/12 throughout the Trust.
Staff in Brook have read the
Restrictive Interventions Policy
and signed that they have read
this.
It is recommended that all staff receive update training in the protection
of vulnerable adults.
2 Immediate and on-going
21

2. RECOMMENDATIONS MADE FOLLOWING INSPECTION OF SAFEGUARDING VULNERABLE ADULTS AND CHILDREN – HUMAN
RIGHTS THEME OF PROTECTION
RECOMMENDATIONS
DETAILS OF ACTION TO
BE TAKEN
TIMESCALE
1. Staff induction, training, supervision and appraisal.
It is recommended that the Whistleblowing policy is developed to include the contact
details of external organisations and agencies.
It is recommended that staff induction records are completed and that staff receive
guidance in relation to the ward‟s SafeguardingVulnerable Adults procedures.
The Hospital Manager spoke to
Risk Management Department
to advise them of this
recommendation. Advised
current policy (dated June 2011)
Based on regional guidance and
DHSS circulars - a request for
further clarification on RQIA's
recommendation - ref per 14 a
referral is made to external
bodies.
16/17 staff in Brook are
trained in Vulnerable Adults -
and Vulnerable Adult
procedures are included on staff
induction forms. Staff receive
ongoing guidance on vulnerable
adult procedures at ward
30 April 2012
Immediate and on-going
22

It is recommended that the acting ward manager and all staff on the ward receive
regular supervision and appraisal.
It is recommended that regular staff meetings are held and that all staff have the
opportunity to attend these.
It is recommended that a staff training and development plan is developed for the ward
and that all training needs are identified and actioned.
meetings, supervision sessions
and posters are displayed on
safeguarding vulnerable adults.
The Ward Manager attended
training on 30/6/12 and has
completed six appraisals to date
- all to be completed by mid
November 2012 and staff have
been allocated dates for their
annual appraisal.
Staff meetings are held 4-6
weekly - or more often if
required. Notices are put up
detailing date and time of
meeting and staff are verbally
invited to attend as well.
This is incorporated in the
annual appraisals. A training file
kept on the ward. All mandatory
training needs are identified
and records kept of attendance
and refresher dates. A weekly
record of attendance of training
is kept. A training needs analysis
31 July 2012
Immediate and on-going
Immediate and on-going
23

for mandatory training and
commissioned courses are
formulised through the WHSCT
Education, Learning and
Development sub-group.
2. Awareness and implementation of procedures for the protection of vulnerable adults.
It is recommended that all staff receive training and information in relation to the
application of the Trust‟s safeguarding vulnerable adults procedures to their area of
work.
16/17 staff inBrook Lodge
have been trained in Vulnerable
Adult Procedures - other staff
member just returned from sick
leave is booked on to next
training session on 7/12/12
Immediate and on-going
3. Incident reporting and risk management.
It is recommended that all incidents in which patients suffer or at risk of harm are
considered withn the context of the Trust‟s safeguarding adults procedures.
All incidents in which patients
are at risk of harm - or suffer
harm are recorded, a VA1
referral form is completed and
forwarded to the Designated
Officer in conjunction with
DATIX forms, daily recording
notes completed and all Trust
Polices followed. As is current
practice, staff continue to
report all untoward incidents
Immediate and on-going
24

via the Trust's Incident
Reporting Procedures (DATIX).
Staff continue to record all
assaults and immediate action
take in individuals' nursing
processes. This recording will
detail antecedent, actual
behaviour (assault),
consequences and possible
contributory factors.
Appropriate care planning
either initiated or reviewed
within both 'victim' and
perpetrator's notes so as to
minimise risk of re-occurrence.
As is current practice, staff
continue to inform next of
kin/care(s) of all assaults and
untoward incidents. Nursing
staff discuss with multidisciplinary
team immediately
or at earliest opportunity as
deemed necessary having
assessed the situation.
Consultation between learning
disability services and the
25

It is recommended that patients‟ relatives are informed of incidents or significant events
occurring on the ward.
Trust's Adult Safeguarding Team
Lead initiated with regard to
VA1 referral processes,
thresholds of behaviours, trends
of individuals' behaviours and
protection plans in keeping with
regional guidance.
All relatives, with the patient's
consent are informed of all
incidents or significant events.
All untoward incidents are
reported via the Trust's Incident
Reporting Procedure (DATIX).
VA1referral forms are
completed. Staff record
conversation with relatives in
patient's nursing process. On
admission, a contract
agreement form is completed to
get contact details and
frequency of information
sharing preferred and is in the
patient's nursing process for all
staff's information.
Immediate and on-going
4. Comments, concerns and complaints.
26

It is recommended that the arrangements for the frequency and appropriateness of
sharing pertinent information with relatives are reviewed and agreed with relatives and
that these are documented within the patients‟ records.
It is recommended that patients are provided with further opportunities to raise
concerns in relation to their care and that these include the provision of advocacy
services and patients‟ meetings.
On all occassions , consent to
share information will be
obtained from patient - if able
to give consent and recorded in
nursing process - a contact
details sheet has been
formulated to gather this
information. Any information
given to relatives recorded in
nursing process in daily
recordings.
Patients can raise concerns
to nursing staff, key workers or
family members. The
programme has a small amount
of funding available and is
currently developing a service
specification to go to tender to
procure an advocacy service.
The procurement process will
progress in the third quarter of
this year 2012. However if a
need presents, the Trust will
source independent advocacy.
Immediate and on-going
31 May 2012
5. Patients’ rights.
27

It is recommended that user friendly information is developed to inform patients of their
right to access information held about them.
Patients who have capacity to
understand are verbally told
about this right and an
information leaflet given to
them - 'Access to health
Records' which contains the
application forms to access the
records. The information leaflet
'Access to Health' records is
available on the ward. On
admission, patients who have
the capacity to understand are
verbally told about this leaflet
and staff will assist the patient
in explaining the information
and processes for accessing
information held about them. If
the patient lacks capacity, the
relatives will be given
information about accessing
information. The leaflet
contains an application form to
access their records and staff or
family will assist the patient to
complete this if they wish to
access their notes.
31 July 2012
28

6. Patients’ money and property.
It is recommended that patients who cannot safeguard their property on the ward are
provided with adequate support.
All patients have their own
individual cash records. All
property on admission recorded
and checked on discharge.
Advice from nursing staff on
property safety and assistance
to that patients safeguard their
property at all times on ward.
Immediate and on-going
6. Child Protection.
It is recommended that staff undertake training in child protection.
A consultancy request has
been made to education
provider, NEDC to provide Level
One Child Protection training on
site over 2 - 4 dates to ensure
all staff obtain safeguarding
Children Level One training for
nursing staff and untrained staff
will receive awareness session
in child protection.
31 July 2012
7. Additional Recommendations.
It is recommended that the arrangements for providing adequate window coverings and
privacy in patients‟ bedrooms are reviewed and that alternatives to curtains are
explored and provided.
Alternatives to curtains have
been researched, including
discussions with other facilities
Immediate and on-going
29

and hospitals. Adhesive privacy
screens have been applied to
the windows of a patient who
has been identified as needing
this, due to a history of pulling
down curtains. Staff have
formulated a care plan to
ensure privacy and dignity are
protected at all times.
30