Waterside 1 and 3, Gransha Hospital - 13 June 2012

MENTAL HEALTH AND
LEARNING DISABILITY
ANNOUNCED INSPECTION
Waterside 1 and 3
Gransha Hospital
Western Health and Social
Care Trust
13 & 14 June 2012
1

Table of Contents
1.0 Introduction ............................................................................................ 3
2.0 Ward Profile ........................................................................................... 5
3.0 Inspection Summary .............................................................................. 7
4.0 Stakeholder Engagement ..................................................................... 10
5.0 Additional Concerns Noted by Inspectors ............................................ 12
6.0 RQIA Compliance Scale Guidance ...................................................... 14
7.0 Summary of Compliance – RQIA Assessment ..................................... 15
Appendix 1 – Quality Improvement Plan ........................................................ 18

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 Western Health and Social Care
Trust of the proposed inspection 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 multidisciplinary records, policies and procedures were
also examined as part of the inspection.
The recommendations made during the previous inspection on 19 and 20
April 2011 were also assessed during this inspection to determine the trust’s
progress towards compliance. The inspectors found compliance in the
following areas:
• all informal and formal complaints are being consistently recorded
including any actions taken in response
• patients meetings take place on a regular basis
• patients and/or carers’ views have been sought and communicated at
multi-disciplinary team meetings, however, a further recommendation in
relation to recording templates has been made
• the ward environments had been fully risk assessed in relation to
ligature points and any required actions taken
• staffing levels were satisfactory but is is recommended that staffing
levels are reviewed again when Waterside 1 reopens
• staff were satisfied that they had been informed of the thresholds for
contacting medical staff in an emergency situation
• records demonstrated that staff complete documentation in relation to
accidents and incidents accurately and in a timely manner
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). Evaluation of compliance
with recomendations in relation the environment in Waterside 1 and activity
provision have been deferred to the next inspection.
3

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.
4

2.0 Ward Profile
Trust
Name of hospital/facility
Address
Western Health and Social Care Trust
Gransha Hospital
Clooney Road
Derry
BT47 6WH
Telephone number 028 7186 0007
Person in charge on day of
inspection
Nature of service - MH/LD
Name of ward/s and category of
care
Number of patients and occupancy
level on days of inspection
Sr Winifred O’Kane
Mental Health
Waterside 1 - older people with
dementia
Waterside 3 older people with
functional mental ill health
16
Number of detained patients on
days of inspection
2
Date of last inspection 19 and 20 April 2011
Name of Inspector
Rosaline Kelly
Date of Inspection 13 and 14 June 2012
Ward profile
Waterside Hospital is an older people’s care unit on the main Gransha
Hospital site. Waterside 1 is an assessment and rehabilitation ward for people
with dementia. Waterside 3 is a ward for older people with functional mental ill
health.
5

At the time of the inspection on 13 and 14 June 2012 Waterside 1 had been
closed for renovations since 9 March 2012. Patients from Waterside 1 had
been accommodated in Waterside 3. Staff from Waterside 1 were working in
Waterside 3.
Accommodation in Waterside 3 included; two day spaces where patients also
dined; a combination of four beds, two bed and single rooms, bathrooms and
toilets; a nurses station; offices and a small kitchen. The ward manager stated
that staff tried to accommodate Waterside 1 patients separately from
Waterside 3 patients. There was also access to an enclosed garden. A range
of different types of seating was available.
Waterside 1 was still being renovated to enhance the environment to reflect
best practice in dementia design. At the conclusion of the inspection it was
agreed with a senior Western Trust representative that Waterside 1 would
reopen by 31 July 2012.
There were 16 patients on the ward during the inspection. Two patients had
been detained in accordance with the Mental Health (NI) Order 1986.
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3.0 Inspection Summary
An announced inspection of Waterside 1 and 3 was undertaken on 13 June
2012 from 9.30am – 5pm and 14 June 2012 from 10am – 5pm. The
inspectors were Rosaline Kelly and Patrick Convery. 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.
The ward’s safeguarding statement, policies procedures and guidelines were
displayed in the office. A safeguarding folder containing local and regional
guidance documents was available. A flowchart describing the vulnerable
adult investigation process was also displayed in the office. Professional
registration bodies guidance documents were also available. Safeguarding
practices were supported by a range of complimentary policies and
procedures. Recommendations have been made in relation to review of
polcies and procedures in a systematic manner.
Staff who met with inspectors appeared to be knowledgeable in relation to
indicators of abuse and how to respond to alleged, suspected or actual abuse.
Guidance for staff on how to recognise and respond to alleged, suspected or
actual incidents of abuse was available. A code of behaviour has yet to be
developed. However, staff who met with the inspectors were able to describe
various other established frameworks that they use to guide practice, such as
Nursing and Midwifery Council Code of Professional Conduct for Nurses and
could describe what they believed the content of a code of behaviour should
refer to.
Review of training records available on the day of the inspection
demonstrated that 25% staff for both wards did not have a recorded date of
attendance at training in safeguarding vulnerable adults. Deficits in updated
training were also identified during the inspection. These shortfalls in training
had also been highlighted at the last inspection. Senior trust representatives
stated their belief during feedback that the records presented during the
inspection may not be a true reflection of training attendance and that some
work is required to update the trust computerised system. It was agreed that
the recommendations made to review records and address deficits in
essential training will be addressed as a matter of urgency. Guidance for staff
in relation to protecting vulnerable adults had not been included in the
induction programme. Other recommendations in relation to the induction
programme have been made.
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Although records of appraisal and formal supervision meetings were available
for some staff, formal supervision and appraisal of staff, including nursing
auxillary staff had not been occurring in accordance with policies and
procedures. Recommendations have been made. The ward is not currently
using volunteers.
Risks had been assessed on admission to the ward by both nursing and
medical staff and immediate actions plans defined. Risk had been reviewed.
However, it was concerning that in relation to one particular serious incident
for particular patient, the comprehensive risk assessment had not been
updated to include details of the event or the additionally identified risk and
related management plan. Although there was some evidence available
during the inspection to demonstrate that those patients usually
accommodated solely in Waterside 3 had been involved in the initial
assessment of need, there was not any evidence available to confirm that
patients and/or their representatives had been comprehensively involved in
needs assessment and care planning.
The ward manager demonstrated a computerised reporting system for
accident, incidents and near misses. Referral to other members of the
multidisciplinary team had been made where necessary, including the trusts
vulnerable adults safeguarding team. However, the ward manager stated that
she did not receive information from the trusts Governance department in
relation to analysis of accidents/incidents, and was not aware how to generate
this information from the computer programme herself.
Records demonstrated that relatives had been informed of any
accidents/incidents. Detailed minutes of discussions with family members in
conjunction with multidisciplinary team meetings were included in patient files
reviewed during the inspection. A complaints leaflet was available. Records of
formal and informal complaints were also available. Discussion with relatives
during the inspection and responses made via questionnaires indicated that
any concerns raised were addressed to the satisfaction of those involved.
A reference to record keeping responsibilities was included in minutes of staff
meetings available on the day of the inspection. Policies and procedures to
guide staff were available. However, review of nursing care plans and nursing
records during the inspection did not demonstrate consistent recording or
accurate record keeping. The ward manager stated that audit of compliance
with recording and records management was not taking place. A
recommendation has been made. Policies and procedures are in place to
govern the requests of relatives or representatives who may wish to access
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information and patients of Waterside 3 who may request access to
information held about them.
The ward manager reported that seclusion and restraint are not used in either
Waterside 1 or Waterside 3. Patients had free access to the enclosed garden
during the inspection and were observed using the garden spaces. Practices
of close observation had been documented in patient notes and agreed with
the medical staff in accordance with the trusts policy and procedures.
Restriction/restraint in terms of use of bedrails was in place for some
individual patients. Bedrails assessments in patients’ notes were reviewed
during the inspection. However documentation had not always been fully
completed and this was discussed with the ward manager. Doors to the wards
are locked. The reason for locked doors had not been fully explained in the
ward booklet, or in individual care plans. This had also been highlighted at the
last inspection.
A policy and procedure for handling patients’ finances was available. The
ward does not handle patients’ monies. Patients who are admitted to the ward
with sums of money are asked to hand the money to relatives or sign the
money to the hospital cash office in accordance with the policy and procedure.
Property lists were recorded on admission to the ward. Five patients
responded to questionnaires issued by RQIA. One respondent stated that
personal items had been taken and found on another patient’s locker. A
patient who met with inspectors during the inspection stated that personal
belongings and valuable items had been taken and not recovered. This
patient stated that personal items appeared to be less secure since both
wards combined. The ward manager agreed that these circumstances were
concerning and that lockable storage for patients to keep valuable items and
personal belongings safe had not been provided.
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 16 5
Carers/Relatives 16 3
Visiting Professional 5 0
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 1
Carers/Relatives 2
Visiting Professionals 4
Staff 2
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:
Five patients responded to questionnaires issued by RQIA. Comments
included:
“Staff always willing to help all patients, answer questions if asked, food
excellent”
“ward freezing cold”
“Care varies”
“Care very good”.
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Carers/ Relatives:
Two carers/relatives were interviewed during inspection. They were very
complentary about care and treatment received;
“fantastic nursing…very high standard.”
Three relatives/carers responded to questionnaires issued by RQIA.
Comments included:
“Excellent, all staff are very attentive, professional and friendly. Excellent care,
staff, facilities and activities”
“Most staff are caring but they engage with patients as little as possible. The
ward is full of elderly patients with dementia and some staff treat them in an
abrupt and brusque manner…I would suggest more interaction with patients
and more planned activity”
“The staff are mostly caring and try to be helpful”
Visiting professionals:
Two consultant psychiatrists and two team leaders were interviewed during
inspection. There were some concerns expressed regarding the admission
process and the assessment and management of risk. The perception from
staff interviewed that the number of inappropriate admissions especially at
weekends and that despite the multi disciplinary assessment the role of
management in the admission process tended to override professional
decision making and the ward could not refuse admission regardless of the
assessment process.
Staff:
Only one member of staff responded to questionnaires issued by RQIA.
Comments included:
“The care provided on this ward is of a high standard, good communication
with patients and families, all care is person centred, unique to each
individual”
Advocates:
The ward does not currently have a formal advocacy arrangement.
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5.0 Additional Concerns Noted by Inspectors
Nursing Records
Review of nursing records, including care plans, during the inspection,
demonstrated an inconsistent method of needs assessment, risk assessment
and subsequent care plans and management plans. Some plans used a
numbering reference, other plans in the same patient files were numerically
labelled. Identified needs and risks did not always result in a relevant and
appropriate care plan or risk management plan. Records did not include a
date of creation, and some were not signed. Care plans were preprinted
generic documents and had not been personalised. Daily entries included
reference to care plans that were not included in the patient file. There was
limited evidence that patients and/or carers had been involved in the care
planning process. Examples of all of these concerns were discussed with the
ward manager during the inspection. The ward manager was also directed to
NMC guidance on record keeping that includes the following:
• NMC (2007) “The quality of a registered nurse’s record keeping is a
reflection of the standard of professional practice. Good record keeping
is a mark of a skilled and safe practitioner, whilst careless or
incomplete record keeping often highlights wider problems with that
individuals practice.”
• NMC (2010) “Good record keeping is an integral part of nursing and
midwifery practice and is essential to the provision of safe and effective
care. It is not an optional extra to be fitted in if circumstances allow.”
“By auditing records and acting on the results you can assess the
standard of the record keeping and communication. This will allow you
to identify any areas where improvements might be made.”
Concerns in relation to record keeping, assessment of need and appropriate
related care plans, personalisation, consistency, and involvement of patients
and/or relatives had been highlighted at the last inspection.
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5.1 Completion of Works to Waterside 1 and Use of Living Space in
Waterside 3 as Patient Accommodation.
RQIA was informed by the trust that refurbishment of Waterside 1 would
commence 9 March 2012 for a period of six weeks. At the time of the
inspection on 13 and 14 June 2012 the refurbishment works had not been
completed. Concerns in relation to the length of time of the refurbishment and
impact for patients of both Waterside 1 and Waterside 3 were discussed with
the Head of Older People’s Mental Health Services. Assurances were given
that the works would be completed and patients able to move back to
Waterside 1 by 31 July 2012.
The use of a living space to accommodate a patient in Waterside 3 was also
discussed with the head of service and lead nurse for mental health.
Assurances were given that this had been an emergency situation and that it
would not recur.
5.2 Availability of catering resources after hours
Concerns were highlighted by the ward manager that there was a lack of
availability of tea and coffee making facilities, bread, cereals, snacks, cups
and utensils after hours. Discussion of concerns with the catering manager
resolved these issues on the day of the inspection with agreement to ensure
that these items are available and restocked on a daily basis by the catering
team. RQIA will contine to monitor this arrangement.

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
4 - Substantially
Compliant
5 - Compliant
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.
Arrangements for compliance
were demonstrated during the
inspection. However, appropriate
systems for regular monitoring,
review and revision are not yet in
place.
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.
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
In most situations this will result
in a recommendation, or in some
circumstances a
recommendation, being made
within the Inspection Report
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
1
2
3
4
5
6
7
8
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.
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9
10
11
12
13
14
15
16
17
18
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.
Describe how the ward
identifies and manages risks for
individual patients.
Outline the mechanisms used
by the ward to ensure that
vulnerable adults have the right
to take risks in relation
to their care.
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
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19
20
21
22
23
24
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.
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.
17