Archived: Hunters Moor Neurorehabilitation Centre for the West Midlands - The Olive Carter Unit

This inspection was not rated because it was in response to concerns raised about the care provided to patients. The inspection took place during the Covid 19 pandemic and was a unnounced. We focussed on the on the key questions of caring and well led.

The Olive Carter unit specialises in neurobehavioral rehabilitation for men and women over the age of 18 years with a primary diagnosis of acquired brain injury.

We will add full information about our regulatory response to the concerns we have described to a final version of this report, which we will publish in due course.

• We found that patients were not always treated with kindness and compassion. There had been an incident of physical abuse towards one patient by a member of staff. The provider reported the incident to the police the local safeguarding team and CQC as soon as they became aware of this. In addition, three members of staff have been suspended and the perpetrator has been dismissed. Patients told us that some staff did not communicate with patients and ignored their request for information
• Patients privacy and dignity was not protected all the time. Some bedroom windows did not have privacy films allowing people to be seen in their rooms.
• There was evidence that a night staff slept during the night whilst they should have been awake to monitor and support patients. A member of staff had reported to the unit lead and registered manager that night staff had made up a bed to sleep in. The Registered Manager addressed this at the earliest opportunity and the nurse was suspended and dismissed.
• Patients were not supported to undertake the therapeutic activities designed to aid their rehabilitation by the rehabilitation assistants.
• Some bedrooms and shared bathroom did not have nurse call systems for them to summon help when they needed help.
• There was poor leadership at unit level. No action had been taken in relation to night staff sleeping, commissioners found communications with the unit difficult and the unit leaders had little oversight or robust governance arrangements to monitor activities at the unit.
• There was poor morale amongst staff who did not feel valued or supported

We rated The Olive Carter Unit as requires improvement overall because:

• Fire doors at the service did not have door closures as they were highlighted as a risk to patients and removed by the service. They had not been replaced in a timely manner; this left patients at risk in the event of a fire. We saw that two of the communal toilets within the ward were visibly soiled.

• Although staff had training on percutaneous endoscopic gastrostomy (PEG) feeding there were no protocols in place to support staff when completing the task.

• We saw during our inspection, a patient taken to their room and staff prevented them from leaving by holding on to the door handle. This was contrary to the training provided by the service. There was no specific care plan to support this type of seclusion.

• Mental Health Act training did not form part of the service mandatory training. Staff were provided with ongoing training from consultant psychiatrists on specific staff training days. Staff signed a record of attendance to provide the service with completion rates.

• Risk assessments were not always updated.

• The lift needed to be replaced and was not in use at the time of the inspection. The manager informed us that the service had developed a plan to replace the lift.

• Staff did not always record fridge temperatures accurately.

However;

• The ward was well equipped, well-furnished and fit for purpose. The service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm.

• The ward had a good track record on safety. The service managed patient safety incidents well. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

• Staff assessed the physical and mental health of all patients on admission. They developed individual care plans, which they reviewed regularly through multidisciplinary discussion. Care plans reflected the assessed needs, were personalised, holistic and recovery oriented.

• Staff provided a range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice. This included access to support for self-care and the development of everyday living skills. Staff ensured that patients had good access to physical healthcare and supported patients to live healthier lives.

• Managers made sure they had staff with a range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for new staff.

• Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.

• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team.