Archived: Rohan

We found the following concerns that the service provider needed to improve:

• Patients’ living environments contained some ligature points that had not been identified on environmental risk assessments.
• Staff were unable to observe or have two-way communication with patients during episodes of seclusion. This meant staff could not effectively respond to physical health emergencies or incidents of self-harm or accidental injury.
• Staff did not provide patients with ongoing physical health monitoring as identified in their care plans.
• Patients were not currently registered with a GP. This meant they did not have access to NHS health checks, referrals to specialist physical care or regular review of existing physical health medicine. The service had proactively tried to address this without success.
• The service did not utilise input from a clinical psychologist to analyse data on patients’ behaviour and review support plans. However, this had been discussed at a recent multidisciplinary meeting and plans were in place to increase psychological input in this area.
• The service made decisions in patients’ best interests and had systems in place to ensure their finances were managed effectively. However, the documentation surrounding these areas needed to be formalised to safeguard patients and staff.

However, we also found the following areas of good practice:

• Patients were supported in spacious and clean environments by sufficient staffing that ensured their safety.
• Following our comprehensive inspection in November 2015, the service had introduced staff training in the use of the defibrillator. The majority of staff had received this training with additional sessions planned.
• Patients had comprehensive risk assessments that allowed them to safely participate in a range of activities in the hospital and community.
• Staff implemented plans that supported patients in the least restrictive way. At the time of the inspection both patients were not in need of restraint following episodes of aggressive or challenging behaviour.
• Following our comprehensive inspection in November 2015, the service had implemented a contract with a local pharmacy to provide regular audits of medicine management.
• Patients had positive behaviour support plans, care plans and risk management plans that were person centred, detailed and correlated with other plans.
• Following our comprehensive inspection in November 2015, the service had increased their participation in clinical audits in areas such as incident reporting, quality of staff debriefs after incidents and the Mental Health Act.
• The service was well supported by the local learning disability community team. This ensured the patients had access to occupational therapists and speech and language therapists.
• The service had responded positively to findings from a Mental Health Act reviewer visit in February 2017. Patients had been seen by an independent mental health advocate and an action plan had been produced to address gaps in Mental Health Act paperwork.
• Following our comprehensive inspection in November 2015, the service had been collecting feedback from patients and carers via surveys and increased phone calls.
• The provider had comprehensively assessed one patient’s care and support needs for living in the community. This was in line with the Transforming Care agenda which is committed to moving people with learning disabilities and autism out of hospital settings into the community.
• Following our inspection in November 2015, the service had been submitting data to the Mental Health and Learning Disability Data Set.