We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
Our rating of this service went down. We rated it as requires improvement because:
- There were not enough staff on Cheviot ward to make sure people always had the staff needed to keep them safe and meet their needs. People told us that when the services were short staffed, they could not do their planned activities and therapies.
- Staff did not receive the right training to ensure they had the skills and knowledge to meet people’s needs. At the time of inspection training in learning disabilities, autism and alternative communication methods was not mandatory and a low proportion of staff had completed training in these areas. Three mandatory / essential clinical training courses and overall rates of supervision and appraisals fell below the trust target.
- For one person, staff applied restrictions which were not proportionate to the current level of risk including long term seclusion and access to personal belongings. There was no plan to end the restrictions.
- One person’s care plan did not reflect an arrangement for communication with their multi-disciplinary team. Staff did not always have access to important information so that they could manage risks and meet the person’s needs.
- People were not always being cared for in safe and therapeutic environments suitable for people with learning disabilities and/or autistic people and people with physical disabilities. On Lindisfarne, people in seclusion did not have privacy and dignity as other staff not involved in their care entered the seclusion area regularly. Seclusion rooms were not fit for purpose on three wards. On four wards, people did not have access to a nurse call alarm system. There were issues with regulating noise and temperature on some wards and three wards had accessibility issues due to stairs. The environmental risk assessment for Rose Lodge had not been reviewed regularly and environmental risk assessments did not detail specific locations of ligature anchor points. The trust was building new wards to improve medium secure environments.
- Staff did not always ensure that people’s records contained evidence of their involvement in decisions about their care and treatment. Blanket restriction register did not contain all the restrictions in operation to ensure these were reviewed regularly.
- The use of restrictive interventions was high and there was a high proportion of prone restraint. There was limited evidence of lessons learnt from incidents shared and there was a delay in staff receiving a post-incident debrief on Acorn ward.
- The food ordering system was not person centred as people had to order their food two days in advance. People also told us mistakes happened with meals and this meant they did not always get their food choice.
- Carers told us that they wanted improved communication and involvement in their relative’s care.
- There were issues with nursing assistants and registered nurses not feeling listened to and involved in multi-disciplinary team discussions and decisions made on Mitford Unit which the trust was trying to improve.
- It was not always clear in some people with a learning disabilities’ records the reason why they had been initially prescribed anti-psychotic medicines.
However:
- The service mostly met the principles of ‘Right support, right care and right culture’.
- Staff managed discharge pathways as well as they could, but people stayed in hospital for longer than needed because it was difficult to find the right care and support in the community. This affected the services’ ability to care for new people who needed the service.
- Staff embraced people’s individuality and preferences on how they wished to live their lives. Some people staying in long-term segregation had regular access to leave to go out and had their own workshops for gardening, horticulture and vehicle repairs. Specialist assessments were completed to enable people to be safe and express their preferences.
- People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood each person’s individual needs. Staff had a positive and warm approach to people and their roles.
- People could do the things that they enjoyed than helped them to learn new things, skills and keep well. There were several health improvement initiatives to improve people’s physical health.
- Staff and people participated in research, clinical audits, benchmarking and quality improvement initiatives.
- The service used systems and process to safely prescribe, administer, record and store medicines.
- Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
- Leaders were visible and approachable and worked flexibly to understand the service, support staff and meet people’s needs. Staff felt respected, supported and valued by managers and colleagues.
Background to inspection
Cumbria, Northumberland Tyne and Wear NHS Foundation trust provide mental health, learning disability and neurological care for people across the north of England. The trust also provides some national specialist services.
The trust provides nine wards that provide care to adults with learning disabilities and/or autistic people at Rose Lodge, Carleton Clinic and Northgate Hospital. These locations are registered to provide the following regulated activities:
- Assessment or medical treatment of persons detained under the Mental Health Act 1983.
- Treatment of disease, disorder or injury.
- Diagnostic and screening.
These wards comprised of:
- Rose Lodge – a learning disability and autism specialist assessment and treatment service for up to 10 people based in Hebburn in South Tyneside.
- Acorn – a learning disability assessment and treatment service for up to six people based at the Carleton Clinic in Carlisle.
At Northgate Hospital in Morpeth:
Autism services:
- Mitford Bungalows is comprised of four bungalows. Three bungalows had one bedroom and one bungalow had two bedrooms. Overall, the service can care for up to five people.
- Mitford Unit is a specialist autism inpatient service for up to 15 people.
Low secure and rehabilitation services:
- Tweed comprises of a low secure ward for up to 15 people and a low secure rehabilitation ward for up to eight men with a learning disability.
- Tyne comprises of a mental health low secure care for up to 12 people and a hospital based rehabilitation in an environment suitable for up to 12 people. At the time of our inspection, Tyne hospital based rehabilitation was being used to care for two people. We only visited the hospital based rehabilitation service as part of this inspection.
Medium secure services were based within the Kenneth Day Unit. All three wards are for men with learning disabilities. We visited:
- Lindisfarne which could care for up to 10 people.
- Cheviot which could care for up to eight people.
There was another medium secure ward called Wansbeck which could care for up to six people. At the time of our inspection, the ward was closed to improve staffing levels across the services. This meant that we did not visit the ward as part of this inspection, however we reviewed data about the service and have included this in our report.
This was the first inspection of all these wards. Our last comprehensive inspection of this core services was prior to the opening of some wards and services being acquired from a different provider. In 2020, following a focussed inspection of some of the wards, we issued four requirement notices in relation to breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. These related to:
- Regulation 9 person centred care
- Regulation 12 safe care and treatment
- Regulation 13 safeguarding service users from abuse and improper treatment
- Regulation 17 good governance.
At this inspection, we found that these actions had been met.
In April and May 2022, we completed a focussed inspection of Rose Lodge and issued two requirement notices in relation to breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. These related to:
- Regulation 12 safe care and treatment
- Regulation 18 staffing
At this inspection, we found that the action in relation to physical health monitoring had been met.
What people who use the service say
People using the service provided mostly positive feedback.
Most people told us that they liked the staff that supported them and thought that staff knew them and their needs well. Most people told us that they could do the things they enjoyed that helped them to learn new things and keep well.
However, people also told us that they could not always go out or do the activities they had planned when there was not enough staff. Some people told us that there were issues with mistakes being made with meals which meant sometimes people did not get their choice of food.
Carers provided variable feedback.
Most carers told us that they felt their relative was safe and received support from staff that knew them well. Some carers told us their relative was more settled emotionally since after entering the service. They felt were welcomed by staff into the service when they visited.
However, many carers told us that they wanted to have more contact with their relatives, be more involved in meetings and receive more information from staff about their relative’s progress. Some carers told us that technology was a barrier to being able to attend the meetings they had been invited to.
Some carers told us there were delays in their relatives being able to move on from the service and that they did not think that all staff were sufficiently trained or experienced for their roles.