The Care Quality Commission (CQC) has published a report following a focused inspection of Charlton Lane Centre, part of Gloucestershire Health & Care NHS Foundation Trust.
Charlton Lane Centre provides specialist assessment, treatment and care for older people with functional mental health problems and people with dementia. It has three wards Chestnut, Mulberry and Willow.
CQC carried out an unannounced inspection of these wards in March, after receiving information that raised some concerns about the safety and quality of the service.
Following the inspection, the overall rating for the wards for older people with mental health problems and people with dementia, dropped from good to requires improvement. The ratings for how safe, effective and well-led the service is, also dropped from good to requires improvement. Caring dropped from outstanding to good, while responsive remains good.
Inspectors found the following:
- The service did not always have enough staff to care for patients or keep them safe. All three wards had vacancies and the trust could not always find bank and agency staff to cover shifts.
- Agency staff did not always have access to the trust’s electronic system to enable them to review clinical information and there was no clear process how these staff would input any information to ensure records were up to date with any identified concerns.
- Patients could not always be seen by staff, as there were blind spots on all the wards. Environmental risk assessments did not include reference to these, or any detail of actions taken to manage these risks.
- Although there were systems in place to safely manage medicines, these were not always managed effectively. There were no processes in place for the management of medication applied via a patch attached to the skin (transdermal patches).
- The wards had dedicated female lounges, but these were often used by male patients and visiting family members. On occasion, the female lounges were used as an area for staff to carry out de-escalation techniques, although they did not meet the requirements of the mental health act code of practice.
- Most staff had completed mental capacity act training, but some were unclear about their understanding, application and recording of the Act and how this affected their work with patients.
However, inspectors also found:
- Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
- Staff assessed the risks and needs of patients and acted on them. Staff had training in key skills and understood how to protect patients from abuse.
- The service managed safety incidents well and learned lessons from them.
- Staff participated in the provider’s restrictive interventions reduction programme and followed national guidance for the physical monitoring of patients after the administration of rapid tranquilisation.
- The service followed the John’s Campaign initiative, which advocates for the right of people with dementia to be supported by their carers in hospital.
- Patients had access to a touch screen designed to help them recall and share events from their past.
- The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for patients to give feedback. Patients could access the service when they needed it and did not have to wait too long for treatment.
The report is available on our website.
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