The Caludon Centre in Coventry is a purpose built facility providing inpatient mental health and learning disability services for adults of working age and mental health services for older people.

Sherbourne

Core service provided: Psychiatric Intensive Care Unit

Male/female/mixed: mixed

Capacity: 11

Spencer

Core service provided: Acute Admission

Male/female/mixed: female

Capacity: 14

Beechwood

Core service provided: Acute Admission

Male/female/mixed: mixed

Capacity: 20

Hearsall

Core service provided: Acute Admission

Male/female/mixed: mixed

Capacity: 20

Swanswell

Core service provided: Older People

Male/female/mixed: mixed

Capacity: 22

Quinton

Core service provided: Older People

Male/female/mixed: mixed

Capacity: 16

Gosford

Core service provided: Services for people with learning disabilities and autism

Male/female/mixed: mixed

Capacity: 9

We found a number of inconsistencies across the different services and good practice within wards had not been shared with other wards.

Some wards were regularly short of substantive staff and there was a heavy reliance on bank or agency workers. Some staff did not know the ward routines and as a result, people did not always receive the care they required. There was little continuity of care for individuals. Some staff did not know about the person they were caring for and had not had an opportunity to read the person’s care plan records.

On some wards, staff were not trained specifically to meet people’s needs and this increased risks to both staff and people using the service. Some staff told us that they had direct contact with their managers while others had little face-to-face contact and had not received supervision or attended team meetings.

There was a system for staff to report incidents that were then reviewed and acted on by managers. However, we found that regular incidents had taken place on Quinton ward, but there was nothing to show that learning from these incidents had taken place to prevent them happening again.

We found the Caludon Centre did not always adhere to the Mental Health Act’s Codes of Practice. Some records did not show that people had been told about their rights under the Mental Health Act which could have impacted on their understanding of how to appeal against their detention and how to obtain the services of an independent Mental Health Advocate to support them.

Some wards were better managed than others and on those wards, there was a lack of support for ward staff.

A risk assessment process was in place; however much of the documentation seen in people’s personal files was incomplete to demonstrate personal risk and been considered. We were told that the doors in place were specially commissioned doors to be ‘anti- ligature’ but the closure was visible when the door was open.

On some wards, people had detailed care plans that showed staff how they should be supported and we saw they were involved in these. Other records were unclear and had not been updated regularly. This meant that staff might not know how to support people to reduce risk and meet their needs.

On some wards, staff worked with the team of professionals involved in each person’s care to ensure that all their needs were met. Staff worked with other providers so that when the person was discharged they received the support they needed.

In outpatients, doctors talked with people and gave them, and others involved in their care, opportunities to raise and discuss issues. The doctors responded to these issues, such as side effects relating to medication.

There was the potential of a risk of harm for the people on Quinton Ward which had a number of breaches in regulations. We had sufficient serious concerns regarding Quinton Ward to issue a Warning Notice regarding this ward. The trust sent us an action plan following the inspection to detail how they were planning to implement improvements. We undertook a follow up inspection in July 2014 and found the trust had taken action to improve the outcomes for people on this ward. We found that the trust had responded and that the ward was much improved with sufficient improvement to remove the warning notice. Details of this visit and our findings can be found within the Older People section of this report.