St Cyril's Rehabilitation Unit is operated by St George’s Care UK Limited.

We undertook this unannounced focused inspection of St Cyril’s Rehabilitation Unit in response to concerns that we identified during a previous inspection on 29 June 2017. As this was a focused inspection we did not rate the service.

We had also carried out an announced inspection of the service on the 1 and 2 of March 2017. Therefore the rating for the provider following a comprehensive inspection in March 2017 remains as inadequate.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was Community Inpatient Services.

We found the following areas for improvement:

• The service had appointed a new hospital manager who was in post on the day of inspection. However, during the inspection period we were informed that the hospital manager had left which meant that the hospital continued to be without a registered manager.
• The hospital management team had monthly meetings with members of the executive team. However, it was unclear from minutes of these meetings what actions had been implemented to make improvements and who was responsible for these.
• The hospital had introduced a system for managing evidence of staff competencies. However, senior staff were not fully aware of these and struggled to provide assurance of the competencies of staff.
• There were a higher number of staff who had completed full competency checks for providing tracheostomy and PEG care since the last inspection, however, these numbers were still low. This meant that we were unsure if there were sufficient numbers of competent staff on shift at all times.
• We found that documentation regarding tracheostomy and PEG care was inconsistent.
• Some improvements had been made with medicines management. However, there were occasions when this was still not carried out in line with hospital policy and required further improvement.

However,

• A new clinical services manager had recently started and a substantive consultant who specialised in neuro-rehabilitation had been appointed, although was yet to start.

• Members of the management team were able to identify the key risks that the hospital currently faced.

• Improvements had been made with the calculation and use of NEWS. Additionally, most patient records that we reviewed had evidence of appropriate escalation taking place when needed.
• Staff rotas indicated that between 1 July 2017 and the time of inspection there had been a senior band 6 nurse on all shifts apart from one to provide leadership.

Following the inspection, we told the provider that they must take some action to comply with the regulations and that they should make other improvements, even where a regulation had not been breached, to help the service improve.

St Cyril's Rehabilitation Unit is operated by St George’s Care UK Limited

We undertook this unannounced focused inspection of St Cyril’s Rehabilitation Unit in response to concerns that were raised with us about the safety and quality of the services provided to patients. This inspection focused on the safety of the services provided and how well led the service was. Where we observed practice in other areas we have included this information in the report. As this was a focused inspection we did not rate the service.

We previously inspected this service using our comprehensive inspection methodology. We carried out the previous announced inspection on 1 and 2 of March 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was Community Inpatient Services.

We found the following areas for improvement:

• Staff did not always recognise, assess and mitigate risks to patients’ safety. This included lack of compliance with the provider’s early warning scoring system. Staff were not always following the provider’s policy for recording and acting on early warning scores.
• Nurse staffing of an appropriate skill mix to provide senior nurse cover was inconsistent. Senior nurses (band 6) were in charge on most shifts but there were an excessive number of shifts, particularly night shifts, where the senior nurse was a band 5.
• The safe management of medicines continued to require improvement. Audits had identified areas for improvement but these had not been addressed and no action had been taken to improve standards.
• The medical cover arrangements were provided on a sessional basis by two consultants from local trusts which did not provide dedicated substantive medical oversight. However, the provider had advertised for a substantive full time consultant. In addition the senior clinical nurse role was vacant, this meant staff were not always able to seek senior clinical nursing advice and support. This also meant that there was a risk of insufficient clinical oversight and challenge within the hospital to recognise and act on areas of poor clinical practice.
• The hospital manager role was vacant and despite temporary cover being provided by a senior member of the corporate team this meant that there was insufficient oversight of the hospital business.

However,

• Staff treated patients with kindness and provided care to patients while maintaining their privacy, dignity and confidentiality.
• Controlled drugs were stored and managed appropriately.
• We found improvements in the way patients individual needs were catered for and considered since the last inspection.

Following the inspection, we told the provider that it must take some action to comply with the regulations and that it should make other improvements, even where a regulation had not been breached, to help the service improve.

When we formally warn a service, or propose action to add or remove a condition, we have to give it time to submit representations to us or appeal to an independent tribunal. We can only publish information about action we've taken when this period has ended.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

At the time of our inspection, we found that patients at St Cyril’s Rehabilitation Unit were receiving timely and appropriate care. Nurse staffing levels were appropriate to meet patient needs. There were periods of understaffing over a number of months however we found evidence that senior managers had taken appropriate steps to try to address this issue. These steps included a recent recruitment program and the increased use of agency staff while recruitment was ongoing. On the evening of our inspection we noted that there were staff members working who were employed by external agencies to address a staffing deficit forpatients who required close observation.

Infection control processes and procedures were in place and medical staffing on the unit was adequate to ensure patients received timely and safe care. Staff were able to access medical advice when they needed to.

We found that records were stored securely and were completed in legible handwriting. However we found examples where a risk assessment had not been fully completed and patient’s early warning scores had not been completed fully. We also noted one occasion where staff completed documentation relating to patient checks retrospectively after telling inspectors that checks had not been undertaken.

All staff including the registered manager and staff from external agencies were aware of how to report and highlight issues of a safeguarding nature. Staff were aware of their responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. We found that that there were occasions when patient’s oral hygiene was not maintained to the standard and frequency set out in their plans of care. Staff treated patients with dignity and respect.

There were a number of audits in place on the unit to monitor and measure the quality of care being provided to patients. There were appropriate governance frameworks in place for the unit and these frameworks were monitored by the director of governance. There were action plans in place to address identified risks. These action plans were current with definable and achievable measures and outcomes.

Staff spoke positively about their leaders and told us that they felt respected and valued. Medical staffing was adequate to ensure patients received timely and appropriate care. Staff were able to access medical advice when they needed to.

We visited St Cryril's to look at how medicines were managed. We spoke with two patients about their medicines and checked the records and medicines of eight people. One patient told us ''This place is lovely, my health has greatly improved since I came here''. Another patient said ''I like living here, they look after me well''.

Overall we found medicines we were handled safely.

We visited this service to look at the way medicines were managed following a scheduled inspection in May 2013.

We spoke with one person who used the service but they could not communicate easily to us their thoughts about how their medicines were handled. We spoke to the staff who were involved in the management of medicines. They explained the work that had been done and the ongoing work to improve the safe handling of medication.

We found that although there were arrangements in place for the safe handling of medicines they were not followed in practice which may have placed patients' health at risk.

Many patients were unable to give either written or verbal consent to their care and treatment and we saw that relatives and health professionals were consulted and best interests meetings had taken place where appropriate and were recorded in people’s care files.

Visitors we spoke with said that they were very satisfied with the care and treatment given to their relative. They would feel able to raise any concerns or complaints they had and they felt confident that issues would be addressed.

Robust recruitment procedures were followed when recruiting new staff and a programme of induction training was in place.

The hospital provided a high standard of accommodation and facilities for rehabilitation.

St Cyril's Rehabilitation Unit is operated by St George Care UK Limited.

We undertook this focussed inspection due to concerns that had been identified through our routine monitoring of services, as well as concerns that had been raised externally with the CQC. We carried out the unannounced inspection on 12 and 13 March 2019.

The main service provided by this hospital was Community Inpatient Services.

We found the following issues that the service provider needs to improve;

• Following our last two inspections of March 2017 and May 2018, we had continued concerns that the service had not used safety monitoring results well. This was because information had not been submitted to NHS Safety Thermometer between January and March 2019. Additionally, we did not see any evidence of patient harms being discussed in minutes of governance meetings that we reviewed.
• The service had not always managed patient safety incidents well. This was because we found that 46 out of 145 incidents that had been reported between October 2018 and March 2019 had not yet been closed. Additionally, we sampled 18 incidents, finding that there was limited documented evidence that action had been taken to reduce the risk of similar incidents happening again.
• Staff had not always understood how to protect patients from abuse. This was because we identified one occasion when it had taken up to two weeks for a safeguarding concern to be raised with the hospital management team. This meant that an investigation into the incident had not been undertaken in a timely manner in order to protect patients from potential abuse.
• Although on most occasions the service had followed best practice when storing medicines, the service had not registered a controlled drugs accountable officer since the previous hospital manager had left in October 2018. This was not in line with the Controlled Drugs (Supervision of Management and Use) Regulations, 2013.
• Although the service had provided mandatory training to staff, records indicated that not all staff had completed this. Records indicated that there were areas of low compliance with training in other areas, include update training for key topics such as continence and catheter care (13%), as well as sepsis and national early warning score (39%).
• Staff had not always kept detailed records of patient’s care and treatment. We identified concerns during our last inspections of March 2017 and May 2018 that information was either difficult to find or was missing. On this inspection we sampled 11 patient records, finding that none had been fully completed.
• Staff had not always updated risk assessments for each patient. We sampled 11 patient records, finding that these had not been fully completed on any occasion.
• During our last inspection in May 2018, we identified concerns that patients would or would not be resuscitated appropriately in the event of an emergency. On this inspection, we identified continued concerns about the completion, review and storage of do not attempt cardiopulmonary resuscitation orders.
• The service had not always provided sufficient numbers of staff with the right qualifications, skills and training to keep people safe from avoidable harm and to provide the right care and treatment.

• The service had not always operated effective recruitment processes to make sure that managers at all levels had the right skills and abilities to run a service providing high quality, sustainable care.
• The service did not always have workable plans identifying improvements that were needed or timeframes in which these were due to be completed. This meant that it was unclear how any required improvements would be implemented in a timely manner and how progress would be measured.
• The service had not used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. Records indicated that governance meetings had not always taken place. For example, monthly hospital governance meetings had not taken place on three out of seven occasions between August 2018 and February 2019. This meant that it was unclear how issues were identified and improvements had been made during these periods.
• The service had not always operated an effective system to identify risks or planned to reduce or eliminate them. This was because records indicated that six out of seven risks that had been recognised had been overdue review since September 2018. Additionally, we found that current risks had not always been identified and managed on the risk management system.

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

• The service had suitable equipment which they had looked after well. We found that improvements had been made since our last inspection of May 2018 to how the hospital made sure that equipment had been serviced in a timely manner.
• The provider who ran the hospital had recruited a new director of nursing who was due to start their employment in April 2019. It was hoped that they would have a key role in providing clear clinical leadership for the service going forward.

Following this inspection, we told the provider that it must take some actions to comply with the regulations. Due to the concerns that we had following the inspection, we issued enforcement action, telling the service that it had to make significant improvements. This is detailed at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North), on behalf of the Chief Inspector of Hospitals