The Glenside Hospital for Neuro Rehabilitation is operated (since August 2017) by Glenside Manor Healthcare Services Limited. The Glenside Hospital for Neuro Rehabilitation is an independent healthcare organisation which provides different levels of care to patients with an acquired brain injury.

The hospital service is split into two sections, the neuro-rehabilitation unit (NRU), and the neuro-behavioural unit (NBU). NRU includes three wards; Avon, Bourne and Wylye (27 beds total), each one led by a senior clinical nurse and a consultant in rehabilitation medicine and rheumatology. These wards could accommodate patients with complex nursing needs, providing physical and cognitive rehabilitation, tracheostomy management and weaning, and nutritional management. The wards have single rooms with ensuite bathroom facilities, which are used for male or female patients.

The NBU is run as a single 14‐bed service, including two wards Ebble and Nadder, and led by a senior clinical nurse and a consultant in neuropsychiatry. The NBU focuses on neuro behavioural interventions which aim to control, reduce and eliminate challenging behaviour, and admits patients detained under the Mental Health Act 1983.

Based in Salisbury, the hospital serves the South West, and takes referals from across the country. On the same hospital complex there are also seven adult social care services. Each service is registered separately with CQC, which means each site on the main complex has its own inspection report.

While each of the services are registered separately, some of the systems are managed centrally, for example, maintenance, systems to manage and review incidents and systems for managing medicines. Physiotherapy and occupational therapy staff cover the whole complex and all services. Factilities such as the hydrotherapy pool are also shared across the whole complex.

We carried out an unannounced focused inspection on 8 November 2018. The inspection was prompted by whistleblowing concerns and information of concern shared with us through intelligence monitoring and system partners. We looked at some elements of safe, effective and well led, and did not rate the service at this inspection.

At the time of our inspection, the CQC adult social care inspection team were undertaking a comprehensive inspection of social care sites, which provide a range of services to complement the neurorehabilitation and the neuro-behavioural pathways. These will be reported on separately although all reports will share some themes around those systems that are centrally managed.

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

We found areas of practice that require improvement in services for people with long-term conditions:

• The service provided mandatory training in key skills to staff but did not make sure everyone completed and understood it. We were not assured there were adequate systems and processes in place to monitor or evaluate mandatory training, or to follow up areas of low compliance.

• There were not robust systems and processes in place for safeguarding or that all staff understood how to protect patients from abuse.

• Infection risks were managed inconsistently and were not being monitored.

• The environment and maintenance of equipment was not managed safely and placed people at risk.

• Staff did not always complete and update all relevant risk assessments for each patient, or take action to ensure patients were appropriately placed or their physical and rehabilitation needs were fully met. They did not always keep clear records or ask for support when necessary.

• The service did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

• Staff did not always keep accurate records of patients’ care and treatment. Records were not all up to date or truly reflective of the patients’ needs.

• The management of medicines at the hospital was not safe and there were problems with the supply of medicines into the service. There was no clinical pharmacy oversight or service to support medicines management which increased the risk of errors.

• The service did not manage patient safety incidents well. Staff recognised incidents but did not always report them appropriately. Not all incidents were reported or investigated and lessons learned were not shared with the whole team or the wider service.

• The service did not monitor safety effectively or use results well. Staff did not routinely collect safety information across all wards, or share it with staff, patients and visitors. We found no evidence to show managers used this to improve the service.

• The service did not have systems and processes to make sure staff were competent for their roles. Some training in specific skills for roles was provided but managers did not ensure these were attended by all staff.

• Not all staff understood their roles and responsibilities under the Mental Capacity Act 2005 or deprivation of liberty safeguards (DoLS). Patients described as lacking capacity to consent to admission and treatment did not have an assessment of their capacity recorded. Legal processes for detained patients were not adhered to.

• Leaders of the service did not have the right skills and abilities to run a service providing high-quality sustainable care.

• The service did not have a vision for what it wanted to achieve or workable plans to turn it into action. Staff, patients, and local community groups had not been involved in developing a shared vision for the service.

• Managers across the service did not all promote a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

• The service did not systematically improve service quality or safeguard high standards of care by creating an environment for excellent clinical care to flourish.

• The service did not have good systems to identify risks, plan to eliminate or reduce them, or cope with both the expected and unexpected.

• The service did not demonstrate a commitment to improving services by learning from when things went well or wrong, promoting training, research or innovation.

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

• The quality of some nursing care plan updates was of a good standard, and in particular, those of the psychologists were comprehensive.

• Medicines were stored securely in locked cupboards that were accessible only by the key holder or nurse in charge.

  Following the inspection, CQC formally requested under Section 64 of the Health and Social Care Act 2008, to be provided with specified information and documentation by 16 November 2018. We requested further information from the unit manager to be provided by 30 November 2018. We received some of the information requested but not all.

  Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with 22 requirement notices. Details are at the end of the report.

  Full information about our regulatory response to the concerns we have described will be added to a final version of this report, which we will publish in due course.

  Nigel Acheson

  Deputy Chief Inspector of Hospitals

We carried out this inspection in order to follow up concerns about low staffing numbers and the potential effect of this on people's care. Concerns had been raised about care in more than one area of the hospital however the majority of concerns were raised about Pembroke Lodge. On this occasion we only inspected Pembroke Lodge.

We found that staff were caring and the staff we spoke with were able to tell us about individual patients and their needs. We found that while there were very large care plans in place for people, these had not always been updated and it was difficult to find clear information about people's care needs. People's needs were not always updated and there was a lack of information about people's emotional support needs. Medication profiles in people's care plans were not accurate.

Medicines were not kept safely. Supporting information for allergies was inconsistent for two people at the home. Supporting information was not available for creams and ointments, labelled “to be used as directed” or “how a person preferred to take their medicines” when taken by mouth.

Staff were positive about the new manager. We found that there were adequate numbers of staff on the unit however there was high use of agency staff. The provider was actively attempting to recruit new staff.

The provider had identified that governance and quality assurance systems had been inadequate and we saw an action plan in place to address this.

We received information that there was a lack of staff and that staff were not supported, so we looked at these two areas during this review. Patients cared for at Glenside Manor, due to their acquired brain injuries have a difficulty in communication, so we observed their treatment and care and talked to staff.

We observed two staff talking to three patients in a small unit for people with brain injury. All five people were relaxed together, with the three patients being treated as individuals by staff. We did not observe anyone on any of the units showing signs of distress of needing to be supported in the management of their complex behaviours. Each of the units that we went to appeared to be busy, but door bells to units were answered very promptly by staff and as we walked around the units, staff were in evidence supporting people. We observed two therapists supporting a person with a mobility difficulty out in the campus grounds. They encouraged the person in what they were doing and made sure that they were safe.

Staff told us that there had recently been issues relating to both staffing levels and training. Our review showed that the provider is aware of these issues and is making much progress in ensuring that people’s needs are met by sufficient numbers of staff, who have the skills needed, to meet their needs.

We rated The Glenside Hospital for Neuro Rehabilitation as good because:

• Staff involved patients and their families in developing their care plans, and ensured that the patients risk assessment was linked into their care plan. These care plans were holistic and relevant for the patient. The hospital had implemented emotional wellbeing assessments.

• Ward managers could adjust staffing levels to meet the clinical need of patients. The hospital used agency staff that were familiar with the ward and provided service specific training to ensure they could meet patient’s needs. The hospital had taken steps to manage staff turnover and staff morale was high.

• The hospital had a wide variety of healthcare professionals and a wide range of facilities, including ample outdoor space, quiet waiting areas and phones that patients could use in private. Professionals used recognised rating scales to measure patient’s progress and discussed this in multidisciplinary meetings.

• The majority of patients reported that they had received good care and reported positive staff attitudes. We saw that staff were positive and engaging when they spoke with patients. Staff helped to ensure patients had access to activities that were meaningful to them and they took steps to help patients feel comfortable when they were moving between wards in the hospitals. They also helped with patients discharge so that their needs would be met after their stay in hospital.

• There were new clinical leads within the hospital and we saw that they had provided good leadership for staff. The hospitals had some robust governance systems that allowed managers to monitor performance and develop quality improvement plans to help ensure good quality care.

However:

• We found that the rapid tranquilisation (the use of medicines to calm/lightly sedate the patient, reduce the risk to self and/or others and achieve an optimal reduction in agitation and aggression) policy was not always clear, and that staff could not demonstrate that they had completed physical observations following administering the medicines. In response, the hospital quickly changed the policy and issued further training to its staff to ensure compliance with national guidance.

• Systems did not always ensure that relevant information was recorded. For example, that staff recorded that they had conducted physical health checks. Staff on Nadder ward had not logged some checks to say they had recorded the temperature of the medicines fridge.