This inspection took place on 18 and 19 April 2016. It was an unannounced visit to the service.

The Royal Buckinghamshire Hospital is a care home with nursing which provides care and treatment for up to fourteen people. At the time of our inspection nine people were living there.

The aim of the service is to rehabilitate people who have suffered a spinal or brain injury. They employ a team of nursing and care staff, physiotherapists, occupational therapists and have a resident medical officer (RMO) on site.

The Royal Buckinghamshire hospital has been renovated and provides accommodation on the first and second floor. The therapy department and administration offices are situated on the ground floor.

In this report the name, of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. At the time of this inspection a new manager was in post and had applied to be registered with the Care Quality Commission.

We previously inspected the service on 5, 6 and 12 November 2014. The service was not meeting the requirements of the regulations at that time. Requirements were made to address our concerns. At this inspection we reviewed the progress made with the requirements from the last inspection. We saw the requirements had been met or were being addressed.

People were assessed prior to admission. A recommendation has been made to improve the way out of hours admissions are managed.

Risk assessments and risk management plans were in place. Accident/ incidents to people were appropriately managed. People’s medicines were handled safely and systems were in place to pick up discrepancies in medicine administration.

People told us they felt safe. Relatives were confident people were safe. Staff were trained in safeguarding and policies and procedures were in place to support safe practice to safeguard people.

People had access to a range of healthcare professionals to promote their rehabilitation. They were actively involved and consulted with on their therapy programme and regular reviews and goal planning meetings took place to monitor their progress. People and their relatives described the therapy provided as “Outstanding, wonderful, second to none and the equipment and facilities as “State of the art”.

A new care plan format had been introduced. These provided guidance for staff on how people were to be supported. People were not actively involved in their care plans and were not encouraged to contribute to them. One person told us the care provided varied and commented “The onus is on me to instruct staff on how I like to be supported”. The provider recognised they still had work to do to provide more person centred care plans.

People felt cared for. Relatives were happy with the care provided. People and their relatives described the care as “Unbelievable and real quality care”. Staff were observed to be kind, caring, enabling and had a good relationship with the people they supported.

Safe staffing levels were maintained and were dependant on people’s needs and dependency levels. Key roles such as ward sisters had recently been introduced to provide clinical leads on shifts. Safe recruitment practices were promoted to ensure staff had the right skills and attributes for the role. Staff were inducted and had received training the provider considered mandatory to their roles. Specialist training was being accessed and provided for staff to increase their knowledge and skills in supporting people with brain and spinal injury.

Staff felt supported although formal supervisions were not taking place regularly and annual appraisals had not yet commenced. The provider was already aware of this and had an action plan in place to address it.

The service was clean, maintained and kept in a safe condition. Plans were in place to refurbish

The Royal Buckinghamshire Hospital is operated by The Royal Buckinghamshire Hospital Limited. It has 22 beds and offers inpatient and outpatient rehabilitation for patients who have a spinal cord injury, acquired brain injury, stroke and other neurological conditions.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced part of the inspection on the 29 August 2018 along with an announced visit to the service on the 5 September 2018.

To get to the heart of patient’s experience 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.

Our rating of this hospital/service went down. We rated it as requires improvement overall.

Our key findings from this inspection were as follows;

• Patients’ risk assessments were not always reviewed regularly and not always consistent in identifying a patient’s level of risk.
• Evidence from the provider’s electronic quality dashboard did not match with the service’s accident and incident tracker. The service could not assure themselves all incidents had been investigated where required.
• The service could not evidence comprehensive systems and auditing processes were in place to identify key risks to service provision ensuring mitigating action had been taken.

However we found areas of good practice;

• Each patient’s physical, mental health and social needs were assessed as a whole. Staff delivered care in line with best practise and the national institute for clinical excellence (NICE) guidelines.
• Patients had access to a range of clinical specialists to support them in their rehabilitation journey and their personal outcome goals
• The new manager was providing strong, recognisable leadership which was valued by staff. They had identified areas for improvement in the working practices and procedures of the hospital since starting at the service and, at the time of the inspection, had already been acting to address these.

We also found areas of outstanding practice:

• We saw an embedded practice of person centred care with staff highly motivated to provide care respectful of patient’s privacy and dignity. Positive relationships were created and nurtured to ensure patients fully engaged with their rehabilitation journey.
• Continuous positive feedback was received and viewed which praised staff for their caring nature.
• Friends and friends important in patient’s lives were actively encouraged and supported to be part of their rehabilitation journey enabling them to continue being involved in the patient’s recovery once discharged from the service.
• The care provided to patients was outstanding, patient’s were supported by staff who had an embedded culture of meeting their emotional and physical needs. Patients were empowered and offered with opportunities to share any emotional concerns they had.
• Staff took the time to develop genuine, warm and respectful relationships with patients to ensure they felt fully supported throughout all aspects of their care and therapy.
• Staff exceeded what was expected of them in their roles to ensure they recognised and took action to ensure patients received highly individualised and compassionate care. Staff went over and above their roles to offer care to patients so they could experience important and significant life events.

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 two requirement notices. Details are at the end of the report.

Amanda Standford

Deputy Chief Inspector of Hospitals (South and London)