Name of CQC registered
location Location ID Name of service (e.g. ward/unit/team) Postcodeof
service (ward/ unit/ team)
Gisburn Lodge RJX51 Gisburn Lodge BB7 4HX
Calderstones RJX04 1 Woodview 2 Woodview 3 Woodview 1 West Drive 2 West Drive 4 West Drive 1 Maplewood 2 Maplewood 3 Maplewood BB7 9PE
Calder
Calderst
stones
ones PPartner
artnership
ship
NHS
NHS FFoundation
oundation TTrust
rust
LLong
ong st
stay
ay//ffor
orensic/
ensic/secur
securee
ser
servic
vices
es
Quality Report
Mitton Road
Whalley
Clitheroe
Lancashire
BB7 9PE
Tel: 01254 822121
Our judgement is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by Calderstones Partnership NHS Foundation Trust and these are brought together to inform our overall judgement of Calderstones Partnership NHS Foundation Trust.
Mental Health Act responsibilities and Mental
Capacity Act / Deprivation of Liberty Safeguards
We include our assessment of the provider’s compliance with the Mental Health Act and Mental Capacity Act in our overall inspection of the core service.
We do not give a rating for Mental Health Act or Mental Capacity Act; however we do use our findings to determine the overall rating for the service.
Further information about findings in relation to the Mental Health Act and Mental Capacity Act can be found later in this report.
Contents
Page
Summary of this inspection
Overall summary
4
The five questions we ask about the service and what we found
5
Background to the service
13
Our inspection team
13
Why we carried out this inspection 13
How we carried out this inspection 14
What people who use the provider's services say
14
Good practice
14
Areas for improvement 15
Detailed findings from this inspection
Locations inspected
16
Mental Health Act responsibilities 16
Mental Capacity Act and Deprivation of Liberty Safeguards 17
Findings by our five questions 18
Summary of findings
Overallsummary
The people who are resident on the forensic wards have complex needs and require highly specialised care. All are detained in hospital under the Mental Health Act and a high proportion (31%) of the total patient population are subject to a restriction order.
The condition of some of the wards was very poor. We visited wards that were dirty, where there were no cleaning schedules and which did not have effective infection control procedures. The design and layout of some of the seclusion rooms did not meet modern standards and were not conducive to the delivery of safe or dignified care. A number of wards had potential ligature points in areas to which patients had unsupervised access.
There had been frequent episodes of both restraint and seclusion in the six months prior to the inspection visit; including 479 episodes in the prone (face-down) position. We found records for one episode of restraint on 1
Maplewood where a patient had been restrained in the prone position using leg straps, despite their care record stating that this form of restraint had proven ineffective for that person. Staff in the low secure units did not always complete the seclusion room records fully. The quality of medicines management was patchy. Staff undertook thorough and comprehensive, multi-disciplinary assessments of the physical and mental health needs of patients and of risks, and the care plans that we reviewed were centred on the needs of the
individual and demonstrated a knowledge of current good practice. At the time of the inspection, the wards had started to introduce user-led, recovery- focussed approaches to assessment and care that captured details of the person’s care needs, strengths, future wishes, advanced statements and decisions. The staff were also introducing measurement of status and outcomes as part of routine practice.
We found many instances of failure to meet the requirements of the Mental Health Act. This is of particular concern given that all of the patients in the forensic services at Calderstones are detained. From the care records we reviewed, staff recognised and
responded to mental capacity issues appropriately regarding consent.
There were blanket restrictions in place in the low secure units that were neither in line with the MHA Code of Practice nor consistent with a recovery-oriented model of rehabilitation.
The clinical teams held regular care programme approach meetings at which discharge was discussed. Also, the forensic services had defined a care pathway that involved patients moving from a medium secure unit to a low secure unit to a step-down ward before being discharged. However, staff told us that there were sometimes delays caused by difficulty in discharging people from the step-down units due to a lack of availability of appropriate accommodation.
Thefivequestionsweaskabouttheserviceandwhatwefound
Are services safe?
Safe and clean ward environments
• A number of ward areas were dirty. In particular:
▪ the general ward environment at Woodview was dirty and a seclusion room had saliva on the windows and a soiled and dirty toilet,
▪ the seclusion room at West Drive 4 was unclean and had a pool of dirty water in the toilet area (although we were told that this seclusion room had been decommissioned, people continued to use the shower),
▪ West Drive 2 ward was dirty,
▪ at Gisburn Lodge, the kitchen was unclean.
• There were concerns about the prevention and control of infection including:
▪ a lack of infection control audits at ward level, ▪ a lack of cleaning schedules on some wards,
▪ no hand washing facilities in areas where medicines were dispensed,
▪ incorrect labelling and use of sharps containers.
• There were potential ligature points in rooms to which people who use services had unsupervised access at Gisburn Lodge, Woodview and West Drive.
• The design and layout of some seclusion rooms were not fit for purpose:
▪ a seclusion room at Gisburn Lodge had a narrow door and a blind spot in the wet area,
▪ a seclusion room at 4 West Drive had no clock that was visible, no light dimmer switch and no control for the heating,
▪ the seclusion room at 1 Maplewood had no toilet (staff told us that if a person was very disturbed they would have to use the floor as a toilet), the air conditioning did not work on the day we visited and the inside of the room could be observed from the main corridor to the ward.
• The first-aid kit on 2 West Drive was kept in a bookcase on a corridor with no signage to inform staff of this. The items in the first aid kit were not stored correctly or were out of date. This included a penlight that did not work, an airway that was out of date and a mask that was stored uncovered in the emergency bag.
Staffing levels
• Ward Managers used a system which identified staffing levels on all wards across the service which helped to identify and cover shortfalls.
• Due to staff vacancies, the trust used agency and bank nurses to cover some shifts and to increase staff levels temporarily when required. Whenever possible managers deployed agency and bank workers to wards with which they were familiar. • Despite these actions, people at Woodview, Maplewood and
West Drive told us that they had had escorted leave cancelled due to there being insufficient staff.
Assessing and managing risk
• All care records that we reviewed contained a ‘historical clinical risk management-20 (HCR 20)’ risk assessment which assessed the risk of violence to self and others. These were updated on a regular basis and in response to incidents.
• Risk assessments were reflected in care plans and we saw evidence both of patient involvement in advanced planning around risk and of creative use of less restrictive interventions. • Despite the good risk assessments, there had been frequent
episodes of both restraint (1661 episodes) and seclusion (333 episodes) in the six months prior to the inspection visit.
• 479 of the restraints were recorded as having been in the prone (face-down) position.
• Staff in the low secure units did not always complete the seclusion room records fully.
• One patient at 1 Maplewood had been restrained in the prone position using leg straps despite their care record stating that this form of restraint had proven ineffective for that person. • A person on 1 Maplewood had defaecated on the floor of the
seclusion room and the floor had not been cleaned during the six-hour period of the seclusion.
• The quality of local medicines management was patchy. Despite the trust having conducted several medication audits, we found:
▪ out of date medicines for intramuscular injection, dating from 2013 and June 2014, on 1 and 3 Woodview,
▪ syringes and saline solution for injections which were out of date by several years on 4 West Drive,
▪ that the medication cupboard, which included the controlled drugs cupboard, was in the kitchen of 4 West Drive.
Reporting incidents and learning when things go wrong
• Clinical staff were aware of and used the trust system for reporting incidents.
• Staff were aware of the safeguarding procedures and told us that they would have no hesitation in escalating concerns to their managers.
Are services effective?
Assessment of needs and planning of care
• All care plans that we reviewed contained detailed pre-admission assessments that had identified people’s social, psychological, physical, cultural, spiritual and emotional needs. • Positive behavioural support plans had recently been
introduced. We saw some examples of these that included advanced decisions about how people wanted their care to be managed when they became distressed; including the use of restraint or seclusion.
• Each person had a relapse prevention plan providing specific details of interventions, which should be put in place if the person’s mental health deteriorated, to prevent a relapse of their illness.
• The trust had met its own target of completing 90% of psychological assessments within 12 weeks of people being admitted to the service.
Best practice in treatment and care
• The care plans that we reviewed were centred on the needs of the individual and demonstrated a knowledge of current good practice.
• The wards were at various stages of implementing, ‘my shared pathway’, ‘my support plan’ and the ‘recovery star’
documentation. These tools were user-led, recovery- focussed approaches that capture details of the person’s care needs, strengths, future wishes, advanced statements and decisions. • Staff monitored status and outcomes through use of a range of
assessment tools. These included Health of the Nation Outcome Scale (HoNOS), Model of Human Occupational Screening Tool (MOHOST), the Recovery Star and a number of specific psychological assessments. However; we found the wards were at different stages of fully embedding some of these in practice.
• Most people told us that they felt they were making positive progress and were very happy with the care and treatment they were receiving. However, several patients in the medium secure units told us that they wanted more opportunity for
rehabilitation to prepare them for stepping down to a low secure facility.
• There was good evidence that people’s physical health needs were being met. The service had a health centre within the hospital grounds. People could access the centre to see a nurse or general practitioner if they had any physical health issues. • People had opportunities for therapy, recreation and relaxation. • Animal assisted therapy was available to all patients. Those
that had participated spoke positively about its benefits.
Skilled staff to deliver care
• The training records we saw showed that staff had access to a range of training relevant to their role in addition to mandatory training requirements.
• The electronic staff records that we reviewed were up to date.
Multi-disciplinary and inter-agency team work
• Care and treatment was delivered through a multi-disciplinary team that included social workers, occupational therapists, psychologists, speech and language therapists and medical and nursing staff.
• Workers from these disciplines attended ward rounds and annual CPA meetings regularly and were actively involved in people’s treatment and care.
Adherence to the Mental Health Act (MHA) and the MHA Code of Practice
• We found instances of where staff were not adhering to the requirements of the Mental Health Act.
• We could not find copies of MHA section papers in the care records of some patients.
• Some patient information leaflets were out of date and did not incorporate amendments to the MHA made in 2007.
• Staff had not given some people a copy of their section 117 leave form and sometimes section 117 leave was given that did not conform to the conditions.
• We found T2 (certificate of consent to treatment) and T3 (certificate of second opinion) forms that were out of date, incorrectly stored or not followed.
Good practice in applying the Mental Capacity Act (MCA)
• From the care records we reviewed, staff recognised and responded to mental capacity issues appropriately regarding consent.
• Within the medium secure services, we found that assessment of people’s capacity was completed for all patients using a template that took into account the four criteria for the determination of capacity.
Are services caring?
Kindness, dignity, respect and support
• The great majority of people who use services that we talked to, or who completed comment cards, told us that they were treated kindly and respectfully by staff. The care interactions that we observed supported this.
• We observed staff knocking on the doors of bedrooms before entering.
• We observed staff responding compassionately to people experiencing emotional distress in a timely and appropriate way.
The involvement of people in the care they receive
• The staff had started to introduce more person-centred approaches to the planning and delivery of care. • Overall, people were offered the opportunity to be fully
involved in all aspects of their care and treatment. This was facilitated by the ‘my ward round- things to talk about’ document that supported people to express their needs and wishes.
• However, most of the care plans we saw were not in an easy read format and most people did not have a copy of their care plan.
• All wards had community meetings.
• Patients were involved in the wider management of the ward or trust. This included as members of a media club, as
contributors to a user led newsletter, in the recruitment of new staff and as representatives on project groups.
• The service had an on-site advocacy service which people could also access. The majority of people we spoke with were aware of the service and how they could access it.
Are services responsive to people's needs?
Access, discharge and bed management
• 43% of the patients in the forensic services had been at Calderstones for more than five years.
• The service had a care pathway that enabled patients to transfer between medium secure, low secure and step-down services based upon their individual risks and needs.
• Staff told us that delays in discharging people sometimes resulted in the pathway being blocked due to beds in lower dependency settings being full.
• Care programme approach meetings, at which discharge planning is discussed with staff from local services, took place
Ward environments that optimise recovery, comfort and dignity
• Facilities on-site which people from all the wards could access dependent upon their risk assessment and care plan. These included a gym, all-weather pitch and football field, art room, gardening, private meeting rooms, a child visiting room, a multi faith room and assessment kitchens.
• Most wards gave people had access to outside space that was sheltered from view; although the garden at Maplewood 1 was poorly maintained.
• At Woodview, internal doors and external windows in
communal areas, quiet rooms, bedrooms and corridors could be overlooked by people using the external garden or
recreational areas. There was no privacy screening on any of these windows. Although one of the panels looking into the female accommodation on Woodview 1 had been fitted with a frosted screen, men on an adjacent ward could still look into the ward.
• None of the wards had a phone to which patients had easy access. Staff told us that people could use a portable
telephone unit, which could be taken into the ward area or use a cordless telephone to make/receive calls dependent upon personal restrictions.
Ward policies and procedures minimise restrictions
• In the low secure units, staff subjected all patients to a pat-down search upon return from unescorted leave. This practice was not based on an individual assessment of the risk posed by each person. Staff told us that consenting to this search was a condition of patients being allowed leave. We considered that this practice constituted a ‘blanket policy’ and was not in line with the MHA Code of Practice.
• The practice of searching people’s rooms and property in the low secure services was not based on an assessment of the individual’s clinical risk. One person on 1 West Drive told us, “I feel abused and neglected by staff who enter my bedroom once a week and search my room and remove my clothes because they say they are soiled.”
Meeting the needs of all people who use the service
• People’s religious beliefs were supported through access to the multi faith rooms available on the different sites or through visits from spiritual leaders at their request. Religious calendars recording all the important dates and festivals of the various religions were displayed in the wards.
• People had access to interpreting and on site advocacy services if necessary.
• Written information that enabled people to understand their care was available across the service. This included information in different accessible formats.
Listening to and learning from concerns and complaints
• Staff provided people with information about how they could raise complaints or concerns about the ward they were staying on.
• Overall, people told us they felt able to raise any concerns they may have with staff and had confidence they would be listened to.
• One person told us that, when they had not been satisfied with the response to a complaint they had made, the chief executive had visited them to discuss the complaint and it was then resolved to their satisfaction.
• The wards actively sought feedback from people through the use of a suggestion box and regular community meetings. Ward meetings had a set agenda which included complaints and feedback. Minutes of the meetings were available for people to look at on the ward.
• Staff described changes that the wards had made in response to feedback from people who used the service.
• The provider had a complaints system which could monitor trends across wards.
Are services well-led?
Vision and values
• We saw copies of the trust values displayed on the wards.
Good governance
• Findings in the other domains show that some of the governance arrangements were not fully effective. This is demonstrated by:
▪ a failure to maintain clean ward environments,
▪ a failure to fully implement infection control procedures, ▪ patchy medicines management procedures,
▪ poor adherence to the requirement of the Mental Health Act. • Some aspects of governance were working better; including:
▪ procedures for receiving, investigating and acting on complaints from people who use services,
▪ procedures for reporting and analysing incidents,
▪ systems for monitoring the provision of mandatory training.
• Ward managers attended a weekly service development meeting with their manager which was the conduit for considering the trust’s strategic plan.
• There was a mixed picture for staff appraisal. Whereas 90% and 100% of consultants and specialty doctors respectively had been appraised at the correct time, the figure for other staff at Band 7 and above was 76% and for staff at Band 6 and below was 70%.
Leadership, morale and staff engagement
• All of the staff that we talked to told us that they were proud to work for the trust and felt supported by their managers • Front-line staff reported that the executive team were visible
and approachable and that they felt there were effective two-way channels of information between the ward and the board. • Ward managers attended a weekly service development
meeting,
Commitment to quality improvement and innovation
• The low and medium secure units all participate in the Royal College of Psychiatrists’ quality network for forensic mental health services; which facilitates standards-based self and peer-review assessments. Participating services are required to produce an action plan to address standards that are not met. • Although performance data was gathered at trust level this was
not always fed back to ward based staff.
Backgroundtotheservice
Calderstones Partnership NHS Foundation Trust provides care and treatment for people with learning disability or autism aged 18 to 65 years.
The trust aims to work directly with people to assist them in reaching their maximum potential and to prepare them for return to community living. The services offer a range of functions, including recovery, rehabilitation and planning for discharge on individual and specific group treatment programmes.
The forensic service has six low secure and three medium secure inpatient wards at the trust headquarters site at Calderstones. A further medium secure service is provided at Gisburn Lodge hospital.
The wards provide care and treatment for adults aged 18 to 65 years old who are detained under the Mental Health Act. People admitted to the service have a history of offending, have been assessed as having the potential to offend or by their actions and behaviour place
themselves or others at significant risk.
The service consists of the following low secure wards for people with a learning disability:
• 1 Maplewood - 24 bed female ward • 2 Maplewood - 16 bed male ward
• 3 Maplewood - 16 bed male ward for people with a personality disorder
• 1 West Drive - 10 bed male ward • 2 West Drive - 14 bed male ward
• 4 West Drive - 16 bed male ward for people who have a personality disorder or autism.
The trust also has four medium secure wards: • Gisburn Lodge - 16 bed male service
• 1 Woodview - 12 bed male unit divided into 2 six-bedded flats
• 2 Woodview - 12 bed male units divided into 2 six-bedded flats
• 3 Woodview - 12 bed female and male units divided into 2-six bedded flats; separate female and male flat. We reviewed the Mental Health Act 1983 monitoring visit reports and previous Care Quality Commission inspection reports for these services and the subsequent action plan response provided by the trust. These helped to inform our inspection plan.
Ourinspectionteam
Our inspection team was led by:
Chair: Professor The Baroness Sheila Hollins
Team Leader: Nicholas Smith, Care Quality Commission The team included CQC inspectors and a variety of specialists including learning disability and forensic
consultant psychiatrists, learning disability nurses, social workers, Mental Health Act Commissioners, clinical psychologists, patient ‘experts by experience’, a family carer ‘expert’; a pharmacist and social workers including approved mental health professionals (AMHP's).
Whywecarriedoutthisinspection
We inspected this provider in the second wave of our new comprehensive mental health inspection programme. We selected this trust to review as they are the single
specialist learning disability trust in England.
Howwecarriedoutthisinspection
To get to the heart of people who use services’ experience of care, we always ask the following five questions of every service and provider:
• Is it safe? • Is it effective? • Is it caring?
• Is it responsive to people’s needs? • Is it well-led?
Before visiting we reviewed a range of information we held about the provider and asked other organisations to share what they knew. We carried out an announced visit from 8 to 11 July 2014. During the visit we held focus groups with a range of staff, such as nurses and doctors. We talked with people who used services who shared
their views and experiences. We talked with staff at each location. We observed how people were being cared for and talked with carers and family members. We reviewed care and treatment records.
We visited all of the forensic wards.
We spoke with 40 people using the service and joined focus groups and patient meetings at both locations and spoke with 40 staff. Also we attended 5 handover
meetings, 4 multi-disciplinary team and 4 Care Programme Approach meetings.
This inspection also allowed CQC to test tools and methodologies that had been developed for inspecting and reviewing services for people with a learning disability and autistic spectrum disorders.
Whatpeoplewhousetheprovider'sservicessay
Those people we met told us that staff treated them with respect, care, privacy and dignity, with many positive comments about staff attitude and that staff were approachable.
People told us that the staff provided them with the support they needed and that they were happy and involved with their care and treatment and that they attended the multi-disciplinary team meetings that discussed their care.
We were told by the people that we met with that they were aware of how to complain and felt comfortable doing so. They were supported to access the community, but there were not always staff to facilitate this.
People explained to us how they would move on from the service and they received support with this.
Some people told us they did not feel comfortable forming relationships with agency staff as they did not know them as well as regular staff.
Goodpractice
We found that the physical health monitoring system in place at Gisburn Lodge was good. There were
arrangements in place for a local General Practitioner (GP) practice to be contracted to review reported health issues and there was regular availability of an advanced nurse practitioner to visit the Gisburn Lodge site to do diagnostic tests and take blood for health and medicine monitoring.
Due to the remoteness of the Gisburn site, the unit had a telemetric system for Electrocardiograms (ECG). This could be linked to the diagnostic centre via the telephone. This meant the tests were instantly read by cardiologists and feedback was provided depending on the urgency of the results. Hard copies were then scanned in the notes. Blood results were accessible through the health centre and then copied onto peoples electronic records.
Areasforimprovement
Action the provider MUST or SHOULD take to
improve
Action the provider MUST take to improve
• The trust must ensure that there are systems in place to improve practice and adherence to cleanliness and infection control.
• The trust must ensure that there is improvement in practices and adherence to food labelling, fridge temperature monitoring and the maintenance of equipment.
• The trust must ensure that there is improvement in practice around storage of refrigerated medicines and disposals of sharps.
• The trust must ensure that there is effective quality monitoring of the systems designed to manage risks to the health, welfare and safety of people using the service and any others who may be at risk from those risks.
• The trust must ensure that staff adhere to their responsibilities under the Mental Health Act 1983 and follow the Code of Practice.
• The trust must ensure staff adhere to the trusts policy regarding the use of mechanical restraint and ensure all staff on wards are suitably trained including agency and bank staff.
• The trust must ensure emergency equipment on the wards is checked to ensure it is current, working and correctly labelled so all staff can access it quickly in an emergency.
Action the provider SHOULD take to improve
• The trust should review the systems currently in place for administering medication from kitchen areas. • The trust should review the physical environment of
the seclusion rooms to ensure that the privacy and dignity of people is maintained and protected. • The trust should ensure that the searching of people
and their bedrooms within low secure services is compliant with the MHA Code of Practice and based on individual risk assessment.
• The trust should ensure that all ligature risk
assessments are reviewed to make sure there are no ligature points where people are unobserved. • The trust should ensure that people's access to the
internet and to personal telephone calls is consistent and is in line with their assessment and care plan, as opposed to meeting service needs.
Locationsinspected
Name of service (e.g. ward/unit/team) Name of CQC registered location
1 Maplewood 2 Maplewood 3 Maplewood 1 West Drive 2 West Drive 5 West Drive 1 West Drive 2 West Drive 3 West Drive
Calderstones Partnership NHS Foundation Trust
Guisburn Lodge Guisburn Lodge
MentalHealthActresponsibilities
We do not rate responsibilities under the Mental Health Act (MHA) 1983. We use our findings as a determiner in reaching an overall judgement about the Provider.
People were detained under the Mental Health Act 1983 on each of the wards; we reviewed patient records and spoke with staff.
A second opinion appointed doctor (SOAD) had seen patients who had been prescribed treatment without their consent, as they lacked mental capacity to do so or had refused, in each case this was appropriate.
We saw patients had access to an Independent Mental Health Advocate (IMHA) and had accessed mental health tribunals to request their detention be ceased.
There were instances where the MHA 1983 Code of Practice was not being robustly adhered to within low secure services, which were:
• Staff were unable to find current information leaflets relating to patients’ rights, the leaflets they provided were dated 1994 and clearly did not reflect
amendments to the Act from 2007
• People often could not take section 17 leave due to lack of staff to escort them.
Calderstones Partnership NHS Foundation Trust
LLong
ong st
stay
ay//ffor
orensic/
ensic/secur
securee
ser
servic
vices
es
• Copies of section papers could not be found in some electronic records
• Out of date section 58 authorisation stored with the current authorisation
• People were not usually provided with a copy of their section 17 leave form
• The condition for section 17 leave was not always linked to the actual leave being authorised.
• We found evidence that capacity assessments
completed by previous Responsible Clinicians and four years old were recorded as the latest capacity test in some recent ward round notes
• Mental capacity assessments were not documented in all records we reviewed.
• Recording by statutory consultees was not found on all files
• We found T2 (certificate of consent to treatment) forms that had been completed by a previous responsible clinician.
• One patient had been given medication not authorised on a T3 (certificate of second opinion) form
• In one record, we found both a T2 (certificate of consent to treatment) and T3 (certificate of second opinion) forms, it was not possible to determine under what authority treatment was been given
• We found one form T3 (certificate of second opinion) was not stored with the medication chart.
• The non-attendance of doctors to people in seclusion was outside of the expectations of the Code of Practice. • The use of restraint practices did not accord with the
requirements
MentalCapacityActandDeprivationofLibertySafeguards
We found some evidence that mental capacity was
considered by staff. The physical health nurse advised that a multi-disciplinary team would be informed and hold a best interests meeting if someone lacked the mental capacity to give consent to treatment.
From the care records we reviewed, staff recognised and responded to mental capacity issues appropriately regarding consent.
Within the medium secure services, we found that assessment of people’s capacity was completed for all patients using a template that took into account the four criteria for the determination of capacity. For people who were on a T2 (certificate of consent to treatment), their capacity was recorded on the weekly case notes.
Detailed findings
* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse
Summary of findings
People were detained under the Mental Health Act 1983 on all wards; we reviewed patient records and spoke with staff.
A second opinion appointed doctor (SOAD) had seen patients who had been prescribed treatment without their consent, as they lacked mental capacity to do so or had refused, in each case this was appropriate.
We saw patients had access to an Independent Mental Health Advocate (IMHA) and had accessed mental health tribunals to request their detention be ceased. There were instances where the MHA 1983 Code of Practice was not being robustly adhered to within low secure services, which were:
• Staff were unable to find current information leaflets relating to patients’ rights, the leaflets they provided were dated 1994 and clearly did not reflect
amendments to the Act from 2007
• People often could not take section 17 leave due to lack of staff to escort them.
• Copies of section papers could not be found in some electronic records.
• Out of date section 58 authorisation stored with the current authorisation.
• People were not usually provided with a copy of their section 17 leave form.
• The condition for section 17 leave was not always linked to the actual leave being authorised. • We found evidence that capacity assessments
completed by previous Responsible Clinicians and four years old were recorded as the latest capacity test in some recent ward round notes.
• Mental capacity assessments were not documented in all records we reviewed.
• Recording by statutory consultees was not found on all files.
• We found T2 forms that had been completed by a previous responsible clinician.
• One patient had been given medication not authorised on a T3 form.
• In one record, we found both a T2 and T3 form, it was not possible to determine under what authority treatment was been given.
• We found one form T3 was not stored with the medication chart.
• We found one patient was prescribed and administered medication outside of the form T3 authorisation.
• The non-attendance of doctors to people in seclusion was outside of the expectations of the Code of Practice.
• The use of restraint practices did not accord with the requirements.
Our findings
Gisburn Lodge
Safe and clean ward environment
We found that the fridge in the therapy kitchen at Gisburn Lodge was running above the maximum operating
temperature. The food stored in fridges had no use by date. We found that the kitchen was not clean.
We observed that staff were re-using tea towels rather than disposable kitchen roll, increasing risk of cross infection. We found that the slop hopper stored in the cleaning cupboard was dirty and there was no hand wash sink in this storage space.
The podiatrist visited whilst we were there and single use items were used, however the treatment was conducted in a non- clinical area in a carpeted room with no available hand washing facilities.
We noted the following in the seclusion facilities:
Are services safe?
• The door leading to the seclusion room was too narrow. Staff would be forced to enter the room sideways if restraining someone, leading to a reduction in the control over restraint which could result in injury to the restrained person. There was an additional risk to staff of assault within a confined space.
• There was a blind spot in the wet area where it is not possible for staff to observe the person
• A large mattress occupied much of the floor space • Staff described how they were able to restrain people in
the prone position on the mattress and then disengage to leave the person in the seclusion room; the large mattress and limited space potentially limits staff ability to exit quickly and leaves them vulnerable to assault. The quiet room was located near to the seclusion room and this was used to de-escalate potential seclusion situations and when a person was showing distress. This arrangement was a less restrictive alternative to seclusion and the approach had reduced the need to place some people in seclusion.
The basin in the toilet and exposed pipework had ligature points. In the sensory room on Woodview we noted a similar basin in place and hairdressing sink with an
expandable hose. The deputy managers were aware of the basins and we were given assurance they would be
replaced, however staff were not aware of the risk of exposed pipework. Staff informed us the basins were not a risk as people were not allowed to use the sensory room without staff supervision.
Safe staffing
Staff reported some staffing level challenges due to the remoteness of the unit and the lack of immediate support from the Calderstones hospital site.
Assessing and managing risk to patients and staff
Staff told us they used the least restrictive option when delivering care and that seclusion was a last resort and for the minimum time necessary. They gave an example of a person requiring seclusion at the main Calderstones site following a serious incident to ensure they received
additional care to manage risks, the person was returned to Gisburn Lodge following the incident. This was
documented and the risk of the patient remaining at Gisburn lodge was discussed with the responsible clinician with the decision to move the person temporarily based on
One member of bank staff confirmed they had not received the advanced restraint training and showed us a physical hold which depended upon pain compliance.
Reporting incidents and learning from when things
go wrong
There is no additional comment for Gisburn Lodge under this sub-heading, all findings in overall summary apply.
Woodview
Safe and clean ward environment
We found food kept in fridges at Woodview had no use by date.
We saw on Woodview 1 that the laundry area was used to store a staff member’s bike and numerous pairs of shoes belonging to staff that they changed into when on duty. On West Drive 2 we found the ward environment was
extremely dirty. We were told that the ward is due to move to another location on 14 July 2014.
In one seclusion room at Woodview there was saliva on an interior window and the toilet was soiled and dirty from the previous occupant. We asked the ward manager to attend to this matter immediately, after two hours the seclusion room had not been cleaned. We visited the following day and it was clean.
On Woodview 1, 2 and 3 we found the seclusion rooms had a fixed seat described by staff as a ‘door stop’; this could be used by people to access the window ledge and meant people could propel themselves onto the floor causing injury.
We raised these issues with the trust during our visit. They informed us there were plans in place to refurbish the seclusion rooms this year which will include the removal of the ligature risks.
Internal doors and external windows in communal areas, quiet rooms, bedrooms and corridors could be overlooked by people using the external garden or recreational areas, walking around the perimeter or looking through internal doors between the flat areas within wards. There was no privacy screening on any of these windows. One of the panels looking into the female accommodation on
Woodview 1had been fitted with a frosted screen but males on an adjacent ward could still look into the ward. One person told us they were intimidated by a person on an
Are services safe?
mouthed obscenities at them through the glass. People’s privacy and dignity was not being maintained and there was a risk of people being intimidated, bullied or harassed as a result. We raised this issue with the ward manager. In the sensory room on the Woodview unit we noted a basin in place and a hairdressing sink with expandable hose which posed a ligature risk.
At 3 Woodview a staff member described how someone was given their insulin injection over the stable door, which was not a safe or dignified procedure.
Safe staffing
People on 1, 2 and 3 Woodview, Maplewood 1 and West Drive 2 told us their leave had been cancelled due to staff shortages and the lack of available staff to escort as required under their section 17 leave authorisations. Staff reported some staffing challenges at 1 Woodview, recruitment of staff following staff leaving the service and at 2 and 3 Woodview due to staff being seconded to other roles.
On Woodview 1, 2, and 3 some people told us there was not enough staff on duty during the evening to support them to attend the onsite social club as often as they wanted to.
Assessing and managing risk to patients and staff
We witnessed staff managing an incident on Woodview 2 with someone who became distressed and threatening towards others, this was managed efficiently and with dignity for the person. Staff remained calm and there was a positive outcome with the person needing short term physical intervention until they had calmed and assured staff they were safe.
The trust had completed several medication audits, however; on 1 and 3 Woodview, we found out of date intramuscular injections dating from 2013 and June 2014.
Reporting incidents and learning from when things
go wrong
There is no additional comment for Woodview under this sub-heading, all findings in overall summary apply.
Maplewood
Safe and clean ward environment
We were also concerned about the environment and use of the seclusion room on 1 Maplewood.The toilet was located next door to the seclusion room and could not be accessed
from the seclusion room. This meant that a person in the room would only be able to access the toilet if staff opened the seclusion room door to enable the person to access the toilet.
• The ward manager told us people who were very disturbed had to go to the toilet on the floor of the seclusion room as it would be unsafe for staff to enter the room.
• We saw the toilet door opened outwards and did not contain a viewing panel in the door. Therefore the door needed to be kept ajar in order for staff to be able to observe the person.
• The room also had a light fitting which could be reached from the bed which could pose a risk to people.
• The air condition unit was not working when we tested it.
• The room was located near the reception area on the main corridor to the ward. It was behind two doors which had clear glass panels in them. The seclusion door also had clear glass panels therefore it was possible to see into the seclusion room from the main corridor.
The person could be seen from the main corridor which compromised their privacy and dignity. We discussed these issues with the ward manager at the time of our visit. The following day, we re-visited the ward and noted that the glass had been covered with an oblique cover. The ward manager told us the air conditioning unit had been reported to maintenance to be fixed.
Safe staffing
There is no additional comment for Maple Wood under this sub-heading, all findings in overall summary apply.
Assessing and managing risk to patients and staff
We were concerned about the care and treatment of one person on 1 Maplewood whose care record for June 2014 recorded the person had been placed in seclusion. Prior to this seclusion, mechanical restraints (straps) had been used to secure the person’s lower limbs, along with the decision by qualified staff to wrap the person in a blanket to prevent movement. The care plan for the individual did not include the use of either method. The trust policy had not been followed as the MDT had not approved the use of mechanical restraints for the person and nor had an independent peer review been sought. The Multi-Disciplinary Team (MDT) notes for a meeting in May 2014 stated that mechanical restraint was not to be used on this
Are services safe?
person as it was ineffective. Whilst in seclusion the person had defecated and urinated on the floor, this had not been cleaned for over six hours even though care records showed that staff had entered the seclusion room during this time and after the room was soiled. The individual cleaned the room after the seclusion ended, staff told us this was the person’s choice and if prevented from doing so would become extremely distressed. There was no mental capacity assessment to support this decision or a care plan in place regarding this choice, neither was there evidence of the risks associated with leaving the person in a soiled room. Alternative management plans, such as providing the person with a disposable bed pan, had not been considered.
The seclusion records relating to this incident were incomplete:
• The designation of the person recording notes was not included.
• The reason for seclusion
• Details of staff reviewing and monitoring seclusion were not recorded.
• No evidence of a post incident review being completed. We raised a safeguarding alert with the local authority over the failure to protect the dignity of the individual, leaving them in a soiled room, during the period of seclusion. There was no evidence to show that a post incident review had taken place or that the person had been involved in this process.
One person on 2 Maplewood explained to us how staff had immediately transferred someone from the ward who had assaulted them and told us, “I think the staff are very good. They look after me and keep me safe all the time".
On 3 Maplewood we were told “I am safe here but if I was worried I would speak to the manager and complain". On 2 Maplewood, three people using the service
independently raised safeguarding concerns with us. We discussed these concerns with the ward manager during our visit and immediate action was taken.
Reporting incidents and learning from when things
go wrong
There is no additional comment for Maple Wood under this sub-heading, all findings in overall summary apply.
West Drive
Safe and clean ward environment
We were particularly concerned about the physical condition of some of the seclusion rooms we saw. On 4 West Drive we found that;
• The room was dirty
• The mattress was stained with paint.
• There was a pool of dirty water on the floor of the toilet area.
• There was also an item of wet clothing behind the toilet. • The room had no clock visible from the seclusion room • There was no light dimmer switch
• There was no control for the heating.
Staff told us that the room had been decommissioned as a seclusion room and not used for over two years. Staff were unable to provide us with evidence to confirm this was the case. From our observations and staff comments, we concluded the shower was regularly used by people on the ward. We were told that this was because the ward did not have a shower other that the type which were, ‘Over the baths’. Staff told us this meant they were unsafe for people with certain medical condition such as epilepsy to use therefore they used the shower in the seclusion room. We discussed the condition of the seclusion room with the ward manager at the time of our visit. The following day we re-visited the room and noted it had been thoroughly cleaned.
The seclusion toilet room door at 4 West Drive was solid with no viewing panel. We were told by staff that this door would be kept locked if a person was using the seclusion room. This meant that the person would not be able to access the toilet without staff entering the seclusion room and opening the door.
We found the taps in both the seclusion room toilets in 4 West Drive and 5 West Drive posed a ligature risk, this had not been identified through audit or escalated onto the wards risk registers. We were told there would always be a member of staff within eyesight of a person in seclusion who required the toilet. However; this was not the case for people who were using the shower room due to the lack of shower facilities on West Drive 4.
At 2 West Drive we observed staff lighting people’s cigarettes at the top of the internal stairs which led to the
Are services safe?
external courtyard, staff were not complying with the law about smoking in a public place, which also created a fire risk. We discussed this with the ward manager who told us they would ensure it stopped immediately.
On 2 West Drive the first aid kit was kept in a bookcase on a corridor. There was no signage to inform people of this. We found that some of the equipment within the kit was not stored correctly or was out of date.
Some syringes and saline solution for injections on West Drive 4 were out of date by several years. The medication fridge on this ward was kept in the laundry room.
Safe staffing
There is no additional comment for West Drive under this sub-heading, all findings in overall summary apply.
Assessing and managing risk to patients and staff
At time of the visit at 2 West Drive, there was a medical emergency taking place, this was dealt with by the ward manager and deputy ward manager in a calm manner.
On 4 West Drive we found some syringes and saline solution for injections which were out of date by several years.
We were concerned to find that the medication cupboard on 4 West Drive, which also contained the controlled drugs cupboards was housed within the kitchen used by people using the service. We raised these concerns with the trust immediately and all out of date medication and syringes were removed. The Ward Manager on 4 West Drive advised the medication cupboard was being addressed.
Reporting incidents and learning from when things
go wrong
There is no additional comment for west Drive under this sub-heading, all findings in overall summary apply.
Are services safe?
Summary of findings
Assessment of needs and planning of care
In the care records we looked at, we found completed pre-admission assessments for each person. These identified people’s social, psychological, physical, cultural, spiritual and emotional needs. Overall, we found that where a need had been identified; an assessment of that need had been undertaken. People received care and treatment from a range of professionals within the multi- disciplinary team to ensure their needs’ were met. A range of
multi-disciplinary assessment tools were used to monitor and assess people’s progress, outcomes and promote their recovery. These included people’s social, psychological, physical, cultural, spiritual and emotional needs. We identified some good examples of collaborative working between the different disciplines within the service. The service was in the process of implementing a recovery-based model of care across the service to promote people’s recovery. We found some good examples of how people had been offered the opportunity to be fully involved in all aspects of their care and treatment.
Each person had ‘Historical Clinical Risk
Management-20’ (HCR-20) risk assessment completed which identified the person’s risk to self and others. Where a risk had been identified, there was a clear psychological risk formulation which had been completed. We saw the trust was piloting a new integrated version with opportunity to enter historical data that was relevant to the continued assessment of individual risk. We noted that the wards did not use any form of structured assessment designed to be used in combination with other risk assessment instruments like the HCR-20. The addition of such tools would create a more balanced risk assessment and include risk of vulnerability which is not included in the HCR-20 for future violence risk.
The wards were at different stages of implementing, ‘My Shared Pathway’, ‘My Support Plan’ and the, ‘Recovery Star’ documentation. These user led recovery tools
provided details of the person’s care needs, strengths, future wishes, advanced statements and decisions. They provided information about how the person’s needs should be met.
Across the forensic service we saw that positive behavioural support plans had also recently been introduced and we saw some examples of these however, these were not developed following
assessments of the functions of behaviour to develop a treatment plan using behavioural approaches. They were based on person centred planning tools and used user friendly language, using people’s words describing how they wanted to be cared for when distressed. These plans were not recognised Positive Behaviour Support Plans.
We saw examples of where people used, ‘My ward round- things to talk about’ which was a document that supported people to express their needs and decisions. Positive behaviour support plans also included
examples of advanced decisions about how people wanted their care to be managed when they became distressed. We saw these plans described how people wanted to be treated using a variety of approaches to try and reduce their distress.
There was evidence that people’s physical health needs were being met. The service had a health centre within the hospital grounds. People could access the centre to see a nurse or General Practitioner (GP) if they had any physical health issues.
We saw from clinical governance meeting minutes that people’s physical health needs and obesity were
considered. We saw information about healthy eating in the occupational therapy kitchens and meeting rooms displayed posters about healthy eating.
Some staff were qualified gym instructors so could be available to supervise people on a one to one basis and monitor people’s physical health prior to and during their use of the gym. We saw evidence that people using the gym had to be physically examined and declared medically fit by a doctor before they could use the equipment.
Best practice in treatment and care
We saw that each person had a care plan. These were
Are services effective?
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
involvement of the person. The care plans we looked at were centred on the needs of the individual person and demonstrated a knowledge of current, evidence based practice.
Most of the care plans we saw were not in an easy read format and most people we spoke with did not have a copy of their care plan however; most people had an activity programme. Some of the wards were in the process of implementing pictorial care plans for people who had difficulties understanding written text however; this had not been fully embedded in practice.
Each person had a relapse prevention plan providing specific details of interventions, which should be put in place if the person’s mental health deteriorated, to prevent a relapse of their illness. We found evidence to show that some people were involved in developing their plan with staff.
The average length of stay for people for patients at Calderstones was over five years. In the focus groups we held staff said the ethos of the hospital had changed significantly over the past two years with the
implementation of a recovery focused approach to the delivery of care and treatment. Staff told us that due to the nature of some people’s risk history, legal
restrictions and appropriate accommodation being available; it was sometimes difficult to move people on from the ward into a less restrictive environment even if this had been identified as clinically appropriate to meet their needs.
A small number of people within the low secure services told us they did not feel they were making progress. One person told us, “No-one has explained what I need to do to move forward.” However; most people told us that they felt they were making positive progress and were very happy with the care and treatment they were receiving. One person told us, “The staff are there for you when you want to talk. I like that the service has a step down system so I can look at moving on.” Another person said, “I feel the staff have supported me well and I am now moving on to a place in the community.” Outcomes for people were also assessed through use of a range of multi-disciplinary assessment tools to monitor people’s progress and promote their recovery. These included: Health of the Nation Outcome Scale
(HoNOS), Model of Human Occupational Screening Tool (MoHOST), the Recovery Star and a range of specific psychological assessments. The tools were used to assess people’s social, psychological, occupational and physical needs and progress. However; we found the wards were at different stages of fully embedding some of these in practice.
One member of staff on 3 Maplewood explained how they had visited a high secure hospital to gain ideas about how the team could improve the service they provided for people. This included offering
psychological formulations to people on admission and working in collaboration with people in goal setting to promote their recovery. The wards used a range of multi-disciplinary assessment tools to monitor people’s progress and promote their recovery.
We found evidence to show that people had access to a range of evidenced based psychological interventions which included relapse prevention work and Cognitive Behavioural Therapy.
The trust provided information which showed they had achieved their target of completing 90% of
psychological assessments within 12 weeks of people being admitted to the service.
The service had good facilities on-site which people from all the wards could access dependent upon their risk assessment and care plan. These included a gym, all-weather pitch and football field, art room, gardening, private meeting rooms, a child visiting room, a multi faith room and assessment kitchens.
All staff were trained in food hygiene so could assist people to access the kitchen in the therapy area.
We found that animal assisted therapy was established and embedded in practice on all wards we visited. Several people we spoke with told us they had been involved in, ‘Pet therapy’ which they had found beneficial.
We found inconsistencies across the forensic service regarding people being able to access the internet. Patients within the medium secure services told us they had supervised access to the internet. The low secure
Are services effective?
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
service had a computer room however; we were told by staff that the computers in this room were not
connected to the internet. Staff told us that the trust was actively seeking a solution to this problem. The trust provided us with evidence that the low and medium secure services had completed the self and peer-review parts of the Quality Network for Forensic Mental Health Services eighth annual review cycle in January 2014. The Quality Network reviewed services against criteria which had been developed from the Best Practice Guidance: Specification for adult medium-secure services, Department of Health 2007.
Maplewood / West Drive met 90% of Medium Secure Standards. It has been noted that the service met 100% of criteria in five of the standard areas, including Physical Healthcare, Physical Security, and Relational Security. The areas identified as most need of
improvement include Governance, Procedural Security and Service Environment.
The Woodview unit met 87% of Medium Secure
Standards. It has been noted that the service met 100% of criteria in three of the standard areas, Serious and Untoward Incidents, Clinical and Cost Effectiveness and Public Health. The areas identified as most need of improvement include Procedural Security, Safeguarding Children and Visiting Policy and Accessible and
Responsive Care.
Gisburn Lodge met 84% of the standards overall and met 100% of criteria in four of the standard areas. Procedural Security and Safeguarding Children were highlighted as areas most in need of improvement. The peer-review process by the Quality Network for Forensic Mental Health Services included an action plan for the Trust to complete its recommendations by 2015 and 2016. As a result of this information we concluded the Trust was open to external scrutiny as a means of improving practice and the treatment and care of people that used the service.
We noted that the child visiting room at Calderstones did not have any toys, pictures or facilities which were child friendly. The manager told us these were on order.
Skilled staff to deliver care
We saw the staff teams that supported people using the forensic service were made up of a variety of different professionals. This included registered nurses for mental health and learning disabilities, medical staff and advanced nurse practitioners in physical health, occupational therapists and psychologists.
We saw some good examples in the care records we looked at of how specialist professionals had been involved in supporting staff to meet people’s care and treatment needs. We saw that some people received input from the Speech and Language Therapists (SALT), diabetic nurses and clinical nurse specialists. We saw evidence that people had been referred to specialist services external to the hospital such as dentists or the acute hospital trust for treatment which could not be provided on-site, including attendance at oncology and ophthalmic clinics.
The training records we saw showed that staff had access to a range of training relevant to their role in addition to mandatory training requirements. The staff we spoke with individually and in our small focus groups told us that they had access to a range of training relevant to their roles and they felt well supported by their local managers. We also saw evidence that staff were recording their e-learning, competency based training books and recording their attendance at training. This ensured individual electronic staff records were kept up to date.
Multi-disciplinary and inter-agency team work
All the staff we spoke with told us that care and treatment was delivered through a multi-disciplinary team (MDT) approach. We saw that ward rounds and CPA meetings had input from the professionals involved in people’s care and that decisions were made using the MDT approach. Documentation in people’s records demonstrated that professionals involved in people’s treatment had prepared reports and contributed to the process. These included social workers, occupational therapists, psychologists and medical and nursing staff. We were able to observe MDT meetings taking place as well as staff handovers on some of the wards and within the occupational therapy departments. We spoke to the
Are services effective?
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
psychotherapist on site at Gisburn Lodge and Calderstones. Staff we spoke with gave positive
feedback regarding the occupational therapy service on both sites and their engagement in meetings to ensure consistency when moving people between services.
Adherence to the MHA and the MHA Code of
Practice
We found inconsistencies and concerns with regards to the application of the Mental Health Act (MHA) 1983 within the forensic services. Some documentation relating to patients detention under the MHA were not made available for scrutiny during our visit as staff were unable to locate them and they were not uploaded onto the patients’ electronic record. This meant it was not possible for staff to determine that they were adhering to the requirements of the MHA for some patients as the necessary documentation was not available and accessible on the ward.
On one ward, we found no capacity assessments in relation to treatment for mental disorder from the current Responsible Clinician (RC).
On other wards, we found patients who had their treatment authorised by a form T2 from a previous Responsible Clinician (RC). We discussed this with the RC and were concerned to find when we revisited the ward two days later the issues remained unresolved and unauthorised treatment continued to be administered. The seclusion records showed significant delays in doctors attending the ward when seclusion had been implemented which was not in accordance with the Code of Practice.
We identified that the patient rights and information leaflets in use on the wards related to the Mental Health Act before it was amended in 2007 and therefore did not inform patients fully of their rights for example; the right to support from an Independent Mental Health
Advocate (IMHA).
We concluded that the service was not effectively adhering to the statutory requirements of the Mental Health Act. This could result in some patients’ rights being compromised or result in them receiving care or treatment by staff which was not authorised.
We checked several patients’ detention and care plan records across the low and medium secure services. We found inconsistencies between the services with regards to the application of the Mental Health Act (MHA) 1983. Within the medium secure services, we found evidence that people were provided with appropriate, timely information about their legal rights in relation to the detention under the MHA 1983.The trust had developed a pictorial leaflet to explain to patients their rights while being detained and a patient we spoke with was very well informed about their rights. However; within the low secure services, we were given a copy of the leaflet that was given to patients to provide information regarding their rights under section 132 MHA. This leaflet was out of date and did not reflect current legislation. We were provided with another leaflet which, although more recent, did not inform the patient of their right to an Independent Mental Health Advocate (IMHA). We found that detention papers were scanned onto the electronic patient record, including admission papers. We were advised that there was no mental health administrator on the Gisburn site and there was a system to ensure that documents were scrutinised as these were held at the Calderstones site.
The Trust had a Mental Health Act 1983 legal documents grading system in place and used a red, amber, green rating check list to monitor when Mental Health Act 1983 legal documents were due to be renewed.
We found evidence across the services that people had access to mental health tribunals and their legal representation was recorded. On each of the wards we inspected, we saw that a second opinion appointed doctor (SOAD) had seen people who had been prescribed treatment without their consent because they did not have the mental capacity to do so or had refused to. The SOAD had stated that it was appropriate for treatment to be given.
We found that patients were not provided with a copy of their section 17 leave authorisation which is not in accordance with the Code of Practice. Some patients told us their leave had been cancelled due to lack of staff availability to escort them.
We spoke with staff about private telephone facilities at Gisburn Lodge. A staff member told us that patients
