Archived: Walkern Lodge

Updated 25 January 2016

• Cambian Healthcare Limited provide inpatient learning disability services at Walkern Lodge hospital.
• Walkern Lodge is a six-bedded independent hospital for women with a learning disability or mental health needs who may be detained under the Mental Health Act 1983. The hospital is not purpose built and is a house set in the community. There were four patients receiving care and treatment and one newly admitted patient the day of inspection. All patients were detained under the Mental Health Act 1983.
• This location is registered to provide treatment for disease, disorder and injury and assessment or medical treatment for persons detained under the Mental Health Act 1983.
• Walkern Lodge was last inspected in June 2013, there were no breaches of the Health, and Social Care Act 2008 (Regulated Activities) Regulations 2010 identified at that time.

A manager and controlled drugs accountable officer was not registered with the Care Quality Commission at the time of our inspection. The provider had plans in place to register the new covering manager for this.

Updated 25 January 2016

From our inspection we found:

• The provider was not providing safe care and treatment.
• Staffing duty rotas showed there were often not enough staff. In one three-week period, 15 nursing shifts were short staffed.
• The provider did not have robust governance systems in place to consistently assess and monitor the quality of the service. We found gaps in patient and management records for risk assessments, safeguarding and incident investigation. Staff were not receiving regular training and support for their role.
• Staff had not carried out adequate assessments of risk for individual patients under their care and care plans were not updated.
• There were environmental risks. The service had no dedicated cleaning staff. Some areas were not clean and this posed a risk that patients and others may get an infection. Two bedroom floors had water from the shower overflow, which posed a risk of people slipping.
• We found risks regarding medicines management practice. Actions by the provider after a pharmacy audit were incomplete.
• Patients’ files did not have key Mental Health Act 1983 and Mental Capacity Act 2005 documents. For example, the record for the renewal of section for a patient after November 2014 was not in the patient’s file.
• Current complaints records were not available and we had concerns that the provider was not responding to patients' concerns raised.
• There had been three managers since May 2015. There had been significant changes to the core staffing and management in the last year. This had affected staff morale.

However:

• A new part time manager from another hospital had just started working at Walkern Lodge. A regional director with oversight of this hospital and others in the area had taken action to ensure manager was available for the hospital.
• Staff used nationally recognised assessments such as the short-term assessment of risk and treatability (START) assessment tool as part of their initial and on-going assessment of risk.
• Staff had ensured that patients who needed higher levels of observation had bedrooms on the ground floor. Staff had easier access to observe and support them if they became unsettled.
• Staff supported patients to keep contact with their family and friends.
• Patients could contact independent advocates as required to help communicate their needs.
• Patients personalised their rooms. Pictorial information and sensory, sound and light objects for patients’ stimulation were available.

Following this inspection, we identified that the provider was not meeting Regulation 12, The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at this location. We carried out enforcement action with the provider and told them to ensure compliance by 13 October 2015. The provider sent us their action plan to meet the regulation and informed us they had plans to close the location by 31 December 2015.