- Independent mental health service
Weaver Lodge
All Inspections
28 February and 1 March 2022
During a routine inspection
Our rating of this location improved. We rated it as good because:
- The service provided safe care. The ward environment was safe and clean. There were some nurse and support work staff vacancies, but managers were trying to fill these posts and deployed agency and bank staff to cover the shortfalls. Staff assessed and managed risk well. They minimised the use of restrictive practices, stored medicines safely and followed good practice with respect to safeguarding. Staff now made sure that women patients had access to a room which was designated as women only.
- Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice.
- The ward team included or had access to a range of specialists required to meet the needs of patients. Staff now screened patients for any psychological needs and, when patients needed psychological input, this was provided. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
- Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
- The service worked to a recognised model of mental health rehabilitation. It was well led, and the governance processes ensured that ward procedures ran smoothly.
However:
- Although staff engaged in clinical audit and most audits were completed to a good standard, a small number of audits had not been fully completed and did not always clearly record what action had been taken to show that shortfalls had been fully addressed. Managers had recently introduced a new system to better record evidence that actions had been completed following audits, but this was not fully embedded.
- Although staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005, there were a small number of shortfalls relating to the Mental Health Act. Mental Health Act administration was provided by a nearby NHS Trust who had picked up these errors and shared responsibility for these shortfalls.
- While there were good mental capacity assessments, best interest considerations for certain decisions about patients who lacked capacity were not always fully recorded on the provider’s own recording systems. It was clear that these decisions were in patient’s best interests through looking at other records.
- Some staff felt that a recently introduced rota system did not fully work to enable a good work/life balance.
19-20 March 2019
During a routine inspection
We rated Weaver Lodge as requires improvement because:
- There was no dedicated female only lounge that was only accessed by female patients
- The service did not offer suitable psychological therapies as part of the service user treatment in line with national guidance on best practice
However:
- Patients received care in a safe and clean environment.
- Staff understood the needs of the patients and had the right skills to deliver safe care and treatment.
- Staff understood how to protect patients from abuse and report concerns.
- Each patient had a comprehensive risk assessment, which staff updated regularly.
- Staff followed good practice and national guidelines in relation to medicines management.
- All staff received training on, and understood the principles of, the Mental Health Act and the Mental Capacity Act.
- Staff compliance with supervision at the service was at 100%.
- Staff treated patients with kindness, dignity, respect and compassion and supported patients and carers to understand their condition and treatment
- Patients were involved in decisions regarding the service.
- Patients had access to volunteer opportunities, were encouraged to pursue their hobbies and interests in the community.
- Patients were aware of how to make complaints about the service.
- Patients were positive about the food at the service and had been included in a recent tasting session.
- Leaders had the skills, experience and knowledge to manage the service.
- Staff felt respected and valued and were aware of the service’s visions and values.
7 October 2016
During an inspection looking at part of the service
We undertook this unannounced focused inspection to review a requirement notice that was given at our last comprehensive inspection in April 2016. We published our inspection report in July 2016. The requirement notice related to the safe question breaches of regulation 17 – Good governance. The provider submitted an action plan and this told us what they intended to do in order to make improvements. We inspected Weaver Lodge on 7 October 2016 to see if these improvements had been made.
We found that the provider had implemented all areas of the action plan. Following implementation of the plan there had been no further medication errors.
The action taken included:
- A copy of the medicine management policy had been given to staff and local protocols had been amended and updated.
- All registered nurses had undertaken a medicine management competency assessment. This will be repeated annually.
- A competency assessment and training plan was devised for support worker staff. Some staff had completed this and others were booked to complete this training.
- The senior nurse practitioner reviewed the weekly medicine audits and took immediate remedial action or undertook further checks where issues had been identified.
- Specialist pharmacy undertook additional monthly audits.
- The daily shift handover proforma was amended to require a daily signature. This was to confirm medication administration records had been checked, and were in order, that day.
The provider had made the required improvements within six months from the date of the last report being published. This means we are able to re-rate the safe domain of the report from requires improvement to good.
This did not affect the overall rating as this was already good.
12 13 April 2016
During a routine inspection
We rated Weaver Lodge as good because:
-
patients told us that staff were kind and respectful and that they felt supported
-
activities were available seven days a week and patients were able to say what activities they wished to do
-
we saw that patients were involved in developing their care plans and had a say in the types of treatments they could receive
-
carers felt included in care and treatment and their views and opinions were considered
-
the hospital was bright, clean and well maintained
-
staffing numbers were adequate and it was rare for activities or one to one time with nursing staff to be cancelled
-
as well as medical and nursing interventions patients had access to occupational therapy and psychological interventions
-
physical health was being regularly reviewed and specialist healthcare staff regularly visited the hospital
-
there were good links between the hospital and community mental health staff
-
all staff had regular training, supervision and appraisals.
However:
-
although regular medication audits were being undertaken, stock discrepancies were being reported and it was unclear what action the managers were taking.
23 May 2014
During an inspection looking at part of the service
Patients told us that staff listened to them and asked for their consent before providing any care and support. We found where patients did not have the capacity to consent, the provider acted in accordance with legal requirements. We looked at care files belonging to 10 patients. In general, all appropriate documentation was signed by patients. Where a patient had not signed a document an appropriate reason was clearly recorded by the staff.
Since our last inspection visit a program of refurbishment had been commenced and was ongoing. The provider was able to demonstrate having made improvements to the environment in order to ensure that patients were appropriately supported and protected from risks.
30 October 2013
During a routine inspection
'The staff are fantastic. I see my (named nurse) when I need to.'
'I'm very well, the facilities are really good, staff are supportive. If you're struggling they'll help you.'
'The staff are excellent. I get on well with them.'
We looked at three care records. Care plans and risk assessments were in place with information about patients care needs and risks identified.
Staff were aware of how to protect patients through the safeguarding vulnerable adults procedure.
There was a system in place to manage complaints.
We found that assessments of patients' ability to consent to care and treatment needed improvement. This was to ensure that there was a clear assessment on which to base treatment.
We also found improvements were needed to the environment to ensure that patients were appropriately supported and protected from risks.
14 August 2012
During a routine inspection
Both people spoken with said that they were treated in a respectful manner by the staff team. They told us that they liked the environment that they lived in. They told us that they felt safe. They said that had a good relationship with the staff. Some comments made were:-
'I get on with the staff great. They give me help when I need it.'
'This is one of the best services I've been to.'
A health care professional who made regular visits to the service told us that a good service was provided. They said that people's needs were appropriately met and that from their observations people liked being at the service.
A social worker who supported a person who used the service told us that care and health needs were appropriately met. They said referrals were made for additional support as this was needed. They described the staff as welcoming and professional in their manner.
We requested information from Cheshire West and Chester Local Involvement Network (*LINks). They had no information to give us at the time of writing this report.
* LINKs are networks of individuals and organisations that have an interest in improving health and social care services. They are independent of the council, NHS and other service providers. LINks aim to involve local people in the planning and delivery of services.
Mental Health Act Commissioner reports
Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.
Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.