Archived: St Cyril's Rehabilitation Unit

Updated 4 December 2019

St Cyril’s Rehabilitation Unit is a single storey purpose built facility which provides accommodation to meet the needs of patients. Facilities include quiet lounges, television rooms and dining areas, a therapy suite, gym and hydrotherapy pool.

St Cyril’s has a total of 26 beds two of which are one bedroom bungalows. These are designed to help patients transition to a higher level of independence prior to discharge. All patients’ bedrooms are single with ensuite bathrooms and fitted with ceiling hoists and a nurse call bell system.

The unit comprises of four bedroom wings, a therapy wing and an administration wing. The therapy wing has a gym and occupational and language therapy.

The service provides a facility for patients with complex needs as a result of neurological impairment or physical disability. There are seven beds in use to meet the needs of patients with challenging behaviour as a result of neurological disability. These patients may or may not be detained under the Mental Health Act (1983, amended 2007). The unit has four separate care and bedroom areas and central communal facilities.

• The Cheshire Suite supports patients with complex physical needs, low awareness or continuing care needs.
• The Grosvenor Suite provides active short to medium rehabilitation with therapy services as required.
• The Westminster Suite offers specialist care to patients with challenging behaviour due to their neurological impairment.
• The Dee Unit supports patients along their rehabilitation programme towards a higher level of independence.

Services provided at the unit under a service level agreement include consultant cover, diagnostics and other allied health professional services.

The hospital has a registered manager who has been registered with the CQC since February 2019. The nominated individual is the Chief Executive.

We carried out an unannounced inspection of St Cyril’s Rehabilitation Unit on the 26 September 2019.  During this inspection there were only two areas being used to care for patients.

Updated 4 December 2019

We found the following issues that the service provider needs to improve;

• Although the hospital had made improvements when managing patient records, we found continued examples of when important information was not available for all staff.
• Compliance with training updates, including mandatory training was low, this included important topics such as basic life support and safeguarding adults.
• Although improvements had been made in referring and investigating safeguarding concerns in a timely manner once concerns had been identified, we found an example of when a safeguarding incident had not reported by a member of staff for two months. This meant that there was a risk that patients were not always protected from abuse.
• The hospital had not always managed equipment well. It was not always clear how the hospital made sure that equipment had been tested for safety in a timely manner.
• We found occasions when do not attempt cardio-pulmonary resuscitation orders were incorrectly completed or not stored correctly. This meant that there was a risk that patients might be incorrectly resuscitated or not resuscitated in the event of an emergency.
• Staff did not regularly use a recognised pain assessment tool for patients unable to verbalise their pain.
• We observed several periods of neutral interactions between patients and staff where staff did not engage verbally or otherwise with patients.
• Although the management team reviewed the complaints policy at the time of inspection, there was no information available to complainants about how to take action if they were not satisfied with how the hospital managed or responded to complaints.
• Although the corporate provider had a clear vision and values for 2013 – 2018, this had not been reviewed. In addition, staff at the hospital were not aware of what these were. The hospital did not always have workable plans so that improvements, identified to us by senior managers, could be monitored for completion.
• Although the hospital showed some consideration to best practice guidance including from the National Institute for Health and Care Excellence, we found that all planned audits measuring compliance against this had not been completed. We had concerns that information from audits had not always been used in a way to make improvements to the service provided.
• The hospital did not have a system for monitoring service level agreements. We found that some of these had not been reviewed since they had been agreed in 2015. This meant that it was unclear how the quality of the services provided were being monitored.

However, we also found the following areas of good practice;

• The hospital had strengthened the leadership team since our last inspection. The hospital had employed a manager who was registered with the CQC, a clinical services manager and a consultant in neuro-rehabilitation.
• Staff informed us that there had been an improvement to the leadership since our last inspection. They felt that members of the hospital management team were visible, open and supportive.
• We found that the hospital had made improvements to the way that national early warning scores were used when identifying a deteriorating patient. Most scores were calculated correctly and patients were escalated in line with hospital policy when needed.
• The hospital had made improvements with the management of medicines. This included the management of transdermal patches.
• Staff had good awareness of the Mental Health Act and their responsibilities within this.
• Personal care was provided in a way which maintained patient’s privacy and dignity.

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 six requirement notices. Details of these are at the end of the report.

Updated 31 August 2018

• Although the hospital had made improvements when managing patient records, we found continued examples of when important information was not available for all staff.
• Compliance with training updates, including mandatory training was low, this included important topics such as basic life support and safeguarding adults.
• Although improvements had been made in referring and investigating safeguarding concerns in a timely manner once concerns had been identified, we found an example of when a safeguarding incident had not reported by a member of staff for two months. This meant that there was a risk that patients were not always protected from abuse.
• The hospital had not always managed equipment well. It was not always clear how the hospital made sure that equipment had been tested for safety in a timely manner.
• We found occasions when do not attempt cardio-pulmonary resuscitation orders were incorrectly completed or not stored correctly. This meant that there was a risk that patients might be incorrectly resuscitated or not resuscitated in the event of an emergency.
• Staff did not regularly use a recognised pain assessment tool for patients unable to verbalise their pain.
• We observed several periods of neutral interactions between patients and staff where staff did not engage verbally or otherwise with patients.
• Although the management team reviewed the complaints policy at the time of inspection, there was no information available to complainants about how to take action if they were not satisfied with how the hospital managed or responded to complaints.
• Although the corporate provider had a clear vision and values for 2013 – 2018, this had not been reviewed. In addition, staff at the hospital were not aware of what these were. The hospital did not have workable plans so that improvements could be monitored for completion.
• Although the hospital showed some consideration to best practice guidance including from the National Institute for Health and Care Excellence, we found that all planned audits measuring compliance against this had not been completed. We had concerns that information from audits had not always been used in a way to make improvements to the service provided.
• The hospital did not have a system for monitoring service level agreements. We found that some of these had not been reviewed since they had been agreed in 2015. This meant that it was unclear how the quality of the services provided were being monitored.

However, we also found the following areas of good practice;

• The hospital had strengthened the leadership team since our last inspection. The hospital had employed a manager who was registered with the CQC, a clinical services manager and a consultant in neuro-rehabilitation.
• Staff informed us that there had been an improvement to the leadership since our last inspection. They felt that members of the hospital management team were visible, open and supportive.
• We found that the hospital had made improvements to the way that national early warning scores were used when identifying a deteriorating patient. Most scores were calculated correctly and patients were escalated in line with hospital policy when needed.
• The hospital had made improvements with the management of medicines. This included the management of transdermal patches.
• Staff had good awareness of the Mental Health Act and their responsibilities within this.
• Personal care was provided in a way which maintained patient’s privacy and dignity.