St Cyril's Neurological Care and Rehabilitation Service

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Information about people’s health needs, wellbeing and care was not accurate or up to date. This increased the risk of staff making both day to day and clinical decisions based on outdated or inaccurate information. There were no effective systems in place to ensure the care provided and the outcomes achieved were effectively monitored. This meant any shortfalls in people’s care and treatment were not identified or addressed. These failings increased the risk of people receiving ineffective care that did not ensure good outcomes and a good quality of life. Overall, people’s legal right to consent to their care was respected in accordance with the Mental Capacity Act. However, some people’s care files contained contradictory information about their ability to consent. People told us they were given a choice in how they lived their life and staff respected their wishes. Staff were deployed effectively across the home, with nurse led units that allocated staff to specific duties each day. Staff told us this system worked well. People told us that staff helped them get washed and dressed and supported them with other daily activities.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us their needs had been assessed. However, records showed the assessment of people's needs was not holistic. Not all of people's needs and risks were identified and assessed with appropriate care or risk management plans in place to guide staff in the safe delivery of care. This placed people at risk of inappropriate and unsafe care that was not effective in supporting health improvements. People's medical needs had not been fully assessed, information on people's needs was often contradictory and out of date and when people's needs had changed, care and risk management plans had not always been updated to ensure the care provided was safe and effective.

The management team acknowledged that improvements needed to be made to improve care plans and related risk assessments to ensure they met people's needs and requirements.

People’s medical needs were not clearly described, and staff did not have adequate information on what these conditions were or how to care for people safely. For example one person lived with epilepsy. This condition was not assessed, there was no care plan in place to advise staff on the type of seizure usually experienced, possible triggers, early warning signs or what support they required when a seizure occurred. Despite the processes in place to assess and review people's needs, the lack of medical health assessments and detailed care plans had not been picked up and addressed. Some care files contained more than one care plan for the same need or risk, with conflicting information and guidance given to staff on how to support people. The process in place to audit and quality check the assessment and care planning process had not identified and rectified this. This placed people at significant risk of inappropriate and unsafe care. For example, one person had four different sets of instructions on how to safely meet their nutritional needs. It was unclear which set of instructions was correct. There was no robust process in place to ensure the care received was carried out appropriately. For example, one person required tracheostomy tube changes every 28 days. Records showed tube changes were not completed within these timescales. This was further complicated by duplicate systems of recording which meant there was no clear monitoring of when tube changes should and had been made.

People did not always experience care which adhered to best practice guidelines or recognised standards. For example, some people required their nutrition, hydration and medicines to be given via a feeding tube called a PEG (percutaneous endoscopic gastrostomy). PEG management did not adhere to National Institute for Social Care Excellence (NICE) Guideline [CG32] Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Or CQC’s guidance on medicines and PEG management. One person's care file contained three different nutritional regimes in respect of their PEG. One of these regimes had been recommended by a qualified health professional yet appeared to have been changed by staff without authorisation. We found that some of the person's medicines should have been given on an empty stomach in order to be effective, yet were given at the same time as their nutritional regime commenced. People's experience of tracheostomy care required improvement. Tracheostomy management did not always follow best practice guidelines from the National Tracheostomy Safety project ‘Toolkit for Healthcare'. This toolkit for example, advised tracheostomy tube changes should be recorded and communicated via the person's tracheostomy passport. Yet during our assessment, one person's tracheostomy passport was not up to date or being used consistently by all staff to record changes. This meant there was no consistent or accurate record of the person's tube changes. People's experience of medicines did not follow good practice guidelines issues by the Royal Pharmaceutical Society, NICE or CQC. Care planning did not adhere to NICE, CQC or Social Care Institute for Excellence and associated linked guidance.

The management team were unable to explain the concerns identified with PEG and Tracheostomy Care, medicines management and poor care planning and acknowledged improvements needed to be made.

There were no robust systems in place to ensure evidenced based practice was adhered to. Audits to assess the quality and safety of both clinical and day to day care did not identify risks found during this assessment. As a result, shortfalls in Tracheostomy and PEG management, medicines safety, assessment and care planning were not identified.

Most of the people we spoke with felt staff worked well together.

Each unit was nurse led. Nursing staff told us they assigned specific staff members to people living in the home each day to ensure their care and treatment needs were met. This included the allocation of staff to people who required one to one staff support. Nurses were responsible for the supervision of care staff on 'the floor' and for ensuring care staff supported people effectively.

Commissioners reported staff worked effectively across teams and with other health and social care professionals in support of people's needs.

There was a process in place to organise how staff teams worked together. An allocation book was used by nursing staff which outlined the support tasks each person required on any given day. Staff referred to this allocation book during their shift. We reviewed the allocation book and found that it was not up to date, some of the names of people to whom staff were assigned were no longer living in the home. Some of the tasks assigned therefore were also not correct. The allocation book had not been updated but staff knew who to support as the person's room number was identified. Day to day 11am management meetings with nurses from each unit to share any important information between shifts, that may require follow up or further investigation took place. Handover reports also supported good communication between team members.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

People told us that staff helped them get washed and dressed and supported them with other daily activities. People’s comments included, "The staff support them [Name of person] and Skype me and they settle much better”; “They assist me with eating and drinking and moving. They are there for me”. People and their relatives felt they were achieving positive steps in their treatment journey. One person said, “I am so grateful to be here and they have helped me so much. I took my first steps yesterday since my accident. I feel like a man again, I am so proud. I get so much help from all the team”. A relative told us, “Staff are very kind and do things like answer their [Name of person] phone if it is ringing. Their speech has improved greatly and being able to have a chat helps with that improvement”.

People's treatment progress was monitored by different therapy teams such as Nurses, Occupational Therapy, Physiotherapy, Speech and Language Therapy, Psychology Team, Doctors and Consultants. These internal therapy teams completed their own assessments. Records of these assessments however were not collated in the person's care file for the management team, nursing staff and care staff to be aware of. This meant it was difficult to form a joined up view of people's treatment needs and progress.

The process in place to monitor and track people's progress and outcomes was poor. People's aspirations, desired outcomes and recognised milestones were not mapped out and monitored for people and staff to see. It was difficult therefore to assess how well people were doing and whether they were at the right stage of recovery at any given time as there was no formal process or recording in place to do this. We saw that people's care files contained some progress information from multi-disciplinary meetings and consultant reviews but an overall view of people's treatment journey and outcomes could not be ascertained without reading through multiple individual meeting records. There was no combined ongoing functional assessment of people's needs and outcomes.

People told us they had a choice how they lived their lives, and said they did so without restriction. They told us staff explained the support they were going to provide and sought their consent prior to providing it.

Staff were aware of the Mental Capacity Act 2005 (MCA) and told us they had completed training in the MCA. One staff member told us that if a person refused care they would “Encourage, keep going back, give them some time, distract them and let them rest”. Another said, “Encourage them, leave them and come back, may need to try a different worker”. However, one staff member told us that if a person refused consent for them to provide care, they would do it without their consent. They told us they would “Assess capacity and help them understand importance. If no capacity do without consent”. This did not demonstrate that the staff member had fully understood the MCA. Only 1 out of 3 care staff spoken with were aware there were some people were subject to Deprivation of Liberty Safeguards (DoLS). Two of the staff team told us nobody was on a DoLS, this was not correct and showed staff did not have a clear understanding of who required depriving of their liberty to keep them safe.

People’s care files contained evidence that people's capacity to consent to most decisions in relation to their care were completed in accordance with the MCA and DoLS processes. One person had two care plans in place for visitors and shopping that described possible restrictions on these activities which had not been subject to a MCA process. The management team agreed the MCA should have been followed before these care plans were implemented. We spoke with the person concerned however and they told us their consent was always sought in the day to day delivery of their care. Information about people’s capacity and communication abilities was sometimes contradictory. Communication aids identified in people’s care plans to help them express their views and participate in decisions about their care were not always in place or in use. This did not show people were being actively supported in decision making at all times.