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Care Quality Commision Inspection report findings for the Caludon Centre 2014

14 November, 2014 by Andy

The Care Quality Commission carried out an inspection at the Caludon Centre in January and July of this year. The CQC Caludon Centre Quality Report 22/07/2014 - can be see in in full at http://www.cqc.org.uk/sites/default/files/new_reports/AAAA1627.pdf

Acute Admission Wards - Summary of findings:

Many staff said that the provider’s senior managers were not visible and they had not regularly seen members of the senior management team around the hospital.

The general ward areas were well presented and clean. However people’s bedrooms were poorly decorated and the facilities for people living on the ward were not always adequate.

Occupancy levels were high and this meant that people were moved at short notice to sleep out on wards for older people, while newly admitted people were given their bedrooms.

Care plans were generic and we found no evidence that people using the service were involved in their care planning process.


We found a risk assessment system in place; however the records we looked at during our inspection were not fully completed.

Correct safeguards had not been put in place to protect adolescents admitted to the service.

The seclusion policy was not robust enough, and resulted in some people spending long periods in seclusion without appropriate independent medical reviews.

Policies and guidelines were in place; however, staff were not always following them.

Some staff were not supported by training and supervision of their care practices, to be caring and compassionate with people.

We found that due to the high use of agency or bank staff, there were concerns about the ability to provide continuity of care.

Some staff did not know about the person they were caring for and had not been given the opportunity to read the person’s care plan records.

People’s privacy and dignity was not always respected.

Services for Older People - Summary of Findings:

We found a number of inconsistencies across the older people services for the Caludon Centre. For example, where there had been good practice within wards this had not been shared with other wards.

We also identified a number of concerns for the older people’s service.

Regular incidents had taken place on Quinton Ward, but there was no indication that learning from these incidents had taken place to prevent them happening again.

There were no robust systems in place to protect people from harm.

The ward was regularly short staffed and relied heavily on bank or agency workers.

The trust had identified the need for increased staffing, but as yet no additional substantive staff had been employed.

Staff were not trained specifically to meet people’s individual needs. This increased the risks to both staff and people living on the wards.

We found Quinton Ward did not adhere to the Mental Health Act’s Codes of Practice. There was no identified female-only lounge on Quinton Ward and they could not provide properly segregated accommodation for men
and women.

Staff were not supported to be able to be caring and compassionate with people, which meant they did not always receive the care they required.

People’s privacy and dignity was not always respected and due to the high use of agency or bank staff there was no continuity of care.

Some staff did not know the person they were caring for and had not been given an opportunity to read their care plan records.

Staff did not adequately include and engage people and their family or carers in the planning of their care and treatment. People had not signed their ward round or care plan records.

We were told that a ward round had not taken place for three weeks, which meant that people’s treatment could not be assessed.

There was a lack of support for staff on the wards.

Staff told us that they had not received supervision or had team meetings.

Services for people with learning disabilities or autism - Summary of Findings:

Some records for patients detained under the Mental Health Act had not been fully completed to show that they, or their
relative, had been involved in decisions.

Records were unclear as to whether or not a person had the mental capacity to consent to their treatment.

People’s records included a detailed health plan so staff knew how to support each person to meet their physical and
mental health needs.

Records for the use of restraint, where needed, were not fully completed to guide staff effectively.

Care plans were in an easy-to-read format so that people could understand and be involved.

Staff had received the specialist training to be able to support a person with complex medical needs.

Mental Health Act responsibilities

We found the Caludon Centre did not always adhere to the Mental Health Act’s Codes of Practice.

Some records did not show that people had been told about their rights under the Mental Health Act which could have impacted on their understanding of how to appeal against their detention and how to obtain the services of an independent Mental Health
Advocate to support them.

We reviewed the care and treatment of people detained under the Mental Health Act on the wards. Documentation relating to aftercare arrangements, required under the Mental Health Act, were poorly completed and there was no evidence that copies had been given to people or their relatives.

Source - Care Quality Commission Inspection Report 22/07/2014