Self-Determination

Direction
Money
Place
Support
Safeguarding

People First Quality Checkers

HOSPITAL CHECKS

Additional Support Unit Report

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Contents
Background

Methodology

Strengths & Recommendations

Main Findings

Observations

Self-determination

Direction

10

Money

12

Place

13

Support

14

Safeguarding

15

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Background
People First Quality Checkers (an arm of Cornwall People First, an organisation run by people with learning disabilities) were commissioned in
October 2012 by NHS Devon and NHS Torbay to conduct a series of person centred checks of Learning Disability Hospitals in the area. The
hospitals are all registered to provide assessment, treatment and rehabilitation for people with learning disabilities.
Following the discovery of the abuses of patients in Winterbourne View, local NHS commissioners felt that there was an urgent need for a better
monitoring and better care in hospital settings and that this should be carried out by people with learning disabilities and family/carers who are all
experts by experience. This form of approach was also heavily supported by both family carer and self-advocate organisations, as well as being
adopted as a principle by the Care Quality Commission (CQC)
Most of the people at these hospitals had been placed at the hospital under the Mental Health Act and are vulnerable to abuse of their rights.
The patients in all five hospitals were placed there by different commissioners from all over England, usually following assessment under the Mental
Health Act. The Team found that whilst most people were happy with the treatment they were receiving at the hospital they were currently residing
in, every single person we spoke to expressed a strong desire to Go Home. In fact they named this as their number one goal for the future. The
Team did not find this surprising, but were very surprised to find that many of the people they spoke to had been in a hospital setting, far from their
original home, since their late teens. Some of the people the teams talked to are now in their thirties.
The Team found this very hard to accept and this viewpoint has been reinforced by the recent report Transforming Care (DoH, 2012) where it is
stated that there will be more emphasis on safe local services and fewer people in hospital. All people currently receiving treatment in hospital will
receive a review by 1st June 2013 and where it is deemed that they do not need to be in hospital a plan will be implemented so they can return to
the community by June 2014. The Team welcome this guidance, which was published during the checking process.
The checks carried out by People First Quality Checkers were originally commissioned by the local NHS commissioners in Devon, Plymouth and
Torbay. However, the outcomes of the checks are going to be of equal use to the individual hospitals and will form a useful development tool over
the coming months and years.

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Methodology
The commissioners at Devon and Torbay wanted the People First Quality Checkers to bring a Team together that would include people with
Learning Disabilities and Family/Carers as well as experts in their fields.
The Team included:
Antony Dunn and Ben Law- both members of the NHS CHAMPs team. CHAMPs are paid members of staff who are all experts by experience. In the
past they have helped to check acute hospitals for the South West Peer Review and are currently checking all of the community hospitals and training all
the staff at local hospitals in Cornwall.
Margaret Upham - family/carer and founder of Partners for Policy Making in Cornwall, Member of Strategic Health Authority (SHA) Winterbourne
View Review Panel 2012 and member of Cornwall Programme Board for Personalisation.
Richard Bow - family/carer and member of the project board Re-Provision of Learning Disability Services, Cornwall (Post Budock Hospital) 20072010, member of the Health Care Commission National Audit 2007, part of the Royal College Of Psychiatrists AIMS Learning Disability and Mental Health Hospital Reviews 2010- present, member Housing Support and Delivery Group, Cornwall Council 2010-Present and a Member of SHA
Winterbourne Review panel 2012
Nory Menneer - is currently a Nurse Consultant for people with learning disabilities in Cornwall. He has been leading in the development of quality
checklists for learning disability hospitals, following the Winterbourne View scandal. Prior to this project, he led on the development of quality
indicators for the South West Acute Hospital Peer Review.
Kate Spenceley - Project Co-ordinator for People First Quality Checkers a service run by people with learning disabilities established to check
services for people with learning disabilities and funded by Plymouth City Council.
The Team1 worked in partnership to develop a unique set of questions that would form the basis of this check. The questions were based on Simon
Duffys seminal work Keys to Citizenship about how people with learning difficulties can best be supported to take their place as full citizens and
the NHS assessment framework.
The questions look at six key areas. The areas are self-determination, direction, money, place, support and safeguarding. There were specific
questions in these areas that were directed towards support staff, management , family carers and people who are receiving treatment at the
hospital2 with weight being given to the experience of the people staying in the hospital and their families.

1. The Team or the Quality Checking Team is used in the rest of this document to describe this group of people
2. There has been some discussion in the team of what to call patients at the Hospitals as the Team have been told that some people do not like the word patient. It was decided that as the individuals in
question are receiving treatment in a hospital this was the best word to use.

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Methodology
The Team also intended to speak to nurses, senior staff, occupational therapists (OT) and advocates using the questions as a framework.
It was the intention of the Team to keep disruption to a minimum and so it was decided that the checks would be conducted over the period of one
day with a preparation day before hand and debrief the day following.
Having agreed the framework the Team invited the hospitals identified by NHS Devon and Torbay to attend an information day. The day explained
the process and asked the hospitals if they wanted to take part.
The information day was also an opportunity to invite peer checkers to be involved. The Team wanted a peer checker (a front line member of staff)
from each hospital to volunteer to check another of the hospitals on the list. It was hoped that this would encourage openness and a sharing of
good practice within the hospitals as well as aid the Team with their knowledge of this kind of service.
With one representative from each of the parties involved the checks would be conducted by five people in total.
The response from the hospitals about the checks was very good. The hospitals were keen to get involved and were very supportive of the process
throughout. The Team would like to thank the hospitals for their participation and enthusiasm throughout.

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Additional Support Unit, Devon

On the 27th of November 2012 the Quality Checking Team visited Exeter Additional Support Unit (ASU) run by the Devon Partnership NHS. The aims
of the unit are to provide support for people with a learning disability who are experiencing, or causing in others ,high levels of distress.
The Team1 were shown around the hospital and later split into small groups to conduct a series of interviews. Team 1 spoke to two patients without
a staff member present and Team 2 spoke to staff members. The commissioner on the Team spoke to senior management.
The following information was gathered from observations by the Quality Checking Team and the people the Team spoke to. The information is
backed up with evidence when stated.
1. Consisting of Margaret Upham, Ben Law, Kate Spenceley, Josie Saunders and Helen Toker-Lester.

Strengths

Recommendations

Patients felt free to attend the clinic that is held every Thursday.
An outcome document for staff and patients is created after
each incident.
A photo board showing what staff are on duty is on display.
A meeting book has been created so that people can have
their say even if they are not well enough to attend the patient
meeting that week
Each week people are asked if they want to make a complaint.
All patients were aware of the advocacy service and felt able to
call this service at anytime.
Accessible care plans (i.e. easy read) are being developed.
Patients are made aware that the ASU is a hospital and that
their stay is on a short term basis.
The staff were positive and approachable.
Patients are invited onto the interviewing panel for new staff.
The ASU has an open house policy so visitors can visit without
appointment.
A What You Said/What We Did easy read learning log is
produced after the patient meetings which summarises
comments and show what the ASU did about them.

There should be regular visits by a self-advocate group.

Regular patient progress reports for family and care managers.
These could be written by patients.
Patients could have more input into environmental decisions.
There could be more personalisation of private spaces.
The patient meeting should be independently facilitated by a
self-advocacy organisation.
Person centred plans should be implemented.
Meeting feedback for patients available in easy read.
Safeguarding and whistleblowing training for patients.

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Main Findings
Observations
The Team observed that the hospital was clean and orderly and good decorative order with fresh paint and pictures on the walls. The Team
observed that patients were speaking up for themselves and demonstrated that they were aware of things that were going on in the hospital.
Staff were observed to be attentive to patients. The team were informed by patients that choices were being offered. The Team were informed by
patients that people are getting information in accessible formats but were unable to confirm this, as the Team were not given permission1 to look
at people files. However the photo board demonstrated that people were being helped with communication. The Team observed that the ASU staff
were talking about others in nice ways (patients and other staff) and the atmosphere seemed to be good.
1. By patients at the unit.

Self-determination
CHAMPS and Quality Checkers to Patients.
The Team talked to two self-advocates who were patients at the hospital. Both patients were very articulate and the Team saw both people on their
own without staff present. One patient had been at the unit for three months and seemed quite positive about the hospital and his experience. The
other patient had been at the unit for sixteen months and she had a very different opinion of the hospital.
When asked about choices around meals and food the Team were told that the food was very nice. When the staff are made aware of what a
person likes this food goes on the menu. A choice between two meals is offered for each main meal1 and people get to make decisions around food
on Mondays, Wednesdays and Fridays. The Team were told that cards with pictures of the meals were available so that some people with specific
communication needs could point to the things they wanted.
The Team were told that there are no resident meetings at the moment2 but that every Sunday patients are asked if they have any complaints or
anything else they would like to say. These comments are recorded in the meeting book and are read out. One patient went on to say that these
comments are not always read out but they should be. The other patient told the Team that the complaints made are not always acted upon.
The Team were informed by the management of the ASU that patients do have regular meetings when they are able to and these are scheduled
to happen once a week. If patients arent able to meet together they ask people individually about their comments and ideas for improvements.
After the meeting a What You Said/What We Did easy read learning log is produced which summarises comments and shows what the ASU did
about them.

1. One of the patients said that this was not enough choice. A brunch was offered each Saturday and a roast on Sunday but as she didnt eat red meat this wasnt much of a choice. She sometimes was
offered chicken but this depended on who was on shift.
2. She had asked several times to have yogurts but she felt this had been ignored.

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Main Findings
Self-determination
Since the visit the Team has been told that the manager will initial the notes and the learning logs and will bring them to the Clinical Governance
Meeting to demonstrate appropriate actions are taken.
The patients informed the Team that they have no say in how the building looks. One of the patients said they thought it would be nice to have a say
on what pictures were on the walls, that the colour of the walls were boring and the bathrooms could be a lighter colour and have windows so that
she didnt feel so shut in.
The management informed the Team that as it is a transitory population they are unable to redecorate for every patient. The ASU have had
suggestions from more than one patient about having some coloured notice boards in the bedrooms so they can display posters and photo and
this is now being actioned. Where this is not possible the ASU will look at creative solutions; for example using black board paint so patients can
personalise their space.
When asked who decides what they do during the day one patient said that they walk or chill out and watch television. He further added If you
need staff support you have to wait but if not, you can do what you want. The other patient told the team all there is to do was watch DVDs and
read magazines. The patient told the Team that she was unhappy because she is young and wants to go out until late. She said she would like to
get paid work and go back to college but that she couldnt do these things whilst she was in hospital. She told the Team that she gets support all
the time and when she is in town this is embarrassing for her.
After talking to the management the Team were informed that the ASU prides itself in ensuring that every patient has an activity schedule. The
ASUs goal is that every patient is given the opportunity to go out into the community every day. The Team were informed that the unit did have two
patients who wanted to be allowed out by themselves, they wanted to be able to go clubbing and to the pub, unfortunately their risk assessment
precluded these activities.
One of the people who the Team talked to said he knew a lot about self-advocacy and was a big believer in it. He added that there were no selfadvocacy groups to go to in Devon anymore. He said he did not have an advocate because he didnt want one. He was aware of the advocacy
service and knew he could call them if he changed his mind. He said peoples mums and dads can speak up for people too.
The other person said they had not heard of self-advocacy and that her lawyer was helping her with her section 17. She told the Team that she did
have an advocate that she could call them any time she wanted to.
Both patients said that they could say if they were not happy, one said that a few weeks ago they were feeling low and were able to talk to staff.
This was documented by the staff member and then added this to their care plan. When asked if the staff have made things better they said yeah
well thats what they are there for. The other said she was very frustrated with being at the hospital . She felt it wasnt the fault of the ASU but of
higher up people. She went on to tell the Team that she felt it was time to move on and she feels stuck here. The patient informed the Team that

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Main Findings
Self-determination
she feels listened to by ASU staff and this is a help to her.
The ASU were aware that one patient did feel stuck at the ASU. This was to do with NHS Devon funding, and the Court of Protection. As soon as
these issues were resolved the patient was transferred.

Family/carers and Peer Checkers to staff to staff and family.

The Team was itold that family are contacted and keept informed by telephone by their named nurse. They were told that visitors can come at any
time and that there are no restricted areas in the hospital but this would depend on the situation. When the Team was in the Unit someone was in
distress and the Team were kept separate from them to allow the patient some space. The Team were told that family and carers can feedback at
the clinic but that there is no formal feedback process.

Commissioner to management
The Team was told that everyone (patients) contributes in their own way to the running of the service on a day to day basis. There is a weekly patient
meeting where they are asked what is good or bad and what would you like to happen. At these patient meetings people have an opportunity to
complain and people can also speak up at the weekly clinics.
There is an internal evaluation service that takes the form of provider compliance assessments, a peer walk around and clinical governance
meetings.
The Team was told that each patient currently receives a comments card on discharge and that this feeds back into the evaluation of the service
and that family/carers can assist with this.
At present nobody who uses the service is leading the evaluation. People are told on admission to hospital about the advocacy services available
and there is easy read information about this on the board.
The Team was told that there is little relationship with self-advocacy groups at the moment and they do not feedback to the service for service
improvement however patients have the opportunity to be members of the new foundation trust if they want to.

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Main Findings
Direction
CHAMPS and Quality Checkers to Patients
People do have meetings to talk about their future and support. The Team was told that there is a clinic every Thursday and parents can come to
these, I dont go but my dad goes on my behalf. He went on to say we write down what we want people to talk about on Wednesdays but I could
go if I wanted to.
The other person told the Team that they go to the clinics sometimes when they have something to say.
When asked about visitors both patients said they have visitors that come when they want but they have to call first. Some visits are supervised and
this causes one of the patients a degree of frustration.
After talking to the management the team were informed that supervised visits are highly unusual and only ever happen as part of a risk
Management Plan and in accordance with the Mental Health Act.
The Team was informed that the ASU does have an open house visiting policy although they protect meal times. The team were informed that this is
because often people have heightened arousal/anxiety at these times. Relatives and carers can visit at any other time and are welcomed on to the
unit where the patient is staying. The unit does ask that if relatives and carers want to avoid missing patients (as patients do go out a lot) that they
phone first, however this isnt a requirement.
One of the patients said that he has a Person Centred Plan (PCP) and this has been produced in an easy read format. The Team was told that the
care plans are written in easy to read language and if they agree to it they can sign them. He told the Team that care plans are written at night.
When asked what will happen when they leave the hospital one person said they would like to go home and this is agreed in their care plan. He said
in the future he would like a job helping people with learning disabilities speak up for themselves. The other said she didnt have a clue what would
happen when she left hospital and that people kept changing their minds. She explained that what she really wanted was to move into a flat on her
own but they say I am not ready1.

1. She went on to say that they wanted her to have support but she didnt want that.

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Main Findings
Direction
Family/carers and Peer Checkers to staff to staff and family.
The Team was told that reviews are taking place monthly or more frequently if required and that patients knew when and where these where
taking place. Patients and family carers are made aware of the outcomes of meetings if they want to know. Family/carers, patients, occupational
therapists, psychologists, care managers and unit managers and nurses all attend the meetings. Support staff do not currently attend.
At each meeting a date is set for the next meeting, and family/carers are informed straight away. Patients have the opportunity to attend all the
meetings if they want to. Care plans are developed with patients if they are interested and some patients are currently doing this.
The Team were unable to look at any plans but were informed that there is currently a dedicated member of staff who is creating accessible
documents for patients.
People do not currently have Person Centred Plans (PCP).
Staff are allocated at night for the next day and this information is put up on the photo board. When asked if the care plans include the people that
are being supported. The person the Team spoke to expressed frustration with the lack of activities and limitation of public transport and support. it
was commented that this might be because of recent staff changes.
The Team were informed that although the Unit feel they know when people are ready to be discharged joined up discharge is a problem and
there is often nowhere for people to go.

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Main Findings
Money
CHAMPS and Quality Checkers to Patients
When the Team asked about money one person said she did her own budgeting and had her own bank account. The other person had an appointee
and his money was kept in a tin in the staff room.

Family/carers and Peer Checkers to staff to staff and family.

The Team was informed by staff that everyone has a tin that is kept in the office. Everything has to be double signed and this is checked daily and a
weekly audit is done.

Commissioner to management
The Team was told there is not a currently a clear breakdown of how much support costs for each individual as the service is part of a block
contract with Devon Partnership Trust (DPT).

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Main Findings
Place
CHAMPS and Quality Checkers to Patients
The Team was told there is not currently a clear breakdown of how much support costs for each individual as the service is part of a block contract
with DPT.

Family/carers and Peer Checkers to staff to staff and family.

The Team were informed by staff that family are encouraged to be involved and to visit people who are in the hospital. The Team was told that food
was prepared on an individual basis and was very good. People have their own food and are given a choice of two dishes per meal. The hospital
takes into account the safety needs of the patients in terms of the building but not their choices.
There are patient meetings on a regular basis where they can make suggestions/comments.
The Team was told that people are given space in their room and that staff are very respectful of their needs. Patients are encouraged to do their
own laundry and the hospital staff do consider the hospital environment as a staff team.
When asked if patients have involvement in environmental decisions, the Team was told about patient meetings as previously mentioned, and told
that items for rooms are risk assessed.

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Main Findings
Support
CHAMPS and Quality Checkers to Patients
Both patients the Team spoke to commented on the board that showed what staff were on shift and both said how helpful they found this.
The Team asked what difference it makes what staff is on, one person told them that some staff are really important. He want on to say you might
not like someone and you think oh well or it might be someone really nice, and so it is good to know.
When interviewed about key workers, both patients told the Team that they have a key worker, named nurse, and also have someone allocated to
them each day. They dont get to choose who their key worker is but added it would be nice.
No one the Team spoke to had any input in interviewing new staff or were involved in staff reviews. One person said I would like it if they asked me.
After talking to the management the Team were informed that the unit does have people with learning disability on every interview panel for staff and
that this practice has been happening for some time.

Family/carers and Peer Checkers to staff to staff and family.

Staff seemed to form a very cohesive unit especially as the Team were informed that they were cuurrently in transition. Staff seemed to have a very
clear idea of their roles and the role of the ASU. Nobody the Team spoke to had met any of the patients, or anyone else with a learning disability
during the recruitment process or in any on-going training.
The management informed the Team that this is because they were very long memebers of staf who had been recruited prior to this initiative being
instigated.
Line managers were reported to be very friendly and open to staff. The staff team was observed being very friendly and relaxed with one another.
Management was seen to be very approachable. Bank staff are being used at the Unit quite a lot at the moment but now that the merger is
complete the Unit believes this will be a very rare occurance.

Commissioner to management
The Team was told that staff are highly trained, and that training is very high on the agenda; this was backed up with evidence.
Line managers work alongside front line staff in the ASU, and the Team were told that staff feel supported by managers because they listen and
respond.

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Main Findings
Safeguarding
CHAMPS and Quality Checkers to Patients
When asked what they would do if someone was hurting someone, one person said they would tell staff, if it was a patient hurting another patient
and the manager if staff were hurting patients. He also said if staff were hurting other staff he would just leave it.
Both patients said they knew what risk assessments were, they did have a say in writing them and they agreed them after they were written up.
When asked if they knew how to complain one patient said they would talk to the management. teh pateints went on to explain that they are also
asked on Sunday night if they have anything to complain about and that this is kept private if you want it to be.
One patient told the Team that they were not sure if they had been given a pack about complaining. The other patient said that the complaints
procedure was very clear, but she did not feel listened to and no longer tell the staff at the ASU what she is feeling.
The team would like to note that the same patient earlier said that she was able to talk to staff and felt that talking to them helped her. 1
People stay in touch with family and friends by mobile phone, but one patient told us that her phone is checked and people listen to her phone
calls.2 She went on to tell the Team that she can go on the internet, but only with supervision.
Staff told us that this was important process and part of a safeguarding action plan.
Both patients told the Team that they are able to receive phone calls from family and friends at any time.Further feedback
One person said they spend a lot of time on their own in their room watching television and the staff have to come and say that I have had enough
time chilling out.
The Team were told by one patient that the television was turned off in her room at 12pm with no exceptions and that this is annoying if she was
watching something.
The team looked at gudlines around healthy sleep patterns and saw that this is is recommended in some cases.
The patient went on to say she would be allowed to go out in the evenings with support but that this would need to be arranged with a doctor. She
said she would prefer to be supported by people her own age and then she wouldnt be so embarrassed. The Team were also told that friends have
to give names and addresses, and the police have to be called when they visit her and this puts them off. She also told the Team that when she is
on the phone staff listen to her calls, and that she can take the phone into her room, but they listen at the door.
The management informed the Team that this was highly unusual for the ASU and was put in place because the patient was in danger of financial &
1. We spoke to the management about this and were informed that the staff always listened to patients wishes, but sometimes arent able to do what they ask due to treatment & risk.
2. She says this is because they want to keep her safe but thinks this is unrealistic as life is not safe.

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Main Findings
Safeguarding
sexual exploitation. The patient always had access to an advocate and a solicitor throughout. These restrictions were proportionate and necessary
and were in place as part of her safeguarding arrangements.

Family/carers and Peer Checkers to staff to staff and family.

Patients can use the phone to stay in touch with family and are encouraged to do so when appropriate. Some people do not keep in contact
with their families for valid reasons, and some are not allowed to contact their family members. The Team was informed that all staff had received
training in and are aware of safeguarding and all staff knew what the process was and what would happen if they reported a concern. The last
concern raised was a few months ago. There is a de-brief after incidents and incidents are discussed at meetings. There is an outcome document
tproduced for staff and patients.
Risk assessment are sometimes written with patients. The Team were informed thatthis is usually longer standing patients. Most are not involved
initially when they move in as they are often quite unwell
Positive risks are taken sometimes - it depends on the individual.
The team were told separately by management that positive risk taking is always part of a patients care plan and the ASU is proud of their record
in ensuring patients with high risks are enabled to take positive risks.
The Team was told that there was a whistleblowing policy and policies are available to patients if they want to see them, this would be available in
easy read if they requested it.

Commissioner to management
There is copy of the safeguarding policy in easy read and other information such as identifying abuse. If a patient wanted to make an alert they
would talk to staff. The last safeguarding was made in October 2012. The unit is registered with the CQC and concerns were raised about care
planning and including people in their discharge. The unit is currently all compliant now.
There are no other organisations that inspect the Unit.
The Team was told that all patients were informed about how to complain and easy read leaflets and comment cards are given to patients so that
they can feedback to the Unit. Actions from this feedback is recorded in Clinical Governance and followed up there.

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Additional information
The Quality Checking Team would like to thank ASU, patients and staff for its
hospitality to them and its enthusiastic engagement in the process.
All rights reserved
All other reproduction is strictly prohibited without permission from the publisher

People First Quality Checkers

If you would like to find out more about our work, please contact us:
People First Quality Checkers
Devonport Guildhall
Ker Street
Devonport
Plymouth
Devon PL1 4EL
Tel: 07866 467 567
Email: info@P1QC.com
Web: www.P1QC.com

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If you would like to find out more about our work, please contact us:
People First Quality Checkers
Devonport Guildhall
Ker Street
Devonport
Plymouth
PL1 4EL
Tel: 07866 467 567
Email: info@P1QC.com
Web: www.P1QC.com

People First
Quality Checkers