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Care Standards Act 2000
Private and Voluntary Healthcare
Plas Coch
Rhyl Road
St. Asaph
LL17 0HU

Date of Inspection
15th January 2008
You may reproduce this Report in its entirety. You may not reproduce it in part or in
any abridged form and may only quote from it with the consent in writing of the
Healthcare Inspectorate Wales.
Regulation Team
Inspection Episode: April 2007 to March 2008
Healthcare Provision:
Contact telephone number:
Registered Provider:
Mental Health Care (Plas Coch) LtdA subsidiary of Castlebeck Group Ltd Responsible Individual:
Bob EllisAndrew MacGlashen - from March 2008 Registered Manager:
Number of places:
Independent Hospital registered to accommodate24 individuals with functional mental health needsand / or learning disability who may be detainedunder the Mental Health Act 1983 Date of first registration:
Date of publication of this report:
Date of previous published report:
Lead Inspector:
Specialist Inspectors/Advisors:
Hugh Apperley – PharmacistSarah Cullen – Assistant Regulation Officer GUIDELINES ON INSPECTION
This report has been compiled following an inspection of the service undertaken by theHealthcare Inspectorate for Wales (HIW) under the provisions of the Care Standards Act2000 and associated Regulations.
The report contains information on the process of inspection and records its outcomes.
The report is divided into nine distinct parts reflecting the broad areas of the NationalMinimum Standards. An overall conclusion of the service’s compliance with Private andVoluntary Healthcare (Wales) Regulations 2002 is recorded.
The HIW’s Inspectors are authorised to enter and inspect healthcare services at any time.
At each inspection episode or period there are visit/s to the service in addition to a rangeof other activities, self- assessment and the use of questionnaires. HIW try to find the bestway of capturing the experience of patients, their relatives/representatives and staffemployed within the service.
At any other time throughout the year visits may also be made to the service to investigatecomplaints and in response to changes in the service. Inspection enables the HIW tosatisfy itself that continued registration is justified. It ensures compliance with: • Care Standards Act 2000 and associated Regulations whilst taking into account the • The service’s own statement of purpose Readers must be aware that the report is intended to reflect the findings of the inspector atthe particular inspection episode. Readers should not conclude that the circumstances ofthe service will be the same at all times; sometimes services improve and converselysometimes they deteriorate. The National Minimum Standards are also very detailed andsome are technical in nature and the HIW does not look in depth at all aspects of thesestandards on each visit.
The report clearly indicates the requirements that have been made by HIW. This includesthose made by HIW since the last inspection report which have now been met,requirements which remain outstanding and any new requirements from this recentinspection.
The reader should note that requirements made in last year’s report which are not listed asoutstanding have been appropriately complied with.
If you have concerns about anything arising from the Inspector's findings, you may wish todiscuss these with the HIW or with the registered person.
The Healthcare Inspectorate Wales is required to make reports on registered facilitiesavailable to the public. The report is a public document and will be available on theHealthcare Inspectorate Wales web site: OVERALL VIEW OF THE HEALTHCARE SETTING
Plas Coch is a detached property situated in its own extensive grounds. It is located justoff the A525 on the outskirts of St. Asaph, near Rhyl in North Wales. It was previously aresidential property that has been converted over recent years to become a health careestablishment. The hospital is part of the Mental Health Care (UK) group.
In August 2007 Mental Health Care (UK) Ltd was acquired by Castlebeck Group Ltd. As aconsequence of this there have been significant changes to the senior management team.
In March 2008 Andrew MacGlashen was nominated to HIW to take over as theResponsible Individual.
The hospital is registered to accommodate 24 females with mental health needs and / orlearning disability who may be detained under provisions of the Mental Health Act 1983.
Services are provided for female patients only.
On the day of visiting there were 17 patients accommodated 14 of whom were detained inaccordance with the Mental Health Act 1983. On the day of visiting there were • 6 patients on Dinorben ward, which was staffed by 2 registered nurses and 6 care • 6 patients on Morfa ward, which was staffed by 2 registered nurses and 3 care • 5 patients in the Coach House, which was staffed by 2 registered nurses and 4 care Night staffing levels appeared satisfactory. The registered manager and the wardmanagers work in supernumerary capacity.
There is a varied programme of therapeutic activity at the hospital that is co-ordinated bythe occupational therapy team.
A comprehensive care and clinical review was conducted in December and January. Thisinvolved capturing the views of both staff and patients about what it is like to be in theservice and the way it is delivered. The review culminated in roadshows across the servicein March 2008 when the findings were reported back to patients and staff. A writtensummary of findings was produced which included an easy read version. This is to becommended.
The main inspection process was undertaken over the course of one day, with theInspections Manager gathering information. The Registered Manager Dafydd Lewis andmembers of staff were involved in the process and were open and professional inapproach.
Information was collated via analysis of documentation made available prior to and duringthe inspection, discussion with the staff team, a tour of the establishment and discussionwith a number of patients who were present.
A number of the care plans were scrutinised. Other aspects of methodology used duringthe inspection included direct observation of care and other practices.
A physical viewing of the premises and grounds was undertaken, and an examination ofpolicies, procedures, information leaflets, maintenance certificates and records. Theviewing included, by the agreement and invitation of occupants, the general condition ofindividual rooms. Communal areas, the laundry, bathroom and lavatory areas were alsoviewed.
The premises were inspected primarily against the Private and Voluntary Health Care(Wales) Regulations 2002, in addition to the core National Minimum Standards for Privateand Voluntary Healthcare services. These standards were also supplemented by theservice specific standards for mental health establishments, including the standards forestablishments where a persons may be detained under provisions of the Mental HealthAct 1983.
Inspector’s findings:
Statement of Purpose
The statement of purpose has been updated since the previous inspection. This will need
to be updated to incorporate details of the corporate changes.
Patient Guide
The inspections manager was advised at the previous inspection that each ward area
were in the process of producing individualised patient guides. The manager reported that
these have not yet been completed. This is an area that must now become a priority for
As stated in previous the last inspection report all patients must be assessed to determinetheir level of literacy and comprehension of information, and the outcome documented inthe medical record. Where it is found that information such as the patient guide isrequired in a revised format to assist comprehension, this must be provided to theindividual(s) concerned.
Notice Boards
A range of information was on display in the therapy areas. This included information on
groups in progress, smoking cessation, complaints process and the whistle-blowing
Arrangements for visiting
Visitors are encouraged not to visit when therapy programmes are underway. Family and
carers are invited to attend reviews and arrangements can be made in consultation with
Requirements made since the last inspection report which have been met:
Action Required
When Completed
Regulation Number
Requirements which remain outstanding from previous inspection activity:
Action Required
To have been
Regulation Number
completed by
include a summary of the Statement ofPurpose, the terms and conditions ofservices provided, a summary of themost recent quality of service/treatmentreview and information as to how themost recent inspection report can beprovided.
0607/a. All patients must be assessed 31 October 2007 comprehension and results must bedocumented in their records.
0607/b. Information for patients must 31 October 2007 New requirements from this inspection:
Action Required
Timescale for
Regulation Number
Inspector’s findings:
Clinical Governance
Agreed systems and processes are in place at Plas Coch as part of a corporate clinical
governance programme within Mental Health Care (UK).
A comprehensive care and clinical review was conducted during December 2007 andJanuary 2008. Senior staff from both MHC and Castlebeck who were from a range ofclinical backgrounds under took the review. The reviewed focussed on the experiences ofpatients and staff in receiving and delivering the service. At the end of the review thefindings were reported via a series of roadshows. A summary of findings was alsoproduced including an easy read version.
The findings of the review were reported under 12 key headings
1. Fundamental care of service users – service users reported they were happy with
the majority of their care, and overall care was deemed to be good. There werespecific ideas put forward for improvement.
2. Service user relationships – relationships were found to be well maintained and
supported with people both inside and outside the establishment.
3. Staff motivation – staff were actively engaged in the review and provided frank
feedback about problems and challenges as well as lots of ideas for improvement.
4. Need for a change in culture – the need for a more open, reflective and trusting
5. Health and safety issues – the need for a review of this particular area was
established to ensure all areas are identified and corrected.
6. Clinical model – the need for a clear clinical model was established. Since the
inspection the clinical model has been developed, communicated to HIW andimplementation has begun.
7. Role of nurses support workers – the need for nursing and support staff to be more
actively involved in therapies was identified. There was recognition of the trainingimplications of this.
8. Role of the manager – more responsibilities are to be devolved to managers at a
9. Staff support and communication – recognition of the need to ensure continuing
professional development, appraisal, supervision and peer support is available to allstaff. The development of an academic programme.
10. Training – need for specialist clinical training both at induction and ongoing.
11. Quality/ clinical governance – plan to integrate MHC clinical governance with that of
12. IT data systems – need to improve data systems and support for staff.
The comprehensiveness of the review and the depth of involvement of patients and staffboth in the review and the feedback is to be commended. The actions resulting from thereview will be monitored by HIW as part of the ongoing inspection programme.
Policies and procedures
There are a range of corporate policies and procedures in operation across the company.
A register of policies, procedures and protocols was seen that specifies the date the
document was agreed for circulation, the date due for review, and the date the document
was reviewed.
Care Programme Approach
A CPA policy was submitted to HIW. The manager reported that patient centred care is
being delivered through the implementation of the Care Programme Approach. The
multidisciplinary team meets regularly and reviews for each patient are held 6 monthly.
There was evidence that carers and family members are invited to CPA reviews.
The manager reported that the audit programme was being developed. This wouldinclude audit for CPA.
Patient Centred Care
HIW has been advised that the new model of care ‘SHARED’ (Supportive Help Achieving
Realistic and Effective development) to be implemented at Plas Coch is a user focussed
programme based on a recovery model, dialectical behavioural therapy and cognitive
behavioural therapy. It was reported that the model has been implemented in Castlebeck
services for some time and is being established as an accredited training programme
leading to degree level qualification via affiliation with the University of York.
Detailed activity plans were being developed for a number of patients. Nursing andoccupational therapy staff described a broad range of actives on offer for patients such ascollege attendance, horse riding, computer courses and adult learning.
Ward staff also gave accounts of patient holidays, and said that wherever possiblepatients have an annual holiday escorted by staff.
Patient mix
The patients accommodated at Plas Coch have a broad range of needs including
schizophrenia, learning disability, personality disorder and drug induced psychosis. There
is also a significant age range of patients. The manager reported that areas of specialism
and future provision at Plas Coch were under review as part of the action plan from the
clinical review. This will need to be reflected in an updated Statement of Purpose.
Patient Views
Staff reported that patient meetings are held regularly on each of the units. This provides
an opportunity raise any issues they may have. A number of patients asked to meet with
the inspections manager as part of the inspection. They were all happy with the care and
treatment received and said they would approach a member of staff if they had any
As referred to earlier in this report, patients were involved in focus groups to capture theirviews of the service as part of the clinical review.
Patients were complimentary about:ƒ The way they were treated by staff.
ƒ Availability of holidays.
ƒ Activities and educational opportunities.
ƒ Being able to make friends and their accommodation.
They identified the need for improvement in:ƒ Availability of cooking and activities at weekends and eveningsƒ Their involvement in planning meals and for meal times to be more relaxed.
ƒ Bathroom and toilet facilities.
ƒ Availability and number so staff to go out.
ƒ Clarity regarding the points reward system.
Advocacy arrangements
There is an agreement with Conwy and Denbighshire Mental Health Advocacy Service to
provide advocacy for patients at Plas Coch.
Privacy and dignity
Plas Coch is a female only service. The staff mix includes male and female staff, but
there are always female members of staff available to chaperone if required.
Each bedroom was personalised with a selection of belongings, hi-fi, TV and otherpersonal effects. One patient had their own Sky satellite dish and telephone to their room.
Each of the bedrooms has ensuite facilities so that occupants are able to manage theirpersonal hygiene in privacy.
Requirements made since the last inspection report which have been met:
Action Required
When Completed
Regulation Number
0506/2. A review date should be 18 May 2006 recorded on each policy document.
0607/c. There must be written policies 31 October 2007 with guidance issued by WelshAssembly Government, and whichhave an issue and review date.
0607/d. A clinical audit programme 31 October 2007 Requirements which remain outstanding from previous inspection activity:
Action Required
To have been
Regulation Number
completed by
0607/e. The clinical audit programme 31 March 2008 implemented.
0607/f. The multi disciplinary team 30 September 2007 all patients have a structured day andare able to benefit from the range oftherapies and activities on offer.
0607/g. The registered persons must 30 September 2007 Plas Coch to minimise any compromisein quality of the service caused aninappropriate mix of patients to becared for in the same area.
New requirements from this inspection:
Action Required
Timescale for
Regulation Number
Inspector’s findings:
Registered Manger
The registered manager of the hospital at the time of inspection was Mr Dafydd Lewis,
who is a registered mental health nurse, and has been the registered manager at Plas
Coch for some years.
Responsible Individual
Mr Bob Ellis was the responsible individual for New Hall and the other Mental Health Care
(UK) independent hospitals. There was evidence of visits as required in the regulations.
Regular meetings have also been developed with HIW to discuss progress and any
issues that may arise.
In March 2008 Andrew MacGlashen, Operations Director was identified as ResponsibleIndividual for Plas Coch and the other MHC (UK) independent hospitals in Wales.
Human Resource Policies
A range of corporate policies and procedures are produced and reviewed by the human
resources department at Mental Health Care (UK).
The staff team at Plas Coch includes the Manager and Deputy Manager, and a ward
manager for each of the wards. These staff are not incorporated into the daily staffing
numbers. There are no staffing notices in place for Plas Coch.
The manager reported in pre-inspection information that in the past 12 months 18 staffhad left the service, 15 staff had been recruited and there were 5 vacancies. This is ahigh turnover of staff and will be monitored by HIW.
On the day of inspection the following staff were present at the establishment. The staffteam at Plas Coch included • A ward manager and team of registered nurses and care support workers on Dinorben Ward, Morfa Ward and the Coach House • Housekeepers – 2 in post and a vacancy at time of inspection • Consultant Psychiatrist – a long term temporary arrangement in place.
• Occupational therapist and 2 OT technicians – there was a vacancy for the occupational therapist at the time of inspection.
• An administrator / receptionist.
The service has not had continuity from an occupational therapist for some time, whichimpacts on patient programmes. At the time of writing the report HIW was advised that anoccupational therapist had commenced within the service.
It is reported that the psychologist has expertise in the field of learning disability, and thatother members of staff have some experience in this area. HIW will follow up separatelythe issue of qualifications of staff because for the current conditions of registration toremain - being registered to accommodate 24 individuals with functional mental healthneeds and / or learning disability, there must be greater provision of staff withqualifications in learning disability.
Agency staff are also used at Plas Coch, the manager reported that they have been usedon 30 occasion of past 12 months.
There is an arrangement with the School of Health Care Sciences in Bangor that studentnurses are able to undertake placements at Plas Coch.
Supervision and Training
The manager reported that he provides supervision for the deputy manager and the 3
ward managers. Supervision is then cascaded through the staff at Plas Coch. The ward
managers supervise the registered nurses and the registered nurses supervise the care
support workers.
The manager reported that a training plan is in place and an annual training plan wasobserved to be on the wall in the office. This will assist in identifying those staff who haveand those who have not attended training. The manager reported that training wasfocussed on mandatory training such as fire, manual handling and first aid at the time ofinspection. He reported that training linked to clinical diagnosis of patientsaccommodated at Plas Coch was linked to supervision rather than formal training.
The registered persons must ensure that there is training for staff linked to the therapiesand treatments in the service to ensure all staff have the skills and competencies todeliver the to be provided statement of purpose.
Requirements made since the last inspection report which have been met:
Action Required
When Completed
Regulation Number
0607/h. Training records must be 31 October 2007 provision, non-attendance or identifyingthose due for updates can easily beidentified.
0607/j. A record must be maintained at 30 September 2007 Requirements which remain outstanding from previous inspection activity:
Action Required
To have been
Regulation Number
completed by
0607/i. There must be suitably 30 October 2007 nurses and other members if the multidisciplinary team to provide a servicefor those with a learning disability.
New requirements from this inspection:
Action Required
Timescale for
Regulation Number
0708/1 The registered persons must 31 August 2008 measures in place to improve retentionof staff.
0708/2 The registered persons must 31September 2008 linked to the therapies and treatmentsin the service to ensure all staff havethe skills and competencies to deliverthe to be provided statement ofpurpose.
Inspector’s findings:
Number of Complaints
The manager reported in the pre inspection information that 10 complaints had been
received during the year. These were predominantly in relation to one lady who
complains regularly.
The complaints log was not checked on this occasion. The manager reported that it iscomprehensive and kept up to date.
Information on complaints
There is a complaints policy and information on complaints on notice boards around the
As easy read information leaflet in relation to complaints has been developed for thosewho have limited literacy skills.
Whistleblowing policy
A Whistleblowing policy is available for staff to use as necessary and is advertised on
notice boards throughout the establishment.
Requirements made since the last inspection report which have been met:
Action Required
When Completed
Regulation Number
0607/k. Comprehensive record to be 30 September 2007 and dealt with in relation to Plas Coch.
0607/l. Information on complaints must 31 October 2007 Requirements which remain outstanding from previous inspection activity:
Action Required
To have been
Regulation Number
completed by
New requirements from this inspection:
Action Required
Timescale for
Regulation Number
Inspector’s findings:
Description of premises
Plas Coch was previously a residential property that was converted in 2001 to become a
healthcare establishment.
The establishment is accessed from the A525 dual carriageway to Rhyl just outside StAsaph. It is located in a rural area but there are other residential properties in the vicinity.
Plas Coch is reached via a short drive from the main road.
There is adequate parking at the establishment and the spaces are marked out to ensure
parking is in appropriate locations.
The exterior of the property was in need of redecoration on the day of inspection. Much ofthe external paintwork was cracked and peeling, especially on the windows. The managerreported there was a rolling programme of work, this needs to be adjusted to preventbuildings from looking neglected before work is allocated to them.
Dinorben Ward
is located on the ground floor of the main building. It is the ward to which
patients are admitted and assessed.
The ward area comprises 8 single bedrooms, a dining room which is shared with MorfaWard, two lounges, clinic room, nurses station and communal toilet and bathing faculties.
The following items were noted for action 1. The furniture in the smoking room required replacement2. Room 8 – bubble in the flooring – trip hazard.
Morfa Ward is located on the first floor in the main building. The ward comprises 8 single
bedrooms, kitchen/dining area, two lounges, clinic room, nurses station and communal
bathing and toilet facilities. It is the ward to which patients move when they are settled
and are preparing for discharge. There is a greater focus on rehabilitation and daily living
Patients have a choice to either eat in the dining room, or to prepare their own food andeat in the ward kitchen dining room. Each individual has a locked cupboard to store theirprovisions in the kitchen.
The Coach House is a separate 2-storey building to the rear of the premises. It provides
slow stream rehabilitation for 8 individuals and is generally an area where patients have
greater dependency on staff.
There is a separate kitchen, dining room, lounge, smoking room/conservatory andbedrooms. The dining room is used as an activity room at other times of the day andthere were colourful pictures on display in the area that had been completed by patients.
The following items were noted for action 1. Stairway – cracked window pane at top of the stairs2. Fire notices required details filled in.
3. Fridge /freezer door was broken – required replacement.
4. Condensation problems in the kitchen area.
5. Room 6 – there were cobwebs in room6. Room 7 – WC required a ‘deep clean’.
There is a maintenance person on site. However some of the maintenance that requires
action requires additional resource. The exterior of the building had not been addressed
at the time of inspection. The manager reported that the maintenance requirements had
been reviewed when Castlebeck acquired the company. The decision had been made to
focus on patient areas in the first instance and that staff and exterior work would follow
The registered manager reported that there were normally 3 housekeepers for Plas Coch.
There were 2 housekeepers in post and 1 vacancy on the day of inspection. Standards of
cleanliness were much improved since the last inspection, however there were still some
areas for improvement.
Therapy areas
The main therapy room is located inside the main entrance on Dinorben Ward. It is a
colourful room and there was evidence of the groups taking place such as creative
writing, well being group, smoking cessation, exercise and arts/ crafts. The OT
department also provide individual cooking assessments, adult learning/ literacy.
Kitchen and Catering
Records of fridge/ freezer and cooking temperatures were evident. The cook explained
that dry goods were ordered in bulk but meat, fruit and vegetables were obtained from
local suppliers.
Breakfast is usually cereals and toast, a cooked lunch is provided and then a light supper.
A copy of the last inspection report by the Food Safety Team/ Environmental HealthOfficer is requested. This must be accompanied by progress towards any actions thatwere required as a result of the inspection.
Offices – meeting rooms
Plas Coch has a large meeting room and a number of smaller rooms that are pleasantly
decorated and are able to offer accommodation for training, Mental Health Review
Tribunals and CPA reviews.
Relevant certificates were submitted with the pre inspection information to HIW. The
certificates and maintenance records were reviewed at the time of inspection.
There was evidence of weekly fire alarm tests, fire drills twice a year and fire training for
staff. The inspection manager advised the fire training should be incorporated into the
overall training record/plan for staff. The time to evacuate the premises was recorded at 2
minutes for the Coach House and 4 minutes for the main building.
Records were available to evidence fire extinguisher checks and a fire alarm inspectionand test within the previous12 months Equipment
A small lift is located in the main building. Servicing and maintenance certificates were in
place for this equipment.
Clinical Waste
Contracts were in place for the removal of clinical and pharmaceutical waste.
Outbuildings/ gardens
There are large grounds to the rear and the side of establishment some of which are used
by patients. It is suggested greater use could be made of these areas in providing
activities for patients.
Requirements made since the last inspection report which have been met:
Action Required
When Completed
Regulation Number
0506/3. Replace the carpet / floor 21 July 2006 the inspection visit.
0506/4. Provide adequate fire safety 14 October 2006 provisions to the consulting room onMorfa ward.
0607/p. Confirmation must be provided 30 September 2007 Safety Certificate of 03/07/06 has beencompleted.
0607/q. An action plan for the areas 30 September 2007 must be submitted as a component ofthe action plan to respond to thisreport.
Requirements which remain outstanding from previous inspection activity:
Action Required
To have been
Regulation Number
completed by
0607/m. The rolling programme of work 31 October 2007 buildings from looking neglected beforework is allocated to them. Externalwindows need painting.
0607/n. A suitable standard of 30 September 2007 areas. The registered manager mustprovide a report to HIW on how this willbe achieved and monitored.
0607/o. A review of the catering 30 September 2007 the amount of pre-heated food that isavailable for reheating, and to ensurethe catering arrangements meet theneeds of the establishment.
New requirements from this inspection:
Action Required
Timescale for
Regulation Number
0708/3 The following areas require 31 August 2008 4. Fire notices required details filled in.
5. Fridge /freezer door was broken – Condensation problems in thekitchen area.
0708/4 A copy of the last inspection 31 July 2008 Environmental Health Officer isrequested. This must be accompaniedby progress towards any actions thatwere required as a result of theinspection.
Inspector’s findings:
Risk Management Policy
A corporate risk management policy is in place.
Management of untoward incidents
The patients at Plas Coch present with complex and challenging behaviours. Untoward
incidents are reported in line with the requirements of Regulation 27.
In February 2008 there was an incident where the screws from one of the upstairswindows was removed by a patients using the arm from a pair of glasses. The patientsubsequently jumped from the window and suffered a fractured leg. As a result a checkwas required of all window and their security.
The untoward incident policy revised on 26/11/2007 does not cover all the aspectrequired in National Minimum Standard NMS M32 – Management of serious anduntoward incidents. The policy must be updated with this in mind. HIW requires a copy ofthe written review findings including recommendations and changes in practice.
Management of Violence and Aggression
Training is provided centrally to manage incidents of violence and aggression, this
comprises a 2-day course with a 1-day refresher. Seclusion is not provided at Plas Coch.
A policy for rapid tranquillisation is place. It is a priority that registered nurses receivetraining in administration of medical gases, anaphylaxis and first aid, and the equipmentavailable on the premises match that of the policy.
Each care plan also incorporates a risk assessment for the individual. Some patientskeep their own mobile telephones, the manager reported this decision is determined bythe individual risk assessment.
Resuscitation equipment
First aid kits and resuscitation equipment were in place. The manager reported that
resuscitation and anaphylaxis training was completed before Christmas.
Medicines Management
There is a contract in place with Crooks pharmacy in Queensferry for the supply of
medicines. Deliveries are made monthly, which arrive about a week before they are
Policies are in place for medicines management, self-administration of medicines andhomely administration of medicines. Records are kept to show when homely medicinesare administered. Staff reported that training in medicines management is provided at acorporate level. The responsibility for obtaining, prescribing, storing, use, handlingrecording and disposal of medicines is clear.
Staff reported that prescribing for physical conditions is carried out by a GP. Psychotropicprescribing is carried out by the psychiatrist.
All wards visited were asked about any information provided to service users about theirmedicines. Staff reported that patients are informed by the psychiatrist about themedicines they will be taking. It would be valuable if a range of information leaflets wereavailable for commonly used medicines, suitable for service users’ needs.
The following areas for action were identified1. Audit checks at the Coach House appeared haphazard. Check must be in line with the agreed policies and procedure for the safe running of the establishment.
2. All fridges for storage of medicines must have a maximum/minimum thermometer fridge. These temperatures must be recorded and actions taken if the temperature isoutside the safe range. On Dinorben Ward several fridge readings were taken andgave negative temperatures. It was not clear what action had been taken to ensurethe medicines were safe to use.
3. A photograph of the patient must be attached to the MAR sheet. On Morfa Ward it was reported that the patient had refused.
4. An up to date BNF must be available on each ward.
5. Members of staff interviewed at the time of inspection were not certain about procedures for unused CDs. There was no evidence of the usage of Controlled Drugsat the time of inspection.
6. Clozaril monitoring records were on cupboard in the clinic, but no evidence was seen 7. Staff must check that labels on medicines are clear, and take appropriate action if they 8. A response to the areas for action identified in the internal medicines audit undertaken by Christine Okafor on 26 November 2007.
Mental Health Act
The Mental Health Act Commission visited Plas Coch on 30 August 2007 to review
conditions for patients detained under the Mental Health Act 1983. File, records and
documents were found to be well-organised and easy to access with legal documentation
in good order.
5 Recommendations were made as a result of this visit.
1. To provide the MHAC with the outcome of the investigation regarding the observed, in appropriate staff interaction with a patient at the Coach House.
2. To ensure there are sufficient members of staff to meet the changed needs of the patients on the Coach House, which includes the provision of occupational therapyservices.
3. To review the operation of the locked door policy on Dinorben Ward and advise 4. To ensure there is continuity of OT services on Morfa Ward.
5. To consider reviewing the psychology input and frequency of senior house officer input for patients who require medical attention.
Requirements made since the last inspection report which have been met:
Action Required
When Completed
Regulation Number
0607/s. There must be a record in 31 August 2007 resuscitation equipment and first aidkits0607/t. A medicines management audit 31 October 2007 must be undertaken at least monthly.
The audit must incorporate monitoringof• Drs signature prior to administration Requirements which remain outstanding from previous inspection activity:
Action Required
To have been
Regulation Number
completed by
0607/r. The resuscitation policy must 30 September 2007 Confirmation must be provided thattraining and equipment is in place tosafely and effectively implement eachof these policies.
0607/u. HIW must receive confirmation 30 September 2007 New requirements from this inspection:
Action Required
Timescale for
Regulation Number
0708/5 The Management of serious 31 September 2008 updating to address all aspects of NMSM32.
0708/6 HIW requires a copy of the 31 July 2008 plans in relation to incident on 23/02/080708/7 Medicines audit checks at the 31 August 2008 agreed policies and procedure for thesafe running of the establishment.
0708/8 All fridges for storage of 31 July 2008 maximum/minimum thermometerfridge. Temperatures must be recordedand appropriate actions taken if thetemperature is outside the safe range.
0708/9 An up to date BNF must be 31 August 2008 0708/10 A photograph of the patient 31 August 2008 sheet.
0708/11 All registered nurses must be 31 August 2008 CDs.
0708/12 Clozaril monitoring records 31 August 2008 should be evident with the MAR sheet.
0708/13 Staff must check that labels on 31 August 2008 appropriate action if they are not.
0708/14 HIW requires confirmation of 31 July 2008 internal medicines audit undertaken byChristine Okafor on 26 November2007.
0708/15 An update in response to the 31 August 2008 is to be provided as part of theresponse to this report.
Inspector’s findings:
Data Protection Act
There was evidence that staff and patient records are stored to meet the requirements of
the Data Protection Act.
Staff Records
Ten staff personnel files were perused. The files constituted a representative sample of
staff from all healthcare disciplines. The wording of recruitment documentation is
consistent and correct. Two referees from previous employers are sought wherever
practicable, in line with the Private and Voluntary Healthcare (Wales) Regulations 2002.
It is noted as good practice that application pre-screening forms are used as part of therecruitment procedure.
Up-to-date Criminal Records Bureau disclosure numbers were found on every staff fileperused. Personnel file checklists are used to ensure that all required information is onfile prior to the start date of each member of staff.
Written records of interviews for each member of staff were also viewed. These recordsincluded questions, answers and scoring forms used by interviewers. It was noted thatreference request forms were updated in 2006. As a result, the questions posed in post-2006 reference requests and the information provided by referees is detailed andthorough.
Significant progress had been made in terms of ensuring all staff members undertookmandatory training sessions. Some up-to-date certificates and training planning chartswere viewed. It is recommended that to evidence this work, all up-to-date trainingcertificates or copies should be placed on personnel files as soon as they are received.
Records held at the head office were checked as part of the inspection. It was noted thatthe Responsible Individual and the Director of Legal Services did not have a CRB thathad been issued in the last 3 years. A written notification for action was issued andconfirmation was subsequently received that this had been rectified.
Patient records
A sample of records were reviewed on inspection. Entries were generally noted to be
compliant with the requirements of the national minimum standards.
Comprehensive care plans were in place for each patient that had been regularlyreviewed and informed by risk assessment.
It was evident form the records that each discipline is represented and contributes to thecare team meeting. Staff reported that primary nurses create care plans but are notpresent at multi disciplinary team reviews. It is suggested this practice is reviewed tomaximise the continuity of care for patients.
At the last inspection it was noted that seized patient property forms were in use forpatients in the Coach House where property identified as a risk to the individual had beenremoved. The inspections manager advised that all such forms must be dated, and arecord and copy must be maintained of the return of such property. There was noevidence that t this had been actionedHN/Plas Coch/0708 Patient Money
A random check was made on the patient money records and balances held on the ward.
The records appeared to be in good order and the balances tallied with the records.
At the last inspection the social worker reported having difficulty with one of the localauthorities in Wales who said they were not able to process a referral to the Court ofProtection. Confirmation is required whether this has now been actioned.
Staff reported that patients at Plas Coch receive an annual allowance of £250 to assistwith clothing purchases. Each patient also benefits from an annual allowance of £260towards a holiday.
Requirements made since the last inspection report which have been met:
Action Required
When Completed
Regulation Number
0607/x. There must be records 30 September 2007 purposes of the establishment tocomply with regulatory requirements.
0607/w. The registered person must 30 September 2007 on which professionals make theirentries into patient records, to ensureit is fit for purpose and is line withestablished best practice.
Requirements which remain outstanding from previous inspection activity:
Action Required
To have been
Regulation Number
completed by
0607/v. All property forms must show 30 September 2007 returned must be recorded.
0607/y. Confirmation must be received 30 September 2007 that all patients required to be referred to the Court of Protection have has thisdone.
New requirements from this inspection:
Action Required
Timescale for
Regulation Number
Inspector’s findings:
It was reported that no research is undertaken in the establishment. The previous report
advised that the manager must be assured that any staff undertaking academic study
involving a research project and using information from the service provided at Plas Coch
area ware of the requirements to gain relevant approval.
The manager reported that the policy was under review at the time of inspection.
Requirements made since the last inspection report which have been met:
Action Required
When Completed
Regulation Number
Requirements which remain outstanding from previous inspection activity:
Action Required
To have been
Regulation Number
completed by
0607/z. Research policy must be 30 September 2007 published guidance from WelshAssembly Government and theimplementation of the Mental CapacityAct New requirements from this inspection:
Action Required
Timescale for
Regulation Number
Inspector’s findings:
The focus of the inspection and report for this year has been to report on compliance with
the requirements made previously in the context of the compliance with standards and
regulations made under the Care Standards Act 2000.
Submission of a detailed action plan in relation to the 14 outstanding and 16 newrequirements is required as a result of this report as set out below.
The registered person must ensure that the action plan submitted identifies the actionstaken in relation to the requirements and progress up to the time of submission of theaction plan.
An action plan was received in September 2007 in response to the previous report but 2monthly updates have not been received at HIW as required in the report. Whereconfirmation has not been received that a requirement has been met, it will be carriedforward until HIW is satisfied that there is no longer a breach of regulations.
New requirements from this inspection:
Action Required
When Completed
Regulation Number
0708/16 HIW requires the submission 31 August 2008 of an action plan addressing all the 30 November 2008 requirements made this year and those 28 February 2009 may at any time require aperson who carries on or which the registrationauthority considers monthly, and a copy submitted toHIW on the last day of the thirdmonth until all requirements havebeen met.
Inspector’s Name: H Nethercott
Date: 2nd September 2008
Inspector’s Signature:


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