NHS Greater Glasgow & Clyde

Adults with Incapacity (Scotland) Act 2000

Report of the Supervisory Body to Board Clinical Governance Committee on Operation of Part 4

For the year 2011

Anne Hawkins Director Glasgow City CHP William Street Clinic 120 William Street Glasgow G3 8UR

October 2012

Page 1 of 23

Contents Page Page No

1. Introduction 3

AWIA Context and Overview of Act 3 Board’s role under Part 4 6 DWP Appointeeships 6

2. Role of Supervisory Body 6

3. Policy & Operational Procedure 7

4. Management of Funds 7

5. Training Activity 8

6. Inspection and Monitoring 9

7. Policy Development 10

Page 2 of 23 1. Introduction

(a) Adults with Incapacity and Overview of the Act

1.1 The Adults with Incapacity (Scotland) Act 2000 provides a framework for decisions to be made on behalf of adults (those aged 16 years or over) who lack the ability (capacity) to make decisions about their own finances or welfare, including decisions about medical treatment. It provides a regulated structure which allows others to make decisions on individual’s behalf subject to safeguards and in specific well-defined situations.

1.2 The basis for “incapacity” as defined in the Act is either mental illness or inability to communicate (normally due to a physical condition). The main groups to benefit include people with dementia, people with a learning disability, people with an acquired brain injury or severe and chronic mental illness, and people with a severe sensory impairment.

1.3 The Act aims to ensure that solutions focus on the needs of the individual: for example, a person with dementia may be able to decide what sort of support he/she would prefer to help with day to day living, but be unable to manage his/her money. In such a case a financial intervention may be all that is needed. In other circumstances a combination of welfare and financial measures may be necessary.

1.4 The Act is divided into a number of distinct Parts each dealing with certain circumstances.

Part 1 sets out the general principles of the Act.

Part 2 covers both Welfare and Financial Power of Attorney and allows an individual who currently has the capacity to make decisions to plan for the future and specify how and who should act for them in the future should they become incapable to act for themselves. They do this by executing a formal legal document and registering it with the Public Guardian who supervises this Part of the Act.

Part 3 is about making arrangements to Access Funds of an Adult where they are no longer able to manage their affairs. This Section is also overseen by the Public Guardian and is limited to withdrawal of monies from established bank accounts etc to meet on-going day to day living expenses. An Access to Funds Order is sought by a relative, carer or approved organisation.

Part 4 allows a hospital or care home manager to manage the finances of residents who do not have capacity to do so themselves. This report is about the Health Board’s role in this respect. More detail is given below.

Part 5 allows treatment to be given to safeguard or promote the physical or mental health of an adult who is incapable of giving or refusing consent to the treatment in question.

Page 3 of 23 Part 6 Covers Intervention and Guardianship Orders where a carer, relative or local authority can apply to the Sheriff Court for either:-

An Intervention Order – where a one off decision is required on behalf of the adult who lacks capacity to make it; or

A Guardianship Order which is more appropriate where there is an ongoing need to manage complex on–going issues.

Both these types of Orders can cover Financial and Welfare matters.

1.5 The Act is founded on a number of underlying principles. As such the Act aims to protect people who lack capacity to make particular decisions, but also to support their involvement in making decisions about their own lives as far as they are able to do so. Anyone authorised to make decisions made on behalf of someone with impaired capacity must apply the following principles:

Principle 1 – benefit

• Any action or decision taken must benefit the person and only be taken when that benefit cannot reasonably be achieved without it.

Principle 2 – least restrictive option

• Any action or decision taken should be the minimum necessary to achieve the purpose. It should be the option that restricts the person’s freedom as little as possible.

Principle 3 – take account of the wishes of the person

• In deciding if an action or decision is to be made, and what that should be, account must be taken of the present and past wishes and feelings of the person, as far as this may be ascertained. Some adults will be able to express their wishes and feelings clearly, even although they would not be capable of taking the action or decision which is being considering. For example, he/she may continue to have opinions about a particular item of household expenditure without being able to carry out the transaction personally.

Principle 4 – consultation with relevant others

• Take account of the views of others with an interest in the person’s welfare. The Act lists those who should be consulted whenever practicable and reasonable. It includes the person’s primary carer, nearest relative, named person, attorney or guardian (if there is one).

Principle 5 – encourage the person to use existing skills and develop new skills

Page 4 of 23 (b) Board’s Role under Part 4

1.6 As indicated above, Part 4 allows a hospital or care home manager to manage the finances of residents who do not have capacity to do so themselves subject to compliance with relevant procedures and compliance with the Act and a Code of Practice issued by the Scottish Government in July 20031. For Care Homes and NHS residential premises, the “Supervisory Body” is responsible for overseeing the operation of Part 4 of the Act2. The Supervisory Body in relation to Care Homes is the Care Commission and for NHS premises it is the relevant Health Board. Within NHS Greater Glasgow & Clyde the responsibilities of the Supervisory Body have been delegated to a Group lead by the Director of Glasgow City CHP. Also in membership are the Lead Associate Medical Director and the Nurse Director of Mental Health Services together with the Head of Nursing for the RAD and Clinical Services Manager Emergency Care. The Group is supported by the Legislation Team and the Glasgow City CHP Head of Administration.

1.7 Part 4 is seen as a default power to intervene where the other provisions within the Act have not been invoked. Within the NHS setting all residential establishments are issued with a Note of Authority to manage residents’ financial affairs. Such Notes are issued once the Supervisory Body is satisfied that the necessary procedures are in place. Notices last for a maximum of one year and then require to be renewed. Within NHS Greater Glasgow & Clyde three separate Registers of Authorised Establishments are maintained covering:-

• Adult RAD and Acute Physical In-patient Services

• Older People’s Services within CH(C)Ps

• Adult Mental Health, Learning Disabilities and Addictions.

A copy of the Registers as at December 2011 is attached as Appendix A to this report.

1.8 As well as authorising the establishments, named individuals (and deputies) are appointed as authorised managers to manage patients' funds under the Act. Under the Act they require to be issued with a Note of Authority to act.

1.9 Authorised managers then need to be granted a Certificate of Authority to manage the affairs of each named resident who is covered by Part 4 of the Act.

1 Code of Practice for Supervisory Bodies under Part 4 of the Act ISBN 0 7559 1041 9 2 The State Hospital Board performs this role in relation to the State Hospital Page 5 of 23

(c) Department of Work and Pensions Appointeeships

1.10 Alongside the provisions relating to Part 4, staff of the Board are often appointed to administer State Pension Benefits received by residents. These arrangements are separate from the Part 4 provisions but as a general rule the same principles about accounting for monies entrusted to the Board’s Officers apply in these cases and the funding managed is monitored by the Supervisory Body.

2. Role of the Supervisory Body

2.1 The Supervisory Body is responsible for monitoring and reviewing the manner in which managers of authorised NHS establishments are conducting the management of residents’ funds under Part 4 of the Act. For this purpose the Supervisory Body:-

• approves and periodically revises Policy and Operational Procedures;

• reviews and approves the inclusion of Authorised Establishments on the Register, issues Notes of Authority to Managers and Deputies and approves issue of Certificates of Authority in relation to individual patients;

• monitors activity and local procedures to ensure compliance with NHS Greater Glasgow & Clyde Financial Operating Procedures;

• commissions regular inspection visits to Authorised Establishments and Managers;

• oversees a continual programme of training in the operation of the Act for staff; and

• has responsibility for investigating any complaints received or commissioning enquiries as it thinks fit.

2.2 Where it is appropriate, the Supervisory Body can approve that procedural requirements about intimation to patients of the intention to apply for authorisation to manage funds is not made. It also has a role where an Authorised Manager proposes to dispose of any moveable property of a resident in excess of £100 or where it is proposed to hold residents funds under Part 4 in excess of £10,000. Such requests are time limited to ensure that monies are spent for the benefit of residents and that other more appropriate means of managing their financial affairs are fully explored.

Page 6 of 23 3. Policy & Operational Procedures

3.1 One standard Policy and Operational Procedure applies across the Board area. Within the document there is included sample letters and forms for use by Authorised Managers. The Policy and Operating Procedure was reviewed in November 2011 and the current Policy and Operational Procedures are due for further review in December 2013.

3.2 Within the Policy and Operational Procedure the role of the Authorised Manager is clearly set out as is the Inspection and Monitoring arrangements which are undertaken by the Legislation Team. Feedback from Inspection and Monitoring visits is provided to relevant Authorised Managers and responsible Directors. An important element of the Monitoring procedure is the sharing of good practice (See Section 6 below).

4. Management of Funds

4.1 NHS Greater Glasgow and Clyde published financial accounts at 31 March 2011 showing funds held in patients’ private funds accounts amounted to £3,658,574. These funds were held on behalf of approximately 900 patients at 18 hospital sites. Only a small proportion of patients have their funds managed under Part 4 as illustrated in Table 1

Table 1 – Management of Funds for the Calendar Year 2011 – AWIA Part 4

Pending Part 4 at New in Revocations at Year Part 4 at Location 01.01.11 Year in Year End 31.12.2011 Adult Mental Health Learning Disability Addictions and Adolescent 73 28 9 0 92 Older People Mental Health within CHP/CHCP 53 2 11 0 44 Adult RAD and Acute Physical Inpatient Resident Services 7 1 0 0 8 Total 133 31 20 0 144

Page 7 of 23

4.2 There continues to be a higher number of DWP Appointeeships held as shown in Table 2.

Table 2 - Management of Funds - DWP Appointeeships for the Calendar Year 2011

Pending DWP at New in Revocations at Year DWP at Location 01.01.11 Year in Year End 31.12.2011 Adult Mental Health Learning Disability Addictions and Adolescent 130 37 30 1 138 Older People Mental Health within CHP/ CHCP 75 17 30 1 63 Adult RAD and Acute Physical Inpatient Resident Services 10 1 9 Total 215 54 61 2 210

4.3 Table 3 shows details of the relative position between Part 4 and DWP Appointees within Mental Health Services at the start and end of the year by value of funds held.

Table 3 – Snapshot of Value of Individual Funds Managed

< £10,000 > £10,000 > £20,000 > £30,000 >75,000.00 01.01.2011 AWIA 48 39 31 14 1 DWP 121 40 32 15 1 31.12.2011 AWIA 62 23 28 29 2 DWP 128 23 28 29 2

5. Training Activity

5.1 Training has been delivered during 2011 in a variety of different forms:

• A stand alone module delivered on a once per month basis available to all key staff with priority to Authorised Managers and Patient Affairs / Cashier staff. • A stand alone module delivered on-site to staff groups, predominantly Nursing and Patient Affairs staff, closely linked to training needs identified during Inspection and Monitoring visits. • On a one to one basis for key personnel.

Page 8 of 23 • As a shortened version incorporated into the AWIA introductory training. The training covers the provisions in the Act relating to the Management of Residents Finances; it is open to healthcare staff who would be involved in decisions about the management of patients’ finances. It is expected that this will be Patient Affairs / Cashiers, Medical staff, Ward Managers, Charge Nurses and Senior Staff Nurses.

5.2 The overall Aims and Objectives have been:-

• To provide a working knowledge of provisions within the Act relating to the Management of Residents Finances. • To improve the knowledge base of staff in relation to the Act

5.3 By the end of a session it is intended that staff will have, through discussion:

• Demonstrated an understanding of the roles of the Supervisory Body and Authorised Managers • Demonstrated an understanding of the application process • Demonstrated an understanding of their role in the ongoing management of funds • Knowledge on how to seek appropriate support

5.4 Appendix B provides a detailed breakdown of the categories of staff and areas where training has been delivered during the year.

6. Inspection and Monitoring

6.1 A summary of the number and findings from Inspection and Monitoring visits undertaken during the year is provided at Appendix C. Arising from these visits a number of good practices have been identified and shared with Authorised Managers. Examples include:

• Lead Nurse retains copies of Certificates of Authority, MDRT/Part 4 Minutes in folder for all patients in her area of responsibility. • Note of Authority is copied, laminated and posted on each ward. • Full minutes retained in case notes and records. Good record keeping showing AWI principles are in operation • Supporting evidence freely available and well documented utilisation of patients’ funds to allow relatives to visit from abroad • Encouraging skills of individuals in work placements • The team plan is to improve practice by developing a monthly check list template to capture issue of notification to Supervisory Body and seek a regular Bed Management Report to continue to ensure assessment of Capacity requirements on six monthly basis. • Residents have attended Money Management Course at Reid Kerr College • Resident funds used to purchase PC’s for 2 individuals.

Page 9 of 23 • Pictorial care plans in place for each resident includes legislative position e.g. Part 4 and involves Speech and Language Therapists.

6.2 During the latter half of 2009 the Lead Director commissioned the Internal Auditors, PriceWaterhouseCoopers to conduct a review of our procedures under Part 4 of the Act. The scope of the review was to independently review and confirm that appropriate arrangements have been implemented to meet the requirements of the Act. Feedback was generally positive. Recommendations made on reviewing the frequency of inspection monitoring and adjustment of the template used to make it more specific in terms of checking conformity for each resident with the Act’s provisions have both been given further consideration by the Supervisory Body. The inspection tool and template has been reviewed and improvements are now implemented.

6.3 Arising from individual cases the Supervisory Body in 2011 produced Good Practice Guidelines which have been circulated to Authorised Managers to assist them in maximising the benefit to residents from the utilisation of funds in innovative ways. These were developed in association with the MHS Patient Focus and Public Involvement Forum.

7. Future Policy

7.1 During late 2008 the Scottish Government Health Analytical Services Division on behalf of the Primary and Community Care Directorate, Community Care Division commissioned research into Part 4. The aims of the study were to:

• assess the effectiveness of Part 4 of the Act including: the uptake; benefits to residents; and key stakeholders’ experiences of using the provisions in Part 4 of the Act; and

• make recommendations on any action needed.

• The research found that there was a very low level of uptake of AWI Part 4 across all sectors.

7.2 Whilst the research was reported in December 2009 as yet, again this year, there has been no response to its finding from the Scottish Government. Those recommendations which are within the control of the Supervisory Body e.g. encouraging expenditure on befriending services are being promoted within NHS Greater Glasgow & Clyde.

8. Conclusion

8.1 The responsibilities under Part 4 of the Act relate primarily, but not exclusively, to those who lack capacity due to mental illness. The Director of Glasgow City Community Health Partnership (CHP) has lead accountability to the Board for ensuring that the Board’s obligations across the organisation for AWIA Part 4 are met. This is achieved through the Supervisory Body which is a formally constituted Committee of the Board. The Supervisory Body originally reported to the Mental Health Partnership Committee and now following the disbanding of that Page 10 of 23 Committee to the Mental Health Services Quality and Clinical Governance Committee.

8.2 During the year 2011 considerable effort has been expended in completion of the annual inspection and monitoring programme, reviewing the monitoring template and implementing improvements. The good practice guidelines entitled ‘Guide to the purchase of goods and services through the use of personal funds’ have been widely distributed. Training has been developed to include a specific financial management module and has been delivered to an extensive group of staff at a variety of venues and sites and individual Authorised Managers and teams have been supported to progress applications. The Legislation Team will continue to provide support to all sectors of the Board with responsibilities for adults with incapacity under Part 4 of the Act.

E Anne Hawkins Director Glasgow City CHP October 2012

Page 11 of 23

Appendix A

ADULTS WITH INCAPACITY (SCOTLAND) ACT 2000 MANAGEMENT OF RESIDENTS FUNDS REGISTER OF AUTHORISED ESTABLISHMENTS 1

Adult Mental Health, Learning Disability, Forensic, Senior Officer Dr Michael Smith Addictions and Adolescent Deputising Officer Anne Hawkins

In-Patient Area Authorised Responsible for Authorised Establishment Manager/Deputy North West Glasgow AMH Colin McCormack Gartnavel Royal Hospital All Adult MH in- Colin McCormack Head of Mental Health 1055 Great Western Rd patient services GRH Tom McKay Glasgow G12 0XH site North East Glasgow AMH David McCrae Stobhill Hospital, a) Adult Wards - David McCrae Head of Mental Health Mackinnon House MacKinnon House, a) & b) Mary 133 Balornock Road Stobhill O’Donnell Glasgow G21 3UZ

The Orchards (formerly b) Adult Wards – Ruchill Hospital) Orchards (formally 153, Panmuir Street, Ruchill Hospital) Glasgow

Parkhead Hospital c) Adult Wards - c) Bob Gillies 81 Salamanca Street Parkhead Hospital Glasgow G31 5ES South Glasgow AMH Calum MacLeod Leverndale Hospital All adult admission Calum MacLeod Head of Mental Health 510 Crookston Road long stay & rehab. June MacLeod Glasgow G53 7TU Wards, Leverndale,

Southern Gen. Hospital Wards 31+32 SGH. 1345 Govan Road Glasgow G42 9TY

Renfrew AMH Fiona McNeill Dykebar Hospital, a) all adult Katrina Phillips General Manager – Clyde MH Grahamston Road, admissions Alexander Buchanan Paisley, continuing care & Renfrewshire Rehabilitation wards- PA2 7DE Dykebar

Royal Alexandra Hospital, b) all adult MH Katrina Phillips Corsebar Road, admission wards – Alexander Buchanan Paisley, Dykebar & RAH Renfrewshire PA2 9PN

Page 12 of 23 Inverclyde AMH Susanna McCorry-Rice Ravenscraig Hospital, Corlic C –AMH John Mitchell Head of Mental Health Inverkip Road, continuing care & Gillian Robb Greenock Rehabilitation ward PA16 9HA

Inverclyde Royal Hospital IRH – Adult MH Larkfield Road, admission ward & Greenock IPCU PA16 0XN West Dunbarton AMH David Elliott Vale of Leven Hospital, All AMH – Vale of David Elliott General Manager Main Street, Leven Hospital Lynne Kennedy Alexandria, Dunbartonshire. G83 0UA NHS GGC Forensic Martin Montgomery Leverndale Hospital a) All Forensic Wards Martin Montgomery General Manager 510 Crookston Road Leverndale, Wards Jane Cairney Glasgow G53 7TU 5+6, Campsie, Whitehouse, Boulevard and Balloch

Rowanbank Clinic b) All Forensic Wards, Stobhill Hospital, Rowanbank Clinic 133 Balornock Road Glasgow G21 3UZ

NHS GGC Addictions Eric Steel Eriskay House, All in-patient Addictions Eric Steel Head of Addictions NE Stobhill Hospital, beds Stobhill campus. Gail Reid 133 Balornock Road Glasgow G21 3UZ

Kershaw Unit All in-patient Addictions Gartnavel Royal Hospital beds Gartnavel 1055 Gt Western Road campus. Glasgow G12 0XH Clyde Learning Disability Martin Montgomery Blythswood House, All LD in–patient beds - Martin Montgomery General Manager Fulbar Lane, Clyde Tom Kelly GGC Forensics R Renfrew GG Learning Disability Martin Montgomery 2 & 4 Waterloo Close All NHS in –patient Martin Montgomery Joint General Manager Kirkintilloch beds – LD Partnership Fiona Roberts Greater Glasgow Learning Glasgow G66 2Hl Disabilities Partnership Netherton 19 Blackwood Street Anniesland Glasgow G13 1AL

Overtoun Court 65 Rodger Drive Rutherglen Glasgow G73 3QZ

Pineview In-patient Unit Canniesburn Hospital Switchback Road, Bearsden G61 1QL

09.01.2012 Page 13 of 23

NHS GGC Adolescent Alex Fleming Skye House All in-patient Alex Fleming Service Manager Stobhill Hospital adolescent beds – Lauren McLelland 133 Balornock Road Stobhill campus Glasgow G21 3UZ Inverclyde AMH Susanna McCorry-Rice Ravenscraig Hospital, Corlic C & D –AMH John Mitchell Head of Mental Health Inverkip Road, continuing care & Gillian Robb Greenock Rehabilitation wards PA16 9HA & Gryffe unit

Inverclyde Royal Hospital IRH – Adult MH Larkfield Road, admission wards Greenock PA16 0XN West Dunbarton AMH John Russell Vale of Leven Hospital, All AMH - Christie Lynne Kennedy General Manager Main Street, Ward Paul McLeod Alexandria, Dunbartonshire. G83 0UA NHS GGC Forensic Martin Montgomery Leverndale Hospital a) All Forensic Wards Martin Montgomery General Manager 510 Crookston Road Leverndale, Wards Barbara Wilson Glasgow G53 7TU 5+6, Campsie, Whitehouse, Boulevard Rowanbank Clinic and Balloch Stobhill Hospital, 133 Balornock Road b) All Forensic Wards, Glasgow G21 3UZ Rowanbank Clinic

Dykebar Hospital, c) Bute Ward, Dykebar Grahamston Road, Paisley PA2 7DE NHS GGC Addictions Eric Steel Eriskay House, All in-patient Addictions Eric Steel Acting General Manager, Stobhill Hospital, beds Stobhill campus. Gail Reid Glasgow Addictions 133 Balornock Road Partnership Glasgow G21 3UZ Clyde Learning Disability Martin Montgomery Blythswood House, All LD in–patient beds - Martin Montgomery General Manager Fulbar Lane, Clyde Tom Kelly GGC Forensics R Renfrew GG Learning Disability Martin Montgomery 2 & 4 Waterloo Close All NHS in –patient Fiona Roberts General Manager Kirkintilloch beds – LD Partnership Learning Disabilities Glasgow G66 2Hl

Netherton 19 Blackwood Street Anniesland Glasgow G13 1AL

Overtoun Court 65 Rodger Drive Rutherglen Glasgow G73 3QZ

NHS GGC Adolescent Alex Fleming Skye House All in-patient Alex Fleming Service Manager Stobhill Hospital adolescent beds – Lauren McLelland 133 Balornock Road Stobhill campus Glasgow G21 3UZ

09.01.2012 Page 14 of 23

ADULTS WITH INCAPACITY (SCOTLAND) ACT 2000 MANAGEMENT OF RESIDENTS FUNDS REGISTER OF AUTHORISED ESTABLISHMENTS 2

Older People Mental Health within CHCP/CHP Senior Officer Mari Brannigan Deputising Officer Andrew Strachan

In-Patient Area Authorised Responsible for Authorised Establishment Manager/Deputy North West Glasgow MH Colin McCormack Gartnavel Royal Hospital OPMH wards Colin McCormack Head of Mental Health 1055 Great Western Rd Glasgow G12 0XH Tom MacKay

North East Glasgow MH David McCrae Stobhill Hospital a) OPMH wards David McCrae Head of mental Health 133, Balornock Road, a, b & c) Alison Paterson Glasgow G21 3UZ

Birdston N.H. b) OPMH wards Birdston Road, Milton of Campsie G66

The Orchards c) OPMH wards 153 Panmure Street, Glasgow G31 5ES

Parkhead Hospital d) OPMH wards d) Bob Gillies 81 Salamanca Street Glasgow G31 5ES South Glasgow MH Jillian Torrens Leverndale Hospital OPMH wards Jillian Torrens Adult Services Manager 510 Crookston Road Christine Murphy Glasgow G53 7TU

Darnley Court N.H. OPMH wards 787, Nitshill Road, Glasgow G53

Rodgerpark N.H. OPMH wards 10, Rodger Drive, Glasgow G73 Renfrew MH Fiona McNeill Dykebar Hospital, OPMH wards Katrina Phillips General Manager – Clyde MH Grahamston Road, Alistair Barclay Paisley, Renfrewshire PA2 7DE

Royal Alexandra Hospital, OPMH wards Corsebar Road, Paisley, Renfrewshire PA2 9PN

09.01.2012 Page 15 of 23 Inverclyde MH Susanna McCorry-Rice Ravenscraig Hospital, Dunrod – OPMH John Mitchell Head of Mental Health Inverkip Road, ward Ravenscraig Gillian Robb Greenock PA16 9HA

Larkfield Unit Ward 4 Larkfield Unit Ward 4 Larkfield Road, OPMH admission Greenock ward PA16 0XN West Dumbarton MH David Elliott Vale of Leven Hospital, OPMH wards Lynne Kennedy Head of Mental Health Main Street, a) Karen Masson Alexandria, Dunbartonshire. G83 0UA

Dumbarton Joint Hospital, OPMH wards b) Teresa McKernan Cardross Road, Dumbarton, Dunbartonshire G82 5JA

Page 16 of 23

ADULTS WITH INCAPACITY (SCOTLAND) ACT 2000 MANAGEMENT OF RESIDENTS FUNDS REGISTER OF AUTHORISED ESTABLISHMENTS 3

Adult RAD & Acute Physical In-patient Senior Officer Jacqueline Nicol resident services A&E Dept Western Lead Responsibility Older People’s Services Deputising Officer Elaine Burt Anne Harkness - Director, RAD Management Offices SGH Responsible for Area Authorised Responsible for Authorised Establishment Manager/Deputy West Glasgow a) Western Infirmary All wards Western Infirmary a) Liam Gallagher Dunbarton Road Site Facilities Manager Glasgow G11 6NT a) Audrey Blair Site Facilities Manager

b) Gartnavel General All wards Gartnavel General (b & c) Stuart Campbell Hospital Hospital Site Facilities Manager 1053 Great Western Road Glasgow G12 0NY

c) Glasgow Homeopathic All Wards Homeopathic Hospital Hospital 1053 Great Western Road Glasgow G12 0NY

d) Drumchapel Hospital d) All Elderly & Rehabilitation d & e) Maria Pitticas 129 Drumchapel Road in-patient services (Bute, Facilities Manager Glasgow G15 6PX Cumbrae, Arran & Kintyre Wards)

e) Blawarthill Hospital e) All Elderly in-patient and 129 Holehouse Drive Continuing Care Wards (Islay GlasgowG13 3TG & Tiree)

f) St Margaret’s of f)Continuing Care partnership f) John McLintock Scotland Hospice Elderly beds Hospital Administrator East Barns Street Clydebank G81 1EG

North Glasgow a) Stobhill Hospital, All wards Stobhill a) Marjorie McCulloch 133 Balornock Road Deputy Site Facilities Manager Glasgow G21 3UZ

b) Glasgow Royal All wards GRI b)Anne MacLeod Infirmary Deputy Site Facilities Manager 84 Castle Street Glasgow G4 OSF

Page 17 of 23 Area Authorised Responsible for Authorised Establishment Manager/Deputy South Glasgow a) & b)Southern General a) All Wards Southern a)Ronnie Clinton Hospital General Hospital (excluding Site Facilities Manager 1345 Govan Road Adult MH, PDRU and ward a) Sharon Hutchison Glasgow G42 9TY 53)(RAD Wards –51, 54, 55, Hotel Services Coordinator 56, 57)

b) PDRU & ward 53 SGH b) Richard Hassell – Clinical Services Manager

c) Victoria Infirmary c) All Wards Victoria Infirmary c-g) Marjorie McCulloch Langside Road Deputy Site Facilities Manager Glasgow G42 9TY c-g) Ronnie Clinton Site Facilities Manager d) Mansionhouse Unit d) All Elderly & Rehabilitation 100 Mansionhouse Road in-patient services including Glasgow G41 3DX Stroke & CC – North 1, North 2, North 3, South 1, South 2, South 3, Cathkin View & Lomond View

e) Mearnskirk House Newton Mearns e) Continuing Care Glasgow G77 5RZ

f) Darnley Court Nursing Home f & g) Continuing Care 787 Nitshill Road Partnership Elderly Beds Glasgow G53 8LF

g) Rodgerpark Nursing Home Rodger Drive Rutherglen

East Glasgow

a) Lightburn Hospital a) All Elderly & Rehabilitation a–c)Anne MacLeod 966 Carntyne Road in-patient services Deputy Site Facilities Manager Glasgow G32 6ND a–c) Rose Anderson Facilities b) Greenfield Park b) Continuing Care Nursing Home (East) Partnership Elderly Beds 291 Myreside Street GLASGOW G32 6BX

c) Four Hills Nursing c) Continuing Care Home Partnership Elderly Beds 8 Hazlitt St, Ruchill Glasgow G20 9NU

Page 18 of 23

Area Authorised Responsible for Authorised Manager- Establishment Deputy Clyde Beth Culshaw General Manager, RAD

Inverclyde

a) Inverclyde Royal a) All Wards Inverclyde a-c) Catriona Glenn, Hospital Royal Hospital (excluding Clinical Services Manager – Larkfield Road, Adult & OPMH) IRH RAD Greenock PA16 0XN

b) Larkfield Unit, b) All Elderly & Rehabilitation a-c) John Kennedy Inverclyde Royal in-patient services (except Clinical Services Manager Hospital PDRU Larkfield Unit) Larkfield Road, Greenock PA16 0XN

c) PDRU Larkfield c) PDRU Larkfield Unit c) Richard Hassell – Clinical Unit Services Manager

Renfrew a) Royal Alexandra a) All Wards Royal John Kennedy, Clinical Hospital, Alexandra Hospital (excluding Services Manager Corsebar Road, Adult & OPMH) Paisley, Renfrewshire Catriona Glenn – Clinical PA2 9PN Services Manager – IRH RAD (Deputy)

West Dunbarton Vale of Leven All Wards Vale of Leven John Kennedy, Clinical Hospital, Hospital (excluding Adult & Services Manager Main Street, OPMH) Alexandria, Catriona Glenn, Dunbartonshire. Clinical Services Manager – G83 0UA IRH RAD (Deputy)

Page 19 of 23 Part 4 Management of Residents Finances - Training Report Appendix B 1st January – 31st December 2011 Staff Trained by Discipline Nursing Medical Social Care AHP Advocacy Vol. Orgs Other PT Affairs Authorised Staff Manager Trained Part 4 31 2 0 0 0 0 0 0 1 34

Financial 87 8 0 0 0 0 7 5 1 108 Management

Staff Trained by CHP / Service Glasgow CHP Glasgow CHP Glasgow CHP East Ren. West Dun. East Dun. Renfrewshire Inverclyde North East North West South CHP CHP CHP CHP CHP Part 4 6 3 1 0 0 1 3 0

Financial 11 0 13 5 6 0 31 0 Management

Addictions Learning Forensic Adolescent Acute Division Other Disabilities Part 4 5 19 1 0 6 0

Financial 0 33 0 0 0 9 St Margaret’s Hospice Management

Training Dates Part 4 9 16/02/2011 16/03/2011 20/04/2011 18/05/2011 29/06/2011 20/07/2011 25/08/2011 20/09/2011 20/10/2011 Financial 9 18/02/2011 13/03/2011 08/04/2011 12/05/2011 12/05/2011 17/05/2011 23/05/2011 13/06/2011 14/07/2011 Management Part 4 2 23/11/2011 19/12/2011 Financial 1 03/11/2011 Management 21

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APPENDIX C

Summary of Inspection Visits

Authorised Register Date of No of No of Res No Findings of Visit Establishment 1 Adults Inspection Resident Appointeeship Records 2 Older Subject Examined People to part 4 3 RAD

Victoria 3 14.01.11 7 13 3 Partially compliant Infirmary,Mansionhouse Training; Involvement of Unit, Mearnskirk, Darnley medical staff and nursing Court and Rogerpark leadership required Nursing Homes Revisit

Vale of Leven and 2 14.01.11 1 1 1 Compliant Out of date Dumbarton Joint Hospitals stationery. Lack of detailed minutes Training offered Skye House 1 21.01.11 0 0 1 Partially Compliant Out of date Cash Book,not recording patients status in Cash Book Parkhead Hospital 1 26.01.11 0 2 2 Partially Compliant No evidence of Incapax reviews Parkhead Hospital 2 26.01.11 0 1 1 Partially Compliant No evidence of Incapax reviews Leverndale Hospital 1 28.01.11 21 21 5 Compliant Southern General 3 28.01.11 0 0 0 Partially Compliant No evidence of Incapax reviews Leverndale Hospital 2 01.02.11 0 0 0 Compliant Darnley Court NH 2 01.02.11 3 8 3 Compliant Rogerpark NH 2 01.02.11 8 9 3 Compliant

Gartnavel Royal Hospital 1 11.03.11 9 11 2 Compliant

Kershaw Unit 1 01.04.11 0 0 0 Compliant

Netherton 1 01.04.11 6 7 2 Fully compliant

Overtoun Court 1 06.04.11 6 6 2 Compliant

Forensic Services 1 08.04.11 11 11 4 Fully Compliant Leverndale Hospital

Western Infirmary 3 15.04.11 0 0 0 Compliant Authorised Manager is developing a system to ensure assessment of capacity taking place for all residents Gartnavel General Hospital 3 10.05.11 0 0 0 Support required to encourage AM to meet the requirements of policy and procedures

Lightburn Hospital 3 11.05.11 0 ? 0 Unable to carry out inspection visit as records unavailable team provided advice and assistance on the day

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Larkfield Unit and 3 10.06.11 0 0 0 Fully Compliant Inverclyde Royal Hospital

Ravenscraig Hospital 2 10.06.11 3 3 3 Compliant Very good records and spending plans

Dykebar Hospital 1 27.05.11 7 9 2 Fully Compliant Excellent record keeping Lead Nurse audits 100% Each ward ha resource pack Dykebar Hospital 2 27.05.11 7 9 2 Fully Compliant Excellent record keeping Lead Nurse audits 100% Each ward ha resource pack Ravenscraig Hospital 1 10.06.11 6 7 3 Compliant Very good records and spending plans Gartnavel Royal 2 09.09.11 3 6 3 Compliant

Blythswood House 1 09.09.11 5 5 3 Fully Compliant Excellent record keeping at ward level and patient affairs Greenfield Park NH 3 13.09.11 0 0 0 Offered further training and Authorised Manager failed to respond; Arrange for AM and staff to have further training; implement policies and procedures Fourhills NH 3 21.09.11 0 2 0 No record of assessment of capacity; No MDT review; Support required to encourage AM to meet the requirements of policy and procedures 96 163 46

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Evidence of Good Practice (Extracted from Inspection Reports)

Permission from Supervisory Body to the Authorised Manager for Mearnskirk Hospital the use of a patient’s own funds for taxi expenses to allow an elderly relative to visit Good patient involvement in multi-disciplinary team reviews (MDTs) Vale of Leven and Dumbarton Joint Hospitals Patients and their relatives encouraged to be involved in all aspects Skye House of their care and financial management. Good minutes 100% Compliance with evidence of Lead Nurse Monthly reviews Parkhead Hospital Deputy Authorised Manager is exploring with MDTs possibility of Leverndale Hospital using patients’ own funds for the cleaning of their personal possessions Authorised Manager sends monthly reports to wards who are likely Southern General to have patients meeting residency criteria and quarterly to rest of Hospital wards The Deputy Authorised Manager holds regular monthly meetings Gartnavel Royal with the patient affairs manager to ensure regular review of AWI Hospital policy and procedures. Continuation of use of patients’ funds in the provision of alternative therapies e.g. therapeutic massage for those with continuing mental health problems Staff continue to organise holidays, outings and activities wherever Netherton possible. Last year a patients funds had been used to fund travel costs for a relative from overseas to visit. Staff to be praised for the care and attention shown – up to and including the winding up of the now deceased patient’s affairs Staff continue to organise holidays, outings and activities wherever Overtoun Court possible Development of AWI folders by Lead Nurse has proved very Leverndale Forensic successful Staff continue to organise outings and activities wherever Service possible e.g. evidence of private art tutoring Incapacity Discharge Checklist completed for all discharged Dykebar Hospital patients. Authorised Manager organised training for all MDT members including Consultants. Well organised systems and good cooperation between Authorised Manager and Patient Affairs service. This could be shared around other patient affairs department This quality of information gathering could be shared. Authorised Larkfield Unit and Manager provides evidence of assessment of capacity by reporting Inverclyde Royal system, she has also set up ward reporting system detailing AWI Hospital status, capacity and appointeeship/pension information Where appropriate, a small number of patients use an individualised Ravenscraig Hospital private laundry service The services of a personal trainer have been engaged for one Blythswood House resident to maintain his fitness level

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