Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

The Bethlem Royal Hospital

Monks Orchard Road, Beckenham, BR3 3BX Tel: 02032286000

Date of Inspections: 24 March 2015 Date of Publication: April 19 March 2015 2015 16 March 2015

We inspected the following standards to check that action had been taken to meet them. This is what we found:

Respecting and involving people who use Met this standard services

Care and welfare of people who use services Action needed

Safeguarding people who use services from Action needed abuse

Management of medicines Met this standard

Safety and suitability of premises Action needed

Safety, availability and suitability of equipment Met this standard

Supporting workers Met this standard

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 1 Details about this location

Registered Provider South London and Maudsley NHS Foundation Trust

Overview of the The Bethlem Royal Hospital is part of South London and service Maudsley NHS Foundation Trust (SLaM). The hospital provides mental health services across various specialties including Acute, Forensic and Neuropsychology.

We carried out this inspection at Fitzmary 2 ward, which is a national psychosis inpatient ward within the grounds of The Bethlem Royal Hospital. The service is a 23 bed, mixed gender ward that offers assessment and treatment for adults suffering from treatment-resistant psychosis who have had treatment elsewhere where progress has proven difficult.

Type of services Care home service with nursing Domiciliary care service Community based services for people with a learning disability Long term conditions services Community based services for people with mental health needs Hospital services for people with mental health needs, learning disabilities and problems with substance misuse Rehabilitation services Urgent care services

Regulated activities Accommodation for persons who require nursing or personal care Assessment or medical treatment for persons detained under the Mental Health Act 1983 Transport services, triage and medical advice provided remotely Treatment of disease, disorder or injury

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 2 Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page Summary of this inspection:

Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 What we have told the provider to do 5 More information about the provider 5

Our judgements for each standard inspected:

Respecting and involving people who use services 6 Care and welfare of people who use services 7 Safeguarding people who use services from abuse 9 Management of medicines 10 Safety and suitability of premises 11 Safety, availability and suitability of equipment 13 Supporting workers 14

Information primarily for the provider:

Action we have told the provider to take 15 About CQC Inspections 17 How we define our judgements 18 Glossary of terms we use in this report 20 Contact us 22

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 3 Summary of this inspection

Why we carried out this inspection

We carried out this inspection to check whether The Bethlem Royal Hospital had taken action to meet the following essential standards: • Respecting and involving people who use services • Care and welfare of people who use services • Safeguarding people who use services from abuse • Management of medicines • Safety and suitability of premises • Safety, availability and suitability of equipment • Supporting workers This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, carried out a visit on 16 March 2015, 19 March 2015 and 24 March 2015, observed how people were being cared for and talked with people who use the service. We talked with staff, reviewed information given to us by the provider, were accompanied by a pharmacist and were accompanied by a specialist advisor.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

What people told us and what we found

We spoke with nine patients. We spoke with 13 staff of different disciplines which included nurses, pharmacist, consultant psychiatrist, occupational therapist, charge nurse, activity coordinator, social worker, ward clerk, inpatient administrator, and a health care assistant. We also spoke with the ward manager and clinical services manager.

The majority of patients we spoke with said they were happy with the service and the staff were kind and caring. We observed caring and positive interactions between staff and patients on the ward.

We identified concerns across a number of areas that we looked at. Patients' care plans were not always reviewed on time and we did not see evidence of patients' involvement in their care planning. Patients' individual care plans did not include identified risks. Daily planning meetings and weekly community meetings did not regularly happen. Some risk assessments were not up to date.

Patients were not protected against the risk of abuse. Some of the staff were not aware of who the trust's safeguarding lead was or which local authority to report to. We found that some incidents had not been reported appropriately. Staff did not understand safeguarding procedures and referrals were not made to the appropriate authority immediately.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 4 You can see our judgements on the front page of this report.

What we have told the provider to do

We have asked the provider to send us a report by 08 May 2015, setting out the action they will take to meet the standards. We will check to make sure that this action is taken.

Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 5

Our judgements for each standard inspected

Respecting and involving people who use services Met this standard

People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run

Our judgement

The provider was meeting this standard. Patients' privacy, dignity and independence were respected.

Patients were supported in promoting their independence and community involvement.

Reasons for our judgement

During our visit, we observed positive interactions between staff and patients, staff were knowledgeable about patients' individual needs. There were curtains over the window of each bedroom door and we saw staff knocking on doors before entering. We saw some rooms had been personalised including one that had a poster of a singer and this singer's CD was playing in the bedroom.

An independent advocacy service visited the ward every week and the majority of patients we spoke with were aware of this service and had been able to access it when needed.

On the ward, patients had access to an Xbox, pampering, breakfast group, table tennis, table football, arts and crafts, a computer and music. There are two occupational therapists and an activities coordinator on the ward. The occupational therapy facilities included pottery, IT, woodwork, gardening and art groups. On the day of our visit, one of the occupational therapists was taking two patients out on an activity off the ward and there was also a cooking session. We asked people about the activities provided and most were happy with the activities they could access. One patient said they could go for walks in the grounds, garden, cook, play bingo and cards. We saw one patient being encouraged to go for a walk with a member of staff. The psychologists also delivered weekly recovery and mindfulness groups that patients spoke positively about.

The majority of patients we spoke with knew who their named nurse was and felt that they could easily approach staff. However, some patients said that they were not always able to access 1:1 time with their nurse.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 6 Care and welfare of people who use services Action needed

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement

The provider was not meeting this standard. Patients did not experience care, treatment and support that met their needs and protected their rights. Care plans did not detail all the needs of the patients and so did not ensure that they received the right support to meet their needs. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report.

Reasons for our judgement

We reviewed eight patient care records and spoke with nine patients. Many of the risk assessments and care plans had not been reviewed by the date stated for it to be reviewed. Patients' views were not documented on care plans and identified risks were not included in care plans.

The records of three patients included a brief risk screen that indicated significant risk with a need for an enhanced CPA or full risk assessment. However these had not been completed. Three of the records did not have risk assessments completed within 72 hours. For example, one patient who was admitted on 23 February 2015 did not have a risk assessment at the point of our visit on 19 March 2015. We saw that history which informed the risk assessment, this came from consultant referral letters and old notes and did not involve the patient or their relative/carer. This meant that patients were not been adequately assessed in a timely manner to ensure risks were being properly managed.

In five of the records we reviewed, the care plans had not been reviewed by the review date stated. A patient admitted on 23 February 2015 did not have a care plan in place. Risks that had been identified in patients' risk assessments were not included in their care plans. For example, one patient's risk assessment referenced type 2 diabetes and cellulitis on their feet. However, this was not mentioned in their care plan. Another patient who had a child did not have a risk assessment completed for this until three months after admission and was also not included in their initial care plan. There was documentation of patient involvement and copies of care plans being given to patients for three of the records we reviewed. The sections for review date, patient's comment and indication if a copy was given were blank in the other records. Four of the patients we spoke with said they did not have a copy of their care plans and, two other patients said they did not know about their care plan, one patient said, "I'm not sure what it is".

There were good examples of capacity and best interest assessments in some of the records. Staff had a good understanding of the Mental Capacity Act (2005) and held best

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 7 interest meetings for areas where patients may lack capacity in relation to financial issues, tenancy issues or medical records. We also saw examples of smoking care plans and the provision of nicotine replacement therapy as there is a trust-wide non-smoking policy in place. However, some of these plans had not been written until two weeks after the patient had been admitted.

A Mental Health Act review visit on 10 November 2014 found the patient care plans to be minimal and generic, no patient views being were recorded, identified risks were not being address in individual care plans and patients were not being given copies of their care plans. The provider's action statement stated that a teaching session would be delivered on co-production of quality care plans by 12 March 2015. Staff we spoke to during our visit said this had not yet been delivered.

We saw on the activities board that daily planning meetings were scheduled to take place on the ward at 9.30am every morning. These meetings were an opportunity to discuss with patients the daily groups and activities, daily notices, and staffing. Staff we spoke with said that these did not happen every day due to staff availability. The daily planning meeting was not held on the days of our visit. The last meeting recorded we saw was held on 13 February 2015. There were also supposed to be weekly community meetings held for patients, but these did not happen regularly on the ward. This meant that patients were not able to be actively involved in the daily planning of their care.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 8 Safeguarding people who use services from abuse Action needed

People should be protected from abuse and staff should respect their human rights

Our judgement

The provider was not meeting this standard. Patients who use the service were not protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report.

Reasons for our judgement

All staff we spoke with were not aware of who the trust's safeguarding lead was or which local authority to contact to raise a safeguarding alert. The general understanding was that all safeguarding alerts were referred to the ward social worker to manage. This meant that alerts were not being referred by all members of staff or during out of hours. We saw in one patient's records that they were at risk for financial exploitation, but a safeguarding referral had not been made by staff as the social worker was absent from the ward during this time. Staff were also unclear of the procedures once they raised a safeguarding alert, how the referral was managed and communicated to all members of the team or reviewed in order to share learning. Staff were aware of serious incidents that had happened on the hospital site, though there was limited awareness of the learning from these or changes made as a result.

The safeguarding records we reviewed showed that some safeguarding concerns had not been referred to the local authority, safeguarding lead or had not been referred immediately after the concern had been raised. Some incidents had been dealt with as a serious incident or a complaint and a safeguarding referral had not been made. We raised concerns immediately about the lack of reporting about specific incidents and the provider told us they would take action to make safeguarding referrals for these incidents.

Staff we spoke with had a good understanding of safeguarding issues and put plans in place to manage these on the ward. However, there was a lack of knowledge around reporting and monitoring procedures. We were provided a copy of the trust's safeguarding policy that stated all members of staff were responsible for raising a safeguarding alert and that referrals should be made within 24 hours. We saw that staff had completed safeguarding training.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 9 Management of medicines Met this standard

People should be given the medicines they need when they need them, and in a safe way

Our judgement

The provider was meeting this standard. Patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

Reasons for our judgement

Medicines were kept securely in both treatment rooms on the unit. Staff monitored fridge temperatures daily to ensure that they remained in the safe range. However we saw that there were some days in the last two months where this had been omitted. Controlled drugs were stored appropriately and stocks were checked daily. Medicines were available for use. Nursing staff were aware of the procedures for managing medicine.

We looked at the prescriptions and medication administration records. These were completed clearly and included allergy information and legal status of the patient. Charts that we checked showed that medicines had been prescribed appropriately in line with Mental Health Act documentation. The administration of medicines was signed by two nurses or coded to show why it was not given. We saw medicines being given to patients. Nurses explained why the medicine was important and took time to ensure that it was taken safely. Some patients were taking medicines that required regular blood testing to maintain safe levels. We saw that these tests were done and the doses adjusted appropriately. As part of their treatment some patients had periods of leave away from the service. We saw that their medicines for this time were managed safely following risk assessments.

Some medicines were prescribed to be used 'as required' where patients may need increased observations after their use. We saw an example of where these had been used and observations recorded. The pharmacist for the unit showed us an audit of the records of these, and other, clinical observations known as modified early warning scoring system. They showed us the actions put in place as a result of the audit to ensure that the records were completed correctly.

Pharmacists were present at all ward rounds and attended professional leads meetings. The pharmacist took a full medication history for each patient and this was used to inform further treatment options. Pharmacists were involved in supporting nursing and medical staff with the dissemination of information about medicines and the investigation of incidents. Learning from incidents was fed back to the ward and nurses could describe how this had improved practice. Audits were regularly done on areas such as missed doses, the safe and secure storage of medicines and bowel monitoring which were used to inform practice.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 10 Safety and suitability of premises Action needed

People should be cared for in safe and accessible surroundings that support their health and welfare

Our judgement

The provider was not meeting this standard. Patients, staff and visitors were not protected against the risk of unsuitable premises. The ward was not adequately maintained and the clinic room was too small to carry out patient observations safely and effectively. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report.

Reasons for our judgement

Care was provided in an environment that was not adequately maintained. Staff told us that things took a long time to be repaired and were not able to provide completion dates for on-going maintenance issues.

There was no heating source in the communal lounge and there was damp on the ceiling. We were told during our 16 March visit that heating was due to be installed but were not provided with a date for this. On our 24 March visit the heating units were being installed.

One of the toilets in the male corridor was out of order. We were told this had been out of order for two years as it was due to be refurbished. However, staff were not able to provide us with a date for completion. A treatment room was also due to be refurbished but was being used for storage. The current clinic rooms were not large enough for a treatment bed, this meant that blood tests and ECGs were taken when the patient was sitting in a chair or lying on their bed in their room. It is inappropriate to use patient's bedrooms for this purpose which is their personal space.

At the time of our visit, there was another ward at this hospital that was non-compliant in this area due to ligature risks. Since our last inspection at this location, there has been the death of a patient as a result of a ligature. There were several ligature risks on the ward including in the patients' bedrooms, communal bathrooms and communal areas. During our visit we were provided with a Ligature Reduction Audit tool that was dated 24 December 2014 and completed on 23 February 2015. This audit identified high risk ratings for ligature points. However no completion dates were included in the actions, despite being told by the provider that any Level 1 risks would be addressed immediately. Since our visit, we were given a revised plan that included dates for some of the works to be completed by September 2015.

Staff told us they managed patients with high risk of self harm by placing them on higher levels of observation. Staff were assigned hourly to each corridor to observe the area and

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 11 records confirmed this.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 12 Safety, availability and suitability of equipment Met this standard

People should be safe from harm from unsafe or unsuitable equipment

Our judgement

The provider was meeting this standard. People were protected from unsafe or unsuitable equipment.

Reasons for our judgement

Some staff expressed concern for the shortage of personal alarms as there were only six units available on the ward. There was no clear policy on which members of staff used the personal alarms but they were initially allocated to domestic staff due to an incident that occurred last year. Personal pull alarms were provided as an alternative, however not all staff we spoke to were carrying an alarm on them. There were wall alarms located across the ward that could be used and identified which zone the alarm was being raised. Staff told us that new units were to be ordered but did not have a completion date. The provider might find it useful to note that this may mean that an alarm could not always be raised immediately to ensure the safety of patients and staff.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 13 Supporting workers Met this standard

Staff should be properly trained and supervised, and have the chance to develop and improve their skills

Our judgement

The provider was meeting this standard. Patients were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

Staff received appropriate professional development.

Reasons for our judgement

Staff we spoke with all said they had good support and there was good teamwork on the ward. They spoke of being respected by all the different disciplines. New staff had a two week induction before working on their own and temporary staff were provided with an induction. We saw completed records of these inductions.

Records showed that staff were up to date with their annual appraisals. Staff we spoke with said most of them had received monthly supervision. We reviewed the supervision and training records. The provider might find it useful to note that staff were unable to locate the supervision log. This was kept as a paper copy and not stored electronically.

Some staff spoke of accessing continual professional development including psychological interventions in psychosis, physical health, phlebotomy, dual diagnosis and mentorship training. We reviewed the training log dated March 2015. This showed that several staff members were not up to date on mandatory training courses. For example, it showed that seven permanent qualified staff had not updated their Promoting Safer and Therapeutic Services (PSTS) physical intervention training. This training record was separate from the electronic training system that sends alerts if staff are not compliant with mandatory training. Management acknowledged that these records were not up to date and did not accurately reflect the courses that had been attended by staff as staff told us that they had completed their mandatory training. The provider might find it useful to not that the lack of up-to-date training records on the ward may mean that there is a risk that information about training that is due or out of date is not accurately picked up at ward level.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 14 This section is primarily information for the provider

Action we have told the provider to take

Compliance actions

The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activities Regulation

Accommodation for Regulation 9 HSCA 2008 (Regulated Activities) Regulations persons who require 2010 nursing or personal care Care and welfare of people who use services Assessment or How the regulation was not being met: medical treatment for persons detained The provider had not taken proper steps to ensure patients were under the Mental protected against the risks of receiving inappropriate or unsafe Health Act 1983 care by means of carrying out an assessment of needs and designing and planning care that met their individual needs. Transport services, Patients were not supported to participate in making decisions triage and medical about their care. advice provided remotely This was a breach of Regulation 9 (1)(a)(b)(i)(ii) of the Health and Social Care Act 2008 (Regulated Activities) Regulations Treatment of 2010, which corresponds to Regulation 9(1)(a)(b)(3)(a)(b)(d) of disease, disorder or the HSCA 2008 (Regulated Activities) Regulations 2014. injury

Regulated activities Regulation

Accommodation for Regulation 11 HSCA 2008 (Regulated Activities) Regulations persons who require 2010 nursing or personal care Safeguarding people who use services from abuse Assessment or How the regulation was not being met: medical treatment for persons detained The registered person did not have effective systems and under the Mental processes in place to ensure that patients were safeguarded against the risk of abuse.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 15 This section is primarily information for the provider

Health Act 1983 This was in breach of Regulation 11 (1)(a)(b) of the Health and Transport services, Social Care Act 2008 (Regulated Activities) Regulations 2010, triage and medical which corresponds to Regulation 13(1)(2)(3) of the Health and advice provided Social Care Act 2008 (Regulated Activities) Regulations 2014. remotely Treatment of disease, disorder or injury

Regulated activities Regulation

Accommodation for Regulation 15 HSCA 2008 (Regulated Activities) Regulations persons who require 2010 nursing or personal care Safety and suitability of premises Assessment or How the regulation was not being met: medical treatment for persons detained Patients, staff and visitors were not protected against the risks of under the Mental unsafe or unsuitable premises. The ward was not adequately Health Act 1983 maintained and the clinic room was too small to carry out patient observations safely and effectively. Long-standing maintenance Transport services, issues were not being addressed. triage and medical advice provided This was a breach of Regulation 15(1)(a)(c) of the Health and remotely Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to Regulation 15(1)(c)(e) of the HSCA 2008 Treatment of (Regulated Activities) Regulations 2014. disease, disorder or injury

This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The provider's report should be sent to us by 08 May 2015. CQC should be informed when compliance actions are complete. We will check to make sure that action has been taken to meet the standards and will report on our judgements.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 16 About CQC inspections

We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re- inspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 17 How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement If the breach of the regulation was more serious, or there action taken have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 18 How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact.

Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 19 Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 20 Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 21 Contact us

Phone: 03000 616161

Email: [email protected]

Write to us Care Quality Commission at: Citygate Gallowgate Newcastle upon Tyne NE1 4PA

Website: www.cqc.org.uk

Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.

| Inspection Report | The Bethlem Royal Hospital | April 2015 www.cqc.org.uk 22