Priory Hospital Burgess Hill NewApproachComprehensive ... · • The service worked to a recognised treatment model appropriate to the patient group. It was well led and the governance

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

PriorPrioryy HospitHospitalal BurBurggessess HillHillQuality Report

Gatehouse Ln,Goddards Green,HassocksBN6 9LETel: 01444 231000Website: www.priorygroup.com

Date of inspection visit: 24 and 25 AprilDate of publication: 12/06/2019

1 Priory Hospital Burgess Hill Quality Report 12/06/2019

Overall summary

We rated Priory Hospital Burgess Hill as good because:

• The service provided safe care. The wardenvironments were safe and had enough nurses anddoctors. Staff assessed, managed and mitigated riskswell. They were actively minimising the use ofrestrictive practices and followed good practice withrespect to safeguarding.

• Staff developed holistic, recovery-oriented care plansinformed by a comprehensive assessment. Theyprovided a range of treatments suitable to the needsof the patients and in line with national guidanceabout best practice. Staff engaged in clinical audit toevaluate the quality of care they provided anddeveloped sufficient action plans to address issues.

• The ward teams included or had access to the fullrange of specialists required to meet the needs ofpatients on the wards. Managers ensured that allsubstantive, bank or locum staff received training,supervision and appraisals. The ward staff worked welltogether as a multidisciplinary team and with thoseoutside the ward who would have a role in providingaftercare.

• Staff understood and discharged their roles andresponsibilities under the Mental Health Act. Staff hada good understanding of the Mental Capacity Act.

• Staff treated patients with compassion and kindness,respected their privacy and dignity and understoodthe individual needs of their patients. They involvedpatients and families and carers in care decisions.

• The service worked to a recognised treatment modelappropriate to the patient group. It was well led andthe governance processes ensured that wardprocedures ran smoothly.

However:

• On the rehabilitation ward staff were not consistentlyfollowing the hospital policy for medical monitoring ofpatients using the ward’s seclusion facilities. On oneoccasion staff had not followed up the physical healthconcerns of a secluded patient.

• The service had regular medicine errors highlighted bymonthly pharmacy audits although there was learningfrom this and the incidents were reducing.Additionally, medicine labelling and patientinformation for medicines that patients took whentransferred or discharged was not appropriate. Clinicroom refrigerators were dirty on Michael Shepherdward and their cleaning records showed several datesmissing within the previous month. Expired medicineswere not being disposed of in accordance withhospital policy.

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Acute wardsfor adults ofworking ageandpsychiatricintensive careunits

Good –––

• The service provided safe care. The wardenvironments were safe and had enough nursesand doctors. Staff assessed, managed andmitigated risks well. They were actively minimisingthe use of restrictive practices and followed goodpractice with respect to safeguarding.

• Staff developed holistic, recovery-oriented careplans informed by a comprehensive assessment.They provided a range of treatments suitable to theneeds of the patients and in line with nationalguidance about best practice. Staff engaged inclinical audit to evaluate the quality of care theyprovided and developed sufficient actions plans toaddress issues.

• The ward teams included or had access to the fullrange of specialists required to meet the needs ofpatients on the wards. Managers ensured that allsubstantive, bank or locum staff received training,supervision and appraisals. The ward staff workedwell together as a multi-disciplinary team and withthose outside the ward who would have a role inproviding aftercare.

• Staff understood and discharged their roles andresponsibilities under the Mental Health Act 1983.

• Staff treated patients with compassion andkindness, respected their privacy and dignity andunderstood the individual needs of their patients.They involved patients and families and carers incare decisions.

• The service was well led and governance processesensured that ward procedures ran smoothly.

However:

• The service had regular medicine errors highlightedby monthly pharmacy audits. Additionally,medicine labelling and patient information formedicines that patients took when transferred ordischarged was not appropriate.

Summary of findings


Forensicinpatient orsecure wards

Good –––

• Staff rarely used physical restraint and seclusionand did so only after verbal de-escalation hadproved unsuccessful. Staff participated in theprovider’s restrictive interventions reductionprogramme. Staff completed a positive behavioursupport plan for each patient, in collaboration withthem.

• Patient risk assessments and care plans wereviewed were personalised, holistic andup-to-date. Care plans were recovery oriented andincorporated the strengths and goals of the patient.

• Patients had access to individual and groupsessions with the ward psychologist.

• Staff promoted the importance of a healthy lifestyleto patients. Patients had good access to physicalhealthcare.

• Staff received mandatory training, an annualappraisal and regular supervision sessions. Staffattended regular team meetings, to discuss topicssuch as safeguarding cases; compliments andcomplaints; recent incidents; and, staff-relatedissues. All staff participated in reflective practicesessions, where they could discuss instances ofgood practice and areas for development.

• Staff treated patients with compassion andkindness and understood the individual needs ofeach patient. Staff involved patients in careplanning and risk assessment and actively soughttheir feedback on the quality of care provided.Patients had access to general and specific mentalhealth and mental capacity advocacy.

• Staff supported patients to spend time away fromthe ward and to maintain relationships with theirfriends and relatives. Staff supported patientsduring referrals and transfers between services.

• All patients had their own bedroom, with en suitetoilet and shower. The ward had a range of roomsavailable for meetings, therapy sessions, relaxationand activities, including a well-equipped clinicroom.

• Leaders had the skills, knowledge and experience toperform their roles and had a thoroughunderstanding of the services they managed.Patients and staff told us that managers wereapproachable.

Summary of findings


• Staff felt respected, supported and valued. Stafftold us the provider promoted equality anddiversity within the hospital and said they felt ableto raise concerns without fear of retribution.

However:

• The clinic room refrigerators were dirty and theircleaning records showed several dates missingwithin the previous month.

• Expired medicines were not being disposed of inaccordance with hospital policy.

Long stay orrehabilitationmental healthwards forworking-ageadults

Good –––

• The service provided safe care. Staff assessed andmanaged risk well. They managed medicines safelyand followed good practice with respect tosafeguarding.

• Staff developed holistic, recovery-oriented careplans informed by a comprehensive assessment.They provided a range of treatments suitable to theneeds of the patients cared for in a mental healthrehabilitation ward and in line with nationalguidance about best practice.

• The ward team included the full range of specialistsrequired to meet the needs of patients on thewards. Managers ensured that these staff receivedtraining, supervision and appraisal. The ward staffworked well together as a multidisciplinary teamand with those outside the ward who would have arole in providing aftercare.

• Staff were up to date with training and understoodtheir roles and responsibilities under the MentalHealth Act 1983 and the Mental Health Act Code ofPractice and discharged these well.

• Staff treated patients with compassion andkindness, respected their privacy and dignity, andunderstood the individual needs of patients. Theyactively involved patients and families and carers incare decisions.

• Staff planned and managed discharge well andliaised well with services that would provideaftercare. As a result, discharge was rarely delayedfor other than a clinical reason.

Summary of findings


• The service worked to a recognised treatmentmodel appropriate to the patient group. It was wellled and the governance processes ensured thatward procedures ran smoothly.

However:

• Staff were not consistently following the hospitalpolicy for medical monitoring of patients using theward’s seclusion facilities. Staff had not followed upthe physical health concerns of a secluded patient.

• Patients did not have free access to hot and colddrinks, nor to the ward garden without theassistance of ward staff. Patients wanted moreopportunity to prepare their own meals. Areas ofthe ward needed repair and more regular cleaning.

• The ward garden was small and without seating,and patients could not access it without a staffescort.

Summary of findings


Contents

PageSummary of this inspectionBackground to Priory Hospital Burgess Hill 9

Our inspection team 9

Why we carried out this inspection 9

How we carried out this inspection 9

What people who use the service say 10

The five questions we ask about services and what we found 11

Detailed findings from this inspectionMental Health Act responsibilities 15

Mental Capacity Act and Deprivation of Liberty Safeguards 15

Overview of ratings 15

Outstanding practice 48

Areas for improvement 48

Action we have told the provider to take 49

Summary of findings


Priory Hospital Burgess HIll

Services we looked atAcute wards for adults of working age and psychiatric intensive care units; Forensic inpatient or secure

wards; Long stay or rehabilitation mental health wards for working-age adults.PrioryHospitalBurgessHIll

Good –––


Background to Priory Hospital Burgess Hill

The Priory Hospital Burgess Hill is a purpose-builthospital providing acute and psychiatric intensive careunits as well as specialist medium and low secureservices and long stay rehabilitation services for peoplewith mental health needs. The hospital currently had fivewards open which included one male acute ward, onemale PICU ward, one female PICU ward, one female lowsecure forensic ward and one high dependency femalerehabilitation ward with a specific 12 monthpsychologically led programme of treatment for patientswith a high acuity of need. One medium secure forensicward was closed to admissions following a previousserious incident and was undergoing a full refurbishment.The hospital told us that this would not be re-opening asa medium secure ward.

The hospital last had a comprehensive inspection inOctober 2016, with further follow up visits in June 2017,April 2018 and September 2018.

The most recent inspection was a focused responsiveinspection which was carried out in response to CQCreceiving concerning information about the service. Atthat inspection, areas for improvement were identifiedbut no breaches of regulation were found.

The hospital is registered to provide the followingregulated activities:

• Assessment or medical treatment for persons detainedunder the Mental Health Act 1983

• Diagnostic and screening procedures• Treatment of disease, disorder or injury.

There was a registered manager in place at the hospital.

Our inspection team

Our inspection team consisted of four CQC inspectors,one assistant inspector and six specialist advisors with avariety of mental health experiences.

Why we carried out this inspection

We inspected this service as part of our ongoingcomprehensive mental health inspection programme.

How we carried out this inspection

To fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

During the inspection visit, the inspection team:

• visited all five wards at the hospital, looked at thequality of the ward environment and observed howstaff were caring for patients

• spoke with 12 patients who were using the service• spoke with the hospital director• spoke with the ward manager or acting managers for

each of the wards• spoke with 23 other staff members; including doctors,

nurses, occupational therapist, psychologist,pharmacist, health care assistants and domestic staff

• attended and observed two hand-over meetings

Summaryofthisinspection

Summary of this inspection


• looked at 27 care and treatment records of patients• carried out a specific check of the medicine

management on all wards

• looked at a range of policies, procedures and otherdocuments relating to the running of the service.

What people who use the service say

Patients were largely positive about the service. Patientsreported feeling safe on the wards and respected by staffmembers. They felt that most staff were supportive andapproachable. Patients said they felt involved indecisions regarding their care and confident to raise anyconcerns.

Patients told us that they were given the opportunity tofeedback about the quality of the service on the ward in avariety of ways.

However, patients also stated that they would like to seean improvement to the quality of the food and have moreopportunity to cook for themselves. They also felt thatthere were parts of the ward environment that neededrepair which was not happening in a timely way.Additionally, patients felt that they wanted more activitiescoordinated on the wards.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated safe as good because:

• All wards were safe, well equipped, well furnished, wellmaintained and fit for purpose.

• The service had enough nursing and medical staff, who knewthe patients and received basic training to keep people safefrom avoidable harm.

• Staff assessed and managed risks to patients and themselveswell and followed best practice in anticipating, de-escalatingand managing challenging behaviour. All staff received apersonal alarm and the hospital had recently installed a‘pinpoint’ alarm system.

• Staff used restraint and seclusion only after attempts atde-escalation had failed. Staff actively participated in theprovider’s reducing restrictive interventions committee.

• Staff understood how to protect patients from abuse andexploitation and the service worked well with other agencies todo so. Staff had training on how to recognise and report abuseand exploitation and they knew how to apply it.

• Staff had easy access to clinical information and it was easy forthem to maintain high quality clinical records.

• Staff regularly reviewed the effects of medications on eachpatient’s physical health and monitored patients’ physicalhealth appropriately.

• The service managed patient safety incidents well. Staffrecognised incidents and reported them appropriately.Managers investigated incidents and shared lessons learnedwith the whole team and the wider service.

However:

• On one occasion we saw that staff were not following thehospital policy and Mental Health Act Code of Practice formedical monitoring of patients using the seclusion facilities.Staff had not followed up physical health concerns of asecluded patient.

• The service had regular medicine errors highlighted by monthlyaudits. The service did demonstrate an improvement month onmonth since highlighting and addressing medicine errors.Medicine labelling and patient information for medicines thatpatients took when transferred or discharged was not

Good –––




appropriate or complete. The clinic room refrigerators onMichael Shepherd ward were dirty and expired medicines werenot being disposed of according to the hospital organisationalpolicy.

• Some wards areas were visibly dirty and ward staff wereunaware of the cleaning schedule of domestic staff.

Are services effective?We rated effective as good because:

• Staff assessed the physical and mental health of all patients onadmission. They developed individual care plans which werereviewed regularly through multidisciplinary discussion andupdated as needed. Care plans reflected the assessed needs,were personalised, holistic and recovery-oriented.

• Staff ensured that patients had good access to physicalhealthcare and supported patients to live healthier lives.

• Staff used recognised rating scales to assess and record severityand outcomes. They also participated in clinical audits anddeveloped appropriate actions plans from these.

• The ward teams included or had access to the full range ofspecialists required to meet the needs of patients on the wards.Managers made sure they had staff with a range of skillsrequired to provide high quality care. They supported staff withappraisals, supervision and opportunities to update and furtherdevelop their skills. Managers provided an inductionprogramme for new staff and there was a seamless integrationbetween bank or agency staff and substantive staff on thewards.

• Staff from different disciplines worked together as a team tobenefit patients. They supported each other to make surepatients had no gaps in their care. The ward teams had effectiveworking relationships with other relevant services outside ofthe hospital.

• Staff understood their roles and responsibilities under theMental Health Act and discharged these well. Managers madesure that staff could explain patients’ rights to them. Staffdemonstrated sound knowledge of the Mental Capacity Act.

However;

• Staff lacked the confidence to complete mental capacityassessments for patients even if they were the moreappropriate person to undertake it.

Good –––

Are services caring?We rated caring as good because:

Good –––




• Staff treated patients with compassion and kindness. Theyrespected patients’ privacy and dignity. They understood theindividual needs of patients and supported patients tounderstand and manage their care, treatment and condition.

• Staff involved patients in care planning and risk assessmentand sought their views on the quality of care provided. Theyensured that patients had easy access to independentadvocates.

• Staff suitably informed and involved families and carers of thecare and treatment provided to the patient.

Are services responsive?We rated responsive as good because:

• The service managed beds well. This meant that a bed wasavailable when needed and that patients were not movedbetween wards or hospitals unless this was for their benefit.Discharge was only delayed due to ongoing placement fundingdifficulties.

• The design, layout, and furnishings of the service supportedpatients’ treatment, privacy and dignity. Each patient had theirown bedroom with an ensuite bathroom and could keep theirpersonal belongings safe. There were quiet areas for privacy,phone calls and visits.

• The food was of a good quality and choice and patients couldmake hot and cold drinks at any time.

• The wards met the needs of all people who used the service –including those with a protected characteristic. Staff helpedpatients with communication, advocacy, cultural and spiritualsupport. Patients had access to a multi faith room and couldvisit their chosen place of worship to attend religious services,subject to individual risk assessment.

• The service treated concerns and complaints seriously,investigated them and learned lessons from the results, andshared these with the whole team and the wider service.

However;

• On Amy Johnson ward, the outdoor space for patients was ofpoor quality with no seating or shelter and patients did nothave open access to hot and cold drinks on the ward.

Good –––

Are services well-led?We rated well-led as good because:

Good –––




• Leaders had the skills, knowledge and experience to performtheir roles, had a good understanding of the services theymanaged and were visible in the service and approachable forpatients and staff.

• Staff felt respected, supported and valued. They reported thatthe provider promoted equality and diversity in its day to daywork and in providing opportunities for career progression.They felt able to raise concerns without fear of retribution.

• Our findings from the other key questions demonstrated thatgovernance processes operated effectively at ward level andthat performance and risk were managed well. All staff receivedregular supervision and appraisals and mandatory training hada high completion rate.

• Ward teams had access to the information they needed toprovide safe and effective care and used that information togood effect.




Mental Health Act responsibilities

We do not rate responsibilities under the Mental HealthAct 1983. We use our findings as a determiner in reachingan overall judgement about the Provider.

Mental Health Act training was mandatory for all staff andwe saw that attendance was high and that this trainingwas renewed every year.

Consent to treatment was in place for all the patients thatwe reviewed. Patients confirmed to us that their rights

under the Mental Health Act had been explained to themregularly and we saw reminders on the ward manager’sdashboard when it was time to renew explanations ofpatients’ rights. Staff had access to support from theMental Health Act office.

Patients told us that they had access to an independentmental health advocacy service and we saw the contactinformation displayed on all ward noticeboards.

Mental Capacity Act and Deprivation of Liberty Safeguards

Mental Capacity Act and Deprivation of LibertySafeguards (DoLS) training was mandatory for all staffand completion rates for this training were high. Staffrenewed their training every year.

Staff we spoke with were aware of the principles of theMental Capacity Act. However, we found that ward staffwere not participating in the assessment of patients’capacity and this was left solely to the ward doctors butthis didn’t directly impact the timeliness of assessments.

We saw that capacity assessments on a decision-specificissues were recorded in care records where appropriatesuch as managing finances or managing their personalcare and that best interests meetings had been held.

Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Acute wards for adultsof working age andpsychiatric intensivecare units

Good Good Good Good Good Good

Forensic inpatient orsecure wards Good Good Good Good Good Good

Long stay orrehabilitation mentalhealth wards forworking age adults

Requiresimprovement Good Good Good Good Good

Overall Good Good Good Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Are acute wards for adults of workingage and psychiatric intensive care unitservices safe?

Good –––

Safe and clean environment

Safety of the ward layout

All wards undertook daily risk assessments of the careenvironment. The nurse in charge undertook four checks aday and appointed security lead for each ward undertookfurther daily checks.

Security leads were assigned on each shift on all wards andthey had a checklist to complete for the ward whichincluded finding, reporting and actioning anyenvironmental risks found. Only staff who were suitablyexperienced on their ward and competent with the rolewere assigned.

There were multiple blind spots and ligature risks acrossthe wards. However, the service undertook ligature riskaudits and blind spot risk assessments every six months.Each identified risk was mitigated by staff presence,individual risk assessments or building modificationswhere possible. Staff were present and observing all areasof the ward.

Additionally, the service utilised closed-circuit televisioncalled ‘care protect’ in all public areas and bedroomswhere patients consented to this. Otherwise, all bedroomcameras were switched off with a ‘hood’ placed over them.In addition to footage being shown in the nursing office, anexternal company employed experienced healthcare

professionals to monitor the footage and contact the wardsif something of concern was noted. We saw this in actionwhilst inspecting Edith Cavell ward and staff respondedquickly and appropriately. Staff were aware of areas of riskwithin the wards and ligature cutters were readily availableand identifiable around the wards in the event of anemergency.

All staff who joined the service were required to completeligature audit workbooks to ensure that they fullyunderstood the management of ligature points and theobservation policy.

All wards were single sex wards and all patient bedroomswere en-suite with shower rooms.

All staff received a personal alarm and set of keys fromreception when signing in to work. There were appropriatesystems in place within reception to ensure alarms werecharged and working. The majority of ward-based staff alsoreceived a radio.

All wards had recently installed a ‘pinpoint’ alarm system.This system ensured a fast, audible sound was relayed toall wards when a staff alarm was pulled anywhere acrossthe hospital. Display units on multiple sites on each wardclearly displayed where the distress call was coming fromand ensured that the assigned responder for each wardcould quickly locate the call and attend.

All staff received an appropriate induction and training onsecurity to ensure proper use of alarms and the key system.All rooms had alarms that patients or staff could use toalert staff to any incident.

Maintenance, cleanliness and infection control

Domestic staff were employed by the service and attendedthe wards daily. However, some ward areas were visibly

Acutewardsforadultsofworkingageandpsychiatricintensivecareunits

Acute wards for adults of workingage and psychiatric intensivecare units

Good –––


dirty with debris and stains. Additionally, ward teams wereunaware of what was due to be cleaned and what hadalready been cleaned by domestic staff each day. Therewas a disconnect between ward teams and domestic staffin this regard.

On Wendy Orr ward, domestic staff were given a patienthandover and advised to switch their radios onto the samefrequency as ward staff to ensure their security whilstworking on the ward.

All furnishings were in good working order and appropriatefor the wards.

Staff adhered to infection control principles and aninfection control audit was conducted monthly by theservice.

Seclusion room

Seclusion rooms allowed for clear observations andtwo-way communications. Each seclusion room had atoilet and shower facilities with an appropriate blind toprotect patients dignity. The rooms also had visible clocks.

Nursing reviews of seclusion were carried out by therequired two registered nurses. All seclusion paperworkthat we viewed was appropriately completed anddemonstrated good recording of 15-minute observations,with two hourly reviews undertaken by nursing staff.

Clinic room and equipment

All clinic rooms were fully equipped and had accessibleemergency equipment and medicine. All equipment wasappropriately calibrated, maintained and portableappliance tested

The service appropriately monitored, recorded andmaintained clinic room and fridge temperatures.

Safe staffing

Nursing staff

Each ward was staffed using an agreed staffing ladder thatwas in place. The staffing ladder calculated the number ofstaff required based upon patient numbers, acuity andobservations, following national guidance on safe staffing.All ward managers had an understanding of the staffingladder. Staffing levels and the staffing ladder were reviewedby the Priory Group’s central team annually to ensure itconformed with national guidance.

The hospital currently had high levels of staff vacancies. Asof December 2018, they had a 47% overall vacancy rate.However, the hospital had improved on this at the time ofour inspection and had employed a dedicated workforcerecruitment lead to drive recruitment and we sawnumerous offers in place and staff awaiting final checks tobegin employment. Additionally, the hospital managedbank and regular agency staff well to ensure that all shiftswere filled and safe staffing levels maintained.

There was a recruitment plan in place that included a rangeof targeted recruitment campaigns as well as retention andstaff wellbeing initiatives for the current workforce.

Each morning there was a hospital-wide handover meetingbetween ward managers and senior staff to discuss wardbusiness, including staffing levels. Where ward managersrequired additional staffing to account for escalation of riskon the wards, there was an appropriate procedure in place.

Each day shift ran between 7.30am and 8pm with aminimum of two registered nurses and four healthcareassistants, with each night shift running between 7.30pmand 8am with four members of staff that included at leastone registered nurse. The shift pattern in place allowed fora 30-minute handover between shifts.

Bank and agency staff were deployed in the service tomaintain safe staffing levels. Where they were used, theservice tried to ensure that they were familiar with the wardthey were working on and regularly used to ensurecontinuity of care for the patients.

All bank and agency staff received an induction to theservice and had to complete competency checks beforebeing allowed to work on the wards. Additionally, bank andagency staff had to undertake a prevention andmanagement of violence and aggression course beforethey were permitted to work independently on the wards.

Bank and agency staff had the same access to supervision,training and care records as substantive staff members. Thebank and agency staff were fully integrated within wardteams. Staff reported being treated the same assubstantive staff and were also given additional roles andresponsibilities when necessary to further theirdevelopment.

There was a regular staff presence across the wards with aneffort by staff to keep their time in the nursing office to aminimum to ensure they were interacting with patients.



Good –––


Medical staff

There was adequate medical cover across the service withdedicated ward consultants and specialty doctorsavailable.

There were appropriate out-of-hours duty systems in placefor on-call consultants who stayed in on-siteaccommodation and on-call managers.

Additionally, the service had a visiting GP who attendedweekly and we saw appropriate agreements in place withfurther external healthcare professionals such as dietitians,tissue viability nurses and dentists.

Mandatory training

The service had an overall compliance rate of mandatorytraining for all staff of 98%. This exceeded theorganisation’s target of 92% and included all substantive,locum and bank staff.

The hospital employed a learning and development lead tomonitor when training was due and ensure ward staffcompleted it. Staff received protected time if required inorder to complete training and we saw evidence ofovertime being paid to staff in order to complete trainingoutside of their normal working hours.

Assessing and managing risk to patients and staff

Assessment of patient risk

We reviewed 17 patient risk assessments and found themall to be present, up to date and thorough, assessing arange of relevant risks. All patients received a riskassessment on admission that was updated at least everyweek during ward round, or sooner if required.

Staff completed standard risk assessment forms on theelectronic care records system that were based upon thefive P’s model; presenting, predisposing, precipitating,perpetuating and protective. This was to ensure all riskswere identified as well as triggers, behaviours and actionsto take.

Additionally, patients had positive behaviour support plansin place which listed in a patient’s own words what theywished to happen should they become challenging oragitated.

Management of patient risk

Staff demonstrated a good knowledge of their patients andthe risks they posed. Management plans were in place forall identified risks in the patient care records we reviewed.

Staff were assigned to different roles for each shift toensure staff understood their roles that day. Theseincluded a security lead, observations lead and rapidresponse leads.

The service had an observational policy in place that staffwere aware of and followed. There was a good staffpresence about the wards to minimise risks associatedwith the ward layouts and we saw staff actively attemptingto be as least restrictive as necessary with observations.Decisions of decreasing observation levels were taken bythe full multidisciplinary team. All staff completed acompetency assessment before undertaking patientobservations.

There was a search policy that staff adhered to. The serviceundertook regular random room searches and morefrequent searches based upon intelligence or incidents andevents.

Staff applied blanket restrictions on patient’s freedom onlywhen justified on the basis of risk. For example, patientswere individually risk assessed for certain items on theward and also for access to areas such as the kitchen.

All ward entrance doors were locked. The doors had clearsigns explaining the rights of informal patients to leave.Ward staff told us that if an informal patient wanted toleave the ward they would unlock the doors for them.Where concerns regarding the patient’s wellbeing or safetywere identified, staff would use their holding powers underthe Mental Health Act 1983 and inform a doctor toundertake an immediate mental health assessment for thepatient.

The service had a reducing restrictive practices committeethat met monthly and we saw positive change towards thison the wards. There were plans to create separate hospitalentrances for the acute mental health wards to enable theenvironment and reception areas to be less restrictive totheir patients. The current entrance was based on a moresecure hospital design and patients and staff described thedelays that this could cause in entering or leaving the site.

The hospital site was smoke-free at the time of theinspection. Patients were informed of this either before or



Good –––


during admission. The wards encouraged and supportedsmoking cessation and offered nicotine replacementtherapy and/or disposable electronic cigarettes to allpatients requiring it.

Use of restrictive interventions

For the six months prior to May 2019, the service reported71 incidents of seclusion, with Helen Keller ward thehighest reporter with 29 incidents of seclusion.

We saw evidence that demonstrated staff followedappropriate procedures during and after seclusionincluding patient observation, recording, monitoring andde-briefing of staff and patients.

There were 123 incidents of physical restraint over thesame period of time. Helen Keller ward had the highestlevels of restraint with 85 incidents. Three incidents ofrestraint on the same ward led to intramuscular rapidtranquilisation being administered. Staff ensuredappropriate monitoring of patients following rapidtranquilisation and the service undertook monthlymonitoring audits to ensure consistency.

The service reported zero episodes of prone restraint.

The hospital had an active reducing restrictiveinterventions programme in place and the servicedemonstrated a reduction in restrictive interventions overthe last 12 months.

Each incident of restraint was reviewed by the hospitalsprevention and management of violence and aggressiontrainers to ensure that restraints were appropriate andnecessary.

Since the hospital appointed a new hospital director, wesaw significant changes in place in an attempt to reducerestrictive practices across the hospital site. There was areducing restrictive practices committee meeting monthlythat fed into overall governance meetings that also hadappropriate patient representation. Risk planning, riskmanagement and care planning had recently changed toensure greater patient involvement in their care alongsidepositive risk taking to further develop rehabilitation and allwards were taking part in the ‘safewards’ initiative toimprove working relationships and cultures between staffand patients. A working group regularly met to discuss thesafewards initiative and its implementation.

Safeguarding

Staff demonstrated a sound knowledge of safeguardingand how to raise a safeguarding alert. All eligible staff hadcompleted the safeguarding adults and safeguardingchildren mandatory training.

There was a clear safeguarding process in place to aid staff,with a hospital safeguarding lead available for support.Staff were aware that they could raise a safeguardingconcern directly with the local authority and recentchanges to the safeguarding form explained this and gavedirect contact details for the local authority.

The hospital had a safeguarding tracker and discussedopen cases, referrals and actions plans at fortnightlysafeguarding committees.

There were family rooms and safeguarding procedures inplace for when children visited patients. The rooms wereoff the ward environment and prevented children fromhaving to enter the wards.

Staff access to essential information

The service utilised an electronic patient care recordssystem which most staff could access. Substantive staff,bank and longer-term agency staff all had their own securelogin for the system.

Staff told us of their frustrations with the IT systems inplace, stating that they often froze and lost unsaved workon the electronic care records systems. We saw evidencethat this issue had been escalated to senior managementand plans put in place with the Priory IT teams to improvethis.

Medicines management

The service appropriately stored and reconciled theirmedicine. All medicine used on the acute and PICU wardswas in date and appropriately labelled.

The service had good links with the local pharmacy team. Apharmacist visited the wards once a week. Regularmedicine audits were undertaken by the pharmacy team.Findings from their audits were passed to the consultantfor that ward who had to action and respond to the auditsvia an electronic system. Additionally, we saw discussionsaround medicines management in clinical governancemonthly meetings with the pharmacist attending meetings.

However, there were multiple errors flagged within auditsthat occurred each month. These included missedmedicines, recording omissions and medicine errors. Errors



Good –––


were all flagged and appropriately mitigated and managedand we saw that monthly error numbers had reduced sincethe issue was recognised and addressed by the newlyappointed senior management team.

Each ward team appropriately responded to all concernsraised within recent audits and this was an improvementon previous months whereby responses were omitted. Thisimprovement was due to medicines managementdiscussions and action plans being implemented. Staffreceived supervision around medicines management andrepeated competency assessments to refresh theirknowledge of the process.

When staff gave patients medicines to take home whendischarged or transferred, they were not appropriatelylabelling patient medicines or supplying sufficientmedicine information. We saw standard blank labelssupplied by the pharmacy, however staff were not fullycompleting these to give all information to patients.

An allocated staff member appropriately recorded dailyclinic room temperatures and clinic fridge temperaturesand detailed actions when this fell out of acceptableranges.

Staff regularly reviewed the effects of medication onpatients’ physical health. A suitably experienced member ofstaff was assigned on each ward as the physical healthchampion and utilised National Early Warning Score(NEWS) charts to monitor the physical health of everypatient daily. We saw appropriate actions taken when thescores from the tests indicated that closer monitoring wasrequired.

Track record on safety

In the previous 12 months, there was one serious incidentreported from this core service and related to an infectioncontrol incident on Helen Keller ward.

There was a sufficient process in place to ensure thatserious incidents were thoroughly investigated and anychanges in practice or learning was appropriatedisseminated to ward staff.

Reporting incidents and learning from when things gowrong

The service implemented an electronic incident reportingsystem, IRIS, that all staff had access to and could use toreport any incidents. All incidents raised were sent through

to ward managers to review and then to seniormanagement for final sign off. Incident forms clearlydetailed immediate actions taken, including any physicalinterventions. If originally submitted forms wereambiguous or incorrectly filled in, ward managers sentthese back to the reporter to amend.

The director of clinical services kept a tracker of wardincidents and identified themes to discuss at clinicalgovernance meetings.

Staff were aware of which types of incidents requiredreporting and we saw evidence of an array of types ofincidents being appropriately reported.

Where changes to practice and learning could be takenfrom incidents, we saw this disseminated to staff via teammeetings, multidisciplinary meetings and learning frombulletins and posters placed on ward office doors.

Staff reported that they received a debrief after seriousincidents and that patients also received this support togain their perspective of incidents.

Are acute wards for adults of workingage and psychiatric intensive care unitservices effective?(for example, treatment is effective)

Good –––

Assessment of needs and planning of care

We reviewed 17 care records across the service and eachone contained a detailed initial patient assessment. A fullrange of assessments was undertaken on admission to theservice including mental health and physical healthexaminations by a member of the medical team.

Staff completed initial 72-hour care plans with patients onadmission and conducted more thorough care plans oncethe patient had settled on the ward.

The service recently introduced a care plan approach thatagreed holistic care planning with the patients based onfour key aspects of their recovery. These included; ‘keepinghealthy’, ‘keeping safe’, ‘keeping connected’ and ‘keepingwell’. Staff commented positively on the implementation ofthis style of care plan.



Good –––


Care plans were personalised, gaining the views of thepatient throughout, holistic in nature and goal or recoveryorientated. Staff completed thorough care plans andupdated them when necessary. Additionally, patients wereengaged to create positive behavioural support planswritten in their own words to make staff aware of eachpatient triggers and wishes during challengingcircumstances.

Staff clearly documented when care plans were offered topatients and when this was refused.

The service utilised a physical health screening tool calledthe national early warning score (NEWS). The tool isnationally recognised to support the detection andresponse to clinical deterioration in physical health ofpatients. The service regularly audited their NEWS charts toensure consistency of care and recording. We saw clearactions taken when items were flagged within the audits.There was evidence of regular electrocardiograms andblood tests when required. An electrocardiogram is a testwhich measures the electrical activity of the heart to showwhether it is working normally.

The service had a visiting GP once a week in which therewas an appropriate referral process in place to continuephysical health screening and monitoring for patients andto refer elsewhere when necessary. The service alsoemployed a full-time practice nurse that was available tosupport patients with their physical health needs.

Best practice in treatment and care

The service provided a range of care and treatmentinterventions through psychological intervention,occupational therapy and fitness and wellbeingprogrammes. These included mindfulness, anxiety groups,anger management and coping skills.

Given the relatively short length of stay, psychology clinicswere introduced to the acute mental health wards toprovide assessment, formulation and treatmentrecommendations for patients rather than fullpsychological therapy provision.

The service recently employed a full-time leadoccupational therapist and had worked to fully recruit theiroccupational therapy team. On inspection, each ward hada dedicated occupational therapy assistant who delivered

a timetable of activities Monday to Friday, with nurse-ledactivities at the weekend. We were told of plans toimplement a full seven-day activity programme in thefuture, once this initial routine had been implemented.

Staff supported patients to lead healthier lives. The serviceimplemented appropriate smoking cessation support,discussed and held groups on healthy eating and couldrefer onwards for substance misuse issues. The serviceemployed a full-time health and wellbeing lead andpatients had access to a dietician.

All wards used Health of the Nation Outcome Scales toindicate if patients’ health and wellbeing improved duringtheir admission to the wards

Skilled staff to deliver care

Teams were staffed by a variety of experienced andqualified mental health workers including consultantpsychiatrists, specialty doctors, nurses, psychologists,occupational therapists, social workers, health careassistants, a health and wellbeing manager and students ortrainees. All staff members reported that they felt wellintegrated and utilised within the teams. Multidisciplinaryteam meetings were well attended by a range of healthprofessionals.

Ward managers ensured that all new staff receivedappropriate inductions and had passed the relevantcompetency tests before working on the wards. The serviceimplemented a thorough four-week programme ofinduction for all new substantive staff members thatincluded periods of shadowing, training andsupernumerary shifts on the wards.

All staff received regular supervision. Supervision treeswere in place for all wards except Wendy Orr, due to recentteam changes. All staff including bank and agency staff hadaccess to and were receiving supervision and some wardsadditionally ran reflective practice group sessions withstaff.

All staff were up to date with their yearly appraisals.

The service kept an overall supervision log that was kept upto date by supervisees and collated by the learning anddevelopment lead for the hospital to discuss at clinicalgovernance meetings.

All wards held weekly team meetings to discuss businessmatters on the wards and to raise any concerns.



Good –––


The hospital ran monthly staff ‘have your say’ forums, withstaff representatives from across services at the hospital.

There were opportunities for development and training tostaff and ward managers ensured staff were givenappropriate additional responsibilities on the wards tosupport this. Training was delivered both internally andexternally with some staff members gaining furtherrecognised qualifications.

Ward managers dealt with poor staff performanceeffectively and fairly. They received support from thecentral Human Resources department and we sawadditional supervision and support put in place for staffmembers requiring it.

Multi-disciplinary and inter-agency team work

The service held weekly multidisciplinary meetings todiscuss each patient on the ward. These were wellattended by professionals involved in patient care. All teammembers reported feeling fully integrated in their teams.

Patients, carers and family members were invited tomultidisciplinary meetings and patients reported that theyfelt listened to in the meetings. The service evidenced thatpatients received appropriate information about theirmedicine and treatment.

There were effective handovers between each shift change.The shift patterns allowed for a full 30-minute handoverbetween shifts. Patient risk and status, physical healthissues and management of current patient levels ofobservation alongside recent events and behaviours of theprevious shift were discussed. staff demonstrated athorough understanding of the patients in their care.

Despite many patients being placed at the service a longdistance from their home, we saw evidence of goodworking relationships with patients’ local authorities, carecoordinators and community mental health teams whennecessary. Where there were issues arising from inactivityor uncooperativeness from a patient’s local authority tohelp appropriately move patients on, the service tookpositive steps to overcome this including raisingappropriate safeguarding referrals.

Adherence to the MHA and the MHA Code of Practice

Mental Health Act training had been completed by 98% ofstaff at the service. Staff demonstrated a good workingknowledge of the Mental Health Act, the code of practiceand the guiding principles.

All wards had access to a Mental Health Act administratorfor support and monitored requirements and compliancewith the Act and Code of Practice. Monthly audits andreports were pulled by the Mental Health Act office andsent to ward managers for review.

Patients had clear and easy access to independent mentalhealth advocacy and there were three separate advocacyservices that visited the location.

Staff informed patients of their rights on admission andregularly re-informed them thereafter, or after anysignificant change to their admission and care.

Staff ensured that patients were able to take their section17 leave from the hospital and there was an appropriateconsideration of risk given to this. Before any patient couldtake their leave, the nurse in charge conducted and signedoff a five-point risk assessment of the patient.

Patients’ detention paperwork and records wereappropriately monitored and stored and copies of themwere made available on the electronic care records systemfor staff to gain access.

Consent to treatment certificates were in place for patientsalongside their medicine records. These certificatesdemonstrated that patients detained under the MentalHealth Act had the proper authorisation in in place for theirmedicine.

Each ward had a clear notice displayed on the wardentrance doors informing informal patients of their rights toleave the ward freely.

Good practice in applying the MCA

All staff at the service had completed Mental Capacity Acttraining as part of mandatory training. Staff demonstrateda sufficient knowledge of the Act and the five statutoryprinciples.

Deprivation of Liberty Safeguards training was a separatecourse that had been completed by 99% of staff as part ofmandatory training. The service made no Deprivation ofLiberty Safeguards applications in the last 12 months.



Good –––


Staff could access appropriate Mental Capacity Act policiesand guidance via the hospital’s shared drive and couldrequest support from the Mental Health Act office ifrequired.

Staff took practical steps to enable patients to understandtheir care and make their own decisions. This included theuse of interpreters and signers for those requiring them.

We saw evidence of discussions and consideration ofmental capacity in multidisciplinary case reviews and carerecords. There was a considered and appropriate approachto patients’ capacity.

Where staff suspected patients lacked capacity for specificsituations, formal capacity assessments were undertakenand best interest decisions were made followingconsultation with the relevant people.

However, we found that all capacity assessments werecompleted by the medical team. Nursing staff told us thatthey requested capacity assessments from the medicalteam regardless of what the capacity assessment was for.We didn’t see this directly impacting the timeliness ofassessments.

Are acute wards for adults of workingage and psychiatric intensive care unitservices caring?

Good –––

Kindness, privacy, dignity, respect, compassion andsupport

Staff interacted with patients in a respectful andunderstanding manner and gave responsive andappropriate help and support to patients when theyneeded it. Staff spoke of patients in meetings in a kind andcompassionate manner and demonstrated a deepunderstanding of their patients, their risks and wishes.

There was a clear effort by the service and its staff tointeract with patients and minimise their time in wardoffices.

Patients reported that most staff were helpful, respectfuland caring towards their needs and took a genuine interestin their wellbeing.

Staff supported patients to understand and manage theircare and treatment. Staff held one-to-ones with patients,supplied patients with information leaflets and respondedto queries promptly.

Staff understood and were sensitive to patients personal,cultural or religious needs.

Staff ensured patient information was kept strictlyconfidential at all times.

Involvement in care

Involvement of patients

Patients who were new to the ward received an orientationfrom ward staff as part of settling in. If patients were too illwhen admitted to the ward, they were later orientated bystaff. Patients also received ward welcome booklets whichdetailed the information about the ward.

There was clear evidence of patient involvement in careplanning. Patients’ views were included and patients wrotetheir own positive behaviour support plans. Care planswere signed by patients and it was clearly documentedwhen a care plan was given to a patient or if they refused.Patients reported feeling listened to and were givenopportunities to comment on their care in ward rounds.

Each ward held morning planning meetings with patientsto discuss the day’s events and decide which activities theywould like to partake in. There were weekly communitymeetings held on the wards to discuss further ward wideissues and gave opportunity for patients to have their sayon the service.

Patient representatives from the wards were also invited togive the views and opinions of themselves and their peersin monthly clinical governance meetings. Additionally, thehospital had recently introduced a patients’ forum that metmonthly with the hospital director and senior managementteam.

Patients had easy access to advocacy service provided bythree separate organisations. These were well advertisedaround the wards and within patient information booklets.

Involvement of families and carers

The service informed and invited family members andcarers to patient wards rounds and updated them whenchanges to patients care or risk occurred.



Good –––


Staff informed family members and carers when patientswere close to discharge or hospital transfer in order to fullyinform and involve them in the process.

There was a carers’ forum in place at the hospital that metmonthly and a carers’ and family members’ surveyconducted annually.

Are acute wards for adults of workingage and psychiatric intensive care unitservices responsive to people’s needs?(for example, to feedback?)

Good –––

Access and discharge

Bed management

Referrals were received and triaged by a central point ofcontact within the Priory group. The service did not holdany waiting lists and had a target time of one hour toaccept or reject referrals made. In the last six months, nopatients waited longer than 12 hours to be admitted fromthe time of acceptance.

For the 12 months prior to 31 December 2018, the servicereported an average bed occupancy of 83% and an averagelength of stay of 36 days.

The service predominantly received patients out of areafrom their home locations. The service aimed to stabilisepatients as efficiently as possible and worked with patients’local care coordinators to repatriate them to servicesnearer home at the earliest convenience.

A clinical commissioning group within Sussex had recentlylifted a patient placement freeze on the service following apositive quality review. It was hoped that this would lead tomore appropriate local placements of patients to theservice.

Beds were always available for patients returning fromleave.

When patients were moved or discharged this was done atan appropriate time of the day. We saw the service andstaff actively working to ensure that patients were notmoved during the evening or night.

Discharge and transfers of care

In the last 12 months, the service had eight patients whosedischarge was delayed. The ward with the highest numberof patients whose discharge was delayed was Edith Cavellward with four.

All patients whose discharge was delayed were due topatients’ funding arrangements for appropriate clinicalplacements elsewhere. We saw the service activelyattempting to speed up the process with regular contactwith patients’ funders and escalating issues wherenecessary.

The service liaised with patients’ funders, care coordinatorsand local community mental health teams whenappropriate to plan for the patients’ discharges.

The facilities promote recovery, comfort, dignity andconfidentiality

All patients had their own en-suite bedrooms and were riskassessed to receive their own key. For those patientswithout a key, they could request that staff locked orunlocked their doors.

Additionally, the service recently implemented a ‘careprotect’ CCTV system that patients could consent to beingswitched on in their rooms. Patients received informationon the system and were given the choice to consent to thisor not and an appropriate agreement was put in place forthose consenting to it.

Patients were permitted to personalise their bedroomswith pictures and photos if they wished.

Patients and staff had access to a full range of rooms andequipment including activity and therapy rooms, clinicrooms, quiet rooms, de-escalation rooms, seclusion rooms,secure outside space, on-site gymnasium and Activities ofDaily Living kitchen unit for occupational therapyassessments.

All wards had quiet rooms where patients could meet withvisitors and family rooms off the wards where childrencould visit the service.

Patients were individually risk assessed as to whether theycould have their own mobile phones on the ward.Additionally, each ward had a payphone within a privateroom for patients to use.

Patients had access to hot and cold drinks at all times.



Good –––


Meeting the needs of all people who use the service

The service had disabled access to the wards and allocateddisabled rooms with wider entrances and wet rooms toallow for wheelchairs.

The service had information leaflets available for patientsregarding their treatment and available services. Therewere display boards around the wards explaining patients’rights, advocacy services, complaints process andtreatment.

Information leaflets were only available in English on thewards, however staff explained that they could be orderedin differing languages when necessary.

Patients had a choice of food to meet any dietaryrequirements and wishes. Patients reported that the foodserved was generally of a good standard.

Patients were involved in debriefs after events to gain theirviews and received feedback on the outcomes of anyinvestigations into incident and complaints.

Listening to and learning from concerns andcomplaints

The service received 27 complaints for the 12 months priorto December 2018. Eight were upheld and seven werepartially upheld.

Patients were aware of how to raise concerns andcomplaints on the wards. There were posters explainingthe process around the ward and information in theirwelcome booklets. We saw staff attempting to resolvematters locally before a complaint was made. Weeklycommunity meetings gave patients a chance to raise theirconcerns.

Staff knew how to handle complaints. All staff hadcompleted handling complaints mandatory training andcomplaints were investigated appropriately.

The service undertook quarterly complaints audits toidentify themes and to gain patients perspectives on howthey felt their complaints were handled

Are acute wards for adults of workingage and psychiatric intensive care unitservices well-led?

Good –––

Leadership

Leaders within the service had a variety of experience, skillsand knowledge required to ensure an efficient running ofthe service.

Leaders had a clear understanding of the service and wardthey managed and were visible on the ward. Theydisplayed a good rapport with patients and wereapproachable to both patients and staff.

All staff were aware of senior leaders within the service andreported feeling confident to approach them directly ifconcerns arose.

Additional responsibility and leadership developmentopportunities were afforded to all staff on the wards to aidtheir development. This contributed to the hospitals widerstaff recruitment and retention aims.

Vision and strategy

Staff were aware of the local hospital’s aims anddevelopment goals but were not aware of the wider Priorygroup’s vision and values. Staff reported a disconnect withthe Priory group. However, they were dedicated to theirroles within the local hospital.

The hospital’s senior leadership team effectivelycommunicated with staff regarding change and theirvisions for the future. Ward staff praised the efforts of thenew members of the senior management team andrecognised the positive change they had on the service in arelatively short period of time.

However, staff were unaware of senior leaders external tothe hospital.

The service had an active ‘have your say’ staff forum thatmet monthly to discuss staff concerns and issues. We sawevidence of discussions within this forum taken into clinicalgovernance meetings and change brought in as a result.Staff told us they felt listened to and confident to give theiropinions.

Culture



Good –––


Staff reported feeling respected and well supported in theirroles. They expressed pride in working at the hospital andwith their colleagues, although there was a disconnect withthe wider Priory organisation as a whole.

Staff told us that they felt confident and comfortable inraising issues and concerns either within local ward teamsor wider senior management without fear of retribution.They were aware of the whistle-blowing process andunderstood the steps to take if they needed to raise aconcern anonymously.

We saw that ward managers dealt with poor staffperformance effectively and fairly with the help andsupport of the human resources team. We saw extrasupport and supervision in place for those staff requiring itand appropriate disciplinary proceedings in place whennecessary.

Staff supervision and appraisals discussed staff careerdevelopment and plans, and actions were put into place torealise these.

Staff had access to an employee support programme tosupport their own emotional and mental wellbeing.However, staff we spoke to who had accessed the servicereported that it was of very poor standard with one staffexplaining that it left them feeling worse.

Governance

There was a clear governance structure in place to ensurethat risks and concerns were appropriately raised andacted upon. Staff supervision, appraisals and mandatorytraining was appropriately monitored and maintained,incidents and complaints were sufficiently investigated andlearning was taken.

There were frameworks in place to ensure that ward orservice level essential information was shared anddiscussed with the appropriate teams and people.

There was evidence of learning from incidents, complaintsand safeguarding alerts across the service. We saw efficientchange in practices and/or environmental improvementswhen issues had been identified.

The service undertook a range of audits to ensure thatquality standards were maintained. Actions followingmedicines audits had recently improved and there was adecrease in medicine errors since this was a standingagenda item within clinical governance meetings.

Senior management conducted monthly quality walkround visits of the wards and put in actions plans toaddress any concerns found.

The service suitably informed external partners such asclinical commissioning groups, local authorities and theCare Quality Commission when incidents or events thatneeded notifying occurred.

Management of risk, issues and performance

There was a hospital-wide risk register in place that listedkey risks based upon departments. For example, there wereclinical risks, strategic risks, reputational risks andenvironmental risks. All risks were given an initial risk ratingand then a further risk rating after mitigating actions andcontrols were put in place. After mitigation, no risksremained high on the risk register.

Any concerns raised by staff on inspection matched thoseon the risk register and were being actively acted upon.

The service had contingency plans in place in case ofemergency, for example, through disease outbreak or ITsystem failures.

Information management

The service could collect quality assurance data from thewards using electronic systems and the inputting of datawas not too burdensome to front line staff.

Staff had access to equipment and technology required fortheir work. Where information technology inefficiencieswere noted by the service, we saw improvement plans inplace to address this.

Ward managers had easy access to information pertinentto their role. They could access staff supervision andappraisal data, mandatory training data and informationon patient care and staffing levels.

Engagement

Staff had access to up-to-date information about the workof the provider through the intranet, bulletins and noticesin the ward offices.

Community meetings were held weekly on all wards toallow patients the opportunity to provide feedback on theservice and carers and family members were encouraged togive feedback



Good –––


The service had patient representatives sit in on andcontribute to key senior leadership meetings and hadstanding agenda items to allow for patient representativeitems.

Learning, continuous improvement and innovation

The service had a reducing restrictive practices committeewith good patient representation to improve on this aspectof care. We saw a positive change and commitment withinthe service to ensure this occurred across the wards toimprove the culture.

The service employed a dedicated learning anddevelopment lead to ensure staff development and careeraspirations could be achieved. This role fed into thehospital’s overall recruitment and retention programme.



Good –––


Safe Good –––





Are forensic inpatient or secure wardssafe?

Good –––


Safety of the ward layout

Each patient had their own bedroom with en-suite showerand toilet.

Staff conducted regular risk assessments of the careenvironment. The ward had a daily allocated security staffmember who completed an environmental checklist. Theward manager completed weekly ligature andenvironmental audits.

The provider had installed convex mirrors to improve sightlines along corridors to reduce the risk of blind spots. Staffwere always present on the corridors and had aclosed-circuit television (CCTV) system in place. The CCTVsystem was monitored by an external agency but staff hadaccess to the video feed in the nursing station. Staff couldaccess recordings when needed. For example, staff usedrecordings during investigations of incidents andcomplaints. Patients were aware that CCTV was in use.Patients had signed a form to confirm they were aware thatCCTV recordings were being made. CCTV was in place in allthe bedrooms, however these were covered up andswitched off unless formal consent had been given by thepatient.

The ward had a very thorough ligature assessment thatincluded all ward areas. Risks to the patient were managedthrough individual risk assessments and the use of staff

observation. The ward had a useful one-pagediagrammatic summary which was on display in thenursing office. This showed the location of high-risk areasand the location of two sets of ligature cutters. Staff wereconfident in identifying ligature risks and knowing where toaccess ligature cutters when needed.

Staff carried personal alarms with them at all times aroundthe hospital, which they received from the reception at thestart of their shift. Wall mounted nurse call systems weremounted in each bedroom, with an additional alarm in allen-suites. There were also additional alarms in thecommunal bathroom and kitchen.

Maintenance, cleanliness and infection control

Although the ward environment was looking tired, all theward areas were visibly clean and tidy. On the day of ourinspection, the communal areas were being repainted.Staff told us that a refurbishment programme was takingplace throughout the hospital. However, staff wereunaware of the time frame for this.

Cleaning records were up to date and demonstrated thatthe ward areas were cleaned regularly. We observedhousekeeping staff cleaning the ward areas.

There were handwashing signs and facilities appropriatelyplaced around the ward.

Seclusion room

Michael Shepherd ward did not have use of its ownseclusion room. The two closest seclusion rooms had beendecommissioned as the service had declared them not fitfor purpose. The ward had use of two further seclusionrooms. One seclusion room was located through a disusedward on the first floor. The second seclusion room waslocated on the ground floor, on a male acute ward. Staff

Forensicinpatientorsecurewards

Forensic inpatient or securewards

Good –––


were therefore potentially required to escort patients beingmanually restrained through several doors and down aflight of stairs in order to access the seclusion suite. Thehospital had considered the best way to manage any suchpatient transfers in the best and safest way for both staffand patients. The hospital had a procedure in place forwhen female patients had to use the male seclusion room.Staff would telephone the ward in advance and use aseparate corridor from the male ward to escort femalepatients to the seclusion room.

Seclusion rooms allowed clear observation and two-waycommunication and a visible clock. There was an en-suitetoilet and shower in both seclusion suites. The toilet in themale ward seclusion suite was situated so that it was indirect view of the staff viewing window, which potentiallyimpaired the privacy and dignity of the occupant. However,the window had a privacy blind that the staff could operateto mitigate against any potential distress.

Clinic room and equipment

Staff stored medicines securely. Records were made ofmedicine refrigerator and room temperatures on a dailybasis and these were all within the expected temperatureranges. Staff were confident in applying the policy andprocedure in place for when temperatures were above safelimits.

A pharmacy service was provided by an external contractor.The pharmacist provided an audit check of the medicinesfridge temperature checks.

Clinic rooms were fully equipped with accessibleresuscitation equipment and emergency drugs. Recordsshowed that staff were regularly checking clinic roomequipment. The contents of the emergency medicine bagswere checked regularly by hospital staff; all contents werefound to be in date.

On the day of our inspection the clinic room fridge wasdirty. However, this was rectified immediately by a memberof staff. Cleaning records showed several dates missingwithin the previous month and there was no record of clinicroom cleaning audits.

Safe staffing

Managers had calculated the number and grade of nursesand healthcare assistants required for each shift. The wardhad a capacity of 16 patients, with seven admitted at thetime of our inspection. The daily staffing rota was divided

into a day and a night shift. Managers had calculated thattwo nurses and four healthcare assistants were requiredduring the day and one nurse and four healthcareassistants at night. The ward manager could adjust staffinglevels daily to take account of case mix and enhancedobservation.

The ward staff team had vacancies for two healthcareassistant vacancies, three band five nurses and one bandsix nurse. Managers appointed locum staff to provide thebest possible continuity of care to patients, pendingrecruitment of permanent staff. Managers deployed bankand agency staff to fill ad hoc shifts as needed, to maintainsafe staffing levels. The hospital prioritised the use ofknown bank and locum staff to maintain consistency andfamiliarity with the patients. Bank and agency staff receiveda thorough induction to the ward. This induction wasrecorded and signed by both the agency staff member andnurse in charge.

The provider was actively trying to recruit new staff. Theyadvertised at local petrol stations and shops; attended jobfairs; and, engaged with universities.

A qualified nurse was present in communal areas of theward at all times.

Staffing levels allowed patients to have regular one-to-onetime with their named nurse. The ward manager trackedthis through regular clinical audits. None of the patients wespoke with raised concerns about the availability of staff.

Patients and a carer we spoke with stated that staffshortages rarely resulted in staff cancelling escorted leaveor ward activities.

There were enough staff to carry out physical interventionssafely and staff felt supported to bring in more staff whenneeded.

Medical staff

There was good medical cover day and night. A doctorcould attend the ward quickly in an emergency. A forensicpsychiatrist for the ward provided medical cover between9am and 5pm from Monday to Friday. Outside these hours,a duty doctor was available. This doctor was based on site.

Mandatory training

All mandatory training had been completed by at least 93%of staff throughout the hospital.



Good –––



Assessment of patient risk

The inspection team looked at the care records for fivepatients. Staff conducted a thorough risk assessment ofevery patient on admission and updated it regularly,including after any incident. Staff used the recognised riskassessment tool, Short Term Assessment of Risk andTreatability, known as START. All five care records werethorough and up to date. Each patient had a positivebehaviour support (PBS) plan in place, that clearlyidentified triggers and behaviours and how these could bemanaged by staff. Staff worked with patients in atherapeutic way to help them understand and managetheir risks. In addition, the service completed, or updated ahistorical clinical risk management assessment, known asan HCR-20, in the first three months of admission. TheHCR-20 form documents the patient’s forensic history indetail. The service updated this assessment every sixmonths

Management of patient risk

Staff followed the hospital’s policy on observations. Staffused four levels of observation ranging from observingpatients every 15 minutes to two nurses being with thepatient at all times. Staff reviewed observation levels athandovers and in multidisciplinary team meetings. Staffcould only reduce the level of observation after a review bya doctor. The service did not permit patients to have itemsthat could cause harm such as sharp objects, drugs,alcohol or cigarette lighters. Staff searched each patient’sproperty when they were admitted to the hospital andwhen they returned from leave.

Staff applied restrictions on patients’ freedom only whenjustified. Staff told us they had to switch off the hot water tomake hot drinks due to the risk posed by an individualpatient. Therefore, patients had to ask staff for access tothe kitchen or ask the staff member to make them a drink,depending on their individual risk.

Use of restrictive interventions

There were 10 episodes of seclusion in the six months priorto our inspection. These episodes involved four patients.There had been no episodes of seclusion since February2019. Staff used seclusion appropriately. Nurses carried outappropriate reviews and staff observed patients atappropriate intervals in line with the provider’s policy.

There were no reported episodes of long-term segregationfor this ward in the past 12 months.

There were 10 instances of the administration of rapidtranquilisation in the past 12 months. The NationalInstitute for Health and Care Excellence (NICE) defines rapidtranquilisation as ‘use of medication by the parenteralroute (usually intramuscular or, exceptionally, intravenous)if oral medication is not possible or appropriate and urgentsedation with medication is needed’. We reviewed sixrecords where patients had been administered rapidtranquilisation. All records followed established nationalguidance.

There were 14 episodes of restraint in the past four months.These episodes of restraint involved five patients. Staffused positive behaviour support plans to understand howeach patient would prefer to be restrained, if needed. Stafftold us they used restraint only as a last resort when verbalde-escalation techniques had failed to calm the patientsufficiently. The Priory Group operated a policy of not usingprone (face down) restraint.

The ward participated in the provider’s restrictiveinterventions reduction programme. Patients had freeaccess to cold water, bedrooms, bathrooms. Patients hadto seek staff support to use the communal kitchen for hotdrinks, garden and activities rooms.

Safeguarding

We saw evidence that staff made safeguarding referrals tothe local authority and could explain how to protectpatients from harassment and discrimination, includingthose with protected characteristics under the Equality Act.

Staff had a good understanding of how to identify adultsand children at risk of, or suffering, significant harm. Theyinformed us that they had a good relationship with thelocal authority and safeguarding referrals were alwaysmade quickly and appropriately. Staff could access supportfrom the on-site social worker if needed.

Staff followed safe procedures for children visiting thehospital. Children were not allowed on Michael Shepherdward. If children visited the hospital, a private family roomby the hospital reception, was used.




Good –––


Staff had access to electronic records throughout thehospital, using a system called Carenotes. This informationwas available to all members of staff, including agency andbank members who had completed their induction.


The provider had an appropriate medicines managementpolicy, which incorporated ordering, storing, administeringand destroying medicines. We reviewed the medicinesadministration charts for all patients on Michael Shepherdward. We found that staff kept accurate records of thetreatment patients received.

Stock medications were shared between wards within thehospital. This included named patient medicine from award that had closed. Expired medicines were not beingdisposed of in accordance with hospital policy. This meantthat stock levels were exceeding a six-week supply.

Staff reviewed the effects of medicines on patients’ physicalhealth regularly and in line with NICE guidance. Forexample, patients with diabetes had their blood sugarlevels checked regularly and this was appropriatelyrecorded.


There were 10 serious incidents in the past 12 months. Allincidents were investigated thoroughly by the hospital.


Staff we spoke with were confident in reporting incidentsusing the electronic system.

Staff told us that information was discussed at ward level inthe staff communication book, through individualsupervision and at staff meetings when serious incidentsoccurred across the hospital. Staff met for a reflectivepractice session once a month, led by the ward’s traineeforensic psychologist. Learning from incidents across thisand other Priory hospitals was shared with staff via amonthly bulletin from the hospital director.

Staff told us that they received a debrief after every incidentand had multiple opportunities to discuss incidents. Theward manager highlighted the need for staff involved in theincidents to be present at the debrief and reflectivepractice and arranged multiple debrief sessions toaccommodate all staff.

Are forensic inpatient or secure wardseffective?(for example, treatment is effective)

Good –––


We reviewed the care records for five patients. Staff haddevised patient care plans to meet the needs identifiedduring assessment.

The care plans we looked at were personalised, holistic andrecovery oriented, incorporating patients’ strengths andgoals.

Staff updated care plans when necessary.

Staff completed comprehensive mental and physical healthassessments of each patient in a timely manner afteradmission.


Patients had access to a range of psychological therapiesthat were delivered in line with guidance from the NationalInstitute for Health and Care Excellence. The psychologyteam individually assessed each patient and formulatedtheir personalised therapeutic plan. Patients had access toindividual and group sessions, such as dialecticalbehaviour therapy (DBT); ‘hearing voices’; and, ‘boundariesand self-harm’.

Patients had good access to physical healthcare. A GPspent one day each week at the hospital and there was aphysical health lead nurse available within the hospital.The ward had good links with their local general hospitals.Patients had access to chiropody and dental appointmentsas needed.

Staff used Health of the Nation Outcome Scales to measurethe health and social functioning of patients on the wards.

The provider operated a smoke-free environment and staffsupported patients with nicotine replacement therapy.

Staff promoted the importance of a healthy lifestyle topatients. Staff encouraged patients to make healthy dietarychoices and partake in physical activity.



Good –––


Staff participated in clinical audits, benchmarking andquality improvement initiatives.


All non-medical staff on Michael Shepherd ward hadreceived an appraisal as at 30 April 2019.

Medical staff had completed their revalidation process.

The provider’s target for clinical supervision was for eachmember of staff to receive a monthly supervision session.During each of the six months within the period October2018 to March 2019, over 90% of planned sessions weredelivered.

Staff were experienced and qualified and had the rightskills and knowledge to meet the needs of the patientgroup.

The ward team had access to a comprehensive range ofspecialists required to meet the needs of patients. As wellas a consultant forensic psychiatrist and nurses, themultidisciplinary team comprised occupational therapy,psychology and social work staff. A pharmacist visited theward each week and other health professionals, such asspeech and language therapists, dieticians andphysiotherapists were available as needed.

All staff participated in reflective practice sessions, wherethey could discuss instances of good practice and areas fordevelopment.

Staff held regular team meetings. Minutes for the meetingswere recorded and accessible to all staff.

Staff we spoke with felt that managers supported them toaccess training appropriate to their current role and tosupport their continual professional development.

New members of staff received a corporate induction fromthe provider and a ward-based induction from the wardmanager.

Managers dealt with poor staff performance promptly andeffectively.

Multi-disciplinary and interagency team work

Staff attended a handover session when commencing theirshift.

Representatives from the ward staff team attended a dailyhospital-wide morning meeting. Topics discussed at themeeting included recent incidents, staffing levels andstaff-related issues; and, key events for that day.

Staff and patients from the ward attended a joint dailyplanning meeting five days per week (Monday to Friday).

Staff attended a monthly multidisciplinary businessmeeting, at which they discussed topics such assafeguarding cases; compliments and complaints; recentincidents; and, staff-related issues.

Staff on Michael Shepherd ward had effective workingrelationships with staff on other wards within the hospital;senior managers; multidisciplinary clinical and medicalstaff; and; support staff.

Staff reported having effective working relationships withexternal teams such as social services, plus local advocacyservices and health professionals.

Adherence to the Mental Health Act and the MentalHealth Act Code of Practice

The provider submitted training compliance data prior toour inspection. They stated that 98% of staff hadcompleted training in the Mental Health Act.

Staff we spoke with had an appropriate level ofunderstanding of the Mental Health Act, the Code ofPractice and the guiding principles in respect to theirindividual role within the organisation.

Staff had access to policies and procedures on theapplication of the Mental Health Act. Staff also had accessto appropriate administrative support and legal advicefrom a central team within the hospital. The Mental HealthAct administrative team contacted ward staff to remindthem of important events, for example when a patient’speriod of detention was nearing its end.

Patients could request specialist independent mentalhealth advocacy as desired. There was informationdisplayed within the ward on how to contact the advocacyservice.

In general, staff ensured that patients could take theirallotted section 17 leave (permission for patients to leavehospital) as arranged. Sometimes staff needed to move thetime or shorten the duration of escorted leave, due to timepressures within the ward, but they did this in consultationwith the patient concerned.



Good –––


Staff requested the input of a second opinion appointeddoctor when necessary.

We reviewed Mental Health Act paperwork for patients onall wards and found them to be in order and stored so theywere accessible to staff who required them.

We saw evidence that staff explained patients’ rights tothem at the point of admission and at regular intervalsthereafter.

Staff carried out regular audits of Mental Health Actdocumentation.

Good practice in applying the Mental Capacity Act

The provider submitted training compliance data prior toour inspection. They stated that all staff had completedtraining in the Mental Capacity Act.

Staff we spoke with had an appreciation of the MentalCapacity Act and its five statutory principles.

The provider had a policy on the Mental Capacity Act,including Deprivation of Liberty Safeguards. Staff we spokewith were aware of the policy and had access to it. Theyknew where to obtain advice on the application of theMental Capacity Act, including Deprivation of LibertySafeguards.

Staff assessed patients’ capacity to consent to treatmentduring multidisciplinary meetings. Capacity and consentwere recorded appropriately in the care records wereviewed.

Are forensic inpatient or secure wardscaring?

Good –––


Staff attitudes and behaviours when interacting withpatients showed that they were discreet, respectful andresponsive, providing patients with help, emotionalsupport and advice at the time they needed it. Patients toldus that staff were always around to talk to and staff wouldmake time for them. Patients told us that staff were kindand respectful.

It was clear, from our observations that staff had a goodrapport with patients. Staff supported patients tounderstand and manage their care, treatment or condition.

Staff understood the individual needs of patients, includingtheir personal, cultural, social and religious needs. Staffspoke about patients in a respectful manner andmaintained their confidentiality at all times.

Staff and patients said they could raise concerns aboutdisrespectful, discriminatory or abusive behaviour orattitudes towards patients without fear of theconsequences.

Involvement in care

Staff used the admission process to inform and orientpatients to the ward and to the service. Staff told us thatthey prioritised showing the patient to their bedroom andmaking sure the patient had food and drink. Introductionto the ward was done at the patient’s preferred pace.

Patients said that they were given advice about thetreatments available to them and these were regularlyrevisited.

Care plans and risk assessments were written in a way thatwas personal to the patient and most incorporated thepatient’s own views. Patients told us that staff talked tothem regularly about their care plans and that staff offeredthem a copy. Patients were involved in their ward roundand review meetings.

Staff communicated with patients so that they understoodtheir care and treatment, including finding effective ways tocommunicate with patients with communicationdifficulties. Staff could access leaflets and information ineasy read format and in different languages. The hospitalorganised interpreters and signers when needed.

Patients were able to give feedback on the service at themorning ward meeting and at the weekly communitymeeting. The occupational therapist regularly asked forfeedback about the ward timetable, so that it catered tothe patients’ hobbies and needs. In January 2019, amonthly patients’ forum was introduced. Patients couldalso attend hospital-wide reducing restrictive practicemeetings. This had led to patients on Michael Shepherdward having access to mobile phones, following individualrisk assessment.



Good –––


Staff had access to a general advocate, independentmental health advocate and an independent mentalcapacity advocate. Patients were all aware of the types ofadvocacy available to them and staff regularly contactedadvocates on the patients’ behalf.

Involvement of families and carers

Families and carers could be involved in patients’ care if thepatient wanted this. The service provided patients withleave from the ward to maintain contact with their families.

Families and carers were invited to patients’ reviews ifconsent had been given by the patient.

Families and carers were notified after incidents hadoccurred.

in the care records we reviewed.

Are forensic inpatient or secure wardsresponsive to people’s needs?(for example, to feedback?)

Good –––


Bed management

The provider reported that the average bed occupancy rateon Michael Shepherd ward during the period April 2018 toMarch 2019 was 43%.

The provider did not supply data for the average length ofstay for patients on Michael Shepherd ward.

The provider reported that there were four out of areaplacements on Michael Shepherd ward during the periodApril 2018 to March 2019.

Patients’ bedrooms were kept available for them when theywere on leave.

Patients were not moved between wards during anadmission episode unless it was justified on clinicalgrounds and was in the interests of the patient. Themedium secure ward at the hospital had closed forrefurbishment in 2018. Four patients from the mediumsecure ward were transferred to Michael Shepherd ward, asthey were deemed appropriate for the low secure setting.

Discharge and transfers of care

The provider reported that there were four delayeddischarges from Michael Shepherd ward during the periodApril 2018 to March 2019.

Staff told us that the main causes of delayed dischargewere awaiting confirmation of either the funding for theongoing placement, or the ongoing package of care.

Staff supported patients during referrals and transfersbetween services.

Facilities that promote comfort, dignity and privacy

All patients had their own single bedroom and so were notexpected to share with other patients.

All bedrooms had an en-suite toilet and shower. There werealso communal toilets and a communal bathroom on theward.

Patients could personalise their bedroom with pictures anditems of their choice.

Patients had a lockable space in their bedroom. Staffsecurely stored the key for each patient locker in the wardoffice.

Patients could access their bedroom during the day.Patients were given their own bedroom key in line withindividual risk assessment.

The ward had a well-equipped clinic room that was largeenough to enable staff to conduct physical examinationson patients.

Patients had access to their own mobile telephone in linewith individual risk assessment. Staff stored mobiletelephone chargers in the ward office and charged patienttelephones on their behalf. The ward also had a fixedtelephone for patient use.

The ward had its own enclosed garden. Staff supervised allpatient access to the garden. Patients accessed the gardenvia a set of stairs, from the ward on the first floor. Patientswho were unable to negotiate the stairs to the gardencould use the hospital’s central courtyard garden, whichthey accessed by lift.

The ward had a range of rooms available for meetings,therapy sessions, relaxation and activities.



Good –––


The ward had a quiet space for patients to meet withvisitors. However, patients often met with their visitors in aroom near the hospital’s main reception.

Patients we spoke with had mixed views on the quality andchoices of food on offer. One patient was generally happywith the food but stated that some meals were unhealthy.Another patient told us the food did not taste good.

Patients could make hot or cold drinks and access a snackat any time of day or night. However, at the time of ourinspection, patients had to ask staff for a hot drink, as aresult of the individual risk assessment of one patient.

Patients’ engagement with the wider community

Staff supported patients to have escorted and unescortedleave from the ward when appropriate, to ensure theydeveloped and maintained relationships with otherservices and their friends and relatives.

Staff supported patients and carers, to organise family visitsto the hospital. Staff provided emotional support topatients both before and after visits, as needed.

Patients had access to education through the hospital’srecovery college. Priory Hospital Burgess Hill was anapproved Oxford Cambridge & Royal Society of Arts (OCR)examination board, enabling patients to gain recognisedqualifications in mathematics and English.


The internal environment within the ward had level accessand was therefore suitable for people with restrictedmobility.

The ward had one bedroom that was set aside for patientswith restricted mobility. Every bedroom had an en-suiteshower and toilet.

Patients could use a multi-faith room located just outsidethe ward. Patients could visit their chosen place of worshipto attend religious services, subject to individual riskassessment. Patients could access spiritual support fromdifferent religions and faiths upon request.

Staff could access interpreters as needed and couldarrange for information leaflets to be translated intodifferent languages upon request.

Patients had the choice of eating food from differentcultures and could select meals that met specific dietaryrequirements.

Information on a variety of topics was available to patients,from details of how to complain or give feedback; how toaccess advocacy support; contact details for other localagencies; and information on physical and mental healthissues and treatments.


According to the provider, Michael Shepherd ward receivedone complaint during the 12-month period January toDecember 2018. The complaint was partially upheld.

The ward received a total of seven compliments during the12-month period January to December 2018.

Staff displayed information about the complaints processwithin the ward. Patients we spoke with knew how to makea complaint and did not express any concerns about howstaff followed the complaints process.

A carer we spoke with was happy with the feedback theyreceived. They told us that staff had been open and honestin relation to the issue.

Staff we spoke with were familiar with the complaintsprocess and they told us they discussed the outcome ofcomplaints during team meetings, to learn from anymistakes that had been made. Staff were happy with thelevel of feedback they received from complaints.

Are forensic inpatient or secure wardswell-led?

Good –––

Leadership

The ward manager had the skills, knowledge andexperience to perform their role effectively. Most of thesenior management team had been recently appointed,but showed a clear understanding of the service, had theexperience to deliver good quality care and were anenthusiastic team.

Leaders had a good understanding of the services theymanaged. They could explain clearly how the teams wereworking to provide high quality care. Team leaders andsenior management had daily meetings to discuss theday’s running of wards and a clinical governance meetingmonthly to discuss clinical risk.



Good –––


The ward manager was a visible presence on the ward andhad a good rapport with patients and staff. Staff feltsupported by the ward manager, hospital senior managersand the wider multidisciplinary team. The seniormanagement team completed an environment qualitywalk round once a month and made themselves known topatients and staff.

Development opportunities were available for staff andgoals were identified within supervision sessions.

Vision and strategy

Staff were familiar with the provider’s vision and values ofputting safety first, putting the patients at the centre ofeverything they do, taking pride in their work andcelebrating success and valuing staff. The hospital has abi-monthly employee award that rewarded staff fordelivering these vision and values.

Staff had the opportunity to contribute to discussionsabout the strategy for their service through the staff forumrun by the hospital director. Staff could also anonymouslygive feedback through yearly staff surveys.

Culture

Staff we spoke with felt respected, supported and valued.

Staff felt positive and proud about working for the providerand their team. It was acknowledged that staff wereanxious about low patient levels on the ward and how thiswould impact on staffing levels. The management teamwere reassuring staff to alleviate anxiety.

Staff felt confident in how to use the whistleblowingprocess. Staff felt able to raise concerns without fear ofvictimisation. None of the staff we interviewed raisedconcerns about bullying or harassment.

Managers dealt with poor staff performance promptly andefficiently.

Teams worked well together and staff were able to supportacross the site, when needed.

All staff had annual appraisals and monthly supervision.Staff could increase the level of supervision on a case bycase basis, to offer extra support.

Governance

The service had robust systems in place to ensure thatmanagers had access to information pertinent to their

roles. The service had oversight of supervision andappraisals, beds were managed well and incidents,safeguarding concerns and complaints were appropriatelylogged, investigated and learned from.

The service used an electronic dashboard, which was usedto monitor quality objectives, human resourcesinformation, financial data and occupancy levels. Seniormanagers all had access to the dashboard to ensurecompliance. A monthly score card was sent to the hospitalfor mandatory training, incidents, complaints andmedicines, so that staff could take action if areas forimprovement were identified.


The hospital had a site-wide risk register. Staff reported thatthey could easily escalate any issues to service leads ifrequired which could then be put onto the risk register.

The risk register contained entries relating to staff concernsand the areas of risk described by senior staff.

The service had a contingency plan in place to ensurecontinuity of service if there was an emergency effectingservice delivery.


Staff had access to sufficient equipment and informationtechnology in order to do their work. The secure recordkeeping system was easily available to staff to updatepatient care records and review, during ward rounds andother team meetings.

Closed-circuit television was in operation in the communalareas of the ward. This aided incident investigations asmanagers could request to view footage. Managers wereable to have oversight of incidents and could developlearning from this.

The care records system was shared hospital wide and heldconfidentially on systems that only staff had access to witha secure username and password. This eased informationsharing between wards and teams.

Team managers had systems and dashboards in place tosupport them in their role. This included information onstaffing, supervision and appraisals, training and serviceperformance data.



Good –––


Staff made notifications to external bodies, such as theCare Quality Commission, police and local safeguardingauthority as needed.

Engagement

Staff and patients were kept up to date with serviceinformation through weekly bulletins, newsletters, staffintranet, team meetings and community meetings inaddition to the service website.

Directorate leaders engaged with external stakeholderssuch as commissioners, Healthwatch and NHS England.


The ward participated in the safe wards scheme and wereworking towards implementing all aspects of theprogramme.



Good –––


Safe Requires improvement –––





Are long stay or rehabilitation mentalhealth wards for working-ageadults safe?

Requires improvement –––


The ward was on the first floor of the hospital building andhad 13 patient bedrooms although at the time ofinspection the ward was capped at a maximum of tenpatients.

Staff had a clear line of sight from the nurse’s office to themain ward lounge and dining area. There was good use ofconvex mirrors to ensure that nurses could view areas ofthe ward not in direct line of sight.

The ward had closed circuit television cameras (CCTV) inthe communal areas and this had a live stream in thenurse’s office. Following an incident, staff could requestCCTV of the ward events from an external company whostored the recordings. There were cameras in the patientbedrooms which were activated only with the consent ofthe individual patient. At the time of the inspection nopatient had given consent for these cameras to be switchedon.

The bedrooms were located on two wings of the ward. Allrooms had en-suite shower rooms and had a range ofanti-ligature fittings including the bathroom fittings.Bedroom doors had viewing panels which the patient andstaff could control. These gave patients privacy but alsoallowed staff to carry out patient observations. All patientshad a key to their room.

All patient areas had been assessed by staff for ligaturerisks and staff were aware of the location of high-risk areas.The most recent ligature audit had been completed on 18January 2019.

There was a kitchen on the ward where patients couldmake hot or cold drinks. The kitchen was locked andpatients needed a member of staff to unlock the kitchenand remain with them while they made a drink.

There was a regular housekeeping schedule in place andwe saw routine cleaning happening during our inspection.However, areas of the ward flooring were stained, and therewere crumbs and food debris on the kitchen floor, worksurfaces and toaster. The dining room did not have acurtain on the window as the previous curtain had notbeen replaced and there were areas of plaster on the wallsthat needed filling and redecorating.

All staff carried an alarm and there were call buttons in thecommunal areas and bedrooms for patients and staff toalert if there was an emergency or if they neededassistance.

The ward had a clinic room which was clean and wellorganised. However, the clinic room fridge lacked adequateshelving which meant that staff were unable to keepmedicines in an ordered way and the clinic room bin didnot operate via a foot pedal which was a risk tocross-contamination from staff handling the bin lid. Weinformed ward staff of these issues at the time ofinspection.

The ward had access to two seclusion facilities which werelocated on two other wards at the hospital. Patientsrequiring seclusion were transferred to these facilities bystaff. Staff demonstrated how this was done safely and

Longstayorrehabilitationmentalhealthwardsforworkingageadults

Long stay or rehabilitationmental health wards for workingage adults

Good –––


preserving the dignity of the patient during the move fromone ward to another. The rooms allowed good levels ofpatient observation and had a two-way communicationsystem for patients to speak with nursing staff.

We reviewed the recent seclusion records for the ward. Wefound on one occasion that the ward staff had not followedthe hospital policy in relation to the frequency and timingof medical checks for a secluded patient and had not takensufficient actions to follow up physical health concerns forthat patient. The hospital policy stated that patients inseclusion should be reviewed by a doctor at the first hour,then subsequently every four hours until reviewed by themultidisciplinary team.

On the first episode of seclusion the patient received amedical review after one hour. However, all subsequentreviews were omitted. Whilst still in seclusion, the patientreported feeling unwell and following an abnormalelectrocardiogram (ECG) reading, they were taken to thelocal general hospital for assessment. However, the patientabsconded before this assessment and they were returnedto the ward seclusion facility by ward staff. They werereviewed by the doctor within two hours of thecommencement of this episode of seclusion. No furthermedical reviews were undertaken by hospital doctors andthe patient did not receive further assessment ormonitoring in light of the previous abnormal ECG reading.We brought this to the attention of the hospital managersat the time of inspection.

Safe staffing

There was a two-shift pattern on the ward. The day staffworked a 7.30am to 8pm shift and the night shift was7.30pm to 8am. This allowed staff a half-hour period for ashift handover. The regular staffing numbers were twoqualified nurses and two health care assistants in the daytime and one registered nurse and two health careassistants at night. We reviewed the ward roster and sawthat these staffing ratios were being met.

There were significant vacancies for registered nursing staff.The ward had a whole time equivalent of 5.7 registeredmental health nurses (RMNs) of which 2.2 were filled withpermanent employees. The ward filled the vacant hourswith regular locum agency staff who had been working atthe hospital for some time and had good knowledge of thepatients. There were no vacancies for health care assistantsat the time of inspection.

All bank and agency staff received an induction to theservice and had to complete competency checks beforebeing allowed to work on the wards. The agency staffreceived regular supervision from the ward manager.

The ward manager used a staffing ladder set by theprovider. This tool calculated the number of staff requiredbased upon patient numbers, acuity and observations,following national guidance on safe staffing. The maximumday time staffing when the ward had a full complement ofpatients was two nurses and two health care assistants.Staff said that they could request additional staffing whenthere were additional demands such as for escorted leavefor patients or a higher level of enhanced observations.Staff and patients commented that at times the staffinglevels were not sufficient to meet all the ward activitieswhich meant that patients were waiting for staff to beavailable to have access to locked areas of the ward, andthe garden area.

The medical cover was provided by a full-time consultantpsychiatrist based on the ward. The staff we spoke withsaid that support from the consultant was readily availableand the doctor was very responsive and helpful whenpatients and staff needed them.

Staff sickness rates at the hospital were low at 2.4%. Theward had one long term staff sickness which was beingmanaged via the provider’s sickness policy.

Staff received mandatory training and completion wasmonitored on a central record. At the time of inspectioncompletion rates for training were good at over 95%.Mandatory training included courses covering infectioncontrol, safeguarding, basic life support, safe handling ofmedicines and fire safety.

Staff working on the wards had also completed training inthe prevention and management of violence andaggression and also techniques to support positivebehaviours. This meant that they learned to keepthemselves and patients safe if they were involved in anincident on the ward.


We reviewed six sets of care records for patients from bothwards. There was evidence in all records that risk screening



Good –––


had taken place. The clinical staff assessed risks using thetool embedded in the patient’s electronic clinical record.This covered five risk areas: presenting, predisposing,precipitating, perpetuating and protective.

Ward staff completed a risk assessment for all patients atthe point of admission and then at regularmultidisciplinary team reviews and following anysignificant event. All patients had a detailed riskassessment in place and we saw that this was beingreviewed by staff at regular intervals.

Ward staff told us that they had been working to improvethe quality of the patient risk assessments. The riskmanagement plans that we reviewed were comprehensiveand included the involvement of the patient in theirformulation.

All patients had positive behaviour plans. These wereindividualised care plans to support patients who have, ormay be at risk of developing, behaviours that challenge.These were person-centred and had clear records of whenthe plan was reviewed and amended. Staff were trained inthe completion and review of the plans.

Staff we spoke with were knowledgeable aboutanticipating, de-escalating and managing challengingbehaviours and relational security. Staff were up to datewith training in recognising and de-escalating aggressivesituations which included the prevention and managementof violence and aggression (PMVA), and training in positivebehaviour support.

We saw that staff were completing and recording regularobservations of patients following the hospital policy.These were carried at levels set by the hospital doctor andreviewed by the multidisciplinary team. Decisions ofdecreasing observation levels were taken by the fullmultidisciplinary team. All staff completed a competencyassessment before undertaking patient observations.

The service had a reducing restrictive practices committeethat met monthly and we saw positive change towards thison the wards. There were plans to create separate hospitalentrances for the acute mental health wards to enable theenvironment and reception areas to be less restrictive totheir patients. The current entrance was based on a moresecure hospital design and patients and staff described thedelays that this could cause in entering or leaving the site.

The hospital site was smoke-free at the time of theinspection. Patients were informed of this either before orduring admission. The wards encouraged and supportedsmoking cessation and offered nicotine replacementtherapy and/or disposable electronic cigarettes to allpatients requiring it.

Safeguarding

The staff we spoke with were confident about how torecognise and report safeguarding concerns.

A member of the senior team was a lead for safeguardingadults and children on the ward. They maintained contactwith the local authority safeguarding team for advice onsafeguarding concerns. We saw a detailed log ofsafeguarding concerns raised with the local authoritysafeguarding team was held by the ward manager tomonitor the progress and outcome of investigations.

Staff received annual training in safeguarding adults andsafeguarding children. At the time of inspection thistraining had been completed all staff.


At the morning handover, nursing staff recorded andshared essential patient information from each shift. Thiswas later discussed with the full multidisciplinary team(MDT) at the morning meeting. This included discussingany incidents that had happened overnight and anystaffing pressures on the wards.

Staff allocated their roles for each shift at the morninghandover. These included: patient allocation to individualnurses, key duties such as supporting patients with section17 leave, patients who required increased levels ofobservation or assistance with their physical health. Thismeant staff had clear information regarding their duties onshift.

Patient information was securely stored on an electroniccare records system. All staff, including locum nurses, had alog-in for the electronic patient records which includedcare plans and risk assessments for each patient. They alsohad access to the electronic incident reporting system sothey could read and report of any serious events thathappened on their shift.


Medicines were securely stored in locked cabinets in theward’s clinic room which was also locked. The ward had



Good –––


secure storage for controlled medicines and managedthese safely according to the hospital policy. The medicineswere safely stored and disposed of and a pharmacistcompleted a monthly audit of the clinic room and fed-backany learning to the hospital managers.

There were good arrangements in place with the pharmacyprovider to support the medicines management process.The visiting pharmacist reported any medicines issues tothe senior team and reported to the hospital governancemeeting every three months and reported that the warddoctor and nursing staff were responsive to maintaininggood standards.

Staff regularly reviewed the effects of medication onpatients’ physical health. A suitably experienced member ofstaff was assigned on each ward as the physical healthchampion and utilised National Early Warning Score(NEWS) charts to monitor the physical health of everypatient daily. We saw appropriate actions taken when thescores from the tests indicated that closer monitoring wasrequired.

We reviewed the medicines charts for several patientswhich were generally in good order. We found one occasionwhere a chart for a patient detained under the MentalHealth Act contained a medicine that was not recorded ontheir T2 treatment authorisation certificate. This error hadsubsequently been amended by the prescribing doctor.However, an incident form had not been completed. Weraised this with the ward staff during our inspection.

In all cases a signed patient’s consent to treatment formwas stored alongside their medicines chart. For patientsdetained under the Mental Health Act the requiredtreatment authorisation forms were present and had beensigned by the clinician in charge of the person’s treatment.

Patients’ allergies were clearly recorded on the charts.


There had been 84 incidents of restraint involving 12patients in the six months ending December 2018. Therehad been no incidents of rapid tranquilisation in these sixmonths. The hospital did not use prone restraint or trainstaff in its use.

There had been three incidents of patients being secludedin the six months to December 2018.

The most frequent types of incident on the ward wereself-harming behaviours including the ingestion of foreignbodies, tying ligatures, and violence and aggression.


All staff had log-ins to record incidents on the hospital’selectronic IRIS reporting system. These were reviewed andsigned off by the ward manager and discussed within 24hours at the daily hospital meeting with the senior team.

The staff we spoke with were knowledgeable about theprocess for recording incidents and felt confident in usingthe electronic reporting tool.

The hospital was introducing Safe Wards to all the wards.Safe Wards is a model that helps staff understand anddiffuse conflict and flashpoints on the ward and seeks tocreate a more peaceful environment.

The senior team discussed all incidents at the monthlygovernance meeting. Learning from incidents was sharedby the senior team via a lessons-learned briefing and wesaw that these were available to staff in the nursing officeon the ward.

Are long stay or rehabilitation mentalhealth wards for working-ageadults effective?(for example, treatment is effective)

Good –––


We reviewed the clinical records for six patients, which werestored on the electronic care records system. All care planswe saw were in good order, current, and had been regularlyreviewed. Patients’ immediate and long-term goals wererecorded along with the interventions and supportrequired to accomplish these.

The care plans for each patient were individualised, holisticand recovery-focused, and based on the assessed needs ofthat person. They covered a broad range of recovery goalsincluding the use of dialectical behavioural therapy tofocus on mindfulness, interpersonal effectiveness andemotional regulation.



Good –––


Patients were encouraged by staff to become involved intheir treatment and care plans. They were supported tocreate their own plans and present these to themultidisciplinary team for feedback. All patients had abehaviour support plan which was reviewed frequentlywith nursing staff. Patients were given a copy of their plansand it was clear that they had been involved in their careplan formulation.

All patients received a physical health assessment onadmission including blood pressure, electrocardiogram,blood tests and body mapping. We saw from the carerecords we reviewed that regular physical health checkswere being maintained and recorded in patient notes. Theservice carried out a monthly audit of the quality of thephysical health assessments received by patients.

Patients had access to a GP who visited the ward weekly.


Patients were offered a specialised rehabilitation servicedesigned to address the needs of women with complexpersonality disorders and complex needs. This wasdelivered in a 12-month rehabilitation programme whichcombined dialectic behaviour therapy (DBT), support frompsychiatry and a programme of recovery activities led bynursing and occupational therapy staff. The use of DBTapproaches in the treatment of emotionally unstablepersonality disorder was an evidence-based approach andwas in line with best practice guidance for this patientgroup.

The rehabilitation programme was led by the wardpsychiatrist and the ward lead psychologist with thesupport of the occupational therapy assistant. Patients hadstructured days between 9am and 4pm from Monday toFriday. Each morning started with a whole ward goalsetting meeting which was followed by a health walkoutdoors. Patients attended a DBT-based session each daywhich focused on skills learning and mindfulness. Patientsalso had individual therapy sessions with ward psychologystaff.

The patients we spoke with were very aware of the natureand duration of their treatment programme. They wereencouraged by staff to prepare and contribute to a weeklyreview of their treatment and progress at the wardmultidisciplinary review meeting.

Patients were supported in other activities by nurses andoccupational therapy assistants and these includedbudgeting and shopping, baking, art and relaxation.Patients could also use the hospital gym with support froma trained member of hospital staff.

The patients’ progress was measured by recording monthlyHealth of the Nation Outcome Scales (HoNOS) scores. Thiswas a scale scoring patients’ health and social functioningand measuring changes in the levels of their needs over thetime of their admission.

Other recognised measures which were used by nursingand psychology staff on the ward to measure patientoutcomes included the work and social adjustment scale(WSAS) where patients assessed their levels of impairmentin achieving day to day tasks; the Beck depressioninventory (BDI) which rated the severity of patients’depressive symptoms, and the CORE outcome measurewhich patients used to give feedback about the impact oftherapy.

Patients were supported by staff to lead healthier lives andthis included support with smoking cessation and nicotinereplacement therapies, diet and healthy eating and regularexercise. The service employed a full-time health andwellbeing lead and patients had access to a dietician.


The multidisciplinary team comprised one full-timeconsultant psychiatrist, registered mental health nursesand healthcare assistants, a lead psychological therapist,therapy assistants, an occupational therapist assistant and1.5 days of a qualified occupational therapist (OT). The OTtime available to the ten patients on the ward had recentlybeen reduced by 50% to the current level. Whilst patientswere having access to a range of programmes to help withtheir living skills, they all reported that they would likeaccess to more cooking sessions.

Staff we spoke with told us that they received regularmonthly supervision. The hospital target for monthlysupervision was 95%. Supervision records showed theward was meeting this target on most months in the last 12months but there was some fluctuation when thecompletion rates fell below target.



Good –––


There was a clear supervision structure in place with staffreceiving support from the relevant professional colleaguesand this included staff who were long-term locum workers.Staff also participated in regular reflective practicemeetings and locum staff also attended.

The service was up to date with staff appraisals, and alldoctors had completed revalidation.

Multi-disciplinary and inter-agency team work

There was a nurses’ handover at the beginning of the dayand when the night staff replaced the day staff. Daily at9am there was a hospital morning handover meetingattended by all ward managers, senior leads including theconsultant psychiatrist and the hospital director.

Areas covered by the morning meeting included relationalsecurity, risk and observation levels, incidents andsafeguarding,

Staff and patients told us that the multidisciplinary teamworked well together and were effective and approachable.

We saw in patients’ records that contact with referringteams, commissioners and other stakeholders in thepatients’ care pathway was being well maintained by thehospital senior team. This included attendance bycommunity staff at patients’ care programme approachreview meetings.

Parents, family and carers were invited to the patients’reviews at set times during the treatment programme andcould attend the six-monthly care programme approachreview meetings.

The ward had a positive relationship with the local visitingGP. The visiting GP supported patients with physical healthmonitoring and scheduled health check-ups.

Adherence to the MHA and the MHA Code of Practice

At the time of inspection, 98% of ward-based staff hadcompleted mandatory training in the Mental Health Act(MHA). Staff we spoke with demonstrated a good workingknowledge of the MHA and the Code of Practice.

There were six patients on the ward at the time ofinspection, five of whom were detained under the MentalHealth Act.

Staff recorded in patients’ electronic notes that they haddiscussed patients’ rights with them.

We saw completed consent to treatment forms for allpatients. We identified that one patient had beenprescribed a medicine that was not written up on their T2treatment authorisation form. This had been corrected bythe doctor.

The ward had the support of the hospital based MentalHealth Act administrator. The administrator sent remindersto staff regarding approaching expiry dates for patients’detention periods and planned patients’ tribunals andmanagers hearings.

Staff recorded arrangements for leave from the hospital(section 17 leave) on patients’ electronic notes. Patientstold us they could generally take their leave, includingescorted leave. However, they also commented that therewere times when the ward was very busy and their leavehad been cancelled.

Good practice in applying the Mental Capacity Act

At the time of inspection, 99% of eligible staff hadcompleted mandatory training in the Mental Capacity Act(MCA) and Deprivation of Liberty Safeguards (DoLS).

Staff we spoke with were aware of the principles of theMental Capacity Act.

The application of the Act was however carried out solelyby the ward doctors but this didn’t impact on thetimeliness of assessments. We saw in care records thatdoctors had considered patients’ capacity on adecision-specific basis. They recorded capacityassessments regarding specific decisions in the patient’scare records.

Are long stay or rehabilitation mentalhealth wards for working-ageadults caring?

Good –––


During the inspection we saw supportive and caringinteractions from the staff towards the patients. Staffbehaviours were kind and attentive and it was clear thatthe patients were confident in speaking to the ward staff.



Good –––


Patients spoke positively about the attitude of the majorityof staff and said that the ward doctor and the wardmanager were approachable and helpful.

Patients were ambivalent about the quality and choice ofmeals available.

Patients said that at times they had to wait to get access tothe ward garden which was on the ground floor andrequired staff to escort them as they needed to passthrough other parts of the hospital which were locked. Atbusy times on the ward staff were unavailable to escort andremain with patients in the garden.

Involvement in care

The patients had a daily goal setting meeting attended bystaff and patients which focussed on the patient’s prioritiesand activities for the day. There was also a weeklycommunity meeting to discuss where patients could raiseconcerns and make suggestions about the running of theward.

Patients were encouraged to take active roles in theplanning of their care as part of their rehabilitation processand this included creating their own care plans with thesupport of nursing and therapy staff.

Patients told us that they were encouraged to includecarers and family in planning their care and treatment ifthey wished to. Patients told us that there were challengesto this as their families had to travel long distances to visitthem and on some occasions they were unable to go outwith family as they did not have any leave.

Patients took part in a quarterly hospital-wide survey oftheir satisfaction with the service. The three areas surveyedwere satisfaction with staff, with care, and with the wardenvironment. The highest satisfaction score for patientscurrently receiving treatment on Amy Johnson ward in theDecember 2018 survey was that 65% felt listened to by staff,and the lowest score in this period was that 50% of patientswould recommend the service to others. These scores weresignificantly higher in the same period for patients who hadbeen discharged from this ward at 77% and 78%respectively. This demonstrated that patients’ feedbackscores on their experience increased after treatment.

Are long stay or rehabilitation mentalhealth wards for working-ageadults responsive to people’s needs?(for example, to feedback?)

Good –––


There were six patients on the ward at the time ofinspection. Two patients had recently been discharged asthey had completed their rehabilitation programme. Thebed occupancy for the last six months had averaged 90%.

The ward took referrals from NHS commissioning groupsand patients were generally referred by their communitycare co-ordinator. The hospital received referrals from awide geographical area and this meant that patients couldbe a long way from their home area.

Staff we spoke with told us that they considered retainingregular contact with services in a patient’s local area wasimportant in ensuring that they would have servicesidentified when they were ready for discharge. We saw thatcommunity mental health staff from the patients’ localteams were invited to care programme approach reviewmeetings. In the last three months of the 12-monthprogramme patients spent increasing amounts of time inthe local community as a preparation for discharge.

Criteria for referrals to the ward were female patients with adiagnosis of emotionally unstable personality disorder,including patients with co-morbidities such as trauma,psychosis, Asperger’s syndrome or eating disorders.Patients with eating disorders were accepted if their bodymass index was above 16.

The ward did not accept referrals if the patient had ahistory of assaulting behaviour or used violent behaviour.The ward criteria also excluded patients with a diagnosis ofanti-social personality disorder or psychopathy.

Patients who were referred received a two-stageassessment. They had a face-to-face assessment with twosenior staff and were invited to spend a day on the ward.They then had a second assessment includingpsychometric tests and interviews and received detailsabout the treatment model and expectations for theprogramme. This ensured that patients were fully informed



Good –––


of the nature of the 12-month rehabilitation programmebefore their admission began. Patients who had beenassessed were given the outcome of the assessmentprocess within three weeks.

The average length of stay on the ward at the time ofinspection was 255 days. The ward manager told us thatthere was flexibility with length of stay if patients needed toexceed the 12-month programme in order to secure themost appropriate step-down placement. There were nopatients whose discharge was delayed on this ward.

The facilties promote recovery, comfort, dignity andconfidentiality

The ward had its own outdoor space. However, the gardenwas a small slope of grass without any seating, shelteredarea or plants. Patients also reported that the access to thegarden was dependent on staff taking them through otherareas of the hospital to reach it. The hospital director hadapproved a plan to improve the facilities available in thegarden.

The ward had a comfortable central lounge and dining areawith television and information for patients. A secondlounge area on the ward was furnished with seats andequipped with a television. An activities room and quietlounge were available to patients.

Patients had en-suite showers in their rooms and there wasa ward bathroom equipped with a bath.

All patients had keys to their rooms, and a locked storagecupboard in their bedrooms for personal items. The key forthe cupboard was held by the nursing staff.

The flooring and the walls in some of the busiest areas ofthe ward were showing wear and tear. These areas hadlimited decoration such as prints, posters or noticeboardsto add interest for the patients.

The occupational therapy staff supported patients in adedicated kitchen area to become more independent withmenu planning, shopping and meal preparation.

The patients’ activity programme included arts and craftstime, yoga, access to the sports hall and staff organisedsports, pampering and time using the ward computers. Wesaw that staff were supporting patients with an art sessionduring the inspection.

Patients were able to use their own mobile phones and usetheir vaping devices on the ward. There was a computerroom where patients had supervised access to the internet.

Patients’ engagement with the wider community

Patients told us they had access to the local community forshopping and when visited by their family. On the day ofinspection two patients had escorted leave to visit the localopticians.

Most of the therapeutic programme had ward basedtherapeutic time and occupational therapy led activities,however patients told us that they had escorted leave tothe nearby local town.

Patients’ families were welcomed to visit and familiesmeeting with clinical staff was part of the patient’srehabilitation programme.


There was information available to patients on ward noticeboards and on admission patients were given aninformation pack about the hospital. Information includedhow to raise complaints, safeguarding information, thecontact numbers for advocacy services and informationabout the Mental Health Act and the Mental Capacity Act.

There was a general advocacy service for patients. Anadvocate visited the ward each week to be available topatients and they had information about how to contactthe advocate whenever they needed advice or support.

Staff told us that if they needed information provided inother languages or if a patient required an interpreter thehospital could provide these services.

The hospital had an adapted bathroom and a lift whichmeant that the ward area was accessible and useable for apatient with mobility difficulties or who required awheelchair.


The ward had received four formal complaints in the 12months to December 2018. Two of the complaints wereupheld by the provider, one was partially upheld and onewas not upheld. The service had completed an audit offormal complaints in November 2018 to better understandrecurring themes and the types of issues that causedpatient dissatisfaction.



Good –––


The ward kept an informal complaints log where patients’complaints were recorded with the hospital response. Wesaw the completed logs where the ward manager haddetailed the actions taken as a result of the complaint andhow the response had been given to the patient. Patientswere also given information about how to raise formalcomplaints and this was also posted on the wardnoticeboards.

Patients were aware of how to raise concerns andcomplaints on the wards. There were posters explainingthe process around the ward and information in theirwelcome booklets.

The ward had a weekly community meeting where patientscould raise issues and concerns about the running of theward directly with staff.

Are long stay or rehabilitation mentalhealth wards for working-ageadults well-led?

Good –––

Leadership

There was a clear organisational structure at PrioryHospital Burgess Hill and the roles of professional andmanagerial leads comprising the multidisciplinary teamwere defined. The senior team were appropriately qualifiedand they had significant experience of delivering mentalhealth services.

We observed that the medical director, ward manager andsenior psychologist were frequently present on the wardand their interactions with staff and patients were warmand respectful.

Vision and strategy

The ward senior team spoke positively about the strengthsof the therapeutic programme on the ward. They coulddescribe openly the areas in which they wished to seeimprovements in the ward environment and demonstratedthat they had strategies to make the changes.

Staff we spoke with had a clear view of the purpose of theirward as a rehabilitation service offering a recovery focused

treatment programme. The provider had produced a clearservice description stating the model of care, the criteria foradmission to the hospital and the outcome measures usedto mark patient progress to discharge in to the community.

Staff were positive about the ward purpose and shared realpleasure that two patients had been recently dischargedafter successfully completing their rehabilitationprogramme. However, staff expressed some concern thatthe current staffing numbers on day shifts meant that therewas always pressure to complete all the ward tasks andmeet patients’ needs including escorted leave.

It was evident that staff were working in a compassionateand collaborative way to help patients build skills andconfidence and this extended in to supporting patients tohave an active role in making decisions about their careand treatment.

Culture

Staff were positive about the atmosphere and the ethos ofthe ward. They spoke warmly about the support theyreceived from colleagues and the senior team.

Staff were receiving regular supervision, training andappraisal.

Staff we spoke with told us that they felt confident aboutraising any concern they had to senior staff. All staff wereaware of the organisations whistle-blowing policy.

Governance

There was a clear governance and reporting structurewithin the hospital and up to the larger organisation. Thehospital had a daily morning meeting to review anysignificant events and risks, including incidents andstaffing. This meant that priorities that affected the wardwere reviewed every day.

There were daily patient planning meetings and a weeklypatient community meeting and issues raised at thesewere shared at team meetings and at the hospitalgovernance meeting.

Senior management conducted monthly quality walkround visits of the wards and put in actions plans toaddress any concerns found.

We saw that learning from incidents, complaints andsafeguarding across the hospital were shared with all wardstaff.



Good –––


The hospital held regular forums where issues concerningthe wards were discussed and actions taken. Theseincluded a monthly governance meeting also a weeklyward management meeting. All patients on the ward had aweekly review of their care with the multidisciplinary team.


The ward manager had access to a dashboard ofinformation which was mostly drawn from patients’electronic clinical notes and the incident reporting system.This showed a broad range of patient-related indicatorsand performance against agreed targets. A monthly reportwas created for the ward performance and includedmandatory training, incidents, complaints and medicines.

The hospital risk register was reviewed by the senior teameach month and detailed actions to mitigate each risk wererecorded, and where appropriate an action plan had beendeveloped to monitor progress to reducing or eliminatingthe risks. Current high risks included recruiting andretaining suitable staffing, the high levels of acuity of thepatients on the wards, and the levels of therapeuticactivities available to patients.

The ward staff we spoke with could articulate the service’srisks and the mitigations and strategies that were in placeto further reduce and manage them.


All ward staff had access to the wards clinical recordssystem for patients which meant that staff, including locumstaff, had the most current patient information.

The incident reporting tool was linked to the patients’records so if a patient was involved in an incident, thedetails also appeared on the patient’s record. This helpedmaintain patient and staff safety on the ward.

All staff were up to date with their training in informationgovernance. The mandatory courses included dataprotection and confidentiality, cyber security and ITsecurity. This helped staff recognise how to safeguardconfidential information relating to patients and staff.

Engagement

Staff that we spoke to were positive about their jobs andworking at the service.

Staff had access to up to date information about the workof the provider through the intranet, bulletins and noticesin the ward offices.

Community meetings were held weekly on all units to allowpatients the opportunity to provide feedback on theservice.

The ward had access to feedback from families andpatients. The ward sought feedback from patients who hadbeen completed their treatment and had been discharged.

The service made appropriate notifications to externalagencies, such as local safeguarding teams.


The ward took part in the Priory annual audit programmewhich included in 2019 an audit of patients’ sexual safetyplans, and an audit of self-harming behaviours to identifytrends and take actions to reduce the incidents ofself-harm.

At the time of inspection this ward was not participating inany formal accreditation scheme.



Good –––


Areas for improvement

Action the provider MUST take to improve

• The provider must ensure that all abnormal physicalhealth risks are followed up.

• The provider must ensure that all patients in seclusionreceive medical reviews according to the hospitalpolicy and the Code of Practice.

Action the provider SHOULD take to improveAction the provider SHOULD take to improve

• The provider should ensure they reduce medicineerrors, appropriately label ‘to take out’ medicines andprovide sufficient patient information.

• The provider should dispose of expired medicines inline with organisational policy.

• The provider should ensure that clinic roomrefrigerators are kept clean at all times.

• The provider should ensure cleaning standards aremaintained and that ward staff are aware of thedomestic teams’ responsibilities and schedule.

• The provider should support the wider MDT to haveconfidence in carrying on MCA assessments if they arethe most appropriate person.

• The provider should ensure that repairs to the wardare carried out in a timely way.

• The provider should ensure that patients have accessto hot and cold drinks on Amy Johnson ward and thatpatients have more opportunities to prepare their ownmeals as part of the rehabilitation programme.

• The provider should ensure that patients have greateraccess to the ward garden and it is suitably furnishedwith seating and a sheltered area.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Assessment or medical treatment for persons detainedunder the Mental Health Act 1983

Diagnostic and screening procedures

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Safe Care and Treatment

The provider did not complete medical reviews for apatient in seclusion according to the provider policy onseclusion and the Mental Health Act Code of Practiceguidance.

The provider did not follow up the physical healthconcerns for a patient following an abnormal ECGreading.

This was a breach of regulation 12.

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

This section is primarily information for the provider

Enforcement actionsEnforcementactions


Documents

Priory Hospital Burgess Hill NewApproachComprehensive ... · • The service worked to a recognised treatment model appropriate to the patient group. It was well led and the governance