10 July 2017
During a routine inspection
We rated the service as good overall because:
- Patients at the hospital were kept safe because there was sufficient staff in place, the multidisciplinary team included a range of professionals, staff sickness absence rates were only 2.6%, staff were trained in emergency first aid and basic and intermediate life support and there was emergency medication in stock.
- The hospital was clean and tidy and complied with the Department of Health guidance on eliminating mixed sex accommodation. Patients’ rooms were fitted with sensor-operated showers and taps and nurse call alarms and the garden area was secure which prevented patients from absconding.
- Staff were trained and qualified to deliver safe and effective care, received regular supervision, and were appraised. Patients did not need to be secluded or placed in long-term segregation and physical restraint was only used as a last resort because staff were trained in de-escalation practices. The provider also had a policy in place to ensure that any children visiting the hospital were kept safe. Staff knew and agreed with the provider’s visions and values. Staff morale and job satisfaction were positive and there was a good level of support from peers and managers.
- People who used the service told us that staff treated them in a caring, compassionate, kind, respectful and dignified manner. People who used the service were involved in decisions about care and treatment and were able to provide feedback on their care and treatment through patient and family forums, meetings with the multidisciplinary team and using comments and suggestions cards. Patients had access to an advocacy service, an interpreter and signer and the hospital ran patient activities seven days a week.
- Incidents and complaints were investigated and lessons learned were used to improve practice. All staff were aware of the need to be open, honest and transparent with people when things go wrong.
- Mental Health Act and Deprivation of Liberty Safeguards documentation was in order. All staff had completed training in the Mental Health Act and Mental Capacity Act and audits took place to ensure staff complied with the Acts. Staff regularly reminded patients of their rights.
- Care records showed the hospital was patient-focussed as they were recovery orientated, person-centred, showed evidence of physical healthcare being assessed and monitored and contained discharge plans. All patients had up to date risk assessments in place.
- Hot drinks and snacks were available to patients 24 hours a day, the Foods Standards Agency awarded the hospital a five star ‘very good’ rating in relation to food hygiene and patients had a choice of food to meet their dietary requirements. Patients could personalise their rooms and accessed their chosen place of worship within the community. There were patient activities seven days a week.
- The provider used key performance indicators and clinical governance mechanisms and audits to monitor practice and improve service delivery. The hospital had a risk register to which staff could add items.
However:
- Curtain rails were not of the collapsible type used to prevent suicides by hanging themselves and were not included in the environmental risk assessment. This was a breach of regulation 12 of the Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Safe care and treatment.
- An audit on 3 July 2017 identified staff had incorrectly administered medication, which had expired on 30 June 2017.
- Dosages on medication labels did not match the prescribed dose recorded on three patients’ medication cards.