All inspections: St Magnus Hospital and St Magnus Nursing

About the service

St Magnus and St Magnus Nursing is an independent mental health hospital and nursing service registered as a single location. This inspection was carried out in St Magnus Nursing service comprising of Rosemary Park nursing and Courtyard unit. The nursing service accommodates and provides personal and nursing care to up to 61 individuals across 3 units, East and West Wings of Rosemary Park and Courtyard unit. The nursing service is a part of a highly specialist, national service provided to older people, predominantly men with behavioural and psychological symptoms of dementia, cognitive impairment and/or enduring mental illness. At the time of our inspection there were 49 people using the nursing service of St Magnus.

People’s experience of using this service and what we found

People received person-centred support around their individual risks. Staff knew people’s individual physical, health-related and behavioural support needs. Staff effectively helped people to take positive risks, maintain their abilities and when they became distressed. People’s care plans were comprehensive and tailored to individual needs and risks.

People and their relatives told us they felt the service was safe. Staff knew how to protect people from abuse and neglect. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People, their relatives and representatives were involved in care reviews, asked for feedback and engaged in the service.

There were enough trained and skilled staff to support people. The provider regularly reviewed staffing levels and deployment of staff in the service to ensure staff were able to provide support to people in a timely and safe way. New staff were recruited safely. People received safe support with their medicines provided by trained staff. Staff adhered to good practice around infection prevention and control.

Staff treated people with dignity, respect and kindness. Staff supported people to access healthcare services when needed and communicated with people in a way they could understand. People and their representatives felt comfortable to express their views and told us management would act on their complaints when needed. People could host visitors and staff supported them to engage in a variety of daily activities.

The provider had clear governance and quality assurances systems. Managers completed regular audits of the service and shared key risks, improvement needs and findings within the provider’s organisation. Improvements were made to the service when needed. For example, records, policies and procedures, guidance for staff or environment were reviewed and changed to minimise risks to people and to improve their experience of care.

Staff felt supported and valued by the management. Leaders were visible in the nursing service on a day-to-day basis. People, their relatives and staff told us they were approachable and worked in a transparent way. The culture of the service was calm, welcoming and inclusive, treating each supported person as an individual.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service when we inspected the nursing service and hospital jointly was outstanding (published 16 March 2020). There was no standalone rating awarded for the nursing service at that time.

Why we inspected

We received concerns in relation to safeguarding, staffing and quality of personal care provided to people in the nursing service of St Magnus. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. Following that inspection site visit we decided to include the key questions of effective, caring and responsive in this inspection in order to ensure the overall rating for the nursing service only was up to date and reflective of this part of the service.

The overall rating for the nursing service of St Magnus is good based on the findings of this inspection. The overall rating of the hospital remains outstanding as we did not inspect this part of the service on this occasion.

We found no evidence during this inspection that people in the nursing service were at risk of harm from the concerns we received which prompted this inspection. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection of the St Magnus Hospital, by selecting the ‘all reports’ link for St Magnus Hospital and St Magnus Nursing on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

This service was inspected using CQC's methodology for inspecting both mental health and adult social care services. The report has been structured to provide an overall rating for the whole location and includes our rating for the low secure wards at St Magnus and older peoples services at both St Magnus and Rosemary Park Nursing Home..

We rated the St Magnus and Rosemary Park as Outstanding overall because:

There was a truly holistic approach to assessing, planning and delivering care and treatment to all patients who used services. This included addressing, mental health and physical health care needs along with their nutrition, hydration and well-being needs. All care plans were personalised, holistic and recovery focused. It was clear from the content of the care plans that patients and their carers had been involved in developing the plans. All patients were risk assessed on admission and had up to date risk assessments which were linked to their care plans

Staff used safe, innovative and pioneering approaches to care. There were individual and group psychological therapies such as cognitive behavioural therapy and dialectical behavioural therapy available to assess and provide treatment and there was a dedicated psychologist in post to ensure psychological evaluation was happening

Staff across both services used an “all about me” document which was kept in the patient bedrooms for patients who had cognitive difficulties to help inform staff of patients’ likes and dislikes. This document was detailed and informative and gave all staff an opportunity to engage with patients in areas of interest

The majority of patients were detained under the Mental Health Act 1983 (MHA) and understand and were empowered to exercise their rights under the Act. The provider supported staff to understand and meet the standards in the MHA Code of Practice. The service had developed a system for ensuring patients supported on a Deprivation of Liberty Safeguards (DOLS) applications were fully tracked and they had their rights and entitlements explained to them and recorded regularly.

Practices around consent and records were actively monitored and reviewed to improve how patients were involved in making decisions about their care and treatment.

Staff were clear about their safeguarding responsibilities to ensure they kept patients safe and knew how to identify and make a safeguarding referral within office hours and during the evening and weekend.

The services supported health care assistants to complete the care certificate standards and senior healthcare workers were offered the opportunity to complete their Nurse Associate training funded by the hospital.

Feedback from patients and their carers and stakeholders was overwhelmingly positive about the way staff treated patients. NHS England commissioners reported witnessing a high level of compassion and understanding when they attended the hospital and reported that the clinical teams took a great deal of time and effort to ensure that the patients were involved in the process as fully as possible. Carers told us that they felt patients were safe, cared for and well looked after by staff. Staff attitude was described as caring, motivated and patients and carers told us that staff went the extra mile to ensure patients’ needs were met.

All staff across the service were observed to be exceptionally and consistently caring and respectful to all patients. Staff used thoughtful, appropriate and considerate language and adapted their style of communication to the patients’ level of understanding. We saw staff always responded quickly to patient requests for additional support such as personal care. Staff were passionate about their work and it was clear they genuinely cared about the emotional wellbeing of their patients and wanted them to feel cared for.

All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking and peer review were proactively pursued, including participation in approved accreditation schemes. High performance had been recognised as St Magnus Hospital is a member of the Quality Network for Forensic Mental Health Services (Royal College of Psychiatrists). St Magnus Low secure unit was found to have fully met 92% of standards, putting it in the top ten low secure units in the network.

Managers, with support from the security lead, completed ligature audits to identify ligature points throughout the wards and gardens. In addition, daily walk-around checks and a weekly environmental check on each ward ensured a regular systematic approach to maintaining a safe environment.
The ward and unit environments at both St Magnus and Rosemary Park were clean and well maintained. Staff followed good infection control procedures and monitored the cleanliness of the environment regularly through conducting audits. The design, layout, and furnishings of the ward/service supported patients’ treatment, privacy and dignity. In St Magnus hospital each patient had their own bedroom with an en-suite bathroom and could keep their personal belongings safe. Across the whole service there were quiet areas for privacy. The bedrooms had been personalised. Carers had supported staff to personalise bedrooms on the wards for patients with dementia.
The food was of an excellent quality and patients could make hot drinks and snacks at any time. The patients were complimentary regarding the kitchen’s ability to meet their individual food choices

Staffing levels and skill mix were planned, implemented and reviewed to keep patients safe at all times. Any staff shortages were responded to quickly and adequately. Registered nurses were visible on the wards and able to spend time with patients on the wards and 1:1 sessions were taking place. At Rosemary Park we observed staff were busy but not rushed, and patients told us call bells were answered quickly when pressed.

Training was managed with the support of the hospitals own dedicated education department in the hospital. Staff were up to date with all their mandatory training and could also access specialist training to support them to deliver good quality care. Support staff were supported to undertake nurse training if they wished.

Use of rapid tranquilisation was low across all wards at St Magnus and staff were using verbal de-escalation skills to ensure that patients’ distress was managed before it required additional medicine
Both St Magnus and Rosemary Park were able to meet the needs of all patients who used the service – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support.

The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and the wider service. Patients told us that they did not have a need to complain. However, they were confident that if they did they would be listened to and the matter dealt with. Families confirmed that there was little need to complain about anything. Staff confirmed that they received feedback from incidents and complaints and that lessons learnt from other wards was shared with them at team meetings, via emails and within supervision and team days.

Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff. Staff consistently reported that managers were supportive and would listen and act on any concerns they raised. Staff felt that the management team were more of a family and nurtured and supported the staff to progress within their roles.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff felt respected, supported and valued. They felt able to raise concerns without fear of retribution. Staff morale was high, and staff told us they were happy in their roles. We observed supportive and cohesive team working and the atmosphere appeared relaxed and encouraging.

However:

Not all staff at St Magnus had access to the electronic patient record. Junior support workers did not have access to the electronic record and could only view them if a member of staff with access login for them. This meant there was a paper copy of care plans and an electronic copy which required updating every time a care plan was reviewed which could lead to confusion within the staff team.

Rosemary Park Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection. Rosemary Park accommodates and provides nursing care for up to 73 people in one adapted building. The building is set out in four living areas, each with their own lounge and dining rooms.

At the time of our unannounced inspection on 28 November 2018 there were 62 people living at the service, all of whom were living with dementia or a mental health condition. Some people had a history of failed placements in other services.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager assisted us with our inspection.

At the last inspection in August 2015 we rated this service as Good in each of the domains. We found at this inspection some aspects of the service had not sustained this rating and as such we have re-rated the service in Effective, Responsive and Well-Led to Requires Improvement.

Staff were not following the principles of the Mental Capacity Act 2005. People had restrictions on their liberty without the legal procedures being followed. For example, we found a lack of decision-specific capacity assessments in place. Some care plan documentation for people was not up to date and did not include specific information. Activities were organised for people to attend, however we heard that some people wished more was going on or wanted activities that were individualised for them. We have issued a recommendation to the registered provider in respect of both areas.

Risks to people had been identified and action taken to help keep people safe. Staff were knowledgeable in their responsibility around safeguarding people from abuse and where people had accidents or where there were incidents, steps were taken to prevent reoccurrence and lessons learned. People received the medicines they required.

People lived in a clean environment that provided equipment suitable for their needs and was checked for its safety. Staff could describe to us what they would do in the event of an emergency, such as a fire. Staff received regular supervision and were trained and competent in their role in general as they had access to an education department which provided mandatory and specialised training. Staff went through a robust recruitment process before commencing in the role.

People told us they enjoyed the food and we found that where people were at risk of malnutrition, or they had specific dietary needs, these were responded to. People’s needs were assessed prior to moving into the service and in the event they required additional input from other healthcare professionals, this was provided to them.

People lived in an environment that was kind, caring and respectful. Staff showed people individual attention and spoke fondly of them. People were known to staff and encouraged to maintain relationships with those who were important to them.

Relatives and professionals told us they felt the service was well managed. Arrangements were in place to quality check the service and people, relatives and staff had the opportunity to be involved in the service. Senior management had good management oversight and the service worked with external agencies to help improve people’s care. The registered manager met their requirements of registration. There was a complaints policy in place and complaints were investigated and responded to.

During our inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made three recommendations to the registered provider. You can read what action we have asked the registered provider to take in the main body of the report.

We rated the core services at St Magnus Hospital as Outstanding because:

The ward environments were safe; all areas were exceptionally clean and very well furnished.
The hospital had a stable leadership team. Senior managers and clinicians were approachable and inspired their staff teams.
The hospital was very well resourced with nursing and other clinical staff to meet safely the needs of the patients. Staff completed all risk assessments and care plans with patients and carers, and regularly reviewed and updated them.
Many patients had complex physical health problems. Patients had very good access to physical healthcare. Some of the nurses were qualified general nurses, others received training in physical health conditions, and a GP visited the hospital site twice a week.
Staff were knowledgeable of the Mental Health Act and Mental Capacity Act and applied the Code of Practice principles well for both. Advocates assisted patients at multidisciplinary care reviews.
Staff were fully committed to working in partnership with patients and carers. Carers were involved in all aspects of care and treatment and were supported by hospital staff. Carers were invited to attend hospital training sessions for example, dementia awareness training.
Staff were extremely caring of patients and visiting clinicians remarked on how well treated the patients were.
There was a full range of facilities for patients including a therapy suite, a gymnasium, and a sensory room. All meals were prepared on–site by the chef and his team using local produce.
Staff had access to an on-site education department that was accredited to provide a range of health and social care certified qualifications.
Sickness rates were below 1%. There were no qualified staff vacancies. Staff felt empowered and motivated to do their jobs well and felt supported by their managers.
Senior managers had developed initiatives to retain and develop their own workforce. This included sponsoring staff to complete nurse registration for both mental health and general nursing, and had recently sponsored five senior support workers to become associate nurses. Psychiatrists were supported to pursue relevant special interests for example, gaining experience in neuropsychiatry.
Subsidised short-term accommodation and subsidised transport was provided for staff.

This was an announced inspection, which took place on the 4, 5 and 6 August 2015.

Rosemary Park nursing home provides accommodation and nursing care for up to 68 people who have various complex needs. It has three separate units within the same building.

The Main House is a 31-bedded mixed-sex unit for people with moderate to severe forms of dementing illness. During our visit, there were 30 people with one room out of commission because of maintenance work.

The East Wing is a 22-bedded single-sex unit for men with early or middle stages of a dementia type illness, or a longstanding mental health illness.

The Courtyard is a 15-bedded mixed-sex unit for people with enduring mental health problems or acquired brain injury who cannot live independently.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

All three units were clean, with good furnishings and were well maintained. Equipment was clean and in good working order. Staff did annual environmental risk assessments and acted on the results. Staff had safeguarding training in their annual mandatory training programme. They understood the forms of abuse and could apply that knowledge to people. Staff in all units managed medication well – including storing, documenting, administrating and disposing of it. The clinic rooms on all units had first aid kits and emergency resuscitation equipment. All staff knew which incidents to report and how to report them. Managers were available to staff for advice about which situations to report. Staff said they were confident in approaching any qualified staff or management for advice.

Each resident had care plans and risk assessments to guide staff in how to care for them. Nursing staff reviewed care plans every six months, with a shorter evaluation each month. Staff followed national guidance in managing and giving medicines and for managing dementia and other physical health conditions. The care team included a psychiatrist, activity coordinators, occupational therapist and social workers. There was good access to physical healthcare. The GP visited weekly and staff could see external healthcare providers including podiatry, chiropody, dieticians and nutritionists, speech and language support and a tissue viability nurse. Staff had formal supervision every eight weeks in line with the supervision policy, with informal supervision as needed. Managers held appraisals annually, with action plans for staff with extra development needs. There was a Mental Capacity Act policy and staff could tell us the principles and how they applied to their people. Each resident had a mental capacity assessment in place and additional assessments for specific interventions, such as medical procedures. Nursing staff recorded best interest decisions in people’ notes and could explain what that meant.

Without exception, staff engaged with people respectfully, calmly and with a warm and friendly manner. They gave the right support when people were distressed or agitated, and always maintained their dignity. Staff understood not only the people’ current needs but also their histories, likes, dislikes and daily routines.

People had personalised bedrooms, with photos and personal items. An activity programme ran through the week. The service had dedicated activity staff and all staff provided extra activities to stimulate people as well.

However;

Staff said although they felt otherwise well supported by managers, they did not feel well supported in dealing with harassment and bullying by people.

At this inspection we focussed on the hospital wards of Park House and Oak. We also looked around the other wards and checked a concern with the heating in the nursing home. We spoke with three patients and five members of the nursing and care team.

The patients we spoke with all said that they were treated well and received care and support in a manner that met their needs. One person told us that the hospital staff were helping him to maintain a healthy outlook on life. Another person said, "I have nothing to be concerned about, I am treated well".

We found that the hospital was meeting the standards we inspected at this visit. We observed people and staff interacting positively. People were treated with respect and staff responded promptly to the requests for assistance from people.

Staff spoke positively about their work, demonstrated a good knowledge of people's needs and how to meet them. They told us they were supported by an approachable senior management team. We received feedback from other disciplines working in the hospital including the speech and language therapist and a social worker. They spoke positively about the care staff, "They work very well with people, their interaction remains positive under very challenging situations.

On this occasion we inspected Rosemary Park Nursing Home. St Magnus Hospital was inspected in July 2011, the report of that visit can be seen on our website www.cqc.org.uk

The majority of people who lived in Rosemary Park Nursing Home were living with dementia and were unable to tell us about the quality of care they received. To enable us to be able to access people's wellbeing we spent time sitting with them observing the care they received. We also observed the level of staff interaction with them. We observed that the staff were attentive to people's needs.

We talked with two visitors while they visited relatives. We also talked to two of the people who lived in the service. The people we spoke with told us that they liked living there and that the care staff showed them respect and looked after them well. They also told us that they were comfortable. One person said that the staff were, 'Nice people, they treat me well.'

We saw that staff were supported through supervision and that they received training essential for caring for people living with dementia and mental heath care needs. When we talked with staff we found that they were knowledgeable about the people they supported. The service had a process in place whereby they sought the views of people who used the service and their relatives. There were appropriate safeguards in place to protect people from abuse.

This visit looked at the outcome areas in St Magnus Hospital and we spoke to people who were accommodated at St Magnus Hospital. We looked at each of the 4 wards in the hospital, which included New Park House, which opened 3 weeks before our visit

We spoke to people and they told us that they were treated well by the staff. They said that the staff ask them if they want any support and that there was always someone around to help.

One person described staff as respectful and polite and said that he can ask for support if he needs it. Another person told us that he knew what medication he was taking and knew that he could refuse to take his medication but understood the procedures that would follow his refusal. Another person said that he had been given an award for his art work, which was displayed in the communal area.

People told us that they were able to make their own decisions about what activities they would like to take part in. One person said that he would like to have more books and suggested that a mobile library visits. Another person told us that he likes to do crosswords and said that staff supports him with this.

People told us that they liked St Magnus and said the environment was first class. One person said how much he liked his room and that he had everything he needed.

We spoke with staff during the visit and they told us that staffing levels were sufficient to meet people's needs. Staff also told us that they talk to people about the support and assistance they are giving and that there are good handovers at the beginning of each shift.

We also spoke to the family liaison officer and she told us the staff are very good and commented 'this place is amazing'. She said that staff are knowledgeable and well trained and that patients are asked about everything and are treated with dignity and their privacy is respected.

St Magnus Hospital and St Magnus Nursing

All Inspections

9 November 2023

During an inspection looking at part of the service

26th November 2019

During a routine inspection

28 November 2018

During a routine inspection

21-23 November 2017

During a routine inspection

4-6 August 2015

During a routine inspection

4-6 August 2015

During a routine inspection

28 May and 6 June 2013

During a routine inspection

28 March 2013

During a routine inspection

14 June 2011

During a routine inspection