calverton hill newapproachcomprehensive report ... · backgroundtocalvertonhill...

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.

CalvertCalvertonon HillHillQuality Report

Ramsdale ParkCalverton RoadArnoldNottinghamNG5 8PTTel:0115 966 1500Website: www.partnershipsincare.co.uk

Date of inspection visit: 24-25 August 2015Date of publication: 03/05/2016

1 Calverton Hill Quality Report 03/05/2016

Overall summary

We rated Calverton Hill as good because;

• Ward dashboards showed all patients had riskassessments and care plans.

• Patients had physical assessments.• In addition to health action plans, patients had health

information cards, which described theircommunication style and needs. They took these withthem to hospital and other healthcare appointments.

• Staff could recognise and report incidents andsafeguarding concerns.

• Staff used a range of outcome tools to monitorpatients' recovery including health of the nationoutcome scores (HoNOS), “recovery star” and “myshared pathway”.

• Patients regularly took part in patient alliance andleast restrictive practice meetings to influence changesin practice.

• The service managed planned transition of patientsfrom one ward to another effectively.

• Staff received appraisals, managerial and clinicalsupervision, and there was a high uptake ofmandatory training.

• Calverton Hill successfully completed the QualityNetwork for Forensic Mental Health Services peerreview process in 2014 and achieved 97% of themedium secure standards.

However;

• Fifteen patients and three carers said they felt unsafein the environment because of the number ofpatient-to-patient incidents.

• For the period 1 April to July 2015, 795 physicalinterventions and restraints occurred involving 26different service users. The risk of harm betweenpatients and to staff by patients remained high in spiteof management strategies such as positive behavioursupport, de-escalation and individual riskmanagement plans.

• The room used by the registered nurse for physicalhealth checks did not have spot lights for closeexaminations, or offer patients privacy andconfidentiality during examinations.

• The uptake of mandatory food hygiene training in 2015was low, only 41 out of 180 (23%) staff completed it.

• Staff used confusing terminology such as locked-doorsegregation and struggled to describe the differencebetween this and seclusion.

• There was no hatch in one seclusion room to passfood and water through. This meant the staff team hadto assemble go in and provide this.

Summary of findings


Contents

PageSummary of this inspectionBackground to Calverton Hill 5

Our inspection team 5

Why we carried out this inspection 5

How we carried out this inspection 6

What people who use the service say 6

The five questions we ask about services and what we found 7

Detailed findings from this inspectionMental Health Act responsibilities 10

Mental Capacity Act and Deprivation of Liberty Safeguards 10

Outstanding practice 26

Areas for improvement 26

Summary of findings


Calverton Hill

Services we looked at

Forensic inpatient/secure wards;CalvertonHill

Good –––


Background to Calverton Hill

Partnerships in Care (PiC) Midlands owns Calverton Hillwhich is a purpose built 64-bedded medium securehospital. At the time of our visit there the unit had 50patients.

Calverton Hill is a medium secure hospital that providescare for patients detained under the Mental Health Act.Patients may have had contact with the criminal justicesystem and may be subject to Ministry of Justicerestrictions.

Calverton Hill registered with the CQC in December 2010to carry out the following regulated activities:

• the treatment of disease, disorder or injury,assessment

• medical treatment for persons detained under theMental Health Act

• diagnostic and screening procedures

Mr Nick Shaughnessy was the registered manager for thehospital.

Calverton Hill provides care for men and women; the aimbeing to promote recovery, minimise risk behaviours andsupport patients to move through to a less secure carepathway within the wider organisation or to externalproviders.

The hospital consisted of four wards each with 16 beds.

• CIumber ward provided care to women with adiagnosis of learning disability and also mental healthproblems or personality disorders.

• Rufford ward provided care for men with a learningdisability.

• Newstead acute admission ward provided care forwomen with mental illness and personality disorders.

• Bestwood ward provided long-term recovery forwomen with mental illness and/or personalitydisorders.

Since registration, the CQC has inspected Calverton Hilleight times. The last inspection in June 2014 found itcomplied with the eight outcomes inspected.

Mental Health Act monitoring visits took place toNewstead ward in October 2014, Rufford and Clumberwards in November 2013. The service developed actionplans following these visits.

Our inspection team

Team leader: Surrinder Kaur The team that inspected the service included three CQCinspectors and a variety of specialists including aconsultant psychologist, an occupational therapist, amental health nurse, and two experts by experience(people who have used services).

Why we carried out this inspection

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

Summaryofthisinspection

Summary of this inspection


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 wellled?

Before the inspection visit, we reviewed information thatwe held about the location, asked for feedback from thelocal NHS England specialist commissioner andcontacted Healthwatch Nottinghamshire.

During the inspection visit, the inspection team:

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

• spoke with 28 patients who were using the service• spoke with 12 nearest relatives or carers• spoke with the registered manager and managers, or

acting managers, for each of the wards

• spoke with 30 other staff members including doctors,nurses, an occupational therapist, a psychologist, asocial worker, a police officer, the Mental Health Actadministrator, and agency staff

• held focus groups with four healthcare supportworkers, four technical assistants and four staff nurses

• spoke with an independent advocate• attended and observed a PiC regional clinical

governance meeting, a multi-agency safeguarding hubmeeting, a daily managers' meeting, a ward handovermeeting, two multidisciplinary team meetings, a nightshift handover, a community meeting and a leastrestrictive practice meeting

• collected feedback from four patients using commentcards

• looked at care and treatment records for 20 patients• looked at 24 medication charts• carried out a specific check of the medication

management on wards• looked at a range of policies, procedures and other

documents relating to the running of the service

What people who use the service say

Patients participated in a least restrictive practice auditand meetings, to discuss restrictive practices. One-to-onesessions with primary nurses took place.

Nine patients said staff always treated them with respectand dignity. Four said they did not receive care in arespectful and dignified way.

Nine patients felt involved in their care and had copies oftheir care plans. Five patients did not.

Fifteen patients reported feeling unsafe because of thelevel of aggressive incidents between patients.

Four comment cards made positive comments about thepsychology groups offered and negative commentsabout the lack of activities and aggression betweenpatients.

Six patients described nurses as being visible in theclinical areas and nine said they were not visible.

The 2015 hospital patient survey received 28 responses,of which 45% rated their care as either excellent or good.

Carers did not have information on how to complain. Notall carers were satisfied with the way staff managedcomplaints.




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

• Ward dashboards showed all patients had risk assessmentsand care plans.

• For 2015, the average mandatory training rate was 91%.• The hospital had introduced close circuit television cameras

(CCTV) in August 2015 following recommendations from themulti-agency safeguarding hub and police.

• Staff knew how to report incidents and safeguarding concerns.• Review of incidents and.safeguarding concerns showed they

had been appropriately managed.• The service produced a quarterly “learning the lessons”

newsletter for staff and lessons learnt were implemented.

However;

• Out of the 28 patients we spoke with ,15 stated that they feltunsafe in the environment due to the number of incidents.Three carers we spoke with also expressed concerns.

• For the period 1 April to July 2015, 795 physical interventionsand restraints occurred involving 26 different service users.

• The risk of harm between patients and to staff by patientsremained high despite management strategies such as positivebehaviour support and de-escalation.

• The room used by the registered nurse for physical healthchecks did not havespotlights for close examination, norprovide privacy and confidentialityto patients.

• The uptake of mandatory food hygiene training was low with 41out of 180 (23%) identified staff completing it in 2015.

• Staff used confusing terminology such as “locked-doorsegregation” for long-term segregation. Staff struggled todescribe the difference between locked-door segregation andseclusion. One seclusion room did not have a hatch to passfood and water through and relied on a team of staff going intothe room

Good –––

Are services effective?We rated effective as good because:

• Ward dashboards showed all patients had up-to-date andevaluated care plans.

• Patients had up-to-date physical health checks.

Good –––




• In addition to health action plans, patients had healthinformation cards, which described their communication styleand needs. They took these with them to hospital and otherhealthcare appointments.

• The Association for Psychological Therapies awarded thehospital a centre of excellence for implementing a positivebehaviour support model called" reinforce, appropriate,implode, disruptive" (RAID). RAID is a preventative approachapplied to patients' challenging behaviour.

• Staff used a range of outcome measures to monitor patients'recovery such as health of the nation outcome scores (HoNOS),“recovery star” and “my shared pathway”.

• Staff received a 12-week comprehensive induction programmeat the start of their employment.

• Staff reported they had good access to training.• Records reviewed showed good access to managerial and

clinical supervision.• We observed good multidisciplinary team working to involve

patients in ward rounds.

Are services caring?We rated caring as good because:

• Staff were respectful and responsive to patients.• Seven patients we spoke with confirmed they had a tour of the

ward when admitted.• The hospital had 14 hours of advocacy per week and the

majority of referrals came directly from patients.• The 2015 hospital patient survey received 28 responses, and

46% of patients rated their care as excellent or good.• Patients took part in regular patient alliance and least

restrictive practice meetings. We observed patient communitymeetings taking place, and saw records of previous meetings.

Good –––

Are services responsive?We rated responsive as good because:

• Patients received assessments within seven days of referral.• Staff supported patients on planned transition to other wards

by visiting the new ward and helping them settle in.• Patients with physical disabilities could access the wards which

had adaptations to meet their needs.• Patients knew how to make complaints.

However:

• In the 2015 hospital patient survey, only 32% of patients whoresponded said the food was good.

Good –––




• The hospital provided a good range of activities, includingwork. Patients' uptake of activities varied. The occupationaltherapist was carrying out an evaluation of why patientsrefused activities.

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

• Patients contributed to the development of each ward'sphilosophy of care.

• Staff described the organisation's values in their commitmentto support patients’ recovery.

• Staff knew most of the senior managers. Good ward leadershipwas evident on some wards. For example, patients on Clumberward said the ward leadership had contributed to lessrestrictions and said that the senior managers engaged withpatients more.

• Governance groups linked the hospital to the regionalgovernance structure and in turn, the PIC organisationalgovernance groups that reported to the board.

• A regional governance meeting discussed policies, seriousincidents, incidents of seclusion, and incidents that required aduty of candour. The meeting discussed lessons learnt. werediscussed.

• The hospital actively recruited staff and took measures to retainstaff.

• There was good ward to board key performance reporting andwards received reports on their performance on a monthlybasis so that they could take action to improve.

• Calverton Hill successfully completed the Quality Network forForensic Mental Health Services peer review process in 2014and achieved 97% of the medium secure standards.

Good –––




Mental Health Act responsibilities

We do not rate responsibilities under the MentalHealth Act 1983. We use our findings as a determinerin reaching an overall judgement about the provider.

We found the hospital adhered to the Mental Health Act(MHA).

Mental Health Act (MHA). training was completed by 164out of 189 (89%) of staff identified in 2015. The providerwas introducing changes reflecting the new MHA Code ofPractice.

The hospital stored detention papers electronically buteven with staff assistance, these were hard to findbecause they were not all filed consistently.

The responsible clinician authorised section 17 leave onstandardised forms. We found one record where theyauthorised leave over a 12-month period withoutspecifying the frequency. In another record, there was no

reference to the Ministry of Justice [MoJ] consenting tothe programmes of leave recorded on the Section 17authorisation. Nursing staff exercised discretion onwhether leave could take place based on the patient'smood and the risk they presented. However, theparameters for this were not set out in forms reviewed.

Staff had access to legal advice from the MHAadministrator's office and the organisation's legaladvisors.

Records and patients confirmed that patients receivedinformation about their rights under the MHA onadmission and every three months, both in writing andverbally.

Certificates of treatment were attached to the medicationcharts.

Mental Capacity Act and Deprivation of Liberty Safeguards

In 2015 Mental Capacity Act (MCA) training was completedby 164 out of 189 (89%) of staff identified .

Staff and patients had electronic and paper access to theMCA Code of Practiceand hospital policies.

Medical staff considered the MCA and Deprivation ofLiberty Safeguards (DoLS) in relation to physical healthconditions. Nurses and social workers contributed todiscussions about referrals for best interest assessmentswhen patients had physical ailments.

Patients received capacity assessments that weredecision-specific.

Staff obtained advice from the MHA administrator’s officeand social workers about the MCA and DoLS.

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Are forensic inpatient/secure wards safe?

Good –––

Safe and clean environment

• We found systems in place to maintain security and aclean environment.

• Staff understood and explained how they implementedthe hospital security policies and procedures tomaintain safety Patients' individual care reviewsdiscussed relational security. Relational security is theknowledge and understanding staff have of a patientand of the environment, and the translation of thatinformation into appropriate responses and care.

• In 2015, 95% of eligible staff received security training.Wards had a designated staff member on each shiftresponsible for security, such as making checks forbanned items and cutlery. Staff signed for keys beforeentering and leaving the ward areas. Staff kept the keyson their person at all times. Wards and all rooms werelocked, apart from the communal areas.

• The hospital had a closed circuit televisioncameras policy. It introduced cameras in the lounge andcorridor areas,in August 2015, followingrecommendations from the multi-agency safeguardinghub and police. Staff reviewed camera footage whenincidents or allegations occurred.

• The hospital had a policy relating to searches ofpatients. This included guidance on how staff shouldrecord consent. Staff searched patients when theyreturned form leave and conducted monthly searches ofpatients' rooms. There had been a number of recent

breaches of security that warranted this action.Thesecurity and patient safety committee looked atprocedural and relational security breaches on thewards and identified lessons learnt

• Each ward had a ligature risk assessment. Theassessments identified what risks were present andtheir management. For example, baths had inset railsthat were potential ligature points. Patients hadindividual risk assessments in place to use thebathrooms and staff supervised the bathroom use. Staffmitigated ligature risks by observations, patientsupervision and keeping some rooms locked when notin use.

• The hospital had adequate space to manage thenumber of patients. Staff views of communal areas andmain corridors in the ward area were uninterrupted.Bestwood ward had blind spots along the therapy roomcorridor where patients were not fully visible. Staff wereaware of this risk and managed it thorough patientsupervision, observation, and patient risk assessments.Bestwood ward had fish eye mirrors in the toiletentrance area as the layout obscured visibility. Fish eyemirrors are attached to corner walls so that people canbe seen coming round the corner.

• All wards provided single-sex accommodationin linewith the Department of Health gender separationguidelines.

• Clinic rooms were clean and tidy. The clinic roomscontained equipment for the assessment of physicalhealth observations. The examination couch onNewstead ward had stopped working and an ordermade to replace it. Clumber ward clinic room did nothave a couch. Patients received physical examinationsin their bedroom as a result.

Forensicinpatient/securewards

Forensic inpatient/secure wards

Good –––


• The room used by the registered nurse for physicalhealth checks lacked spotlights for close examination.The room lacked privacy and confidentiality whenexamining patients.

• Policies on dealing with medical emergencies andprocedures for immediate life support were available tostaff. In 2015, 98% of eligible staff received basic lifesupport and defibrillation training. 73% of clinical staffreceived intermediate life support training.

• Ligature cutters were located in the nursing office andalong the main bedroom corridors. Nurses had keys toaccess these in an emergency.

• Emergency resuscitation equipment was accessible.Staff checked and signed daily that equipment wascomplete and available in an emergency. Emergencymedication was in place and in date.

• Calverton hospital had three seclusion rooms. Seclusionrooms provide supervised confinement of a patient tomanage disturbed behaviour likely to cause harm toothers. All seclusion rooms had en-suite facilities. Therooms allowed clear observations of patients, and hadintercoms that worked. Patients could see a clock toknow the time. One ward shared its seclusion room withanother. Patients had privacy in entering the area fromthe rest of the ward. Staff who knew the patient carriedout the seclusion management.

• Patients used "calming rooms" to calm down and talk tostaff in private and to have personal space to reflectwhen they felt agitated. The rooms provided seating,and provided low stimuli by keeping the room bare ofother furnishings. Patients were not locked in the rooms.

• The wards appeared clean and tidy. We saw domesticstaff cleaning the wards and we saw completed cleaningrotas. Eight patients told us that bathrooms were notalways clean, and six said they were. All patients saidthat the kitchen areas were clean. The furniture wasclean.

• The hospital had a re-decoration plan. Patients wereinvolved in ward refurbishment meetings to replace andimprove furnishings and choose the décor.

• The hospital had a preventative maintenance schedulethat was up-to-date. It identified timescales for checksand maintenance work throughout the building,including monthly ward checks for repairs. This meantthe building was well maintained.

• All patients we spoke with said they had lockers to keeptheir possessions safe.

• Health and safety representatives carried out monthlyenvironmental risk audits. The health and safety officerand maintenance officers carried out health and safetyand fire risk assessments annually. The health andsafety group monitored the action plans.In 2015,96% (221 out of 229) of eligible staff received health andsafety, fire and manual handling training.

• In 2015, the uptake of mandatory food hygiene trainingwas low. Only 23% (41 out of 180) of eligible staffcompleted it.

• There were good infection control measures inplace. Hand gels were available on walls for staff andvisitors to use. In 2015, 91% (208 out of229) of staff received infection control training. Theprovider carried out infection control audits.

• Patient areas and bedsides had nurse call systems.Nurses carried alarm systems and radios forcommunication. The inspection team received alarmsto carry. We observed a response to an alarm call. Staffcame quickly and calmed the situation effectively. Inrecords reviewed, an incident had occurred in which apatient had seized a nurse alarm.

Safe staffing

• We found safe staffing levels were maintained throughthe use of bank and agency nurses.

• In April 2015, Calverton Hill had 89.9 whole timeequivalent (WTE) substantive clinical staff. From March2014 to April 2015, the total number of substantive staffleavers was 24 WTE. In April 2015,overall hospital vacancies were 18%.The overall hospital percentageof permanent staff sickness was 4.8%, slightly higherthan the NHS average sickness rate of 4.4%.

• There were 18 registered mental health nurses and 12registered learning disability nurses. The qualified nurseestablishment was 47.5 WTE. The hospital reported 12.5WTE vacancies for nurses. The support workerestablishment was 66 WTE and the hospital reported 4.5WTE vacancies.

• Core staffing levels were set using a ratio of nurses to thenumber of patients. Rotas showed that core numbersmatched the number on shifts. Ward managers wereable to adjust the staffing levels daily to take intoaccount the needs of the patient mix based on thenumber of observations, activities, and escorts required.Staffing levels were reviewed twice weekly by seniormanagers. The hospital shift coordinator moved staff tocover needs, as required.



Good –––


• Agency staff had three-month block contracts to makesure staff knew the hospital. In the three-month periodfrom February to April 2015, the hospital used agencyand bank staff for 349 shifts. No shifts were unfilled.Rufford ward had the highest number of shifts filled bybank and agency staff with 149 shifts. Patients told usthat they did not always feel safe with bank and agencystaff as they did not know them well.

• We observed qualified nurses present in the communalareas. Patients we spoke with gave a mixed picture. Sixpatients said that the nurses were visible on the wardsand nine patients said that they were not visible at alltimes.

• The 2015 hospital patient survey had 28 respondents ofwhich 31% of patients reported receiving regularone-to-one time with their primary nurse. Staff andpatients we spoke with confirmed there were sufficientstaff providing one-to-one discussion time.

• Managers stated cancellation of activities due to staffingoccurred rarely and audits captured reasons forcancellation. Ward managers produced monthly reportsfor cancelled leave.

• Staff and patients said that there were enough staff toprovide physical care.

• The hospital had three consultants and an associatespecialist. The consultants worked on an out of hoursrota of one in six days. They were on call from 5pm to8am. There was a flat provided for doctors who wishedto stay overnight whilst on call. The consultants werewithin one hour of travelling distance from the hospital.This meant they could respond to emergencies andseclusion reviews.

• There was a very good uptake of mandatory training. In2015, out of 232 staff, the average mandatory trainingrate was 91%. The rate for equality and diversity trainingwas 95%(217 out of 229 staff). 94% of staff receivedinformation governance training. The hospital was ontrack to achieve 100% uptake of mandatory training.

Assessing and managing risk to patients and staff

• We found national tools were used to assess risk, andrisk plans were in place. However, the hospital had ahigh number of restraints and seclusionincidents inspite of a range of interventions used to minimiseviolence and aggression. There were systems in place tomonitor restrictive practices.

• The ward dashboards showed all patients had riskassessments and care plans. The hospital used theshort-term risk assessment and treatability tool (START),and the historical, clinical risk assessment tool (HCR20),a tool predicting a patient’s probability of violence.

• Updates of the START assessment occurred every threemonths and following patient incidents. Seniormanagers checked this during daily morning meetingsabout the previous 24 hours.

• We reviewed 20 records and found all had riskassessments. However, three risk assessments lackeddetail. Staff discussed the risk plans contained in theHCR20 forms at individual case reviews.

• Occupational therapists carried out a range of riskassessments including assessments relating to sharpobjects that patients could use.

• The reduction of restrictive practices was influenced bypatients.Twenty-four patients had participated in a leastrestrictive practice audit relating to food, access tobedrooms, clothing, access to ward areas, lockablespace, and cigarettes. The least restrictive practicemeetings held between patients and staff discussed theaudit findings.

• We observed a least restrictive practice meeting, whichcomprised patient representatives and staff from eachward. Patients talked about smoking restrictions. Theynegotiated that perfume could be left in lockers in thegroup rooms. The meeting discussed the use of mobilephones. The meeting described the reinforce,appropriate, implode, disruptive (RAID) training staffwere undertaking, and once completed staff intended tohelp patients understand RAID better. RAID is a positivebehaviour support approach that aims to prevent andreduce challenging behaviours.

• In the least restrictive practice audit, 14 patientsreported having access to bedrooms at any time of day.However, patients on Clumber ward could not accesstheir bedrooms between 9.30am and 2.30pm whileactivities were taking place unless individual riskassessments allowed.

• Staff updated risk assessments and plans weekly andconsidered access to personal items and bedrooms.

• The hospital had policies on absence without leave,minimising risk from ligature points and searchingpatients. Staff received training on these duringinduction. The observation policy had dedicatedelectronic learning modules. Staff discussed the



Good –––


applications of these policies during staff meetings,clinical supervision, and handovers in relation toparticular patients. The hospital governancegroup monitored the use of policies.

• Staff applied the principles of positive behavioursupport on the wards.

• Staff told us that restraint occurred only afterde-escalation had failed. Staff we spoke with referredto a management of violence and aggression policydated December 2014. In 2015, 95% of staff (155 out of163) received management of violence and aggressiontraining, and 98% of eligible staff (212 out of216) received breakaway and conflict resolutiontraining.

• The hospital had good reporting andmonitoring systems to analyse physical interventionincidents and produced monthly reports to check thatthe rates were decreasing. For the period 1 April to July2015, 795 physical interventions and restraints occurredinvolving 26 different service users. Of these, staff placedpatients into a seated position 308 times,and forearmholds were used 457 times. Prone restraint was used 97times, of which controlled descent to the floor was used48 times. Once on the floor patient’s relocation to a lowstimulus area occurred on 50 occasions and seclusion59 times.

• Medical and nursing staff reported that many patientswere relatively new and presented with complex needsand high levels of challenging behaviour, which led toincidents.

• Although the hospital had implemented theDepartment of Health positive behaviour supportguidance and RAID, had good individual patient riskassessments and trained staff in managing challengingbehaviours, we were concerned these had notimpacted significantly on the numbers of incidents .

• We observed from a distance an incident of a patientattacking another patient without provocation. Thisresulted in an incident of prolonged restraint with fourstaff. The restraint was properly managed, and a doctorand senior managers attended. A discussion aboutfurther management took place and the team made adecision to avoid rapid tranquillisation. The patientcould not be secluded as the seclusion room was in useat the time. Staff completed a body map describing howthe restraint took place, which formed part of theincident report.

• Records showed that 16 patients received injuries fromassaults and staff were injured from assaults on 72occasions. There were 11 injuries to staff during the useof management of violence and aggression techniques,and to four injuries to patients.

• Rapid tranquillisation took place 32 times followingprone restraints. A rapid tranquilisation policy was inplace, which followed NICE guidance. A qualified nursecarried out the physical observations following rapidtranquilisation.

• The hospital had a seclusion and longer-termsegregation policy dated April 2015. Seclusion auditstook place. The governance committee monitored theuse of seclusion and segregation.

• There were 106 incidents of seclusion and 12 incidentsof segregation from 1 November 2014 to 30 April 2015.The highest number of incidents of seclusion (48)occurred on Clumber ward.

• A review of seclusion registerlogss showed thatseclusion was of short duration. Medical staff attendedwithin two hours of seclusion taking place and carriedout reviews in accordance with the Mental Health Act(MHA) Code of Practice.

• Three patients we spoke with reported negativeexperiences of seclusion including not receivingmedication on time, and drinksnot being available onrequest.

• Staff used confusing terminology. The seclusion roomon Clumber ward was in use during the visit. Staff toldus the patient was on “locked-door segregation” as partof a long-term segregation plan (LTS). The patientdescribed themselves as secluded. Staff struggled todescribe the difference between locked-doorsegregation and seclusion.

• Doctors reviewed patients on long-termsegregation once every 24 hours and at weeklymultidisciplinary reviews. We reviewed the LTS recordsof two patients on one ward. We were unable toestablish why the locked-door segregation differed fromthe seclusion policy and why staff recorded it differently.Staff said there had been eight locked-doorsegregations and 15 seclusions since June 2015.

• There was no hatch in the Clumber ward seclusion roomdoor. Staff had to open the door to give the patient food,drink, or medication. Staff told us three to five staff wererequired to enter the seclusion room. This meant thepatient had to wait until a team assembled to have theirneeds addressed. One LTS locked-door plan stated that



Good –––


if it was unsafe for staff to enter, the patient would haveaccess to water from the tap in the shower area.Independent review by staff from Annesley Houseanother Partnerships in Care (PiC) location hadoccurred. As both hospitals shared multidisciplinary(MDT) members, we questioned if this provided theindependent review required by the MHA Code ofPractice.

• There was good medication management andmonitoring. A local chemist suppliedmedicationand delivered it to the hospital. Recordsshowed that staff received and checked the delivery.

• Our observations showed that the staff stored andlocked medications securely in the clinic room. Staffchecked and stored controlled drugs in line withprocedures and signed a checklist. The hospital kept aregister of the administration of controlled drugs. Staffwe spoke with followed the policy for the disposal ofdrugs.

• Daily checks on benzodiazepine stock occurred. Twonurses checked medication administration. On the dayof our visit a tablet of benzodiazepine had gone missing,and investigation of the incident was taking place.

• The pharmacist visited the wards weekly to carry outchecks on request. A pharmacy diary recorded findingsand actions for the wards. The pharmacist checked thetreatment authorisation charts against the medicationprescriptions, and checked high dosagemedication withthe British National Formulary.Thepharmacist discussed the use of out oflicence medication with the medical staff to make surethere was appropriate usage. Checks on the usage of “asrequired” medication occurred.

• Records reviewed showed there were monthly audits ofmedication. The ward manager reviewed the audits. Themain actions resulting from audits related to clericalerrors of dates, and the manager took actionto correctthese.

• The pharmacist completed an online form to provideinformation to their superintendent pharmacist thatoversaw their practice. The pharmacist raised any issueswith the hospital pharmacy and the physical healthgovernance group who took appropriate action.

• The pharmacist was available to patients to discusstheir medications. Easy-read medication informationbooklets were available to patients on request.

• Staff discussed national medicine alerts received duringteam meetings and handovers.

• All medication charts reviewed were in order. We notedas good practice that there was limited use ofpsychotropic medication and limited prescribing anduse of “as required” medication for mental disorders.

• The consultants reviewed psychotropic medication onadmission. The hospital was waiting for the nationalaudit results on psychotropic medications in order tomake improvements.

• Clozapine monitoring took place in line with thehospital policy with patients receiving blood tests andmonitoring of physical observations. The externalclozapine monitoring centre sent the results to theconsultant who approved the administration of thedrug.

• Nurses undertook medication competency checks. Staffreported medication errors as incidents.

• Social workers carried out checks to make sure it was inthe best interests of children to visit. Visits had to bebooked. The visitors' and children’s room was awayfrom the ward, and contained comfortable seating, afish tank and children's toys.

Track record on safety

• We found that serious incidents had occurred andthe dynamics on Rufford ward was unsettled.

• There were 19 serious incidents recorded between June2014 and April 2015. Examples of incidents includedattacks between patients (resulting in loss ofconsciousness in one case), three attempts ofstrangulation of staff, five incidents of physical injuriesto staff resulting in hospitalisation, and two incidents ofthreats with weapons made from broken wardrobes andwindow glass. . The police came to manage an incidenton one occasion.

• The hospital had a designated police officer whoattended the site. The hospital had a zero tolerancepolicy to abuse and criminal acts. The police respondedto all allegations reported to them. Patients receivedcapacity assessments before police interviewed them.Staff trained as appropriate adults attended police



Good –––


interviews with patients. Police and staff described themix of patients as volatile resulting in 70 crimes beingreported between August 2014 to August 2015. Theseincluded common assault, grievous bodily harm, sexualabuse, and racist language. The majority of crimesprosecuted led to guilty verdicts.

• Out of the 28 patients we spoke with 15 stated they feltunsafe in the environment due to the number of patientincidents. Three carers we spoke with also expressedconcerns. We had concerns about the high risk of harmto patients and staff in spite of management strategiesin place. For example in one incident a patient’s life wasat risk from another patient but the hospital had notadequately anticipated or prevented harm. In anothercase, a member of staff was seriously injured.

• We found that Rufford ward presented significantchallenges. The ward held 15 patients with complexneeds, most of whom were unwell and unsettled. Thepatient mix, their level of acuity, and their concentrationon the same ward contributed to a volatile and unsafeenvironment that staff struggled to manage.

• We observed daily morning meetings attended bysenior managers. Senior managers met daily to discussincidents and safeguarding referrals from the previous24 hours. They considered if any incidents met the dutyof candour thresholds. We saw managers checking thatcare plans and START had been reviewed followingincidents. We heard that seven patients went to thecalming suite in the previous 24 hours.

Reporting incidents and learning from when things gowrong

• Staff we spoke with knew how to report incidents. Welooked at four incidents and found they had beenappropriately managed.

• For the period 1 January 2014 to 30 August 2015, CQCreceived 96 incident notifications.Ninety-twonotifications were aboutallegations of physical andsexual abuse between patients, three related to policeincidents and was about a serious injury to a patient.

• A safeguarding policy was in place and discussed duringinduction training. In 2015, 95% of staff (218 out of229)received safeguarding training. Staff we spoke withunderstood what they should report and knew thesafeguarding procedures.

• We looked at six safeguarding referrals and found theyhad been appropriately managed. On Clumber ward, an

incident between two patients had been reported as asafeguarding alert to the local authority, and as a crimeto the police. Staff separated the patientsaccommodating them in separate bedroom corridors.However, they continued to be in the same meal sittinggroup. We discussed this with the ward manager whoagreed to address it.

• The hospital, county council, and police held monthlymulti-agency safeguarding hub meetings. We observeda meeting and looked at the minutes of previousmeetings. The group discussed all newsafeguarding referrals and identified actions. Medicalstaff attended the meeting when appropriate to providea context to the patient’s clinical history. Staff putsafeguarding plans in place for patients followingdiscussions.

• The hospital carried out a patient survey in January2015 to obtain the views of patients involved insafeguarding concerns. Two patients responded. Due tothe sample size, conclusions could not be drawn.

• On Rufford ward, managers (or the hospital) started amonthly “living together group” for staff and patients.Managers gave staff protected time to attend. Staff wespoke with said the introduction of the group hadresulted in a reduction in safeguarding incidents. Theward operated a zero tolerance approach to bullying..Discussions took place individually and in communitymeetings about bullying. Patients and staff talked aboutred behaviours (negative) and green behaviours (good).

• Debriefings following incidents occurred with staff andpatients. Clinical supervision also debriefed staff.

• The hospital governance committee reviewed actionplans resulting from serious incident investigations andcoroner's hearings. Lessons learnt were placed on acentral PiC database and shared locally, regionally, andwhere appropriate, nationally. Monthly team briefsshared learning. Managers also shared iInformation inservice development meetings and ward meetings.

• We reviewed three incident reports containing rootcause analyses. Reports contained a lot of detail andidentified lessons learnt and recommendations. Thehospital provided commissioners of services withinformation.

• Managers gave staff quarterly “learning the lessons”newsletters which set out lessons learnt ranging from



Good –––


minor to serious incidents reported to the board. Wesaw the April 2015 newsletter, which covered lessonslearnt from incidents associated with leave, medication,aggression and self-harm.

• As a result of learning from a death in another PiClocation, Calverton Hill introduced a series of changesto practice. A structured shift handover book containedinformation shared in the senior managers’ morningmeeting. The hospital improved risk management plansand its understanding of risk. Staff discussed risksduring handover meetings and when staff moved wardsto provide cover. The hospital introduced a physicalhealth assessment tool called the national early warningscore (NEWS) .

• Changes resulting from lessons learnt at the hospitalincluded providing an electronic lighter in the garden,which meant that individual lighters were not required.Managers introducedtwilight shifts on Rufford wardfollowing increased occurrence of incidents in theevening.

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

Good –––

Assessment of needs and planning of care

• We found patients had their needs assessed and careplanned. Ward dashboards reviewed confirmed allpatients had care plans that were evaluated andup-to-date. The dashboard also confirmed patients hadup-to-date physical health checks, drug screens, andoutcome measures recorded.

• Records reviewed confirmed patients had 72 hour careplans upon admission. Staff completed a range ofassessments that informed care plans. All patients hadongoing care plans within a week of admission. Nursingstaff reviewed care plans regularly.

• Patients had a care programme approach (CPA)meetings two months following admission and every sixmonths thereafter to review their care and progress. CPAprovides a plan that sets out the services the patient willreceive and provides patients with a care co-ordinatorto make this happen.

• All patients had a "my personal health” file which haddetails of their personal history in an easily readableformat. Staff updated the files monthly.

• Records reviewed showed physical health assessmentsoccurred on admission and staff updated case notesmonthly. Staff completed the national early warningscore (NEWS) tool for physical health checks..

• A registered nurse on site provided physical healthscreening and blood tests. All patients had a fullphysical examination within a week of admission. Thenurse triaged patients wishing to see the GP.

• The 2015 hospital patient survey had received 28responses of which 39% of respondents said theyreceived enough care for physical health problems.Patients we spoke with were satisfied with their physicalcare management. GPs visited the hospital once a weekand provided an on-call service. Patients had a choice ofseeing a male or female GP, however, the female GPvisited monthly.

• Patients told us they had appointments with the dentistand opticians. Staff referred patients for any specialistcare required. A dietician attended once a month and apodiatrist every six weeks to provide advice andtreatment to patients referred to them.

• In addition to health action plans, patients had healthinformation cards, which described theircommunication style and needs. They took these withthem to hospital and other healthcare appointments.

• Patient records were electronic. As a contingency in caseof electronic failures, paper light folders were availablefor quick access to risk and care plans for patients. Staffhad received training in information governance.

Best practice in treatment and care

• The hospital implemented national guidance. Theclinical governance committee made sure staff receivednational institute for health and care excellence (NICE)guidance and undertook some audits of NICE guidance.

• The NICE guidance underpinned hospital policies,medication prescribing, and care plans. Staff we spokewith used guidance in the management of epilepsy,depression, self-harm, learning disabilities andchallenging behaviour, management of violence andaggression, schizophrenia and borderline personalitydisorder.

• The hospital implemented the Department of Healthpositive behaviour support guidance and had policies inplace for managing challenging behaviour.



Good –––


• The Association for Psychological Therapies hadawarded the hospital a centre for excellence forimplementing a model called Reinforce AppropriateImplode Disruptive (RAID) because more than 50% ofstaff had completed the threeday course and RAIDlanguage was reflected in written and spokencommunication. The RAID approach looked atpreventative strategies and carrying out a functionalanalysis of patients challenging behaviour.

• Multidisciplinary ward rounds discussed the functionalanalysis of the patients' behaviours. Functional analysisinvolves looking at triggers and patterns of behaviourand interventions that can be used.

• We saw RAID boards in ward areas, these defined“green” behaviours that were positive, and “red”behaviours that were negative as part of thepreventative approach. Patients understood red andgreen behaviours and referred to them.

• The lead psychologist had undertaken and publishedresearch into the seclusion of female patients withlearning disabilities. They found time spent in seclusionwas shorter than those with mental health problems.

• There was good use of outcome measures to look atpatients' recovery using various national tools. Health ofthe nation outcome scores were used to look at theseverity of the mental illness. Outcome measures in theform of “recovery star” and “my shared pathway”enabled patients to evaluate their progress andrecovery. Recovery outcome measurements occurredthrough the historical clinical risk assessmenttool assessments. Staff used recognised tools for theassessment of mood and feelings on admission andre-applied these to look at outcomes of recovery.Individual clinical review meetings discussed theinformation with patients.

• Clinical audit leads met six-monthly to monitor thehospital audit plan and action plans, and providedinformation to the clinical governance committee.

• Participation in the national audit of anti-psychoticmedication had occurred in 2015, which showed lowusage. A range of audits took place, for exampleprescribing for people with a personality disorder,infection control, patient observation, and the nationalschizophrenia audit. Action plans followed the auditsand the hospital governance group monitoredimplementation.

• Nursing staff carried out audits relating to theenvironment and medication storage.

Skilled staff to deliver care

• We found patients received care from a range of skilledstaff who received training and supervision.

• The multidisciplinary care team consisted of theconsultant, social worker, psychologist, occupationaltherapist (OT), nurse, and speech and languageassistant. The hospital had recently appointed a speechand language therapist. This meant patients couldreceive a variety of treatment approaches.

• Patients had access to talking therapies. A psychologistled substance misuse, anger management and mentalhealth groups and individual sessions for patients.However, On Clumber ward groups were not takingplace. Nursing staff were receiving training to leadgroups. Patients received dialectical behaviour therapy(DBT), a specific type of cognitive-behaviouralpsychotherapy. Other clinical staff also accessedtraining in DBT awarness.

• There were three full-time qualified occupationaltherapists (OT) working Monday to Friday, providing aratio of 1: 20 patients. OT used the model of humanoccupation to make patient assessments. They carriedout assessments of communication and interactionskills. One OT had received specific training in thediagnostic interview for social and communicationdisorders to assess for autism. The OTs provided trainingto ward staff to support patient activities.

• The OT we spoke with explained that the lack of trainingabout sensory integration meant that patients mightnot have their needs met. An example was given of apatient nursed in segregation who may be oversensitiveto sound that led to challenging behaviour.

• Two health and fitness technical instructors, onecreative technical instructor, and four recovery staffprovided patient activities. This team also providedactivities at weekends. They reported that patientengagement was poor at weekends and that there weretoo few staff to escort ground leave to make use offacilities such as the café and gym. Members of the teamhad received managing violence and aggressiontraining, and when wards were short of staff, theysupplemented ward shifts. The team membersundertook driving duties. Consequently, they did notfeel their service was valued.

• Staff received a 12-week comprehensive inductionprogramme at the start of their employment. Staff



Good –––


reported they had good access to training. Staff hadprotected time for electronic learning and training. Thehospital supported distance learning courses for fourstaff as part of their personal development plans.

• Healthcare workers completed the care certificate over12 weeks. Qualified staff were being trained as carecertificate assessors to support more healthcareworkers to undertake the care certificate.

• Doctors had a peer group meeting to discuss andpresent complex patients. Doctors sought advice aboutmedication prescribing from external pharmacists. OnRufford ward, joint ward rounds occurred with anotherconsultant to provide peer review.

• Records and doctors confirmed they had undergoneprofessional revalidation to continue to practice.

• Staff stated and records showed that managerial andclinical supervision took place every four weeks. All staffhad received appraisals.

• No staff were suspended or undergoing disciplinaryaction at the time of our visit.

Multidisciplinary and inter-agency team work

• We found there was good multidisciplinary andinter-agency team work and communication.

• We observed a night shift handover. . Staff kept a writtenrecord of the handoverwdthat followed a structure. Thehandover took 15 minutes. Staff shared informationabout individual patient's behaviours, risk,observations, safeguarding,, and sleep patterns..

• Multidisciplinary meetings took place weekly. Weobserved a meeting consisting of psychiatrist, socialworker, speech and language therapist, nurse,psychologist, and occupational therapist. The meetingdiscussed patients' progress, risks, activities, andbehaviour. Patients could state their views. Staffprojected care notes onto the wall so that the patientand team could see the entries being made. Nursingand therapy staff said they were listened to inmultidisciplinary meetings.

• The 2015 hospital patient survey had 28 responses ofwhich 28% of patients had confidence in the clinicalteam, 32% felt listened to during ward meetings and60% of patients knew who their care coordinator was.

• NHS England commissioning case managers attendedward rounds each month. The hospital also sent weeklyupdates for patients who required additional staff.

• Good relationships between the police and themulti-agency safeguarding hub had developed.

• The hospital held multi-agency public protectionarrangement (MAPPA) meetings before authorisingsection 17 leave for some patients. MAPPA is a set ofarrangements established by the police, localauthorities and the prison service to assess and managethe risk posed by sex offenders and violent offenders.

Adherence to the MHA and the MHA Code of Practice

• The provider adhered to the Mental Health Act (MHA).• In 2015, 89% of eligible staff had received training in the

MHA.• The provider was implementing changes in line with the

new MHA Code of Practice.• Staff and patients had access to the MHA Code of

Practice (COP) electronically and each ward had papercopies. Ward managers shared electronic updates onthe new COP with their teams. Not all staff had receivedtraining in the new COP but the provider was adding itto its induction and mandatory training.

• The MHA administrator kept the original copies ofdetention papers and checked records to ensureadherence to the MHA. Ward dashboards identified thetypes of sections, dates when the three-month rule forgiving medication without consent expired, dates fordetention renewals and reading patients their rights.The MHA administrator sent responsible cliniciansreminders of legal requirements.

• Legal advice was available to staff via the MHAadministrator's office and the organisation's legaladvisors.

• Detention papers were stored electronically. However,they were not all filed consistently in the same place orin date order. This made them hard to find even withstaff assistance.

• Section 17 leave was authorised on standardised formsby the responsible clinician. In one record, leave hadbeen authorised over a 12 month period withoutspecifying the frequency of leave. In another recordthere was no reference to Ministry of Justice (MoJ)consent to programmes of leave recorded on theSection 17 authorisation. Nursing staff had discretion onthe day of the leave to assess if leave could be taken,however, the forms reviewed did not clearly set out theparameters for exercising discretion.

• Patient risk assessments occurred prior to leave.Records reviewed did not state the outcome of the leavein accordance with the Code of Practice.



Good –––


• Records and patients confirmed that patients receivedinformation about rights under the MHA on admissionand every three months, both in writing and verbally.Patients were aware of their right to appeal to themental health tribunal or hospital manager's hearings.Patients received an information pack on admissiongiving information about independent mental healthadvocates and appeals against their detention. Theinformation was available in easy-read format. Patientshad access to solicitors and independent mental healthadvocates.

• The medical staff undertook assessments of capacity toconsent to medication treatment. An audit of consent tomedication treatment in January 2015 recommendedthat written records are made about decisions onconsent to treatment, capacity, and side effects of themedication, and second opinion appointed doctordiscussions and decisions. It also recommended thatoff-license use of clonazepam as an anxiolytic should bedocumented in patients' consent to treatment forms.

• We found there were no records on some filesconfirming that patients had been informed of theoutcome of the second opinion appointed doctor's visitto review medication treatment.

• All medication charts reviewed had treatmentauthorisation certificates. Patients received copies oftheir treatment certificates.

• An audit of emergency medication given under Section62 of the MHA occurred in November 2014. The majorityof medication given under Section 62 was on Newsteadadmission ward. An action plan to improve recording inpatient notes and to monitor the use of Section 62 wasin place.

• The hospital had 12 associate hospital managers whocarried out hospital manager hearings to reviewdetentions and hear appeals. The hospital managershad not discharged any patient from detention.

Good practice in applying the Mental Capacity Act(MCA)

• In 2015, 89% of staff had received Mental Capacity Act(MCA) training. The staff and patients had electronic andpaper access to the MCA Code of Practice and hospitalpolicies.

• Medical staff considered the MCA and Deprivation ofLiberty Safeguards (DoLS) in relation to physical health

conditions, for example, a patient’s capacity to makechoices about taking their diabetic medication. Nursesand social workers discussed referrals for best interestassessments when patients had physical ailments.

• Patients received capacity assessments that weredecision-specific, for example, to manage their finances,or food choices if they suffered from swallowingproblems. Members of the multidisciplinary teamundertook capacity assessments.

• Staff obtained advice from the MHA administrator’soffice and social workers about the MCA and DoLs.

Are forensic inpatient/secure wardscaring?

Good –––

Kindness, dignity, respect and support

• We observed staff being respectful and responsive topatients during our visit.

• Patients gave mixed views about how staff treated them.In the 2015 hospital patient survey, 36% of respondentssaid they always received respectful and dignifiedtreatment from staffDuring our inspection, nine patientswe spoke with said they received respectful anddignified treatment from staff, five patients said theysometimes received treatment with respect and dignity,and four patients said they did not receive suchtreatment.

• Staff knocked on patient's doors before entering and themajority of staff showed an interest in patients'wellbeing.

• Four comment cards received from patients gave mixedviews about the service. Positive comments related topsychology groups. Negative comments were about alack of activities, to being listened to, and patientaggression.

The involvement of people in the care they receive

• Patients gave mixed views about how involved they feltin their care. The 2015 hospital patient survey received28 responses of which 57% of patients felt they wereinvolved in looking at their care plans during wardmeetings and CPA meetings. Forty-two percent felt they



Good –––


were always involved in their goal planning and 67%knew what they had to do to move forward on their carepathway. Five patients we spoke with did not feelinvolved in their care planning.

• Patients received a booklet describing the serviceoffered on admission. A patient acted as a “buddy” tointroduce a new patient to the ward layout and routine.Seven patients we spoke with confirmed a tour of theward occurred on admission.

• The 2015 hospital patient survey received 28 responses.42% of respondents said staff gave them enoughinformation about the hospital. Twenty eight percentsaid they received enough information about care andtreatment, and felt supported on arrival to the ward.

• Nine patients we spoke with felt involved in the carethey received and confirmed they had copies of theircare plans. Five patients reported not being involved intheir care or decisions, and did not have copies of theircare plans. In the ward round, we observed the clinicalteam involving two patients in their care.

• The hospital had 14 hours of advocacy per week. Themajority of referrals came directly from patients.Patients could make contact by telephoneat any time.Patients made good use of the service. The advocatessupported patients during ward roundsand CPAmeetings, and helped them make complaints. Thehospital provided independent mental health advocacy(IMHA) support but did not provide independent mentalcapacity advocacy (IMCA) support..

• Between April and June 2015, the advocate saw 44patients. The advocacy service provided the hospitalwith a quarterly monitoring report listing the types ofissues raised so the hospital could take action toimprove. The report showed that 142 different issueswere raised during April and June 2015.

• Most carers travelled to the hospital from all parts ofEngland. . Some carers had physical health problems. Allcarers we spoke with identified travel and cost as issues

• A carers' survey carried out in 2015 received 11responses. The provider had actions to promote thetravel and hotel substance allowance available andpromote use of 'skype' to maintain contact withrelatives. Increasing communication with carers wasalso part of the action plan.

• Carers we spoke with reported that visits took place inthe presence of staff, affording little privacy.

• Five carers thought that the hospital was a safe place fortheir relatives, and three carers did not.

• Three carers confirmed that polite and friendly staffattended home leave with patients.

• Six carers confirmed that nursing staff gavethem information regularly by phone. Two carerscomplained about the attitude of staff. Carers gavemixed views on how it easy it was to contact and receiveinformation from social workers. Carers who couldtravel reported involvement in CPA meetings, however,there was variability in receiving written informationbefore and after meetings.

• The hospital patient survey carried out in 2015 received28 responses. The action plan submitted by the hospitalcontained only one action, which was to promote'skype'.

• In the 2015 patient survey, 46% of respondents ratedtheir care as excellent or good.

• Patients were involved in decisions about the service.Patient alliance meetings and least restrictive practicemeetings involved patients and occurred regularly. Staffrecruitment had some patient involvement.Redecoration and refurbishment planning consideredpatients' views.

• The hospital planned to introduce an electronic systemin which patients could write about their care, progress,and experience.

• We observed a patient community meeting.. Themeeting planned the patients' activities for the day anddiscussed the ward dynamics. The 2015 hospital patientsurvey asked for patients' views on communitymeetings but there were not enough responses to drawany conclusions.

• The primary nurse supported patients to write advancedirectives about their future treatment.

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

Good –––

Access and discharge

• We found good admission procedures in place anddischarge planning commenced soon after.

• The hospital provided beds to patientsnationally responding to referrals made by NHS England



Good –––


commissioning teams. All wards had admissioncriteria. The hospital referral coordinator discussed thereferrals with the multidisciplinary team and wardmanager.

• Patients received assessments within seven days ofreferral. A doctor and nurse undertook the initialassessment. A psychology assessment was carried outbefore admission, if required. Before admission,patients visited the hospital twice a week and had anovernight stay to become familiar with the staff andenvironment. In the 2105 patient survey, out of 28respondents, 68% of patients received informationabout available treatments before admission.

• Between August 2014 and August 2015, the hospitalreceived 56 referrals. Of these, there were 26 admissions,, 25 rejections due to the patients' levels of acuity(illness) and the potential impact on the ward dynamics,three were undergoingf assessment, and five wereplaced elsewhere by commissioners.

• Newstead ward was an admission ward, and patientstransferred to Bestwood, a recovery ward. Planning tookplace to manage moves between wards. This involvedpatients visiting the new ward during the day, and therewas a handover process between the two ward teams.The multidisciplinary team met on both wards duringthe transition period. Staff worked across both wards toensure the patient settled in.

• Managers reported an average length of stay of twoyears. At the time of our visit, 14 patients had lived therebetween two and seven years.

• Patients always had access to a bed on return fromleave. Moves between wards occurred only as part of aclinical pathway plan. One patient had been transferredto another PiC locationbecause they could not be keptsafe from other patient. However, it was acknowledgedthat it was not the ideal placement for them.

• Patients about to turn 18 years old received activemanagement following the death of a patient in anotherPiC location. We found one 17-year-old patientadmission, following a CQC notification. The CalvertonHill staff made contact with the holding hospital prior toadmission and worked with the hospital staff to get toknow the patient. The hospital made arrangements forspecialist CAMHS support within PiC, and staff hadcontact with the patient's CAMHS consultant. Prior toadmission, staff discussed and wrote detailed care plans

with the holding hospital. Discussions with the patient’scommissioners and the multi-agency safeguarding teamhad occurred. We found a well-managed transition thathad occurred in complex circumstances.

• Discharge planning started following admission andinvolved NHS commissioners. There were delayeddischarges for patients waiting for transfer to othersecure placements. At the time of our inspection, threepeople were awaiting transfer to other placements. Onepatient had been waiting a year for a high secureplacement. The hospital managers worked with NHScommissioners to identify alternative placements.

The ward optimises recovery , comfort and dignity

• The hospital offered more than 25 hours of activity toeach patient.The hospital monitored patients' uptake.Activities took place in a variety of settings.

• The hospital had a full range of rooms and equipment tosupport treatment and care. Wards had large kitchenswhere two or three patients could buddy up andprepare meals and dine together. Wards had largecommunal day rooms with a television. There wereactivity,therapy and computer rooms.

• Patients who wished to be away from the maincommunal lounge areas could book a quiet room. Staffplaced patients requesting a quiet area in a shortcorridor on Rufford ward. Staff placed patients in zonedareas to reduce overcrowding.

• Patients had access to telephones to make calls inprivate. The hospital restricted access to mobile phonesand the internet. .

• All wards had access to outdoor gardens. Staffaccompanied patients when they wanted to go out forfresh air or to smoke. Escorted leave on hospitalgrounds was available to most patients following riskassessments. Some patients we spoke with said thatescorted ground leave depended upon the availabilityof staff to take them out and had to be bookedbeforehand. This was sometimes cancelled.

• Wards had two or three meal sittings to managepatients. There were mixed views onthe quality of foodand choices. Of the patients we spoke with, six patientsreported good quality food and choices and sevenpatients did not like the food. In the 2015 hospitalpatient survey, out of 28 patients, 32% patients reportedthe food was good.



Good –––


• The dining area provided a drink station for hot and coldbeverages. Three patients confirmed they had access tohot drinks and snacks.

• Patients showed us their bedrooms, which they hadpersonalised. The extent to which they could do sodepended upon their risk assessments.

• Seven patients told us they had secure space to storetheir possessions. Subject to individual riskassessments, Patients had keys to their bedrooms.

• We observed patients participating in activities. We sawthe arrival of an animal in-reach service, patients in thecomputer room, and patients cooking in the kitchen.

• Wards displayed activity timetables. Technicalinstructors and recovery workers provided arts, crafts,cooking, self-care, beauty, creative writing, andgardening. They worked with occupational therapists tocarry out community assessments, and supportedleave. The team worked with psychologists to providegroup mindfulness and dialectical behaviour therapy(DBT) sessions. Groups were large, and the team did notalways feel supported by ward staff.

• The technical instructors provided sports on one-to-onebasis. However, the hospital struggled to provide samegender support for women.. The location of the gym andsports hall and the lack of escorts meant patients werenot able to access these facilities easily..

• Staff offered patients work opportunities. Rolesavailable included poultry helper, café assistant,librarian, gym attendant and laundry attendant. Thishad generated lots of interest and patients underwentan interview for the roles.

• The 2015 hospital patient survey received 28 rresponses.Of these, 53% felt there were enough activities to doduring the week, and 18% during the weekend.Furthermore, 32% of respondents said staff encouragedthem to use the computer and internet, and 64%received talking therapies. Patients and staff reportedthat staff's involvement in activities on the wards varied.Eight patients across the wards we spoke with saidthere was a lack of activities provided, with manysessions cancelled, and five patients said staff offeredactivities that met their interests.

• Five carers we spoke with said their main concernwas the lack of activities for their relatives. Managerstold us the main reason for the cancellation of activitieswas patient refusal. The occupational therapist wasreviewing why patients refused sessions.

• The maintenance department responded to changes tothe environment that staff requested, for example, abedroom had recently been converted to a sensoryroom.

Meeting the needs of all people who use the service

• Wards were accessible for people with physicaldisabilities. We saw that a wheelchair-bound patienthad a larger room with a double bed, and assistedbathroom facilities.

• At the least restrictive practice meeting, patients askedfor more pictorial information and for pictorial careplans.

• Staff had access to interpreting services and informationleaflets in different languages.

• In the 2015 hospital patient survey, 14% of patients saidthey always received special diets. Four patients wespoke with said they sometimes received special diets.

• A multi-faith room was available for patients. Itcontained holy books from various religions, and prayermats. .One patient we spoke with used itoccasionally.

Listening to and learning from concerns andcomplaints.

• We found there were systems in place to managecomplaints. Patients knew how to complain. Thehospital learnt from complaints.

• The hospital had a complaints policy. We saw acomplaints information leaflet for staff. In 2015, 94% ofstaff (215 out of 229) received complaints training.

• The hospital received 27 formal complaints betweenApril 2014 to March 2015. Of these, six were upheld,fourcomplaints were partially upheld, 14 (52%) were notupheld, and two were withdrawn.

• Seven patients we spoke with knew how to make acomplaint, and four of these reported positiveexperiences. The 2015 patient survey had 28 responses.Eighty-seven percent of respondents knew how to makecomplaints. Easy-read leaflets were available to patientson how to make a complaint.

• Not all carers we spoke with had received informationabout how to make a complaint. One carer wasreluctant to complain in case it affected their relative,two carers said they were dissatisfied with themanagement of their complaints, and four carers saidthey would raise complaints, if necessary.



Good –––


• Staff we spoke with described how they managedcomplaints. Local resolution of complaints occurred onwards. We looked at informal complaint books whichshowed there were few complaintsmade, all of whichwards resolved locally.

• Staff received feedback on the outcome of complaintsinvestigations and acted on the findings. For example, apatient complained about the removal of her underwirebra following a patient search. The hospital investigatedthe complaint and completed an individual patient riskassessment that resulted in the bra being replaced.

Are forensic inpatient/secure wardswell-led?

Good –––

Vision and values

• The organisation's values were about dignity, respect,attitude, behaviour, and communication. Staffdescribed the organisation's values in theircommitment to support patients' recovery. Patients hadcontributed to the development of each ward'sphilosophy of care.

• There were hospital objectives which wards adopted ,these were about improving the quality of service, forexample, implementation of the national early warningscore tool, the new Mental Health Act Code of Practice,and the new care certificate. The hospital also wished toimprove links with carers.

• Ward managers had objectives, which reflected areasthat the service wished to improve.

• Staff knew most of the senior managers. The chiefexecutive had visited the hospital. Hospital managerswere visible and approachable on the wards and clearlyknew the patients individually. Ward leadership wasevident on some wards, for example, patients onClumber ward said the ward leadership had contributedto less restrictions, more emphasis on de-escalationand less restraints. Patients noticed that the seniormanagers engaged with patients more.

Good governance

• We found good governance systems that monitoredrisks, activity and action plans.

• Governance groups linked the hospital to the regionalgovernance structure and in turn, the Partnership inCare organisational governance groups that reported tothe board. We observed a regional governance meeting..Managers discussed policies, serious incidents,incidents of seclusion, and incidents that required aduty of candour. Managers also identified lessons learnt.We found staff and patient governance booklets on theward which explained the organisations approach andachievements. Posters were displayed throughout thehospital describing how the hospital's governancesystems supported safe, effective, responsive care.

• Staff mandatory training above 90% occured.• The hospital analysed its turnover of staff . 5% of those

leaving did not complete their initial probation period. Afurther 5% of those who left were dismissed for beingphysically incapable to undertake management ofviolence and aggression training.

• The hospital actively recruited staff and took measuresto retain staff. Payments were provided to staff whointroduced someone to the service, new recruits weregiven staged payments as a “golden hello.” Staffreceived relocation payments and subsidisedaccommodation. The provider was looking at thepossibility of paying annual professional nursing fees.

• We reviewed four staff personnel files, which showedthat disclosure and disbarring service, nursing andmidwifery council and occupational health checks hadtaken place. References were obtained.

• Staff received appraisals and supervision, andparticipated actively in clinical audits.

• A sufficient number of staff of the right grades andexperience covered shifts, however, the hospitaldependeed on bank and agency staff.

• Staff were proactive in reporting incidents andmanagers shared lessons learnt.

• We saw posters on the duty ofcandour displayed around the hospital. The duty ofcandour is a legal duty on hospitals to inform andapologise to patients if there have been mistakes intheir care that have led to significant harm. Seniormanagers had received training in the duty of candour.Staff we spoke with understood the duty of candour andconfirmed they had received presentations on the topic.The hospital gave an example of one incident where it



Good –––


had considered a duty of candour and sought their ownlegal advice. No further action was taken in this casebecause it did not meet the threshold, However, thehospital raised a safeguarding alert.

• There were good ward to board systems in place. Wardsreported information relating to incidents,safeguarding concerns, seclusion, and human resourcesissues. The provider analysed the information and thensummarised it in a dashboard. The dashboardprovided information on detention status, rights beinggiven, care programme approach, and individual carerecords. All patients had been assessed as needing apsychologist. Dashboards ensured consent to treatmentwas in date. Risk assessments for leave, current levelobservations were reviewed weekly.

• We reviewed three personnel records and found that theprovider followed good recruitment practice. Theprovider took up references , completed occupationalhealth checks and checked professional registrations.

• The hospital proactively recruited staff. It offered stagedincentive payments, relocation payments, subsidisedaccommodation, and professional fee payments.

• Staff submitted information for the hospital risk register.There were mitigation plans to manage risks.

Leadership, morale and staff engagement

• We found there was visible leadership, good staff moraleand systems in place to engage staff.

• The hospital engaged staff in a number of ways. Thehospital undertook a staff survey in 2015, andsubsequently produced an action plan. Actionsincluded:▪ implementation of staff recognition initiatives▪ arranging manager drop-in sessions where staff

could meet the unit manager informally and givefeedback directly to them

▪ providing staff with the minutes of the staffconsultative committee to help improve staffawareness and understanding of discussion

▪ arranging staff "away days" for teams to reviewcurrent practice and plan for the future.

• Staff told us ward teams had attended staffdevelopment away days. This resulted in a qualifiednurse's forum to share best nursing practice. Theprovider arranged for additional staff to work to allowstaff to attend reflective practice sessions each month.

• Staff described morale was good and felt supported bymanagers. They described good team working and astrong culture of supporting each other.

• Staff understood the grievance, whistleblowing,bullying, and harassment policies. Staff we spoke withwould use the policies, if required.

• Ward clerks provided administrative support to staff,and there were good relationshipsbetween administration office and ward staff. Staffinformed us they had sufficient authority to do theirjobs.

Commitment to quality improvement and innovation

• We found the hospital had implemented systems toimprove the quality of its services.

• Calverton Hill successfully completed the QualityNetwork for Forensic Mental Health Services peer reviewprocess in 2014 and achieved 97% of the mediumsecure standards. Some staff participated as peerreviewers for the quality network for forensic mentalhealth services by visiting other hospitals.

• NHS England had set commissioning for quality andinnovation standards (CQUIN). These related to thefollowing:

• the risk assessment training and learning disabilityprocess completed by March 2015

• the friends and family test implemented at the end ofeach episode of care

• the hospital participated in the reducing prematuremortality in people with severe mental illness (it waswaiting for the publication of the results from the RoyalCollege of Psychiatry).

• the hospital documented and assessed all patientsagainst the cardio metabolic risk factors, as described inthe CQUIN requirements

• a physical health compliance dashboard used tomonitor practice against these areas

• The needs formulation at transition discussed in thehospital and at corporate level to effectively monitorand meet the requirements outlined in the CQUIN.



Good –––


Areas for improvement

Action the provider SHOULD take to improve

• The provider should ensure that the room used by theregistered nurse for examining patients has adequatelighting, and offers privacy and confidentialitytopatients.

• The provider should ensure that all staff completemandatory food hygiene training.

• The provider should provide an environment inwhichpatients and staff feel safe.

• The provider should take measures to reduce thenumber of physical interventions such as pronerestraints.

• The provider should ensure staff understand thedifference between seclusion and long-termsegregation.

• The provider should consider the DOH guidancerecommendation of 15 beds per ward for mediumsecure units.

• The provider should record the outcome of leave inline with the Mental Health Act Code of Practice.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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