the priory hospital chelmsford · chelmsford quality report stump lane springfield green chelmsford...

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 Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Requires improvement –––

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.

TheThe PriorPrioryy HospitHospitalalChelmsfChelmsfororddQuality Report

Stump LaneSpringfield GreenChelmsfordEssexCM17SJTel: 01245 806412Website: www.priorygroup.com

Date of inspection visit: 23 and 24 April 2019Date of publication: 19/07/2019

1 The Priory Hospital Chelmsford Quality Report 19/07/2019

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.

Overall summary

We rated The Priory Hospital Chelmsford as requiresimprovement because:

• The provider had not ensured that they identified andmitigated all risks on the wards, including ligaturerisks, and prescribing errors. They did not have enoughstaff on the Children and Adolescent Mental healthwards to keep young people safe. The Children andAdult Mental Health ward had experienced high levelsof incident reports related to staffing levels, but theprovider had not acted to resolve the issues.

• Pharmacy staff and Mental Health Act internal auditshad highlighted issues with prescribing andadministration of medicine, but staff had not resolvedall of these issues. Managers had not acted to addressissues with staff performance in these areas. We foundissues with storage of medicines and record keepingon one ward.

• Staff on Springfield and Chelmer wards had notcompleted all their mandatory training.

• Staff did not assess the physical and mental health ofall patients in an individualised way.

• The provider’s governance system was not robustenough to ensure the safe care and treatment of

patients. Managers had not identified problems withrisk assessments and medicines audits and did notkeep appropriate records of agency staff workexperience.

However:

• The hospital provided a full multidisciplinary team andtreatments in line with national guidance and bestpractice.

• Staff completed and updated risk assessments foreach patient and used them to formulate care plans tomanage those risks. The service managed complaintsand incidents well and learned from them throughmeetings and bulletins. Managers used lessonslearned and introduced new ways to improve patientsafety.

• Staff on the adult acute wards treated patients withcompassion and kindness, respected their privacy anddignity and involved their family members in decisionsabout their care.

• The design, layout, and furnishings of the wardssupported patients’ treatment, privacy and dignity.

• Patients were positive about the care and treatmentthey received at the hospital and staff supported themto maintain contact with the local community andtheir friends and relatives.

Summary of findings


Contents

PageSummary of this inspectionBackground to The Priory Hospital Chelmsford 5

Our inspection team 5

Why we carried out this inspection 5

How we carried out this inspection 5

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

Overview of ratings 10

Outstanding practice 37

Areas for improvement 37

Action we have told the provider to take 38

Summary of findings


The Priory HospitalChelmsford

Services we looked at

Acute wards for adults of working age and psychiatric intensive care units

Child and adolescent mental health wards

Substance misuse servicesThePrioryHospitalChelmsford

Requires improvement –––


Background to The Priory Hospital Chelmsford

Priory Healthcare Limited is the registered provider forthe Priory Hospital Chelmsford, an independent mentalhealth hospital providing 60 beds. The Care QualityCommission registered The Priory Hospital Chelmsford tocarry out the following regulated activities:

• Treatment of disease, disorder or injury• Accommodation for persons who require treatment for

substance misuse• Assessment or medical treatment for persons detained

under the Mental Health Act 1983• Diagnostic and screening procedures.

The service has a registered manager and a controlleddrugs accountable officer.

The services at this hospital include:

Acute wards for adults of working age:

• Chelmer ward, a 16 bedded mixed sex acute ward forassessment of patients with mental health needswhich also provided care to some patients withaddictions.

• Danbury ward, a 12 bedded mixed sex acute wardproviding inpatient beds for assessment andtreatment of patients with mental health needs.

• Springfield ward, a 12 bedded mixed sex wardproviding assessment and treatment for patients withan eating disorder.

Substance Misuse Services

• Chelmer ward, a 16 bedded ward which treatedpatients who required detoxification alongsidepatients with mental health needs.

• The Lodge, a three bedded mixed sex house forpatients receiving the addictions therapyrehabilitation programme.

Child and adolescent mental health wards (CAMHS):

• CAMHS ward, a 17 bedded mixed sex ward providingassessment and treatment for children andadolescents with mental health needs.

Our inspection team

The team that inspected the service comprised three CQCinspectors, two inspection managers and two specialistadvisers with experience of working in mental healthservices and two experts by experience with experienceof child and adolescent mental health services.

Why we carried out this inspection

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

How we carried out this inspection

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

• Is it safe?

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

Summaryofthisinspection

Summary of this inspection


This inspection was announced.

Before the inspection visit, we reviewed information thatwe held about the location.

During the inspection visit, the inspection team:

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

• spoke with 14 patients who were using the service;• spoke with four family members of patients who were

using the service;

• spoke with the registered manager and managers foreach of the wards;

• spoke with 15 other staff members; including doctors,nurses, and psychologists.

• spoke with an independent advocate;• attended and observed a range of meetings and

reviewed minutes from others;

• Looked at 36 care and treatment records of patients:• carried out a specific check of the medicines

management across the hospital; and• 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 on acute wards told us that staff were kind andcaring and treated them with respect. Patients on thesewards felt they were involved in the planning of their careand could raise concerns through several methods.

Patients on the children and adolescent mental healthward told us that staff were usually kind and caring,however a group of seven patients told us staff did notalways treat them with compassion and kindness or

respect patients’ privacy and dignity. These patients toldus that staff had threatened them and blamed theirbehaviour for short staffing and that night staff were rudeand woke them up at night. Family members told us thatstaff were always kind and helpful. They told us staffinvited them to meetings and staff provided informationabout their relative’s care where appropriate.




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 requires improvement because;

• The provider had not ensured that the ward environments weresafe and well maintained on Chelmer ward. There were ligaturepoints on the wards which staff had not identified or properlymitigated.

• Staff did not follow best practice when storing, giving, andrecording medicines. We found out of date medicines onDanbury ward and on Chelmer ward prescription charts werenot clearly written.

• The service did not have enough nursing staff on the childrenand adolescent mental health wards to keep young people safefrom avoidable harm during incidents.

However;

• Staff completed and updated risk assessments for each patientand used these to understand and manage risks individually.

• Staff kept detailed records of patients’ care and treatment on asecure electronic system.

• The service learned from patient incidents through meetingsand bulletins.


Are services effective?We rated effective as good because;

• Staff provided treatments and care for patients based onnational guidance and best practice.

• Staff from different disciplines, including nurses, doctors,therapists, social workers and psychologists, worked togetheras a team to benefit patients.

• Staff understood their responsibilities under the MentalCapacity Act 2005 and supported patients to make decisions ontheir care for themselves.

However;

• Staff did not assess the physical and mental health of allpatients in an individualised way.

• Staff had not followed legal procedures relating to prescribingmedication under the Mental Health Act 1983. Twoprescriptions did not match details of medications agreed to inconsent to treatment forms.

• The provider had not kept thorough records of the relevantwork experience of agency staff working in the hospital.

Good –––




Are services caring?We rated caring good because;

• Most patients informed us that staff treated them withcompassion and kindness and respected their privacy anddignity.

• Staff on acute wards involved patients and their familymembers in decisions about their care. Family members andcarers felt included in the patients’ care and the providerroutinely invited them to meetings.

However;

• We received mixed feedback from patients on the Children andAdolescent Mental Health ward.

Good –––

Are services responsive?We rated responsive as good because;

• The design, layout, and furnishings of the wards supportedpatients’ treatment, privacy and dignity. Patients had their ownbedrooms and access to quiet spaces.

• Staff ensured that patients maintained contact with the widercommunity through visits to the local community and localgroups.

• The service treated concerns and complaints seriously.Managers thoroughly investigated incidents, and sharedlessons learned with staff through meetings and supervision.

However;

• Chelmer ward was not accessible to patients with mobilityissues as accommodation was located on the first floor andthere was no lift. Staff could admit patients with reducedmobility to Danbury ward instead where there was a lift.

Good –––

Are services well-led?We rated well-led as requires improvement because;

• The provider’s governance system was not robust enough toensure the safe care and treatment of patients. Managers didnot have enough oversight of ligature risks and had notremedied actions from medicines audits.

• The provider had not ensured that medical staff were resolvingerrors relating to prescribing.

• There were insufficient staff on the Children and AdolescentMental Health ward, the provider had recognised this but notacted to resolve it.





• The provider kept employment records of the agency staff whoworked at the hospital but these records did not contain detailsof their work experience.

However;

• Managers across the service promoted a positive culture thatsupported and valued staff, creating a sense of commonpurpose based on shared values.

• The service collected, analysed, managed and usedinformation to support all its activities, using secure electronicsystems with security safeguards.




Mental Health Act responsibilities

• Nursing staff we spoke with understood their roles andresponsibilities under the Mental Health Act 1983 andthe Mental Health Act Code of Practice and how theseapplied to adults and children. However, we foundevidence in prescription records that medical staff hadnot followed legal procedures relating to prescribingmedication under the Mental Health Act.

• We reviewed the paperwork for eight patients detainedunder the Mental Health Act. Paperwork was presentand complete, however, the information written on twoconsent to treatment forms did not match theprescription cards.

• We found that some notes concerning patients, whowere having treatment on an informal basis, used legalterms used for patients detained under the Act.

• Ninety-five per cent of staff had attended annualtraining on the Mental Health Act 1983 andadministrative support was available on site three daysper week.

• Staff explained patient rights under the Mental HealthAct 1983 when required and whenever there werechanges in circumstances.

• An independent mental health advocate visited thewards on a weekly basis to support patients with theirrights and concerns.

• The Mental Health Act administrator completed amonthly audit of Mental Health Act paperwork to ensurethat the ward was meeting the legal requirements of theAct.

• Staff had access to the provider’s policies surroundingthe Mental Health Act and the Code of Practice.

• Staff ensured that patients had access to section 17leave. Staff requested an opinion from a second opinionappointed doctor when necessary. Staff stored copies ofpatients’ detention papers and associated recordscorrectly.

• The service displayed notices to tell informal patientsthat they were free to leave the ward if they wished.

Mental Capacity Act and Deprivation of Liberty Safeguards

• Staff supported patients who lacked capacity to makedecisions for themselves about their care andtreatment. Staff understood when to apply the MentalCapacity Act 2005 in the case of adults and youngpeople and assessed and recorded capacity clearly. Wereviewed the records of 12 patients which demonstratedthat staff had assessment patient capacity and therewas informed consent to treatment.

• Staff received annual training on Mental Capacity Act2005 and Deprivation of Liberty Safeguards and hadaccess to administrative advice.

• Eighty-one percent of staff had training in the MentalCapacity Act and staff we spoke with had a goodunderstanding of the Mental Capacity Act.

• There were no Deprivation of Liberty Safeguardsapplications in the last 12 months.

• The provider had a policy on the Mental Capacity Actand Deprivation of Liberty Safeguards and staff hadaccess to it.

• Staff assessed patients’ capacity to consent totreatment and recorded their decision appropriately.When patients lacked capacity, staff made decisions intheir best interests

• The provider monitored compliance with MentalCapacity Act policy through audits.

Overview of ratings

Our ratings for this location are:

Detailed findings from this inspection


Safe Effective Caring Responsive Well-led Overall

Acute wards for adultsof working age andpsychiatric intensivecare units

Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Child and adolescentmental health wards


improvementRequires

improvement

Substance misuseservices


improvementRequires

improvement

Overall Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Detailed findings from this inspection


Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

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


Safe and clean environment

• The provider had not ensured that all wardenvironments were safe and well maintained. Staffcompleted regular risk assessments of the careenvironment. However, on Chelmer ward the providerhad bedrooms which they identified as safer rooms,designed to reduce risk of ligatures. We found fittings inthese rooms were loose and patients at risk could usethem as a ligature point. We found potential ligatureanchor points in the stairwells which staff had notidentified. A ligature anchor point is the term used todescribe a point to which people might tie something toharm themselves.

• Staff had identified other ligature risks but notsufficiently mitigated them. Staff had identified thestaircase on Chelmer as lower risk due to high stafftraffic, however we observed this area to have low levelsof staff traffic.

• The ward environments allowed staff to observe allparts of the ward using convex mirrors to mitigate blindspots.

• Staff had access to alarms to call for help in case of anincident.

• The wards had fully equipped clinic rooms with all theequipment needed to monitor patients’ physical healthand resuscitation equipment for emergencies. Staffmaintained equipment and kept it clean.

• Chelmer and Danbury wards had separate floors formale and female accommodation which complied withstandards set by the Department of Health.

• The wards were clean, and the furniture was wellmaintained.

• Staff had access to handwashing facilities and hand geland followed infection control principles.

Safe staffing

• The service had enough nursing and medical staff; whoknew the patients and received basic training to keeppeople safe from avoidable harm. However, two familymembers and patients told us there were not enoughstaff to support all activities on the ward thereforesometimes they had to cancel them.

• Chelmer ward had a staffing establishment of 6.4 wholetime equivalent (WTE) nurses and 16.8 WTE healthcareassistants with 1.29 WTE nurse vacancies and 2.84 WTEhealthcare assistant vacancies. Danbury had a staffingestablishment of 6.4 WTE nurses and 7.7 WTE healthcareassistants with 1.1 WTE nurse vacancies. Springfield hada staffing establishment of 6.4 WTE nurses and 1.3 WTEhealthcare assistants with 1.3 WTE nurse vacancies and1.81 WTE healthcare assistant vacancies. We reviewedstaffing rotas as for March and April 2019 and saw thatagency staff and substantive staff overtime was used tocover sickness and observations where patients neededextra support. A qualified nurse was present on thewards at all times. Staffing levels were sufficient to carryout physical interventions and ensure that patients hada one to one time with their named nurse. Medical staffprovided 24-hour cover through an on-call doctor rota, adoctor could attend the wards promptly if there was anemergency.

• Managers discussed staffing levels at the morning ‘flash’meeting each day and had the authority to bring in

Acutewardsforadultsofworkingageandpsychiatricintensivecareunits

Acute wards for adults of workingage and psychiatric intensivecare units



additional staff when needed. Managers prioritised useof regular staff where possible and booked agency staffin block bookings. When managers booked agency staff,they booked those who were familiar with the patientson the ward and ensured they had a suitable induction.Short staffing rarely resulted in staff cancelling escortedleave of ward activities.

• Managers could increase staffing requirements to meetpatient needs. Senior managers had reviewed andincreased the basic staffing level from Danbury warddue to the accommodation being across two floors.

• Managers had not ensured that staff had the skillsneeded to provide high-quality care. We reviewedmandatory training records for all staff on the wards andfound on Springfield and Chelmer wards three out of 78training topics had compliance rates below 75%.Training topics where attendance was low, wereessential for staff to do their jobs effectively. Theseincluded observation practice and rapid tranquilisation,which both had a compliance rate below 60%.

Assessing and managing risk to patients and staff

• Staff completed and updated risk assessments using arecognised risk assessment tool for each patient andused these to understand and manage specific risks forindividuals. We reviewed 13 patient records and foundall of them had a completed risk assessment fromadmission. Staff identified and responded to changingrisks by updating risk assessments on a regular basisand when there had been an incident.

• Staff followed the provider’s policy for the use ofobservations and completed the paperworkappropriately. Staff searched patients and theirbedrooms according to the provider’s procedures.

• Staff applied blanket restrictions on patients’ freedomonly when justified. Informal patients could leave at will.

• During the period of 1 July 2018 and 31 December 2018there were 20 episodes of restraint on the acute wards.These were highest in Chelmer ward, and related todifferent patients. The wards did not use prone restraintor long-term segregation. Staff minimised their use ofrestrictive interventions through de-escalationtechniques and followed best practice when usingphysical interventions on a patient. Staff did not userapid tranquilisation or seclusion. We observed arestrictive intervention which staff completed safely andwith dignity.

Safeguarding

• Staff knew how to identify safeguarding incidentsbut had not reported one on time. Training compliancewith safeguarding was 92%. The team had a socialworker who supported the safeguarding process byreviewing and following up any referrals made to thelocal authority. Staff were aware of the procedure forreferrals and were able to give examples of how theycould protect patients from abuse. All wards displayedposters on the referral process. Reports were made in atimely manner.

• Senior staff reviewed safeguarding cases and concernseach month at the lessons learned meeting. The socialworker provided feedback at this meeting on the actionstaken by the local authority and any protectivemeasures in place.

• The wards had safe procedures for when children visitedpatients at the service. There was an allocated room forpatients to meet with visitors.

Staff access to essential information

• Staff kept detailed records of patients’ care andtreatment on a secure electronic system.

• Patient records were clear, up-to-date and easilyavailable to all staff providing care, including agencystaff.

• The service had a contingency plan should theelectronic system fail. The ward manager kept paperbackup records securely.

Medicines management

• Staff did not follow best practice when storing, givingand recording medicines. We checked the ward’smedicine storage procedures and 27 prescription chartsduring the inspection. We found prescribing errors in sixprescription charts. The pharmacist had highlightedsome errors, but staff had not resolved these errors.

• The provider had multiple medication charts forsome patients. These charts were difficult to follow asthey had been numbered incorrectly. This meant thatstaff could not easily check if patients had beenadministered medication.

• Staff on Danbury had stored patients’ own medicinestogether with stock medicine, some controlled drugswere out of date by three months and the pharmacyhad not removed these for destruction.





• Patients received information about the medicines theywere taking. Staff could offer verbal or written advice inthe form of leaflets. Patients told us that theyunderstood their medicines and staff would review anyconcerns they had.

• Staff regularly reviewed the effects of medications oneach patient’s physical health through regular wardrounds and blood monitoring where appropriate.

• A local pharmacy managed the medicine stock for theward. Staff could order any medicines needed and thepharmacy supplied it promptly. The pharmacist sentmanagers a monthly report on the wards’ compliance tothe service’s medicines management policy, however,prescribers on the wards did not always act to resolveerrors. The pharmacist had raised that medicines ontwo prescription charts did not match the consent totreatment forms, the prescriber had not remedied this.Managers had not acted to manage this performanceissue.

Track record on safety

• Between 12 February 2018 and 27 December 2018 therehad been two serious incidents on the acute wards atthe hospital, one involving a ligature attempt and theother, inappropriate staff behaviour.

• Managers and staff were able to give an example of arecent serious incident were a patient had attempted touse a mattress handle as a ligature point. Theyexplained how they had learned from this incident andhad removed all other handles from the mattresses inthe hospital.

Reporting incidents and learning from when things gowrong

• The service had not identified all types of incident, forexample medicines errors. Managers held a monthly‘lessons learned’ meeting to discuss recent incidentsand what they could learn from them. We reviewed wardmeeting minutes and found staff discussed lessonslearned regularly and this was a standing agenda item.All staff, including agency staff had access to theelectronic reporting system.

• Managers arranged for staff to debrief following aserious incident alongside a psychologist and a seniormanager.

• Staff had not recognised prescribing errors and poormedicines management as incidents and therefore hadnot reported them.

• Staff understood duty of candour, they were open andtransparent when things went wrong. Managers wrote topatients and their families to apologise when anincident occurred.

• Managers investigated incidents that staff had reported,and shared lessons learned with the whole team andthe wider service. Managers sent information from theprovider about incidents which had happenednationally through ward meetings. Staff gave examplesof how practice had changed as a result of incidentreporting.

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

Good –––

Assessment of needs and planning of care

• Staff made care plans which met patients’ needs andupdated them regularly and when an incident occurred.We reviewed 13 patient records and found nine werepersonalised, holistic and recovery orientated.

Best practice in treatment and care

• Staff provided a range of treatments and care forpatients based on national guidance and best practice.

• Patients had access to psychological therapies such asdialectical behavioural therapy, emotional regulationand cognitive behavioural therapy.

• Staff ensured that patients had good access to physicalhealthcare specialists. A dietician visited patients witheating disorders on Springfield ward to ensure that theprovider met patients’ needs for food and drink.

• Staff supported patients to live healthier lives byorganising walks in the local areas, giving advice onhealthy eating and smoking cessation.

• Staff used recognised ratings scales such as the HealthOf the Nation Outcome Scale to assess patientoutcomes.

• During the inspection we did not seestaff using technology to support patients.





• Staff participated in clinical audit, benchmarking andquality improvement initiatives. Each manager hadaccess to data showing how their ward was performingagainst others in the hospital.

Skilled staff to deliver care

• The team included staff from a range of disciplinesincluding doctors, nurses, occupational therapist,clinical psychologists, social workers, dieticians andhealthcare assistants.

• Managers told us they had difficulty booking some staffon training as the provider held training sessions atother hospitals within the Priory group. The service wasworking to resolve this by training local staff to trainothers in topics including safeguarding andmanagement of violence and aggression.

• Managers supported staff with annual appraisals andmonthly supervision and ensured staff received anappropriate induction. The percentage of staff that hadan appraisal in the last 12 months was 100%. Thepercentage of staff that had clinical supervisionregularly was 92%. However, in the staff records wereviewed, supervision records on Chelmer ward lackeddetail and managers had not given actions a timeframefor completion or follow up. Managers ensured that staffhad regular team meetings and kept minutes so thatstaff who could not attend received updates.

• The provider identified staff learning needs and gavestaff opportunities to update and further develop theirskills, through continuing professional developmentsessions and courses offered through the provider’sonline training system. This included specialist trainingfor their roles.

• Permanent staff were experienced and qualified to meetthe needs of the patient group.

• Managers ensured that agency staff had appropriatetraining to work on the ward. However, of the 12 agencyprofiles we reviewed, none included details of therelevant work experience the staff member had for thepatient group. Some patients told us that agency staffdid not know enough about their needs to provide highquality care.

• The service had not had to suspend, or performancemanage any staff in the last 12 months.

Multi-disciplinary and inter-agency team work

• Staff from different disciplines worked together as ateam to benefit patients. They supported each other to

make sure patients had no gaps in their care. Themultidisciplinary team included social workers,occupational therapy, nurses, psychologists, doctors,dieticians and therapists.

• Staff from a range of disciplines would attend a morning‘flash’ meeting where staff could hand over concerns toeach other and agree actions. Human resources teammembers attended this meeting to help co-ordinatestaffing needs but did not join in the clinical discussionsabout patient needs. A Mental Health Act reviewerattended the meeting and identified patients who mayneed their rights reviewed under the Mental Health Act.

• Staff from each discipline attended weekly meetings,ward rounds and lessons learned meetings. Weobserved four meetings and saw that staff involved,collaborated to keep patients safe and aid theirrecovery.

• Staff held twice daily handover meetings where theydiscussed patients’ needs for the day and any changeswhich had occurred.

• The hospital had good links with the local authority. Asocial worker took the lead in liaising with the localauthority on matters of safeguarding and patient needs.

Adherence to the MHA and the MHA Code of Practice

• Nursing staff we spoke with understood their roles andresponsibilities under the Mental Health Act 1983 andthe Mental Health Act Code of Practice, but we foundevidence in prescription records that medical staff hadnot followed legal procedures relating to prescribingmedication under the Mental Health Act. We reviewedthe paperwork for six patients, detained under theMental Health Act, which was present and complete.However, pharmacy audits had highlighted theinformation written on two consent to treatment formsdid not match the prescription cards. We found thatsome notes concerning patients, who were beingtreated on an informal basis, used legal terms designedfor patients detained under the Mental Health Act whenthey were not detained.

• We checked mandatory training records and found 90%of staff had attended annual training on the MentalHealth Act and administrative support was available onsite three days per week.


• Staff explained patient rights under the Mental HealthAct when required and whenever there were changes in





circumstances. Staff ensured that patients had access tosection 17 leave. Staff requested an opinion from asecond opinion appointed doctor when necessary. Staffstored copies of patients’ detention papers andassociated records correctly.

• An independent mental health advocate visited theward on a weekly basis to support patients with theirrights and concerns.

• The Mental Health Act administrator completed amonthly audit of Mental Health Act paperwork to ensurethat the ward was meeting the legal requirements of theAct.


Good practice in applying the MCA

• Eighty-one percent of staff had training in the MentalCapacity Act and staff we spoke with had a goodunderstanding of the Mental Capacity Act.


• The provider had a policy on the Mental Capacity Actand Deprivation of Liberty Safeguards and staff hadaccess to it.

• Staff supported patients to make decisions on their carefor themselves. They understood when to apply theMental Capacity Act 2005 and assessed and recordedcapacity clearly. We reviewed the records of 13 patients.All showed evidence that staff had assessed thepatient’s capacity and there was informed consent totreatment.

• Staff assessed patients’ capacity to consent totreatment and recorded their decision appropriately.When patients lacked capacity, staff made decisions intheir best interests



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

Good –––

Kindness, privacy, dignity, respect, compassion andsupport

• Staff treated patients with compassion and kindnessand respected their privacy and dignity. Patients told usthat staff treated them with dignity and respect. Familymembers were generally positive about the way stafftreated their relatives and said they were respectful.Staff attitudes demonstrated that they were discreet,respectful and responsive.

• Staff supported patients’ individual needs, assessingtheir cultural, mobility and language needs on arrival atthe service.

• Staff supported patients to understand their care andtreatment.

• Staff supported patients to access services outside thehospital when appropriate.

• Staff said they were comfortable raising concerns aboutdisrespectful or abusive behaviour.

• Staff took steps to maintain confidentiality of patients.• The provider had improved preserving patient dignity

when staff conducted searches for contraband items, byhaving a private room near the entrance of the hospitalwith privacy screens.

Involvement in care

• Staff orientated patients and gave them informationabout the service when they admitted them to thewards.

• Patients said they were involved in decisions about theircare and treatment. Staff completed risk assessmentsalongside patients. Staff communicated with patientsabout their care and treatment. They held ward roundmeetings which patients could attend and be involvedin the decision-making. Family members told us theyregularly attended these meetings. The wards also helda weekly community meeting, enabling patients to givefeedback and to voice concerns and issues.





• Family members told us that they were involved in theirrelative’s care when it was appropriate, and staff invitedthem to attend meetings.

• However, staff did not always ensure patients hadcopies of their care plans. Of the six patient care plansreviewed we saw staff had not given four patients a copyand no reason was documented.

• Staff supported patients to access advocacy services.• Staff kept family members involved in the care and

treatment of their relative and gave them opportunitiesto give feedback.

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

Good –––

Access and discharge

• Staff received information about each patient from acentral admissions team prior to their arrival. A doctorwould review this information and decide whether theiradmission was appropriate for the ward. Care plansincluded goals to work towards to be ready fordischarge.

• Between January 2018 and 31 December 2018, theprovider reported that bed occupancy was 78%.Admissions were rarely delayed as there was usually abed available.

• Patients were only moved between wards or hospitalsfor clinical reasons. For example, if the patient had highrisk of self-harm and needed to be placed in a saferoom.

• Between 1 January 2018 and 31 December 2018,patients stayed on the wards for an average of eighteendays. Staff identified that sometimes discharge might bedelayed, to ensure patients had a suitable placement tobe transferred to.

• Between 1 January 2018 and 31 December 2018, theservice reported no delayed discharges. Patientdischarges were planned, and the service ensured thatthey transferred care with copies of notes.

The facilities promote recovery, comfort, dignity andconfidentiality

• The design, layout, and furnishings of the wardssupported patients’ treatment, privacy and dignity.Springfield ward displayed inspirational quotes andpictures on the ward.

• Patients had their own bedrooms with en-suite andcould personalise their bedrooms if they wished.

• There were quiet spaces on each ward where patientscould go, and the hospital had an allocated room wherepatients could meet visitors.

• Patients were offered a choice of food and could accesshot drinks and snacks.

• Patients had access to an outside space shared betweenChelmer and Springfield wards.

• Patients could make a phone call in private.• Staff had displayed information about mental and

physical health on the ward.• Staff searched patients in a separate room with privacy

screens to protect their dignity.• Patients had somewhere to store their personal

belongings.• Staff and patients had access to a full range of rooms to

meet their requirements.

Patients’ engagement with the wider community

• Staff ensured patients maintained contact with thewider community. Staff facilitated walks in the localarea.

• Patients had access to volunteering opportunities,running a café and helping the local farm shop.

• Staff supported and encouraged patients to maintaincontact with their families. Family members were invitedto meetings and could, when appropriate visit thepatient on the ward.

Meeting the needs of all people who use the service

• The service was not accessible to all due to the layout ofthe building. Patients with limited mobility could notaccess bedrooms located on the first floor of Chelmerward as there was no lift. Staff could admit patients withreduced mobility to Danbury ward instead where therewas a lift and bedrooms were accessible.

• Staff sought accessible ways to support patients withcommunication needs, and cultural support. Staff couldaccess information in accessible formats or use aninterpretation or signing service if needed. Anindependent advocate and a chaplain service visitedthe ward each week to support patient needs.





• Staff had displayed information about different types oftreatment, local services, patient rights and how tocomplain on boards around the wards.

• The service met patients’ dietary requirements and gavepeople a choice of food options. A dietician worked withpatients who needed extra support with nutrition suchas those with eating disorders.

Listening to and learning from concerns andcomplaints

• The service treated concerns and complaints seriously.Managers conducted thorough investigations andshared lessons learned via staff meetings and fed backto patients.

• The service gave patients information about thecomplaint’s procedure as part of their welcome pack.

• Staff knew how to handle complaints and kept recordsof both formal and informal complaints. Staff protectedcomplainants from discrimination.

• Staff discussed complaints monthly at the lessonslearned meetings with the multidisciplinary team. Wereviewed team meeting minutes for the three monthsprior to the inspection and saw evidence that managersshared this information.

• The wards had received 13 complaints between 1January 2018 and 31 December 2018. Managersinvestigated these complaints and upheld six. Managersresponded appropriately to remedy any issues raised inthe complaints.

• The provider sought general feedback from patients’relatives through a tablet computer on the receptiondesk, this was new at the time of the inspection, so theprovider had no data.

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


Leadership

• Managers told us they received the right support fromthose above them.

• Managers had a good understanding of the services theymanaged and could explain how staff were improvingthe service to provide good care.

• Staff were positive about the support offered to them bythe people in leadership positions in the hospital.

• Senior managers from the hospital and regional teamwere visible, visited the wards and were open tofeedback to staff.

• Managers had access to leadership developmentopportunities and junior staff could access leadershiptraining.

Vision and strategy

• The service had a vision for what it wanted to achieve,and staff were aware of what this was. Managers linkedthe organisation’s visions and values to staff appraisals.

• Managers had communicated the vision and values tostaff at the service through emails and posters.

• Managers gave staff an opportunity to develop thestrategy for the service through staff representativeswho attended regular governance meetings.

• Staff could explain how they were working towardsdelivering high quality care and could not identifyoccasions when budgets had compromise care.

Culture

• Staff felt respected, supported and valued and werepositive about working within the hospital.

• Managers across the service promoted a positive culturethat supported and valued staff, creating a sense ofcommon purpose based on shared values.

• Staff felt able to raise concerns or whistle-blow withoutfear of retribution. Staff knew the whistleblowingprocess.

• The provider had recently appointed four new staffrepresentatives who would attend meetings with seniorstaff and feedback staff concerns and ideas.

• The provider reported that they had not had to dealwith poor staff performance. Managers dealt with anydifficulties within teams appropriately, however wefound some issues with staff performance related toprescribing. Managers tracked staff sickness andabsence which was low at 3.5% for the hospital. Staffcould access an occupational health service.

• Staff appraisals included conversations about how staffcould be supported to progress in their careers.

• The provider recognised staff success within the servicethrough a national awards programme and a localemployee of the month award.

Governance





• The provider’s governance system was not robustenough to ensure the safe care and treatment ofpatients. Managers had not identified gaps in ligatureaudits and where staff had not acted on medicinesaudits. Managers kept a list of planned environmentalimprovements for the hospital. Environmental auditshad not identified that some of the safer rooms on theward had ligature anchor points. Managers had notacted on performance issues highlighted by Mentalhealth Act audits.

• Meetings for ward staff had a clear structure andcovered incidents, complaints and safeguardingconcerns.

• Managers completed thorough recruitment checks fornew permanent staff, however some agency profileslacked detail on their experience.

• Staff at all levels met regularly at team meetings,handovers, and governance meetings. There was a clearstructure for what should be discussed at thesemeetings and essential information such as learningfrom incidents and complaints was included. Staff wereaware of procedures for working with other teamswithin the organisation.

• Staff on Chelmer ward had not implemented all learningidentified from pharmacy audits which had picked upon administration errors and prescribing errors.These had not been resolved.

• Staff participated in clinical audits including a monthlyquality walk round. Staff understood the process forworking with other teams within the provider andexternal to the organisation to meet the needs of theirpatients.

Management of risk, issues and performance

• The provider had sufficient oversight of the risks on thesite, however there was insufficient oversight ofpharmacy and Mental Health Act audits.

• Staff were able to add concerns to the risk register andward staff could escalate concerns to the ward managerif required. At the time of the inspection we found therewere gaps in the risk register relating to ligatures.

• The services had plans for emergencies, such as ITfailure.

• Staff files showed that managers addressedperformance and absence issues with staffappropriately.

Information management

• The service collected, analysed, managed and usedinformation well to support all its activities, using secureelectronic systems with security safeguards.

• Staff including agency staff, had access to all theelectronic systems they needed, such as patient notesand incident reporting, and were able to locateinformation. Information technology was easilyaccessed and the infrastructure worked well.

• Information governance systems includedconfidentiality of patient records.

• Managers had access to an electronic dashboard whichshowed how their ward was performing according to itsperformance indicators for staffing and finances.

• Staff made notifications to external bodies such assafeguarding notifications when needed.

Engagement

• The provider gave staff information about their workthrough staff meetings and opportunities to feedbackabout the service through staff surveys, forums and staffrepresentatives.

• The provider had an awards scheme for staff who hadgone above and beyond for patients and the hospitalran an employee of the month scheme.

• Patients could give feedback in a number of ways to suittheir needs, through community meetings and surveys.Managers had access to this feedback and used it tomake improvements to the service. Staff involvedpatients and carers in decisions about changes to theservice. Patients were able to apply to be on interviewpanels for new staff. Staff received information aboutcomplaints and feedback in team meetings. Staff couldaccess minutes if they were unable to attend.

Learning, continuous improvement and innovation

• Staff were given opportunities to highlight potentialimprovements and innovations which could be made tothe service. These improvements could be would bediscussed in team meetings or through staff siderepresentatives who sat on meetings with seniormanagers.

• Managers investigated and learned from incidents andmet monthly to discuss how they could improve theservice following incidents and complaints.

• The service was not participating in research ornationally recognised audits such as Royal College ofPsychiatry schizophrenia or psychological therapies





audit. The service was not participating in any peerreview schemes or audits such as Royal College ofPsychiatry accreditation for inpatient mental healthservices.

• The provider had a policy for the promotion of equalityand diversity in the hospital but did not record any datafor monitoring the effectiveness.










Are child and adolescent mental healthwards safe?



• The ward was safe, clean, well equipped, well furnished,well maintained and fit for purpose. Staff could clearlysee all areas of the ward and could utilise a closedcircuit television system in bedrooms if patients werehigh risk. Patients and, where appropriate their familymembers, gave consent for this system to be used and alens cap covered the camera when it was not in use toensure privacy.

• Staff did regular risk assessments and identified allligature anchor points on the ligature risk assessment.Staff created an action plan to mitigate risks to patientswho might try to harm themselves.

• The ward environments allowed staff to observe allparts of the ward using closed circuit television andconvex mirrors to mitigate blind spots.

• Staff had access to alarms in order to call for help incase of an incident.

• The ward had a clinic room with all the equipmentneeded for monitoring patients’ physical health andresuscitation equipment for emergencies. Staffmaintained equipment and kept it clean.

• The ward consisted of two floors which did not complywith standards set out by the Department of Health onmixed sex accommodation. Due to both male andfemale patients being accommodated on both floors.

• Staff had access to hand washing facilities and hand geland followed infection control principles.

Safe staffing

• The service did not have enough nursing staff to keeppeople safe from avoidable harm. The ward had astaffing establishment of 9 WTE nurses and 23 WTEhealthcare assistants with 0.7 WTE nurse vacancies and5.5 WTE healthcare assistant vacancies. The number ofstaff available did not meet service’s minimumrequirements and high numbers of shifts were coveredby agency staff. We reviewed staffing rotas for onemonth and found 11 occasions where there were fewerthan two nurses or three healthcare assistants on shift.Minimum staffing numbers were set by service linemanagers and they reviewed them monthly or whenthere was an incident. Staffing levels were not sufficientto carry out physical interventions and ensure thatpatients had one to one time with their named nurse.We saw evidence in clinical governance meetingminutes that low staffing levels were linked to incidentshowever, the provider had not increased the minimumstaff numbers.

• A qualified nurse was present on the wards at all times.• Managers discussed staffing levels at the morning ‘flash’

meeting each day and had the authority to bring inadditional staff if they needed to account for case mix.Managers prioritised use of regular staff where possibleand booked agency staff in block bookings. Whenmanagers booked agency staff, they booked those whowere familiar with the patients on the ward and ensuredthey had a suitable induction. Short staffing rarelyresulted in staff cancelling escorted leave or wardactivities. However, when incidents occurred patientsand staff told us there were not always enough staff torespond.

• Medical staff provided cover 24 hours a day 7 days aweek through the on-call doctor rota.

Childandadolescentmentalhealthwards

Child and adolescent mentalhealth wards



• Managers had not made sure that all staff had the skillsneeded to provide high-quality care. We reviewedmandatory training records for all staff on the ward andfound nine out of 75 training topics had compliancerates below the provider’s target of 75%. Training topicsessential for staff to do their jobs effectively, such asobservation practice and working with young people,had compliance rates of 50%.


• Staff completed and updated risk assessments using arecognised assessment tool for each patient and usedthese to understand and manage risks individually. Staffreceived advance information from a central referralsteam prior to the patient arriving. We reviewed sixpatient records, and all showed evidence that staff hadcompleted an initial assessment during admission andupdated this risk assessment regularly.


• Staff applied blanket restrictions on patients’ freedomonly when justified. Informal patients could leave at will.

• Staff discussed changing risks at handovers held twicedaily and increased levels of observation if necessary.The multidisciplinary team reviewed risk assessmentstwice a week at the ward round and they invitedpatients to these discussions.

• During the period of 1 July 2018 and 31 December 2018there were 27 episodes of restraint on the ward. Thesewere related to different patients. The wards did not useprone restraint. Staff minimised their use of restrictiveinterventions and followed best practice whenrestricting a patient. Staff did not use rapidtranquilisation or seclusion. We observed one episodeof restraint during the inspection which staff conductedin line with their training and respected patient dignity.

Safeguarding

• Staff knew how to identify abuse and made reports tothe local authority. The team had a social worker whosupported the safeguarding process by reviewing andfollowing up any referrals made to the local authority.Staff were aware of the procedure for referrals and allwards displayed posters on the referral process.

• Training compliance with safeguarding was 85%. Thetraining was for children and vulnerable adults and was

provided by an e-learning module. The provider was inthe process of arranging face to face level twosafeguarding training to improve the quality of thistraining.

• We reviewed two safeguarding concerns raised by theprovider and found that staff had followed proceduresto keep patients safe but had not kept clear recordsfor one of the concerns.


• The ward had safe procedures for when children visitedpatients at the service. There was an allocated room forpatients to meet with visitors.



• Records were clear, up-to-date and easily available to allstaff providing care, including agency staff.

• The service had a contingency plan should theelectronic system fail. The ward manager kept paperbackup records.


• Staff followed best practice when storing, giving, andrecording medicines. We checked the ward’s medicinestorage procedures and 13 prescription charts duringthe inspection. Prescribers of medicine followedguidance and staff kept contemporaneous recordswhen they gave patients medicines.

• Patients received information about the medicines theywere taking. Staff could offer verbal or written advice inthe form of leaflets. Patients told us that they felt theyunderstood their medicines and that staff would reviewany concerns they had.

• Staff regularly reviewed the effects of medications oneach patient’s physical health through regular wardrounds.

• A local pharmacy managed the medicine stock for theward. Staff could order any medicines needed and theysupplied this promptly. The pharmacist sent managers amonthly report on the ward’s compliance to theservice’s medicines management policy and staff on thechild and adolescent mental health ward acted onissues identified.






• Incident numbers were high on the ward, there were 35reports made in February 2018. The service hadrecorded five serious incidents between 1 January 2018and 31 December 2018 on the child and adolescentmental health wards. One incident related to staff onpatient abuse and the staff member was no longerworking with the provider, two incidents related topatient on patient abuse, one incident related to apatient absconding from accident and emergency at thelocal hospital and one related to a patient becomingunwell at a local general hospital.

• The ward manager and staff were able to highlightrecent incidents and actions taken.


• Staff recognised incidents and reported themappropriately using the electronic system. All staff,including agency staff had access to this system.

• Managers arranged for staff to debrief following aserious incident.

• Managers investigated incidents and shared lessonslearned with the whole team and the wider service.Senior staff met monthly to discuss incidents anddevelop lessons learned. We observed one of thesemeetings during the inspection. Staff kept minutes ofthe meeting and followed a standing agenda. Stafffollowed up all actions from previous sessions.

• Staff received monthly bulletins on safety and incidentsfrom the regional team and managers discussed lessonslearned in team meetings and staff supervisions. Theward manager was able to identify an example of howthey had escalated learning from an incident andshared this within the Priory group. Staff gave examplesof how practice had changed as a result of incidentreporting.


Are child and adolescent mental healthwards effective?(for example, treatment is effective)

Good –––


• Staff assessed the physical and mental health of allpatients on admission. They developed individual careplans and updated them when needed.

• During the inspection we reviewed six patient records.All were holistic, personalised and recovery orientated.

• Staff held a care planning meeting with patients whenthey admitted them.

• A referrals team gathered information on the patient’spersonal and family history prior to admission andensured that staff had this when assessing patientneeds.

• During the inspection we did not see staff usetechnology to support patients.


• Staff provided treatments and care for patients basedon national guidance and best practice. Patients hadaccess to psychological therapies such as dialecticalbehavioural therapy, cognitive behavioural therapy anddrama therapy. Staff offered therapies as part of a groupand on a one to one basis dependent on need.

• Staff used recognised rating scales such as Health of theNation Outcome Scale and Health of the NationOutcome Scale for Children and Adolescents to measureoutcomes.

• Staff supported patients with their physical health andencouraged them to live healthier lives with walks andhealthy eating advice.

• Staff participated in clinical audit, benchmarking andquality improvement initiatives. The ward manager hadaccess to data showing how their ward was performingagainst others in the hospital.


• The team included staff from a range of disciplinesincluding doctors, nurses, occupational therapist,clinical psychologists, social workers, dieticians andhealthcare assistants.

• Managers told us they had difficulty booking some staffon training as the provider held training sessions at





other hospitals within the Priory group. The service wasworking to resolve this by training local staff to trainothers in topics including safeguarding and themanagement of violence and aggression.

• Managers supported staff with annual appraisals andmonthly supervision and ensured staff received anappropriate induction. The percentage of staff that hadan appraisal in the last 12 months was 99%. Thepercentage of staff that had had clinical supervisionregularly was 90%.

• Managers ensured that staff had regular team meetingsand kept minutes so that staff who could not attendreceived updates.

• The provider identified staff learning needs and gavestaff opportunities to update and further develop theirskills, through continuing professional developmentsessions and courses offered through the provider’sonline training system. The hospital was currentlytraining four healthcare assistants to become nurses.


• Managers ensured that agency staff had appropriatetraining to work on the ward. However, of the 12 agencyprofiles we reviewed none had details of the relevantexperience the staff member had working with thispatient group.

• The service reported they had not had to suspend orperformance manage any permanent staff in the last 12months but one agency member of staff was no longerworking at the hospital due to an incident.


• Staff from different disciplines worked together as ateam to benefit patients. They supported each other tomake sure patients had no gaps in their care. Themultidisciplinary team included social workers,occupational therapy, nurses, psychologists, doctorsand therapists.

• Staff from a range of disciplines would attend a morning‘flash’ meeting where staff could hand over concerns toeach other and agree actions. Human resourcesattended this meeting to help co-ordinate staffing needsbut were not involved in clinical discussions aboutpatients. A Mental Health Act administrator attended themeeting and identified patients who may need theirrights reviewed under the Mental Health Act.

• Staff from each discipline attended ward rounds andlessons learned meetings. We observed four meetingsand saw that staff involved collaborated to keeppatients safe and aid their recovery.




• Staff we spoke with understood their roles andresponsibilities under the Mental Health Act 1983 andthe Mental Health Act Code of Practice and when thisapplied to children. Staff had access to Mental HealthAct administrative support, available on site three daysper week

• Attendance at mandatory training was low, we checkedmandatory training records and found 70% of staff hadattended annual training on the Mental Health Act.


• Staff explained to patients their rights under the MentalHealth Act when required and whenever there werechanges to their circumstance. Staff ensured thatpatients had access to section 17 leave. Staff requestedan opinion from a second opinion appointed doctorwhen necessary. Staff stored copies of patients’detention papers and associated records correctly.

• An independent mental health advocate visited theward on a weekly basis to support patients with theirrights and concerns.

• The Mental Health Act administrator completed amonthly audit of Mental Health Act paperwork to ensurethat the ward was meeting the legal requirements of theact. We reviewed the paperwork for two patientsdetained under the Mental Health Act, which waspresent and complete.



• Seventy five percent of staff had training in the MentalCapacity Act and staff we spoke with had a goodunderstanding of the Mental Capacity Act and when itapplied to their patient group.






• The provider had a policy on the Mental Capacity Actand Deprivation of Liberty safeguards and staff hadaccess to it.

• Staff supported patients to make decisions on their carefor themselves. They understood when to apply theMental Capacity Act 2005 in the case of young peopleand assessed and recorded capacity clearly. Staffassessed patients’ capacity to consent to their owntreatment if they were under 16 using the Gillickcompetency framework. We reviewed the records of sixpatients, all showed evidence that staff had assessedthe patient’s capacity and there was informed consentto treatment.


Are child and adolescent mental healthwards caring?

Good –––


• Staff attitudes demonstrated that they were discreet,respectful and responsive.

• Carers were generally positive about the way stafftreated their family members and said they wererespectful.

• Staff supported patient’s individual needs by offeringthem ways to record their journeys through scrapbooking and murals. Staff understood the individualneeds of patients including their cultural, social andreligious needs.

• Staff supported patients to understand their care andtheir condition.



• Staff took steps to maintain confidentiality of patients.

• The provider had improved patient’s dignity when theysearched them for contraband items by having a privateroom near the entrance of the hospital with privacyscreens.

Involvement in care


• Patients said they were involved in decisions about theircare and treatment. Staff completed risk assessmentsalongside patients. Staff communicated with patientsabout their care and treatment, they held ward roundmeetings which patients could to attend and beinvolved in the decision making. The wards also held aweekly community meeting, enabling patients to givefeedback and to voice concerns and issues.


• Staff ensured patients had copies of their care plans. Ofthe six patient care plans reviewed, we saw that allpatients had received a copy.



Are child and adolescent mental healthwards responsive to people’s needs?(for example, to feedback?)

Good –––


• Between January 2018 and 31 December 2018, theprovider reported that bed occupancy was 82%.Admissions were rarely delayed as there was usually abed available.

• Staff received information about each patient from acentral admissions team prior to their arrival. A doctorwould review this information, conduct a riskassessment and decide whether their admission wasappropriate for the ward.





• The provider was working on a project alongside NHSEngland to move patients, where possible, to a serviceclose to their home.

• Family members we spoke with said staff were helpfulduring the discharge process and the provider’saftercare was supportive.

• Between 1 January 2018 and 31 December 2018patients stayed on the ward for an average of 52 days.

• Patients were only moved between hospitals if theyneeded to for clinical reasons.

• Between 1 January 2018 and 31 December 2018, theservice reported no delayed discharges. Patientdischarges were planned, and the service ensured thatthey transferred care with copies of notes.


• There was a lounge on the ward, however patients couldnot access it as the air conditioning unit was broken andthe provider needed to complete remedial works forthem to be safe. The provider was aware of this issueand had arranged a replacement to be fitted.

• Staff offered patients opportunities to record theirjourneys and support their recovery through scrapbooking activities, theatrical make up sessions andmural paintings on the ward walls, created by patients.Patients we spoke with were positive about theseactivities and said they helped their recovery.

• The design, layout, and furnishings of the ward orservice supported patients’ treatment, privacy anddignity. There were quiet spaces on each ward wherepatient could go and the hospital had an allocatedroom where patients could meet visitors.

• Patients had their own bedrooms with en-suite andcould personalise their bedrooms if they wished.Patients had a safe place they could store theirbelongings.


• Patients had access to an outside space, however thiswas with staff supervision only.

• Patients could make a phone call in private.• Staff searched patients in a separate room with privacy

screens to protect their dignity.• Staff and patients had access to a range of rooms to

meet their needs.


• Staff supported patients with activities outside theservice, such as work, education and familyrelationships. Family members said they were able tospeak to patients when they wanted, and staff invitedthem to come to regular meetings. At the time of theinspection seven out of the 15 patients on the wardwere from out of the area, the service was actively tryingto transfer them to their home location to keep contactwith their families.

• Patients attended regular education classes at theservice. Staff facilitated students to stay on at the schoolafter they turned 16 to take resits of their exams ifneeded.

• Patients had access to volunteering opportunities, suchas helping a horse sanctuary.



• The service was not accessible to all due to the wardbeing located on the first floor of the building.

• Staff helped patients with communication, advocacyand cultural support. Staff could access information inaccessible formats or use an interpretation or signingservice if needed. An independent advocate and achaplain service visited the ward each week to supportpatient needs.


• The service met patients’ dietary requirements and gavepeople a choice of food options. However, twopatients told us that portions were small and could beimproved.


• The service treated concerns and complaints seriously.Managers conducted thorough investigations and wesaw evidence of lessons learned in investigation reports.Managers discussed complaints monthly at the lessonslearned meetings with the multidisciplinary team andmanagers fed back to patients.

• Staff knew how to handle both formal and informalcomplaints and protected patients from victimisationwhen they made a complaint.





• The provider gave patients information about thecomplaint’s procedure by the service as part of theirwelcome pack.

• The ward received five formal complaints between 1January 2018 and 31 December 2018, two of which wereupheld. We reviewed three of these complaints in detailand managers investigated all complaints individually.Two complaints were partially upheld. Issues raised inthese complaints related to: staff attitudes, physicalhealthcare, access to outside areas and inappropriatetreatment. All complainants received a response fromthe hospital director. All three complaints showedevidence of lessons learned and actions to follow up.

• The provider sought general feedback from patients’relatives and verbally at meetings and through a tabletcomputer on the reception desk. This tablet was new atthe time of the inspection, so the provider did not haveany data.

Are child and adolescent mental healthwards well-led?


Leadership






Vision and strategy



• Managers gave staff an opportunity to develop thestrategy for the service through staff representativeswho attended governance meetings.

• Staff could explain how they were working towardsdelivering high quality care and could not identifyoccasions when budgets had compromise care.

Culture





• Managers dealt with any difficulties within teamsappropriately.

• Managers tracked staff sickness and absence which waslow at 3.5% for the hospital. Staff could access anoccupational health service.


• The provider recognised staff success within the servicethrough a national awards programme and a localemployee of the month award. Two therapists from theward had been nominated for a national recognitionaward.

Governance

• The provider’s governance system was not robustenough to ensure the safe care and treatment ofpatients. Senior staff had identified that a high rate ofincidents on the ward was linked to low staffing levelsbut the provider had not taken action to resolve this.


• Staff at all levels met regularly at team meetings,handovers, and governance meetings. There was a clearstructure for what should be discussed at thesemeetings and essential information such as learningfrom incidents and complaints was included.






• Staff participated in clinical audits including a monthlyquality walk round. The pharmacist sent monthly auditsdetailing staff compliance to the medicinesmanagement policy and the mental health actadministrator audited compliance against the MentalHealth Act 1983. Staff understood the process forworking with other teams within the provider andexternal to the organisation to meet the needs of theirpatients.

• Staff understood the arrangements for working withother teams in the organisation.


• The provider had sufficient oversight of the risks on thesite.

• Managers had access to electronic data via a dashboardwhich they could use to monitor how their ward wasperforming.

• Staff were able to add concerns to the risk register andward staff could escalate concerns to the ward managerif required. We found some gaps in the risk registerduring the inspection, however managers had sufficientoversight and responded to concerns appropriately.









Engagement



• Patients could give feedback in a number of ways to suittheir needs, through community meetings and surveys.Managers had access to this feedback and used it tomake improvements to the service. Staff involvedpatients and carers in decisions about changes to theservice, patients were able to apply to be on interviewpanels for new staff. Staff received information aboutcomplaints and feedback received in team meetings,staff could access minutes if they were unable to attend.


• Staff were given opportunities to highlight potentialimprovements and innovations which could be made tothe service. These improvements could be made inmeetings or through staff side representatives who saton meetings with senior managers.


• All communal areas and bedrooms on the ward had aclosed-circuit television system that an externalprovider remotely monitored to support high-riskpatients. Staff used bedroom cameras with the expressconsent of the patient, who was aware they were beingmonitored, and trained medical staff reviewed thefootage, calling the ward staff if they were concernedabout a patient. We reviewed the provider’s policy forthis system and found that video footage was storedand transmitted securely, and the provider wastransparent with patients about its use. Theorganisation had created leaflets to help patients tounderstand the process for use of these cameras andtheir rights around consent.

• The service was not participating in research ornationally recognised audits such as Royal College ofPsychiatry psychological therapies audit. The servicewas not participating in any peer review schemes suchas Royal College of Psychiatry network for inpatientchildren and adolescent mental health services.










Are substance misuse services safe?



• The provider had not ensured that all wardenvironments were safe. On Chelmer ward the providerhad bedrooms which they identified as safer rooms,designed to reduce risk of ligatures. We found fittings inthese rooms were loose and patients at risk could usethem as a ligature point. On Chelmer ward we foundpotential ligature anchor points in the stairwells whichstaff had not identified. Staff had identified otherligature risks but not sufficiently mitigated them. Staffon Chelmer had identified some areas as lower risk dueto high staff traffic, however we found these areas tohave low levels of staff traffic.

• On the lodge staff had identified potential risks in theenvironment and had assessed patients individually. Ifpatients were assessed as high risk of self harm thenstaff would observe them according to hospital policy.

• The ward environments allowed staff to observe allparts of the ward using convex mirrors to mitigate blindspots.

• Staff had access to alarms to call for help in case of anincident.

• Chelmer ward had a fully equipped clinic room with allthe equipment needed to monitor patients’ physicalhealth. Staff maintained equipment and kept it clean.

• The wards were clean, and the furniture was wellmaintained.

• Staff had access to handwashing facilities and hand geland followed infection control principles.

Safe staffing

• The service had enough nursing and medical staff, whoknew the patients and received basic training to keeppeople safe from avoidable harm.

• Chelmer ward had a staffing establishment of 6.4 WTEnurses and 16.8 WTE healthcare assistants with 1.29WTE nurse vacancies and 2.84 WTE healthcare assistantvacancies. Staff who worked at The Lodge came fromChelmer ward. Staffing levels were sufficient to carry outphysical interventions and ensure that patients had oneto one time with their named nurse. Medical staffprovided 24-hour cover through an on-call doctor rota, adoctor could attend the wards promptly if there was anemergency.

• Managers discussed staffing levels at the morning ‘flash’meeting each day and had the authority to bring inadditional staff if they needed to. Managers prioritiseduse of regular staff where possible and booked agencystaff in block bookings. When managers booked agencystaff, they booked those who were familiar with thepatients on the ward and ensured they had a suitableinduction.

• Managers could increase staffing requirements to meetpatient needs.

• Managers had not ensured that staff had the skillsneeded to provide high-quality care. We reviewedmandatory training records for all staff on the wards andfound three out of 78 training topics had compliancerates below 60%.


• Staff completed and updated risk assessments for eachpatient using a recognised tool and used these tounderstand and manage specific risks for individuals.We reviewed three patient records and found all of them

Substancemisuseservices

Substance misuse services



had a completed risk assessment from admission. Staffidentified and responded to changing risks by updatingrisk assessments on a regular basis and when there hadbeen an incident.

• Staff did not use restrictive interventions for patientsundergoing treatment for addictions and usedde-escalation techniques if required.


• Staff applied blanket restrictions on patients’ freedomonly when justified.

• During the period of 1 July 2018 and 31 December 2018there were no episodes of restraint on the for substancemisuse patients. The wards did not use prone restraintor long-term segregation. Staff minimised their use ofrestrictive interventions through de-escalationtechniques. Staff did not use rapid tranquilisation orseclusion.

Safeguarding

• Staff were aware of the referrals procedure forsafeguarding and posters were displayed on all wards.Staff were able to give examples of how they wouldidentify abuse and safeguard patients.

• Training compliance with the provider'se-learning safeguarding training was 94%.

• The team had a social worker who supported thesafeguarding process by reviewing and following up anyreferrals made to the local authority.


• The wards had safe procedures for when children visitedpatients. There was an allocated room for patients tomeet with visitors.



• Patient records were clear, up-to-date and easilyavailable to all staff providing care, including agencystaff.

• The service had a contingency plan should theelectronic system fail. The ward manager kept paperbackup records securely.


• Staff did not follow best practice when storing, givingand recording medicines. We checked the ward’smedicine storage procedures and 11 prescription chartsduring the inspection. We found prescribing errors inthree prescription charts. The pharmacist hadhighlighted some errors, but staff on Chelmer ward hadnot resolved these errors. On Chelmer ward doctors hadnot reviewed one patient’s medicine after they hadcompleted detoxification.

• Staff had numbered some prescription charts onChelmer incorrectly which meant they could not be sureif other staff had supplied the medication to the patient.

• Patients received information about the medicines theywere taking. Staff could offer verbal or written advice inthe form of leaflets. Patients told us that theyunderstood their medicines and staff would review anyconcerns they had.

• Staff regularly reviewed the effects of medications oneach patient’s physical health through regular wardrounds and blood monitoring where appropriate.

• A local pharmacy managed the medicine stock for thewards. Staff could order any medicines needed and thepharmacy supplied it promptly.


• Between 12 February 2018 and 27 December 2018 therehad been no serious incidents on the substance misusewards at the hospital.

• Managers and staff were able to give examples of recentserious incidents from other wards and lessons learnedthrough those incidents.


• Staff had not identified all types of incidents for examplemedicines errors. Managers held a monthly ‘lessonslearned’ meeting to discuss recent incidents and whatthey could learn from them. We reviewed ward meetingminutes and found staff discussed lessons learnedregularly and this was a standing agenda item. All staff,including agency staff had access to the electronicreporting system.





• Managers arranged for staff to debrief following aserious incident with a psychologist and a seniormanager.


• Managers investigated incidents that staff had reported,and shared lessons learned with the whole team andthe wider service. Managers sent information from theprovider about incidents which had happenednationally through ward meetings. Staff gave examplesof how practice had changed as a result of incidentreporting.

Are substance misuse services effective?(for example, treatment is effective)

Good –––


• Staff assessed the physical and mental health of allpatients after admission. During the inspection wereviewed 6 patient records, in one record, staff hadcopied the patient's assessment from another patient'srecord.

• Three care plans for patients did not fully meet theirneeds as staff had not assessed their alcoholconsumption fully.


• Staff provided treatments and care for patients basedon national guidance and best practice and ensuredthat patients had good access to substance misusespecialists. Staff met patients’ needs for food and drink.

• Patients had access to psychological therapies such asdialectical behavioural therapy, emotional regulationand cognitive behavioural therapy.

• Staff supported patients to live healthier lives byorganising walks in the local areas, giving advice onhealthy eating and smoking cessation.

• Staff used the Clinical Institute Withdrawal Assessmentfor alcohol scale to monitor patients’ withdrawal.Patients had access to a 12-step therapy programme tosupport their recovery.


• Managers supported staff with annual appraisals andmonthly supervision and ensured staff received anappropriate induction. The percentage of staff that hadhad and appraisal in the last 12 months was 100%. Thepercentage of staff that had had clinical supervisionregularly was 92%. However, in the staff records wereviewed on Chelmer ward, supervision records lackeddetail and managers had not given actions a timeframefor completion or follow up. Managers ensured that staffhad regular team meetings and kept minutes so thatstaff who could not attend received updates.

• The provider identified staff learning needs and gavestaff opportunities to update and further develop theirskills, through continuing professional developmentsessions and courses offered through the provider’sonline training system. This included specialist trainingfor their roles.


• Managers ensured that agency staff had appropriatetraining to work on the ward. However, of the 12 agencyprofiles we reviewed, none included details of therelevant work experience the staff member had for thepatient group.

• The service reported they had not had to suspend, orperformance manage any staff in the last 12 months.


• Staff from different disciplines worked together as ateam to benefit patients. They supported each other tomake sure patients had no gaps in their care. Themultidisciplinary team included social workers,occupational therapy, nurses, psychologists, doctors,dieticians and therapists.

• Staff from a range of disciplines would attend a morning‘flash’ meeting where staff could hand over concerns toeach other and agree actions. Human resources teammembers attended this meeting to help co-ordinatestaffing needs but did not join in the clinical discussionsabout patient needs. A Mental Health Act administratorattended the meeting and identified patients who mayneed their rights reviewed under the Mental Health Act.

• Staff from each discipline attended weekly meetings,ward rounds and lessons learned meetings. Weobserved four meetings and saw that staff involved,collaborated to keep patients safe and aid theirrecovery.








• Nursing staff we spoke with understood their roles andresponsibilities under the Mental Health Act 1983 andthe Mental Health Act Code of Practice.

• The substance misuse wards did not routinely detainpatients under the Mental Health act.

• We reviewed staff training records, 70% of staff hadattended annual training on the Mental Health Act andadministrative support was available on site three daysper week.

• Staff had access to the provider’s policies surroundingthe Mental Health Act and the code of practice.


• Seventy percent of staff had training in the MentalCapacity Act and staff we spoke with had a goodunderstanding of the Act.


• The provider had a policy on the Mental Capacity Actand Deprivation of Liberty safeguards and staff hadaccess to it.

• Staff supported patients to make decisions on their carefor themselves. They understood when to apply theMental Capacity Act 2005 and assessed and recordedcapacity clearly. We reviewed the records of six patients,all showed evidence that staff had assessed thepatient’s capacity and there was informed consent totreatment.



Are substance misuse services caring?

Good –––


• Staff treated patients with compassion and kindnessand respected their privacy and dignity. Patients whowere in hospital for substance misuse could lock theirbedroom doors. Staff attitudes demonstrated that theywere discreet, respectful and responsive.

• Patients we spoke with told us that staff treated themwith dignity and respect and were always around whenthey needed them.

• Family members were generally positive about the waystaff treated their relatives and said they wererespectful.

• Staff supported patients' individual needs, assessingtheir, cultural mobility and language needs on arrival atthe service. Staff supported patients to understand theircare and their condition.



• Staff took steps to maintain confidentiality of patients.• The provider had improved preserving patient dignity

when staff conducted searches for contraband items, byhaving a private room near the entrance of the hospitalwith privacy screens.

Involvement in care


• Patients said they were involved in decisions about theircare and treatment. Staff completed risk assessmentsalongside patients. Staff communicated with patientsabout their care and treatment, they held ward roundmeetings which patients could to attend and beinvolved in the decision making.

• The wards also held a weekly community meeting,enabling patients to give feedback and to voiceconcerns and issues.








Are substance misuse services responsiveto people’s needs?(for example, to feedback?)

Good –––


• Between January 2018 and 31 December 2018 theprovider reported that bed occupancy was 78% andpatients stayed on average 18 days. Admissions wererarely delayed as there was usually a bed available.

• Staff received information about each patient from acentral admissions team prior to their arrival. A doctorwould review this information and decide whether theiradmission was appropriate for the ward.

• Between 1 January 2018 and 31 December 2018 theservice reported no delayed discharges. Patientdischarges were planned and the service ensured thatthey transferred care with copies of notes.

• Patients were only moved during their admission whenthis was clinically appropriate, for example when theyhad completed detoxification and were ready tocommence rehabilitation.

• However, of the three patient records we reviewed, nonehad a plan for unexpected discharge.


• The design, layout, and furnishings of the wardssupported patients’ treatment, privacy and dignity.Patients had their own bedrooms with en-suite andcould personalise their bedrooms if they wished.

• The hospital had an allocated room where patientscould meet visitors.


• Patients had access to an outside space.• Patients could make a phone call in private.

• Staff had displayed information about mental andphysical health on the ward.

• Staff searched patients in a separate room with privacyscreens to protect their dignity.

• The Lodge offered an environment that was safe andprovided patients with accommodation like a homeenvironment.

• Patients had somewhere to store their personalbelongings.


• Staff ensured patients maintained contact with thewider community. Patients undergoing treatment foralcohol addiction were able to access a local alcoholicsanonymous group. Staff facilitated walks in the localarea. Patients had access to volunteering opportunities,running a café and helping the local farm shop.



• The service was not accessible to all due to the layout ofthe building. Patients with limited mobility could notaccess bedrooms located on the first floor of Chelmerward as there was no lift. Staff could admit patients withreduced mobility to Danbury ward instead where therewas a lift and bedrooms were accessible. The Lodge wasfully accessible.

• Staff helped patients with communication, advocacyand cultural support. Staff could access information inaccessible formats or use and interpretation or signingservice if needed. An independent advocate and achaplain service visited the ward each week to supportpatient needs.


• The service met patients’ dietary requirements and gavepeople a choice of food options.


• The service treated concerns and complaints seriously.Managers conducted thorough investigations andshared lessons learned via staff meetings.





• The service gave patients information about thecomplaints procedure as part of their welcome pack.

• Staff discussed complaints monthly at the lessonslearned meetings with the multidisciplinary team andmanagers fed back to patients. We reviewed teammeeting minutes for the three months prior to theinspection and saw evidence that managers shared thisinformation.

• The wards had received eight complaints between 1January 2018 and 31 December 2018. Managersinvestigated these complaints and upheld four,managers responded appropriately to remedy anyissues raised in the complaints.

• The provider sought general feedback from patients’relatives through a tablet computer on the receptiondesk, this was new at the time of the inspection, so theprovider had no data.

Are substance misuse services well-led?


Leadership






Vision and strategy



• Managers gave staff an opportunity to develop thestrategy for the service through staff representatives.

• Staff could explain how they were working towardsdelivering high quality care and could not identifyoccasions when budgets had compromised care.

Culture





• Managers tracked staff sickness and absence which waslow at 3.5% for the hospital. Staff could access anoccupational health service.


Governance

• The provider’s governance system was not robustenough to ensure the safe care and treatment ofpatients. Managers had not identified gaps in ligatureaudits on Chelmer and where staff had not acted onmedicines audits. Managers kept a list of plannedenvironmental improvements for the hospital.Environmental audits had not identified that some ofthe safer rooms on the ward had ligature anchor points.


• Staff at all levels met regularly at team meetings,handovers, and governance meetings. There was a clearstructure for what should be discussed at thesemeetings and essential information such as learningfrom incidents and complaints was included.

• Staff on Chelmer ward had not implemented all learningidentified from pharmacy audits, but staff on the TheLodge had implemented changes.






• Staff participated in clinical audits including a monthlyquality walk round. Staff understood the process forworking with other teams within the provider andexternal to the organisation to meet the needs of theirpatients.

• The provider had not had to deal with poor staffperformance but during the inspection we identifiedpoor staff performance with compliance to medicinesaudits on Chelmer. Managers dealt with any difficultieswithin teams appropriately.


• The provider had sufficient oversight of the risks on thesite, however there was insufficient oversight ofgovernance audits.

• Staff were able to add concerns to the risk register andward staff could escalate concerns to the ward managerif required, we found some gaps in the risk registerduring the inspection, however managers had sufficientoversight and responded to concerns appropriately.









Engagement



• Patients could give feedback in a number of ways to suittheir needs, through community meetings and surveys.Managers had access to this feedback and used it tomake improvements to the service. Staff involvedpatients and carers in decisions about changes to theservice. Patients were able to apply to be on interviewpanels for new staff. Staff received information aboutcomplaints and feedback received in team meetings,staff could access minutes if they were unable to attend.


• Staff were given opportunities to highlight potentialimprovements and innovations which could be made tothe service. These improvements could be made inmeetings or through staff side representatives who saton meetings with senior managers.


• The service was not participating in research ornationally recognised audits such as Royal College ofPsychiatry psychological therapies audit. The servicewas not participating in any accreditation schemes.






Areas for improvement

Action the provider MUST take to improve

• The provider must ensure that the ward environmentsare safe and well maintained.

• The provider must ensure they take action to ensurethat issues highlighted by compliance audits arepromptly resolved by staff.

• Staff must ensure that prescriptions for medicationscomply with the Mental Health Act 1983.

• The provider must ensure a robust system is in placeto monitor ligature risk assessments and actions fromaudits for the servicer.

Action the provider SHOULD take to improve

• The provider should ensure that there are enough staffon the child and adolescent mental health ward tokeep young people safe from avoidable harm.

• The provider should ensure that staff on CAMHs wardtreat patients with dignity and respect.

• Staff should ensure that all patients receive regularphysical health monitoring.

• The provider should ensure that staff on the child andadolescent mental health wards involve patients indecisions about their care.

• The provider should ensure that patients undergoingtreatment for substance misuse have plans forunexpected discharge.

• The provider should ensure that they keep records ofthe relevant work experience of agency staff working inthe hospital.

• Managers should ensure that they address issues withstaff performance in relation to audits.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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

Regulated activity

Accommodation for persons who require treatment forsubstance misuse

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

Diagnostic and screening procedures

Treatment of disease, disorder or injury

Regulation 12 CQC (Registration) Regulations 2009Statement of purpose

The provider had not ensured that the ligature riskassessment for Chelmer Ward accurately identified ormitigated all risks.

The provider had not ensured that prescribing errorswere remedied.

The provider had not ensured that all patients receivedphysical health monitoring regularly.

This was a breach of regulation 12.

Regulated activity

Accommodation for persons who require treatment forsubstance misuse

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

Diagnostic and screening procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

The provider did not have appropriate oversight of allenvironmental risks or processes to follow up on actionsfrom audits.

This was a breach of regulation 17

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


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