All inspections: Priory Hospital Arnold

Priory Arnold is an inpatient acute and psychiatric intensive care unit (PICU), for males and females struggling with a wide range of mental health conditions. It consists of 8 male and 24 female acute beds and 10 male and 10 female PICU beds. Priory Arnold was last rated as inadequate (Published June 2023). The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment has been completed following the Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our on-site assessment on 13 May, 14 May, 03 June and 04 June 2024. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand. During this assessment we looked at all quality statements across all 5 key questions. As we assessed all quality statements at this visit it means the current rating reflects the findings from this assessment. At this assessment we found the service had made significant improvements within the environment, patients felt supported by staff and involved in their care and treatment, managers supported staff and appropriate processes were in place to ensure managers had oversight of the service.

Due to the focused nature of this inspection, we did not re-rate this service. The previous rating of inadequate remains. At this inspection, we found:

We have not seen sufficient improvement to the safety of patients since a previous inspection in August 2022, where the rating for safe was inadequate.
The provider did not always deliver safe care to patients. Although they minimised the use of restrictive practices, they did not always manage this well.
Staff did not complete searches of patients after leave in a timely way and according to care plans, to ensure contraband items had not been secreted onto the ward. This was an issue at the last inspection.
The staff on Bestwood and Newstead were not aware of the missing persons policy or its whereabouts on the wards.
Staff did not manage items which could present a risk to the patients, and this led to incidents where harm may occur. They had not learnt from previous incidents where patients had been harmed through access to items which should have been safely stored to keep patients safe.
Staffing did not have the right number of gender specific staff to manage the risks and care needs of female patients.
The number of new staff on the ward was high, and there was a lack of experienced staff who knew the patients well. The staff that were new to the service had not received sufficient training on how to safely manage the risks of the patients.
The wards had a high proportion of staff on duty who were agency staff, who were unfamiliar with patients’ needs and risks.
Staff did not assess and manage risks well. Records showed inconsistent recording of injuries sustained following an incident. Staff did not know how to consistently manage patient risks post incident. Staff did not carry out enhanced observations in line with the way in which they had been prescribed.
The patients enhanced observation records were not always completed properly to reflect when patients were accessing leave from the hospital.
Staff did not understand and discharge their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
The service did not ensure that staff had received sufficient training to be able to care for patients is a safe and caring way.
The service was not well led, and governance processes did not ensure that ward procedures ran smoothly, and patients remained safe.

Our rating of this location stayed the same. The hospital remains in special measures.

We rated it as inadequate because:

We have not seen sufficient improvement to the safety of patients since a previous inspection published in March 2020, where the rating for safe has remained inadequate.
The governance processes and the way the service was consistently led did not always ensure that patients remained safe.
The provider did not always deliver safe care to patients. Although they minimised the use of restrictive practices, they did not always manage this well. Staff did not manage items which could present a risk to the patients and this led to incidents where harm may occur. They had not learnt from previous incidents where patients had been harmed through access to items which should have been safely stored to keep patients safe..
Patients privacy and dignity was not always protected. This was primarily towards women who used the service where sanitary bins were not routinely available and led to women having to hand used items for sanitary use directly to staff.
Patients did not routinely feel that they were treated with kindness and compassion by non-regular staff whose aim was to care for them. Although patients said regular staff who knew them well treated them with kindness and compassion, and supported them.
There was a lack of training for staff to support patients with a personality disorder. The provider had not met its aim of providing training for staff since the previous inspection. This meant that patients did not receive a consistent approach from staff that impacted on their care pathway.
The environment and furniture required improvement. Patients said that furniture was poor and not fit for purpose. There was a lack of provision of furniture to support outside places.
Patients said there was not enough to do and were bored. There was were concerns about access to psychological therapies and that activities were not age appropriate.

However:

The provider actively involved patients and families in care decisions.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The provider managed medicines well and followed good practice with regard to safeguarding.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
Managers ensured that staff received supervision and an appraisal, and mandatory training was mostly up to date.

The Chief Inspector of Hospitals, Ted Baker, is placing Priory Hospital Arnold into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Our rating of this service stayed the same. We rated it as inadequate because:

The service did not always provide safe care. The ward environments were not always safe. The wards had enough nurses and doctors, but these were not always deployed effectively to keep patients safe. Staff did not always assess and manage risk well. Staff did not always administer medicines at the time they were prescribed and monitor the effects on patient’s health.

They did not always provide a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. This was due to shortage of psychologists although these posts had been recruited to. Staff engaged in clinical audit, but this did not always effectively evaluate the quality of care they provided.

The ward teams did not include or have access to the full range of specialists required to meet the needs of patients on the wards. However, the provider had recruited to the psychology team and these staff were starting their induction in the week after our inspection.

The service was not always responsive to identified risks to the safety of patients and slow to identify new risks although some improvements had been made since our previous inspections.

The governance processes did not ensure that ward procedures effectively mitigated risks. Learning from incidents was slow to be embedded.

However:

The wards were clean, and this had improved since our previous inspections.

Staff minimised the use of restrictive practices.

Staff followed good practice with respect to safeguarding.

Staff developed holistic care plans informed by a comprehensive assessment.

Managers ensured that staff received training, supervision and appraisal.

The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.

This was a focussed inspection and we inspected the Safe and Well led key questions only. We did not re rate Priory Hospital Arnold at this inspection.

We found an identified ligature risk had not been reduced despite the provider telling us they had, and others did not have a timescale set to reduce.

Staff did not always assess and manage risks to patients and themselves well.

Some furniture and equipment had not been repaired or replaced.

Leaders did not always demonstrate they had the skills to perform their roles and ensure the safety of patients and staff.

Our findings from this inspection demonstrated that governance processes did not operate effectively at ward level and that performance and risk were not well managed.

However:

The provider had trained all staff in ligature risks and assessed their competency in this since our previous inspection.

The service had enough nursing staff who knew the patients well although there were only two wards open and ten patients.

The wards were clean and maintenance staff had redecorated and removed the graffiti.

The provider had improved the alarm system although some staff said there were still false alarms which meant they did not always respond.

Staff followed the providers infection control procedures.

The Chief Inspector of Hospitals, Ted Baker, is placing Priory Hospital Arnold into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Priory Hospital Arnold is provided by Priory Healthcare Limited and registered with the CQC to provide the following regulated activities:

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

• Treatment of disease, disorder or injury

• Diagnostic and screening procedures

The hospital offers two acute mental health wards for men and women on Newstead and Bestwood Wards and a psychiatric intensive care unit on Rufford Ward for women and for men on Clumber Ward. Rufford Ward opened in May 2020 and Clumber Ward opened in November 2020.

There were 16 beds on each of Bestwood and Newstead Wards which were commissioned by Nottinghamshire Healthcare NHS Foundation Trust and 10 beds on Rufford Ward. There were 10 beds on Clumber Ward, five of which were commissioned by Forward Thinking Birmingham and the other five beds could be spot purchased.

There have been 16 previous inspections to Priory Hospital Arnold. The latest was a follow up inspection in October 2020 following information of concern about Newstead and Bestwood Wards. We only looked at parts of the Safe and Well led key questions and did not rate the hospital. We last rated the hospital following our inspection in October 2019 as requires improvement overall, inadequate for safe and requires improvement for effective, caring, responsive and well led.

Before this inspection we received information of concern from anonymous contacts about Rufford and Clumber Wards and complaints raised by patients on Rufford Ward. We were told that inappropriate restraint and seclusion was used, staff were not clear about how to report safeguarding concerns and felt scared to report, the staff alarm system was not working and the maintenance and cleanliness of wards was poor.

We visited Rufford and Clumber Wards unannounced on the evening of 9 March 2021. We spoke with patients, their carers, and staff by telephone from Rufford and Clumber Wards between 10 to 12 March 2021 and visited Newstead and Bestwood Wards unannounced on 16 March 2021.

This was a focussed inspection and we inspected the Safe and Well led key questions only.

We rated Safe as Inadequate and Well Led as Inadequate and Priory Hospital Arnold as Inadequate overall.

At this inspection we found:

The wards were not safe, clean, well equipped, well-furnished or well maintained.
The provider had not ensured all staff were confident to use the alarm system to summon help in an emergency. This meant some staff did not respond to the alarms or did not know the type of incident they were responding to.
The service did not have enough nursing staff, who knew the patients well.
Staff did not always follow the providers infection control procedures.
Staff did not always assess and manage risks to patients and themselves well. The provider had not fully assessed ligature risks and taken action to reduce them.
Leaders did not demonstrate they had the skills to perform their roles and ensure the safety of patients and staff.
Our findings from this inspection demonstrated that governance processes did not operate effectively at ward level and that performance and risk were not well managed.

However:

All staff including agency staff received basic training to keep patients safe from avoidable harm.
Staff used restraint and seclusion only after attempts at de-escalation had failed.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
Staff had access to clinical information on the providers electronic records system and verbally handed over information about patients risks between each shift.
Staff recognised incidents and reported them appropriately.
The majority of staff told us they could raise concerns without fear of retribution and would do so.
Some staff told us they felt respected, supported and valued.

Following the inspection on 9 March 2021 we served an enforcement notice requiring the provider to take urgent action to keep patients safe. We required action to ensure infection control processes were in place to minimise the risks of cross infection and to assess and reduce ligature risks across the hospital.

Following the inspection on 16 March 2021 we imposed conditions to prevent admissions to the hospital and required the provider to take action to assess and reduce ligature risks. The provider responded to these within the required timescales. The provider also made a decision to close Clumber Ward temporarily which increased the staffing on the other three wards.

Priory Hospital Arnold is provided by Priory Healthcare Limited. The hospital offers two acute mental health wards for men and women on Newstead and Bestwood Wards and a psychiatric intensive care unit on Rufford Ward for women. They also planned to open a psychiatric intensive care unit for men on Clumber Ward. There were 16 beds on each of Bestwood and Newstead Wards which were commissioned by Nottinghamshire Healthcare NHS Foundation Trust and 10 beds on Rufford Ward.

At the previous inspection in October 2019 we rated the hospital as requires improvement overall, inadequate for safe and requires improvement for effective, caring, responsive and well led.

Before this inspection we received information of concern from anonymous contacts about Newstead and Bestwood Wards. We were told that risks were not managed effectively, staffing levels were unsafe and there was a culture of bullying in the hospital.

We only visited Newstead and Bestwood Wards during this inspection. We also spoke with patients, their carers, and staff by telephone from Newstead and Bestwood Wards and staff from Rufford Ward as part of this inspection.

We only looked at parts of the Safe and Well led key questions during this inspection.

The provider had not employed enough permanent registered nurses to work on the wards. The provider was trying to recruit more registered nurses and employed locum staff to maintain safe staffing levels. The provider trained locum registered nurses in their induction and training programme.

The alarm system did not work effectively. Managers had put together a business case to replace this and in the interim the provider issued staff with personal alarms and staff used radios to summon help.

Staff had identified a ligature anchor point on ensuite doors on Newstead and Bestwood Wards and these were being replaced. Staff locked back the doors to reduce the risks in the interim until the work was completed.

Staff did not always manage risks well. Staff had not assessed a patient’s mental state before they went on leave. Staff had not recorded patient’s physical health observations on three patient records seen.

Five patients told us their complaints were not listened to or fully investigated.

Three staff were not aware of the vision and values of the organisation. There were not regular staff meetings on Newstead Ward.

However:

Staff practiced good infection control and followed the providers procedures. This reduced the spread of infection and staff had access to personal protective equipment.

Staff used restraint only after attempts at de-escalation had failed.

Staff followed good practice with respect to safeguarding.

Staff recognised incidents and reported them appropriately.

Staff said that senior managers were visible, and managers sought various ways to engage with staff.

We did not rate Calverton Hill at this inspection. We rated Calverton Hill as requires improvement overall following our previous inspection in October 2019 and the acute mental health wards as inadequate for safe and requires improvement for effective, caring, responsive and well led.

Whilst there was evidence of improvements it was too soon to evaluate the impact as the changes were not embedded. The warning notice was not fully met because:

Staff were still not always clear about what items were restricted for each patient and why. Records showed that staff did not always assess risks to patients and themselves well.
Blanket restrictions remained in place, for example, patients on Bestwood Ward were not able to make hot drinks. Staff searched all patients and their property on admission without evidence of individual risk assessment for this in line with the search policy. Staff were not always confident about how to document searches.
Some staff still did not know about environmental risk assessments.
There was no robust system in place to ensure staff completed cleaning records to show when cleaning tasks were completed.
However:
The wards including the clinic rooms were clean, which had improved from our previous inspection.
There were sufficient quantities of medicines available to ensure the safety of patients and to meet their needs, which had improved.
Staff carried out observations on patients in line with policy and recorded these at the time of the observation, which had improved.

We also found at this inspection:

Nursing staff told us that they did not always have time to interact with patients and patients did not always have regular one to one sessions with their named nurse.
The electronic records systems the hospital used did not provide easy access to clinical information and did not make it easy for staff to maintain high quality clinical records.
Staff did not always review the effects of rapid tranquilisation medicine on each patient’s physical health consistently and did not always record the reasons for giving patients as required medicines.
The recording of incidents varied, and some staff told us they did not receive information about lessons learned following incidents they had been involved in or reported.
The provider had trained staff in how to work with and support patients with a personality disorder and the needs of patients admitted to acute mental health wards, however some staff did not have the skills and knowledge needed.
Staff did not effectively use recognised rating scales to assess and record severity and outcomes of patient’s physical health needs.
Staff meetings did not take place monthly and some staff said their supervision was not monthly as expected.
The governance systems were not robust enough to ensure that the environment was safe and clean and equipment such as patients call bells worked when needed.

However:
The service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm.
Staff followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

Following this inspection, we met with the registered manager, the Priory Healthcare operations manager and regional director to discuss our ongoing concerns. We agreed to increase our engagement and monitoring of the hospital and to bring forward the next comprehensive inspection. The provider has put the hospital onto their enhanced support programme which expects turnaround within twelve weeks.

We rated Calverton Hill as requires improvement because:

The ward environments were not all clean, well-furnished or well maintained.
There were not enough permanent nurses on Bestwood and Newstead Wards. Agency and bank staff were relied upon to deliver safe care.
Staff did not always assess and manage risk or patient safety incidents well.
Staff did not consistently carry out patient observations in line with policy.
The service did not have robust systems to prescribe, administer, record or store medicines safely. Staff did not regularly review or record the effects of medicines on each patient’s physical health.
Staff did not always assess physical health of patients or promote good to physical healthcare.
Staff did not always develop holistic, recovery-oriented care plans. Care plans were not written in a format that was easy to read.
Staff did not engage in regular clinical audits to evaluate the quality of care they provided.
Managers did not ensure that all staff received mandatory training and supervision.
Staff did not clearly assess and record patients’ capacity to make decisions in line with the Mental Capacity Act 2005.
Staff did not always actively involve patients’ families and carers in care decisions.
Staff on Bestwood and Newstead Wards did not plan and manage discharge well.
Some leaders did not have the skills, knowledge or experience to perform their roles, and did not have a good understanding of the service they managed.
The governance processes did not ensure that ward procedures ran smoothly.
Staff did not have easy access to clinical information on the electronic records systems. Multiple systems for recording information were used which led to gaps in the information available to staff.
Staff did not always involve patients in care planning and risk assessment. Staff did not always work collaboratively with patients to understand their individual needs and support them to understand and manage their care, treatment or condition.

However:

Staff followed good practice with respect to safeguarding.
Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The provider employed enough doctors.
Staff treated patients with compassion and kindness and respected their privacy.

We rated Calverton Hill as good because:

The building was safe and generally well maintained.
The provider employed enough staff to support the patients and keep them safe. They trained, supervised and supported staff well.
Nursing staff managed patients’ medicines safely and made sure that emergency equipment was safe and available when needed.
Staff knew how to safeguard patients from abuse and harm.
The multidisciplinary team worked well together to meet patients’ needs.
Staff from the hospital worked well with other teams in and outside the organisation to benefit patients.
Staff followed national guidance to make sure they met patients’ needs.
Staff had an understanding of the Mental Health Act and the Mental Capacity Act and how it affected the patients in their care.
Patients told us that staff supported and cared for them. We observed that staff were kind and respectful to patients.
Staff developed an individual care plan with each patient that showed all staff how to support the patient to meet their individual needs.
Staff supported patients to keep in contact with their family and friends during their stay in hospital.
Staff offered patients a range of activities to meet their needs and appropriate to their interests.
Staff supported patients to meet their religious and cultural needs.
The provider had good governance systems in place. This meant that staff could identify risks and make improvements to the service where needed.
Staff morale was generally good and communication between staff across the hospital was good.

However:

Staff searched all patients on return from escorted leave and did not risk assess for searching individuals.
Doctors had not regularly reviewed medicines they prescribed for patients to take when required.
Several patients thought the food portions were too small and it was sometimes over or under cooked.
There were no pictures or easy to read signs around the hospital.

We rated Calverton Hill as good because;

Ward dashboards showed all patients had risk assessments and care plans.
Patients had physical assessments.
In addition to health action plans, patients had health information cards, which described their communication style and needs. They took these with them to hospital and other healthcare appointments.
Staff could recognise and report incidents and safeguarding concerns.
Staff used a range of outcome tools to monitor patients' recovery including health of the nation outcome scores (HoNOS), “recovery star” and “my shared pathway”.
Patients regularly took part in patient alliance and least restrictive practice meetings to influence changes in practice.
The service managed planned transition of patients from one ward to another effectively.
Staff received appraisals, managerial and clinical supervision, and there was a high uptake of mandatory training.
Calverton Hill successfully completed the Quality Network for Forensic Mental Health Services peer review process in 2014 and achieved 97% of the medium secure standards.

However;

Fifteen patients and three carers said they felt unsafe in the environment because of the number of patient-to-patient incidents.
For the period 1 April to July 2015, 795 physical interventions and restraints occurred involving 26 different service users. The risk of harm between patients and to staff by patients remained high in spite of management strategies such as positive behaviour support, de-escalation and individual risk management plans.
The room used by the registered nurse for physical health checks did not have spot lights for close examinations, or offer patients privacy and confidentiality during examinations.
The uptake of mandatory food hygiene training in 2015 was low, only 41 out of 180 (23%) staff completed it.
Staff used confusing terminology such as locked-door segregation and struggled to describe the difference between this and seclusion.
There was no hatch in one seclusion room to pass food and water through. This meant the staff team had to assemble go in and provide this.

The service provided was safe. This is because we saw clear assessments of risk and care plans to manage any potential risk to people who used the service or others. Evidence was seen of staff attendance at mandatory safeguarding training. Safeguarding concerns were being appropriately referred to the relevant statutory agencies.

The service was effective. Each person had an individual care record which included assessments of specific needs. We saw that care plans were in place for each assessed need. This demonstrated to us that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

The service was caring. People told us that staff had time for them and provided them with the appropriate levels of support. We found that people were having their rights protected under the 1983 Mental Health Act. We noted that people had been granted Section 17 leave following a multi disciplinary assessment of risk..

The service was responsive. Staff were receiving their mandatory training and progress was being made on ensuring that staff received clinical supervisions and annual appraisals. Systems were in place to manage and investigate formal complaints made to the service.

The service was well led. We saw that a clinical assurance framework was in place to ensure that the provider had an effective system to assess and monitor the quality of service. Actions had been taken to address any identified audit concerns.

Staff were friendly and respectful in their approach and interacted with patients in a confident and considerate manner. During the course of our visit we saw that patients were supported to express their views and choices and that staff clearly understood each patient's needs and behaviours. Patients we spoke with told us that they felt staff treated them with dignity and respect. One patient said, 'Yes the staff are generally alright.' Another patient told us, 'The staff are very good, I like it here.'

The provider had addressed concerns in relation to general medical healthcare services and a more structured service was being provided. In all the clinical area observed there appeared to be high levels of staff and patient interactions. It was evident to us that therapeutic, social and individual work was taking place on all three wards.

We found at times there were delays at ward level in reporting safeguarding incidents to the social work team and local authority safeguarding team which meant that investigation was not as prompt as it should have been. We also found that staff were not always following the referral guidance for such matters.

There was an effective complaints system and complaints made by patients were responded to appropriately.

The provider's safety and quality monitoring systems were not fully effective and did not ensure that actions were taken to address matters identified. The provider had not taken action to ensure two refrigerators used for the storage of medication were working properly and that medication administration records were completed properly.

We found that patients were not always involved in their care and treatment. For example, one patient on the male ward raised a concern that when they wanted to talk to their doctor following the ward review the doctor refused, telling them they would have to wait until later in the week. There was no reason given for this refusal and the person found the delay frustrating as they saw the doctor as the person in charge of decisions.

We found that the systems for the storage and administration of medicines was not always safe. For example, where patients received medicines on a, 'when required' basis, for example, to control their challenging behaviour, or in variable doses, for example, 'one or two tablets' there was insufficient guidance for staff on the circumstances these medicines were to be used and in what doses.

All of the patients and staff we spoke with on the male ward told us that the staffing levels had increased significantly, especially since two wards had been merged together. One patient commented, 'We have more time with staff now, and there are more staff available. I feel this is much better.'

The patients we spoke with told us the staff were kind and helpful. One patient told us, 'I think the staff understand me and my needs and they are supportive. I like the staff, they are all fine with me.' One patient told us they thought the staff knew about their physical healthcare needs.

We undertook this visit to follow up on a warning notice which we issued about seclusion being used inappropriately, for long periods and without staff working at the unit following the Mental Health Act Code of Practice in respect of how seclusion should be used and managed. The warning notice was also issued about the use and records of restraint and the efficacy of the admissions procedure.

In assessing compliance, the inspection team spent most of the first day on each of the wards, speaking with staff and patients. We spoke with 13 staff, 16 patients, the manager, occupational therapist and the responsible clinician as well as more senior managers in the organisation. The team consisted of two compliance inspectors, a national advisor and a Mental Health Act Commissioner.

We found the use and length of seclusion had significantly decreased and that this was being used for the right reasons. However, patients and staff and the records we saw provided evidence to show this was not always being recorded consistently.

Two patients told us that they were cold in the seclusion room; some staff acknowledged that it was hard to keep the room warm enough and the manager said they were working on improving the level of heating in these rooms. We found mixed evidence about whether staff offered patients food and drinks whilst they were in seclusion. Some patients said they were offered or provided with regular food and drinks, others said they were not.

Some of the patients we spoke with who had experienced recent seclusion raised concerns about the conduct of some staff. We saw that there was a space for patient views about the period of seclusion in the seclusion packs, but most of those we saw had not had this part completed. This was a useful source of information to assess staff conduct and was not being utilised effectively.

We spoke with patients about the use of restraint. Only one person we spoke with talked to us about being restrained and they said they felt that this was needed at the time. Most of the staff we spoke with felt restraint was used fairly and for the right reasons.

There had only been one new admission since our last inspection. We spoke with staff about the new patient and were told they had settled into the ward well and they felt the admission was appropriate.

We spoke with all of the patients we interviewed about the care they received from staff. One person said 'I want to praise staff for showing they care.' Several patients told us they felt they staff provided good care and support and most people knew who their key workers were. We observed that one healthcare worker in particular was lively, engaging and positive with patients.

However, two patients expressed their opinion that not all of the staff cared about their welfare. Two patients told us they had regular 'talk time,' with staff others told us this did not happen regularly, or they were told to wait.

We were concerned about the admission of a patient on one ward due to their behavioural risks. One patient told us they had been 'terrified' of this patient.

One patient told us that they had been denied a drink for four hours whilst in seclusion. We found that fluids given to patients whilst on seclusion were not recorded in the seclusion booklet so it was unclear if this patient had been offered a drink.

It was apparent from conversations with patients and staff, and from reviewing patient records, that patients were sometimes secluded for hostility, making threats or for non compliance with directives. The rationale for this was not always clearly documented so we did not find evidence in all cases that the least restrictive principle was being adhered to.

We were told by some patients that staff sometimes spoke with them disrespectfully, in a way which they experienced as demoralising and degrading.

People who used services told us they were fully involved in planning their care and recovery. They told us that the staff were very supportive and respectful.

The Commission received 4 separate whistle blowing concerns about Calverton Hill Hospital over the previous six months.

The concerns were that the hospital had insufficient staff and had young inexperienced staff working there, and that patients were being given too much sedative type medicine. Concerns were expressed about staff being unable to manage the challenging behaviour and how a serious incident had occurred on

11 June 2011 in which the police were called to assist the hospital staff at Calverton Hill to control an incident that could have jeopardised the well being of patients and staff on one ward.

When we visited we saw some positive staff patient interaction and some patients said they were satisfied with the range of activities available to them. Although the manager told us that people were consulted about activities some patients told us they were not satisfied with the choice available during weekends and evenings.

Some of the patients and staff told us there were often insufficient staff on the wards to meet patients' needs. They talked about one to one sessions being cancelled on occasions and of being unable to access off ward activities. Staff reported feeling unsafe when there were few staff on the ward and some may have little experience.

We saw that people received their medicines at the correct time, and that (with one exception) the administration of medicine was accurately recorded on prescription charts. Forms that were necessary to authorise the prescribing of certain medicines had been completed.

We spoke with one person during our visit who told us;

"I don't always feel safe."

"I have the opportunity to speak to an independent advocate."

"I've got an appointment with the social worker to discuss my concerns."

"I meet with my key worker to talk about my care plan."

"I've got a copy of my care plan."

"There is a physical healthcare coordinator who helps me make appointments with GP's and dentists."

"There's a new activities co-ordinator and it's better now."

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

These older reports are from our old approaches to inspection, including those from before CQC was created.

All Inspections