All inspections: Cygnet Hospital Sheffield

Our rating of this location improved. We rated it as good because:

The service provided safe care. The ward environments were safe and well maintained. The wards had enough nurses and doctors. Staff assessed and managed risk well, managed medicines safely and followed good practice with respect to safeguarding. They minimised the use of restrictive practices and worked collaboratively with patients towards reducing restrictive practices.
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 audits to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that staff received continuing development of their skills, competence and knowledge; providing training, supervision and appraisal. All staff were committed to working collaboratively as a multidisciplinary team to provide consistent high-quality care, as well as liaising with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
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 young people, in particular, were truly respected and valued as individuals and empowered as partners in their care.
Services were tailored to meet the needs of individuals, and the hospital had created a safe and inclusive environment for LGBT patients. Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. The service was well led and the governance processes ensured that ward procedures ran smoothly.
There were examples of outstanding practice within the child and adolescent mental health service (CAMHS) wards.

However,

The hospital did not always follow best practice with regards to medicines management and application of the Mental Health Act 1983. There was not always clear information management within patient records or incident recording for the adult wards; and although the hospital was working to reduce incidents across the hospital, there was a high number of self-harm incidents on the CAMHS wards. The service did not have consistent quality of staffing from day to night.
The discharge care plans were not always reflective in the adult services and the patients reported that food was not of a good standard.
The provider did not always resolve environmental concerns in a timely way and the hospital’s cleaning processes were not always robust.

Cygnet Hospital Sheffield provides child and adolescent mental health services for male and female adolescents aged between 13 and 18 years old and low secure services for women aged over 18.

We found the following areas for improvement:

Staff did not ensure all patient records in relation to care planning and recording of administration of ‘as and when’ required medication were complete.
There was inconsistency in the prohibited and restricted items for the three wards.
Although the provider had introduced social distancing measures on the ward, these were not always adhered to by staff or patients.

On Griffin and Unicorn wards, some furnishings and decoration were damaged and worn. However, the provider had ordered new furniture, but delivery had been delayed due Covid 19.

However, we found the following areas of good practice:

Staff followed good policies and procedures for observations to ensure patients were safe and well. Staff understood and carried out the duties they were responsible for completing.
The provider had made responsive changes to strengthen leadership and safety on the wards.

This was a focused inspection of one ward. The inspection focused on specific issues that had led us to undertake the inspection. These were relevant to the key questions of ‘is the service safe’ and ‘is the service effective’. The inspection did not impact on the current rating of this location.

We found the following areas of good practice:

Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.
Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team
Staff assessed the physical and mental health of all patients on admission. They developed individual care plans, which they reviewed and updated as needed through multidisciplinary discussion.
The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Managers made sure they had staff with a range of skills needed to provide high quality care.

We found the following areas the hospital needs to improve:

Risk management plans and care plans were brief and did not reflect the level of support and interventions evidenced within the patients’ contemporaneous notes.

We found the following areas of good practice:

Staff were up-to-date with their mandatory training and managers monitored this weekly. Staff received training in the requirements of the Mental Health Act and Deprivation of Liberty Safeguards. Overall, staff compliance with mandatory training was high.
Staff carried out restraint and seclusion only when necessary and could show how they took into account patient preference.
Patients had comprehensive risk assessments which staff updated following incidents.
Patients had a single complete and contemporaneous care record which contained up-to-date care plans and physical health monitoring. Staff used outcome measures appropriate to the patient group.
Patients had meaningful involvement in their care and staff had a collaborative approach to care planning and risk management. Patients could get involved in decisions about the running of the hospital.
Staff kept carers up-to-date with their relatives’ progress and carers attended multidisciplinary reviews.
The hospital had an improved complaints procedure. Patients and carers knew how they could complain and felt their concerns would be taken seriously.
Managers had introduced new initiatives to improve the quality and safety of the wards. The hospital could show a reduction in the use of restrictive practices including restraint and seclusion.
Staff had made improvements to the environment and to the overall of quality of care. Most patients and carers were happy with the care provided by staff.

We found the following areas the hospital needs to improve:

Managers did not always ensure that records demonstrated staff monitored medication fridge temperatures consistently and correctly.
Some of the provider’s policies did not provide enough guidance for staff on the standards expected of them.
Staff did not record when de-brief occurred with staff or patients following incidents.

Although the provider had made improvements and addressed all the areas we told them they must do following our previous two inspections, we were not able to change their ratings. This was because this was a focussed inspection and we only inspected those areas which we required them to address following our last comprehensive inspection in August 2017 and our focussed inspection in September 2017.

We carried out an unannounced focussed inspection at Cygnet Hospital Sheffield on both of the child and adolescents mental health wards: Peak View ward and Haven Ward. Since September 2017 we became aware of a number of incidents and safeguarding concerns on Haven and Peak View wards which gave us concern about patient safety. We requested further information from the provider about how these incidents and safeguarding concerns had been managed. The information we received did not give us sufficient assurance to ascertain whether patients were suitably protected from harm. As a result, we undertook this focussed inspection to review the areas of safeguarding and incident management on the child and adolescent wards in further detail. This inspection was not rated.

During the inspection we found:

The majority of staff on both wards were up to date with mandatory safeguarding training and staff were in the process of undertaking additional training. Staff reported knowledge and confidence about identifying and reporting safeguarding concerns. Contact with the local authority and actions to help safeguard patients were documented in patient records. From a review of seven patient’s care records, we found one instance where a disclosure had not been reported and documented as required.
Staff discussed safeguarding issues and incidents in a number of forums. These included staff meetings, specific safeguarding training and development meetings, multidisciplinary meetings and staff handovers. Patients with ongoing safeguarding concerns had safeguarding care plans in place. These were reviewed regularly but did not always contain details of ongoing safeguarding incidents on the ward.
The hospital had recently introduced an incident review meeting so that managers had a daily discussion about all incidents which took place, any actions required and whether these needed to be notified to external organisations. We saw evidence of learning from serious incidents and staff told us about changes that had been made as a result of these. Managers had introduced new measures to improve information sharing about incidents and any associated learning.

However:

The hospital held a safeguarding tracker to log progress of all safeguarding referrals centrally. This was incomplete in some areas and the data did not coincide with incident data recorded on the central tracker. Following our inspection, the provider told us this had been in the process of being updated due to being a recent implementation
Staff meeting minutes included evidence of some discussion of incidents, but did not demonstrate that learning from incidents were reviewed as a matter of routine. Some staff felt they did not get feedback or information about other incidents at the hospital which may be relevant. An investigation of a serious incident had exceeded the provider’s own recommended timescales.

We carried out an unannounced focussed inspection on 11 and 12 September 2017 at Cygnet Hospital Sheffield on the general adolescent ward called Peak View, following two significant incidents which had taken place. We identified concerns which we fed back to the management team at the time of our inspection. This inspection took place subsequent to the comprehensive inspection of August 2017 where we rated the hospital as requires improvement. This inspection was not rated.

During the inspection we found:

There were shortfalls to the processes for individual patient risk assessment. Records and care plans did not always incorporate known risks relating to patients.
Staff did not review care plans and risk assessments appropriately in response to incidents. Staff did not routinely update information which meant the care and treatment they provided did not always reflect what was documented. We could not be assured that patients were therefore receiving appropriate care in instances where their information was not correct.
Documentation was incomplete in some instances and stored in the wrong records. Some information was difficult to navigate.
Staff did not always record and review periods of patient leave consistently.

However:

Two of the three patients we spoke with said the care was good and they felt safe.

We rated Cygnet Hospital Sheffield as requires improvement because:

Although we noted some improvements since our previous inspections, there were still instances where the provider had not sufficiently addressed previous shortfalls as well as further areas of concern that we identified.
The child and adolescent wards were not fully operating in accordance with the provider’s own policy on ‘same sex accommodation’. Haven ward required environmental improvements; these were underway at the time of inspection.
There were low compliance rates of staff being trained in a number of key areas to help ensure the safe running of the service. In particular, both Spencer and Shepherd wards had low rates of staff trained in managing actual and potential physical aggression and basic and immediate life support.
All wards, except for Haven ward, had not completed resuscitation simulations in accordance with hospital policy. Staff raised concerns about the accessibility of necessary medical supplies. We also found issues with fridge temperatures on all wards except Spencer, whereby temperatures were outside of recommended ranges with no evidence of staff taking action to address this.
Not all care plans for patients on child and adolescent wards were holistic. They did not include clear information about interventions to manage patients at crisis point and their preferences in such situations. There was limited evidence that debriefs took place following individual incidents
There were occasions of staff still using inappropriate terminology within care plans to end seclusion as opposed to a person centred approach. We found instances of where patients with long term health conditions did not have a care plan in place about the support they needed.
Feedback from some patients across all wards was that they did not feel involved in the care planning process. Some felt information staff documented about them was not reflective of their needs and that staff did not involve them in any reviews of their care. Feedback from some patients across wards was that staff were not always caring.
There was still a high use of agency staff within the hospital. This was more prevalent at night across all wards. There was higher agency usage on the child and adolescent wards where vacancies were the greatest. Some patients told us they felt uncomfortable approaching agency staff due to them not being familiar with their needs.
There was no information on display on child and adolescent wards about how to make complaints. Complaints that had been investigated and concluded did not always offer a right of appeal to the complainant.
Patient information was not stored centrally as the hospital used both electronic and paper systems to store information. Information was not always easy to locate and the use of several systems had the potential to cause confusion for staff. It also meant there was greater risk of staff not updating all relevant information.
The service had undergone several changes of senior management which had led to some instability within the hospital. We found governance systems had been strengthened and the provider had made improvements in a number of areas. However, these new working practices and systems were not yet embedded. We still found shortfalls in areas of the service.

However:

Our observations of interactions between staff and patients were positive. Staff treated patients appropriately, with respect and demonstrated good knowledge of their needs.
There was positive feedback from some patients from all wards about staff and the service. There were forums available for patients to attend meetings and put forward their views of the service.
Patients had risk assessments and management plans in place. Staff completed necessary monitoring of patients following episodes of rapid tranquilisation.
We saw evidence of changes to working practices and learning from serious incidents that had taken place. These included changes in policy and systems.
Staff described good multidisciplinary meeting working which we observed in practice, and good relationships with external organisations. Staff teams reported good communication within their teams and regular meetings. Staff had regular supervisions and appraisals and felt supported within their roles.
Haven ward, Peak View and Spencer ward had participated in the Royal College of Psychiatrists quality network reviews. All wards had achieved high scores for the criteria they were assessed against and received positive feedback.
Monthly integrated clinical governance meetings took place where staff were able to discuss and review the performance of the wards and look at any themes, trends and learning.

We carried out an unannounced focussed inspection at Cygnet Hospital Sheffield on Haven Ward following a serious incident which had taken place. We identified a number of issues and shortfalls on Haven ward which gave us significant concern for the health and wellbeing of patients. As a result, we sent an urgent letter of concern to the provider highlighting our findings following the inspection. We requested that they provide us with assurance about what action they were going to take in response to our concerns.

The provider sent an action plan setting out what measures they had taken, or were taking, which we will follow up through further inspection. Following our inspection, the provider voluntarily closed Haven ward to further admissions. We did not rate this inspection.

During the inspection we found:

There were shortfalls to the processes for individual patient risk assessment. There was limited information in care records about patients’ risk warning signs, behaviours they may present with and what support each patient required to help manage these. Records and care plans did not always incorporate known risks relating to the patient. Some records contained several plans for the same areas of risk with differing levels of information.
There was no consistent system to inform all staff about all newly admitted patients to the ward. The hospital operated two alternate shift groups at night with the same staff working in each shift. From staff accounts, there were differences in how they found out background information about patients admitted when they were not on shift.
There were shortfalls in the reporting of, and learning from, incidents. Staff documented descriptions of incidents in patient’s notes but had not always reported these on the incident reporting system. There was no evidence that any learning from incidents was being shared with staff at ward level. Staff did not routinely receive feedback about incidents unless these were serious and post incident debriefs did not always take place.

Safeguarding procedures did not protect patients from the risk of exposure to harm. A number of reported incidents met the criteria for safeguarding but staff had not identified these or logged these as safeguarding concerns. Not all staff were knowledgeable about the ways they could report safeguarding matters, in particular, where these may occur out of hours.

We were not assured patients were always protected from risk of discrimination. Some patients and carers felt staff did not always respect their needs, particularly in relation to their personal lifestyle choices. Patients had concern about some staffs’ attitudes and comments towards them.

Processes for staff engagement and observation of patients were not robust. Staff were expected to complete dual roles such as being part of the response team whilst still being responsible for patient observations. Some staff found difficulty in maintaining five minute observations. The allocation of observations did not always occur in accordance with policy. Not all staff were familiar with the policy or had received training in undertaking observations effectively.

There were risks in relation to staffs’ ability to respond to emergencies. There was no evidence of staff undertaking regular checks of emergency equipment. The latest emergency simulations on the ward showed improvements were required. All staff did not have access to necessary medical supplies such as dressings.

Management of environmental risks was not robust. It was unclear what ligature risk assessment staff were expected to follow. There were repeated incidents of patients breaking through doors with little evidence of effective measures to try to prevent this. There were risks in the environment, such as access to screws in fixtures and fittings, which had led to repeated incidents of self harm by patients.

However:

We observed that staff responded promptly to any incidents and patient feedback was that staff were good at helping to deal with these situations.

Hospital management had already acknowledged shortfalls in adherence to patient observations and had started to address this by way of additional training.

We carried out an unannounced focussed inspection at Cygnet Hospital Sheffield on Haven ward. The inspection took place to establish whether the hospital’s systems and processes were suitably robust at night following a recent serious incident that occurred. We did not rate this inspection.

We found that:

The hospital had suitable systems in place on Haven ward to enable staff to help manage risks to patients using the service. Staff were aware of known risks to young people and the hospital had processes in place to enable staff to escalate any concerns.
Patients’ care and treatment records on Haven ward had current risk assessments in place which staff regularly reviewed. However, we did see an instance where staff had not updated one patient’s risk assessment in response to an incident.

We rated Cygnet Hospital Sheffield as requires improvement because:

Staff showed a disregard for safety policies and procedures in relation to infection control. The hospital did not follow policies and procedures that were in place to minimise the spread of infection. This included not ensuring that equipment was decontaminated. Staff did not follow hand washing procedures and guidance around clothing to reduce risk of infection.

The provider did not ensure it adhered to code of practice guidelines regarding the Mental Health Act. One patient record did not contain valid consent to treatment or authorisation from a second opinion appointed doctor. This patient received treatment without valid consent or authorisation. Staff treated one patient without authorisation under section 62 of the Mental Health Act. Four seclusion records showed that staff did not end seclusion in a timely manner, and two seclusion records contained punitive language. We found blanket restrictions on some wards. Staff did not inform six patients of their rights under the Mental Health Act as soon as practicable after their detention. In addition, two records showed that staff did not inform two patients had not been informed of their rights under the Mental Health Act.
Three patients on child and adolescent wards told us that staff did not treat them well and raised concerns about the care and treatment that they received. We raised these concerns with the registered manager who responded to these concerns appropriately. We also received six comment cards from patients which contained concerns about staff and care treatment. The hospital received 43 complaints about the care and treatment receive. Of these 14 were upheld, 12 were partially upheld, 12 were not upheld and five were withdrawn.
Facilities did not uphold the dignity and respect of patients. The provider had removed the doors to en suite showers and did not provide a curtain on Haven Ward. Patients had damaged areas of the ward and the hospital had not completed repairs. Staff used a search room which was not clean and suitable for use because it had a strong odour. Staff administered medicines from a hatch to patients which did not promote privacy and dignity.

Staff did not manage medicines correctly. They did not control the temperature of fridges and clinic rooms, to ensure medication remained safe to use. Four out of 12 records reviewed showed that staff did not always complete physical health monitoring after rapid tranquilisation as frequently or for as long as the hospital policy stated. Staff had not ensured medication was available to a patient when it was prescribed. When doses of medication were omitted advice was not sought.

We had concerns regarding staffing across the wards. The hospital used a lot of agency staff due to a high level of overall vacancies across the wards. Staff turnover was also high. There were 38 shifts which were not covered by bank or agency staff. This left some shifts without the safe number of staff to treat patients. Attendance at mandatory training was low, this included training that was essential to ensure the safe running of the service. Not all staff received regular supervision and appraisal.

Systems in place to monitor the quality of the service were not effective. Audits did not identify out of date equipment, issues with incorrect or missing mental health act documentation. The hospital operated with some policies from the previous provider. There was no single contemporaneous record relating to patient care and treatment. Some complaints received were upheld or partially upheld when investigated.

However:

Observations of interactions between staff and patients showed that staff knew patients well and treated them with respect.
Feedback from patients on the low secure ward and long stay rehabilitation was positive about the support they received from staff. Patients felt staff included them in decisions made about their care and treatment.

We inspected Cygnet Hospital Sheffield in February 2015 and issued five requirement notices because it was failing to meet regulatory standards within the safe domain. At this re-inspection we reviewed the provider’s action plan relating to the five requirement notices.

At the last inspection in February 2015 we found that the seclusion rooms were not clean and did not allow for patients to be treated with privacy and dignity. The provider was asked to provide an interim solution and add an addendum to their seclusion policy to support this. The provider was also asked to provide a longer term solution to ensure this requirement was being met. At re-inspection we found there had been an addendum added to the seclusion policy for staff to provide strong blankets to patient’s in seclusion to support their privacy and dignity. All seclusion rooms were clean. We saw a plan of works agreed to decommission two seclusion rooms and completely refurbish the remaining two rooms. This was due to commence on 22 February 2016.

At the last inspection in February 2015 we found that incidence of seclusion were not being recorded and stored in line with the Mental Health Act code of practice and hospital policy. We also found that there were blanket restrictions on the child and adolescent mental health wards that were excessive. At re-inspection we found that seclusion paperwork was stored with patient’s records and completed in accordance with the Mental Health Act code of practice and hospital policy. We found that blanket restrictions on Peak View had been reviewed and many had been removed completely. On Haven restrictions were reviewed on a regular basis depending on clinical risk.

At the last inspection in February 2015 we found that the blood pressure monitor was broken and there were no checking mechanisms for medical devices on the CAMHS wards. On re-inspection we found that medical equipment was present and in good working order on all wards.
At the last inspection in February 2015 we found that three fridges used to store medication were unlocked. At re-inspection we found all medication fridges that were storing medication were locked.
At the last inspection in February 2015 we found that the risk register had not been updated since November 2014 and many of the risks needed urgent review. At re-inspection we found the risk register was reviewed and updated at least monthly at governance meetings.

The inspection team were assured that the CQC action plan resulting from the inspection in February 2015 had been completed.

There had also been an increase in incidents being reported to CQC and anonymous concerns received relating to the child and adolescent mental health wards. We reviewed policy and procedure regarding medicines management, the use of agency staff, mandatory training compliance and restrictions placed on young people not detained under the Mental Health Act.

Mandatory training compliance was above 75% in all areas. Overall the records showed 88% compliance for staff having completed mandatory training.
The service provided safe staffing levels, with the use of contracted agency staff to provide consistency where there were difficulties recruiting into vacancies.

However;

We completed a review of medicines management and found that hospital policy was not being followed in several areas; leave and discharge medication was not being dispensed in accordance with hospital policy on Haven Ward. There had been a medication error reported on Spencer Ward which had not been written into the patient’s notes and a cupboard storing medication had been left unlocked on Spencer Ward.
The audit process for checking the environment within the seclusion rooms was not being adhered to and issues were not being addressed promptly.
There were two locked doors on Peak View ward which did not allow informal young people to leave the ward at will. We visited the hospital two weeks after the inspection and found that appropriate capacity assessments and signage informing young people how to ask to leave the ward were in place. This was an interim measure to support the process for non-detained patients until there could be changes made to the environment.

The hospital has recently been acquired by another provider, Cygnet Hospitals NW Limited. It was acknowledged that there have been ongoing issues within the child and adolescent mental health services which have been highlighted by the CQC and NHS England, who are the commissioners of the service. In response to this the provider had commissioned an external independent review of the child and adolescent wards which took place in December 2015. The purpose of the review was to enable a clear and robust understanding of the current clinical practice in order to take immediate action to mitigate concerns, build on good practice and develop a plan for long term sustained improvements. The results of this review will be presented back to the senior team at the hospital on 4th March 2016 together with recommendations for future improvements. Initial feedback had highlighted issues around specialist CAMHS training and the environment. The CQC have asked for a copy of this report once finalised.

Peak View and Haven

in the CAMHS unit we found:

Application of the Mental Health Act was poor.

During the inspection we found issues with privacy and dignity for patients in seclusion. Following a meeting between Alpha Sheffield and the CQC we agreed interim measures for use of seclusion rooms with privacy and dignity while long term measures are being found by the provider. In particular:

Alpha Sheffield have agreed as an interim measure to give a patient in seclusion a strong blanket to protect their privacy and dignity whilst using the toilet.
Alpha Sheffield have agreed to further implement the addendum to the seclusion policy to ensure privacy and dignity.
Long term solutions to this issue have been suggested and we will continue to work with the provider until this solution is found by the provider

The application of the seclusion policy was also poor.

The CAMHS services were over restrictive especially the general CAMHS ward Peak View, with many blanket policies and procedures and the inability of informal patients to exit the ward without delay.

we also found:

That all staff groups felt supported by managers and they had access to supervision sessions both group and individual and other peer to peer support.

Generally patients felt staff were caring, however many young people we spoke to felt that the wards were short staffed and that agency staff did not always know them well enough which led to inconsistencies with care. The provider has an ongoing recruitment plan and 28 new staff have been appointed to the CAMHS services.

Shepherd and Spencer Ward

In the locked rehabilitation and low secure units we found:

The medicine management of drugs was poor on Spencer ward, whilst the clinic was fully equipped and medicine cards were appropriate, we found an out of hours drugs cupboard unlocked within the clinic area.

The wards of Spencer and Shepherd were dirty and there was a lack of cleaning schedule.

There was a risk register for Alpha Sheffield. However this had not been updated since November 2014 and needed urgent attention.

During the inspection we found issues with privacy and dignity for patients in seclusion. Following a meeting between Alpha Sheffield and the CQC we agreed interim measures for use of seclusion rooms with privacy and dignity while long term measures are being found by the provider. In particular:

Alpha Sheffield have agreed as an interim measure to give a patient in seclusion a strong blanket to protect their privacy and dignity whilst using the toilet.
Alpha Sheffield have agreed to further implement the addendum to the seclusion policy to ensure privacy and dignity.
Long term solutions to this issue have been suggested and we will continue to work with the provider until this solution is found by the provider

In addition the seclusion and monitoring of this was poor and many documents were missing. Those we did review showed that the correct reviews and documentation of these seclusions were missing or had not been carried out.

We also found:

Throughout our visit to the wards, we observed staff speaking with people who used the service in a respectful manner.

There was good evidence that patients were involved in their care and care plans.

Patients could make drinks and snacks when they wished.

Patients were actively encouraged to personalise their bedrooms.

Patients had access to spiritual support.

We found that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People told us that they felt well cared for.

We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We found that there were enough qualified, skilled and experienced staff to meet people's needs.

We found that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We found that the provider had an effective system to regularly assess and monitor the quality of service that people receive.

This inspection included checking that improvements had been made to the management of medicines, assessing and monitoring the quality of service provision and records, as the provider was non-compliant following our inspection on 4 June 2013.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. All the patients we spoke with told us they felt they could engage well with staff and felt supported by them. For example, one patient said, 'It was the anniversary of my dad's death and staff were available for one to ones to make sure I got support'. Another patient said, 'Patients shout and threaten people, but staff are good and calm'.

Patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

There were enough members of staff to keep patients safe and meet their health and welfare needs. All but one patient felt there was enough staff on duty to meet their needs, both during the day and night. All staff told us that the staffing levels were sufficient to meet people's needs.

Although improvements had been made, the provider did not yet have effective quality checking systems in place to manage risks and assure themselves of the health, safety and welfare of patients and others.

Patients records were kept safe to maintain their confidentiality and included appropriate information about them.

This inspection included checking that improvements had been made to records as the provider was non compliant following our inspection on 28 January 2013. The provider remained non-compliant.

On this visit we spent time on both Spencer and Shepherd ward.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. Comments by patients included, “I have a named nurse and I speak to her when she is on shift. We discuss the side effects of my medication and the monitoring of my physical health. We discuss any issues that have arisen and any changes” and “my progress is discussed at Care Programme Approach (CPA) reviews.”

Patients who use the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. All the patients we spoke with felt the restraint that had been applied to them was appropriate and justified.

Patients were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

The provider did not have an effective system to identify, assess and manage risks to the health, safety and welfare of patients and others.

Patients were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

Patients experienced care, treatment and support that met their needs and protected their rights. Patients told us they received activities and particularly enjoyed the activities on the Haven, but that they would like more groups to aid their recovery, such as drugs and alcohol, eating disorders, looking at personality disorders and anger management.

There were enough qualified, skilled and experienced staff to meet patient’s needs. Patients told us there was no concern about activities getting cancelled regularly because of a lack of staff. We were told there was now an activities co-ordinator who worked in the Haven every day. One patient was particularly pleased as she said it also ran at the weekends now.

The provider had an effective system to identify, assess and manage risks to the health, safety and welfare of patients and others. This included the re-establishment of the audit committee, with an audit programme for the next year being developed, clinical governance meetings and communicating with patients and staff.

We found there was a lack of proper information about patients because their care records were not accurate and did not include appropriate information and documents in relation to the care and treatment they were receiving. We also found that information and documents held about patients could not always be located promptly.

This inspection was to review improvements at the service. This was because a visit to the service on 17 April 2012 resulted in a compliance action being made against outcome 4, 'care and welfare of people who use services'.

At this inspection we also covered outcome 7, 'safeguarding people who use services from abuse', outcome 12, 'requirements relating to workers', outcome 13, 'staffing' and outcome 16, 'assessing and monitoring the quality of service provision'. This was because we had received information of concern about these outcome areas.

Our inspection was conducted on the two low secure wards, Spencer and Sharman.

A new manager had been appointed and this was her fourth week of employment.

We spoke with four patients about aspects of their care and welfare. They felt staff at the hospital were 'good', 'treated them with respect and dignity' and 'that they related well to their key worker'.

Patients told us that there had been some changes in recent months. For example, they could get a drink whenever they wished to and were able to keep their own snacks in their rooms. Patients told us that they were able to go outside more freely and this had made life much better. Patients also told us that some changes, such as access to the garden area and activities, such as going to the gym and section 17 leave, didn't always take place because of a shortage of staff.

Patients said they were supported by the staff to retain contact with family and friends.

When describing their care, patients identified they had access to health care professionals and attended opticians and dentists if necessary.

We spoke with four patients about whether they felt safe on the ward. They all told us they felt at times it was unsafe on the ward. They said this was because of some incidents that had recently taken place between patients. All patients told us they felt safe with staff.

This follow up inspection was to review improvements at the service and the provider's compliance with six essential standards. Since the last inspection a new manager had been appointed and his application to register had been submitted to the Commission.

On Spencer ward, patients raised no concerns about staff maintaining their confidentiality, but on Sharman ward it was still a concern to three of the six patients we spoke with.

Patients on Sharman ward spoke of the good facilities in 'the haven'. 'The Haven' is a separate area off the ward that includes a good multi-faith room.

Patients told us staff were now completing searches in private areas, which afforded them more privacy and dignity. One patient told us that she had made suggestions to staff about improving the search area and that her suggestions had been incorporated.

Patients were supported in promoting their independence and community involvement. This was demonstrated by patients telling us about weekly meetings which took place on each ward where they could discuss activities, improvements and ward rules. We saw that there had been improvements to the recording of this information, to give a true reflection of what was discussed. Patients led the meeting and took their own minutes and a representative of the organisation also took minutes.

All patients said they were able to contribute to decisions about their care in ward rounds, which told us patients were able to express their views and were involved in decisions about their care and treatment.

We spoke with eight patients to ask them how they consented to their care and treatment including searches of their person and property.

Seven patients told us that they were asked to give consent to being searched. We asked what happened if they didn't consent to being searched. One patient said, "You don't go out." Another patient said, "They'd do it anyway." Another said, "You'd be restrained, but it's not happened to me."

One patient told us that her search arrangements had recently changed as she presented a lower risk than she had previously. She saw this as a positive development.

Four patients told us they now had a folder containing a copy of their care plan and risk assessment for them to look at and check when they needed/wanted to.

We spoke with eight patients. All felt there had been a shift in the restrictions that were applied to them. However, one patient felt there was still a lot the hospital could do to improve this. They gave examples of this as cigarette breaks and access to the kitchen and garden. They eloquently described the impact of those restrictions on their mental health. They said, 'If you're not well and feeling tense and aggravated, it just adds to it and your own baggage.'

Another patient told us that because she had arrived late to the communal area, staff did not allow her to go out for a cigarette.

A further patient told us it would be better if they could go for a cigarette when they wanted to. They told us cigarette breaks were every two hours, you have to be in the communal area fifteen minutes before the break and come back inside after fifteen minutes.

Patients that we spoke with told us about weekly meetings which took place on each ward where they could discuss activities, improvements and ward rules. We saw that there had been improvements to the recording of this information, to give a true reflection of what was discussed. Patients led the meeting and took their own minutes and a representative of the organisation also took minutes. Patients told us decisions and feedback about issues raised in that meeting had improved, but there were occasions when subjects continued to be raised. The new manager was seeking to address this, by monitoring those minutes on a weekly basis. This told us patients were asked for their views about their care and treatment and they were acted on and that the provider took account of complaints and comments to improve the service. It also told us decisions about patient's care and treatment were made by the appropriate staff, at the appropriate level.

In our discussions with eight patients, the overall picture was that patients were provided with information about how they could complain if they were not happy. On Sharman ward there was good feedback from a patient who was able to change their named nurse on request. However, another patient wasn't happy with their named nurse as it was a permanent night nurse, which meant their 1:1's were happening late at night, which they weren't happy with. The provider may find this useful to note, so that they can address this at service level.

However, there was still a perception from three patients that there was no point complaining, as things never got resolved.

This follow up inspection was to review improvements at the service and the provider's compliance with six essential standards.

When we spoke with patients, one told us that confidentiality on the wards was never good. This was because staff discussed information about patients on the ward.

All patients said they were able to contribute to decisions about their care in ward rounds.

Patients that we spoke with told us about weekly meetings which took place on each ward where they could discuss activities, improvements and ward rules. One patient said, they're not always effective, because some things don't always get recorded. On one ward some of the patients told us that they did not get effective feedback in these meetings.

We spoke with one patient who knew the multi-faith room was being implemented, but didn't know they could use it now.

Patients told us searches were still taking place in public areas. This was despite the provider making structural changes to provide a search room in a passageway off the main entrance. This was confirmed because on the visit we saw one patient enter the corridor area off the ward and hold out their arms to be searched. The staff member accompanying them told them it wasn't necessary any more to be searched on their way out.

One patient told us their search usually takes place in the corridor off the ward, but it's never in a private place. Sometimes, they said they can use the recess off the corridor, to make it more private.

We spoke with patients to ask them how they consented to their care and treatment including searching of their person and their possessions. One patient said they'd never been asked to sign a consent form that they agree to being searched or be asked if they verbally agree. They said they are aware rooms should be searched randomly every month, but it doesn't happen.

Another patient told us searches continued and they'd never consented or been asked their permission. They said they could understand random, but not every time. They felt it was easier to agree and go ahead rather than risk losing leave. On a different ward they said searches were more rigorous and included removing your shoes.

Patients told us they didn't like being searched, but understood why staff needed to.

When we spoke with patients it identified there continued to be restrictions placed on patients, that were not all based on individual risk. For example, everyone had to have the majority of their own money and bank cards kept in the office safe. Some patients said they could only have snacks at 14:00 or 20:30. They said this was because some patients were on weight loss programmes.

Patients told us about zonal observations. They said everyone had to be up and in the main patient area by a certain time, and bedroom access varied between individual patients depending on which zonal observations you were on.

On this inspection one patient told us that they felt in the past couple of months, things seemed to be coming together. They said they had been disappointed because they had transferred from an enhanced medium secure ward and expected to continue with at least the same care plan when they came here, but they didn't, they had to 'start again'. They told us they were always searched on the way out of the ward until this morning and have always been searched on the way back onto the ward. They said this includes a 'pat down' and search of property. They said anything that's sealed can be brought onto the ward, but there's no consistency with applying this rule.

On the locked rehabilitation ward, patients were much happier. They felt changes had been made for the best. For example, they could have previously banned items such as mobile phones and pot crockery. They explained they don't have searches and if they do they're random or if there's a reason. One patient said, 'it's improving and getting to be more like a rehabilitation ward. I'm really pleased with the progress.'

In respect of receiving their medication on time, one patient said there had been times when they had been without their medication, because of changes in dosage, but this had got better more recently. For other patients we spoke with, they described their routine for receiving their medication. This demonstrated different routines for patients to take their medication and that a person centred approach based on risk was in place for this.

When we asked patients what changes might improve the ward, one patient thought a beautician. We told them to raise this in the community meeting, which they said they had done. On the locked rehabilitation, one patient thought cooking for yourself.

We asked patients about whether there were enough staff at the hospital to meet their needs. One patient on Sharman ward said in the last two ' three weeks there had been more staff, but it's poor at night. Another patient said there is not enough staff for one to one talk time, which means you have to deal with your problems on your own. You also have to wait to put laundry in, because other patients are on observations. They said numbers of staff always get discussed in community meetings, but the hospital says they are the correct numbers.

During our discussions with patients they said in general staff were good and helpful.

Patients had different experiences of how complaints were dealt with dependent on the ward they were on, but there seemed to have been improvements more recently.

On one ward, one patient wasn't clear how the complaints procedure worked and would only speak to certain staff, because one member of staff had said, 'if anyone blogs on me, I'll make life difficult'.

Another patient told us the procedure they would use to make a complaint. However, although their complaint had been listened to they didn't think the provider had dealt with it correctly, because they'd just moved the problem elsewhere.

On the locked rehabilitation ward patients were much more confident that their complaint would be dealt with.

On this occasion we were carrying out a follow up inspection to look at the provider's compliance with one essential standard, and we did not speak to patients. However, when we inspected this hospital in November 2011 we spoke with patients and found their views about receiving treatment at Alpha Sheffield were varied. Most of the patients that we spoke with on that occasion told us that they had the opportunity to be involved in their care planning and making decisions about their treatment. Patients told us that there were plenty of activities taking place within the hospital that they could participate in, although some told us there was little to do at weekends and that sometimes activities were cancelled due to short staffing. Some patients told us that they liked the staff and felt that they did a good job. Several of the patients we spoke with told us that they found there were too many rules in place. Some patients told us that when they make requests for things the hospital takes a long while to respond. Other patients told us about times when they have made suggestions for improvements and these have been implemented.

Patient's views about receiving treatment at Alpha Sheffield were varied. Most of the

patients that we spoke to told us that they had the opportunity to be involved in their care

planning and making decisions about their treatment. Patients told us that there were

plenty of activities taking place within the hospital that they could participate in, although

some people told us there was little to do at weekends and that sometimes activities were

cancelled due to short staffing. Some patients told us that they liked the staff and felt that

they did a good job. Several of the patients we spoke to told us that they found there were

too many rules in place. Some patients told us that when they make requests for things the

hospital takes a long while to respond. Other patients told us about times when they have

made suggestions for improvements and these have been implemented.

All Inspections

Peak View and Haven

Shepherd and Spencer Ward