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Inspection carried out on 25th - 27th June 2019

During a routine inspection

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

  • The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • 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 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 these 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 involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly.


  • Not all staff were trained in the use of physical intervention.
  • Staff did not keep records of seclusion in line with the Code of Practice.
  • The mobile phone and mail management policy was not in line with the Code of Practice.
  • Not all patients with long term conditions received regular review by an appropriate clinician.
  • Staff did not always record the reason for the use of prone restraint in incident records.
  • Staff did not always record when patients and staff received a de-brief following an incident.
  • The hospital policy for patients with transgender needs was not written in plain English and did not reference any national sources of information.
  • Information about transgender support groups was not available on the wards.

Inspection carried out on 26 February to 1 March 2018

During a routine inspection

We rated this location as requires improvement because:

  • For patients who lacked mental capacity to make key decisions about their care or other aspects of their life, staff did not follow best interest decision-making processes.
  • Staff did not always ensure the needs of gay and transgendered patients were fully met and did not access specialist support to enable them to work effectively with patients with these needs.
  • The provider’s resuscitation procedures and response times did not meet national guidance.
  • Staff did not document the use of mechanical restraint in patient support plans.
  • Staff did not carry out risk assessment for patients with mobility needs.
  • Some of the patient records we looked at did not identify all the pertinent risks. There were some inconsistencies between risks identified in the patient’s health action plan and their risk assessment.
  • Some of the hospital’s policies did not provide staff with the standards expected of them.
  • The hospital’s procedures did not always identify when staff missed safety checks on equipment.
  • The hospital did not do everything it could to protect patients’ privacy and dignity when using communal bathrooms.


  • The hospital had carried out the actions we told them they must at our last comprehensive inspection.
  • The hospital had an effective cleaning schedule in place and staff had received training from the British Institute of Cleaning Science.
  • Staff were up-to date with their mandatory training.
  • The hospital carried out physical health checks and on-going monitoring with all patients.
  • Managers provided staff with supervision and appraisal.
  • Overall, patients and carers thought staff were caring and respectful.
  • Patients had access to advocacy and knew how to make a complaint.
  • Patients had access to a range of activities and a college aimed at promoting recovery
  • Staff worked alongside patients to reduce restrictive practices across the hospital.
  • Managers and members of the multidisciplinary team participated in monthly governance meetings to improve quality and safety.

Inspection carried out on 6 February to 9 February 2017

During a routine inspection

We are placing Cheswold Park Hospital in 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.

We rated Cheswold Park Hospital as inadequate because:

  • When we inspected the hospital in August 2015, we found breaches of four regulations and rated it overall as ‘requires improvement’. Although the hospital had made some efforts to improve services, not enough had been done to remedy the breaches and to maintain improvements in the long term. We also found new problems that the hospital needs to put right, which resulted in our lower rating of ‘inadequate’.
  • Staff did not monitor patients’ physical health regularly and effectively and the hospital still did not have an effective system for monitoring patients’ physical health. Staff had not assessed all risks to patients with long-term health conditions and those self-medicating. They had not prepared comprehensive care plans to ensure that they received the right support, care and treatment to meet their physical health needs, enable safe self-medication and keep them safe.
  • Staff did not manage medicines correctly. They did not ensure that all medication was stored appropriately or securely. They did not keep records on stock acquired from other wards and so might not have been able to identify any stock discrepancies. Staff did not always ensure that patients took the medication they were given.
  • Records to ensure that patients were kept safe and to manage and mitigate risks to them did not contain sufficient information or all of the relevant information. Positive behavioural support plans did not contain information to enable staff to de-escalate incidents. Environmental risk assessments did not always identify risks or contain plans to manage or reduce them. One audit of ligature anchor points (places to which patients intent on self-harm could tie something to strangle themselves) was inaccurate and some staff were unaware of ligature risks.
  • Staff did not follow safety procedures. This included observation of patients, checking electrical equipment and contents of first aid boxes. The provider had undertaken work to remove fixed ligature anchor points from patient ensuite bathrooms. However, four communal bathrooms continued to have standard taps and the provider had not improved the ability for staff to see patients in their bedrooms.
  • The hospital imposed a number of blanket restrictions on patients’ freedom when restrictions should be based on individual risk assessments. Staff on Brook and Don Wards restricted shaving times. Some staff and patients on Don Ward told us that punitive measures were used for patients deemed not to conform to behavioural rules. Staff used physical and mechanical restraint to control and restrict a patient that was not always proportionate to the harm or risk of harm posed by the patient. This was not in line with the Mental Health Act and the code of practice.
  • Staff searched all patients on return from section 17 leave (granted to patients detained for treatment).
  • The provider did not ensure that areas of the hospital were clean or well maintained. Areas of the hospital were visibly unclean, with debris on floors and surfaces. Ward kitchens were worn and tired.
  • The Isle Suite used for long-term segregation did not promote recovery, comfort, dignity and confidentiality, and did not meet the requirements of the Mental Health Act code of practice. The suite was not clean and contained debris and stains in all areas. There was no cleaning schedule for the suite and there were no hand washing facilities for staff. The suite did not have any furniture except a mattress. It did not contain the patient’s personal items, except for stickers on the walls and curtains and the patient was unable to make telephone calls in private. The hospital had not sought an external review of the patient’s circumstances and records did not show evidence that staff had informed the local safeguarding team of the commencement of long term segregation. Documentation of some multidisciplinary reviews contained language relating to continuing seclusion; it was not clear on one record whether an approved clinician had completed the review. Records did not show input of any structured programmes of therapy and activity.
  • The care and treatment records for one patient did not show how staff had assessed the patient’s capacity to make decisions not applicable to their detention under the Mental Health Act. The provider’s policy did not clearly explain the rights of the Lasting Power of Attorney or the scope of their role.
  • Staff prescribed medications for mental disorder for some patients that did not match those stated on consent to treatment forms. This was not in accordance with the Mental Health Act and code of practice. Reviews completed by a community pharmacy identified 47 errors in relation to Mental Health Act paperwork and prescribed medicines between July and September 2016.
  • Some patients raised concerns about their experience of using the service. They had concerns about the quality and variety of food provided, did not like the way that staff treated them, and were not happy with their involvement in meetings about their care and treatment. Some carers raised concerns about communication and their involvement in meetings. Over half of patients’ care plans reviewed did not show evidence of patient involvement or reflect the views of patients. Twenty five percent of patient care plans contained vague and ambiguous statements. Observations showed some staff did not maintain professional boundaries with patients. Community meeting minutes for some wards showed mainly information that staff communicated to patients and not the involvement and views of patients.
  • The hospital’s leadership and governance structure was unclear and complex. Governance committee meeting minutes did not provide assurance that actions were completed. The provider’s systems and processes did not ensure that staff carried out their responsibilities. Staff, including senior managers, did not understand the duty of candour. The records of investigations and serious incidents records did not show evidence of the duty of candour being applied. Staff investigating serious incidents did not follow the provider’s policy and investigations completed did not show evidence of lessons learned. The registered person did not submit notifications to the Care Quality Commission of statutory notifiable incidents in five cases and a further two incidents were submitted with delays.
  • Systems and processes were ineffective and did not ensure that the provider had oversight to ensure that staff files were up to date with the required registrations, qualifications, references, and disclosure and barring service checks to ensure they were fit and proper to carry out their roles. Staff did not receive the necessary training to meet the care certificate standards and not all staff received regular supervision and appraisal.
  • The provider had not obtained the required information to meet the requirements for the fit and proper persons for the organisations directors.
  • The paper-based system for patient care and treatment records was cumbersome. This meant that staff could not easily access records when needed.
  • The provider had not updated some of its policies to reflect changes in the organisation.
  • Team meeting minutes did not contain sufficient information to be an accurate record of meetings and the minutes for Don Ward did not promote morale and engagement of staff.
  • The hospital audit programme was not fit for purpose. Staff had not completed actions including re-auditing later, not all audits had action plans and those that had did not all have timescales.
  • Staff did not uphold the privacy and dignity of patients as they administered patients’ medication through a hatch from clinic rooms; other patients and staff could see patients taking their medication.


  • The provider had reduced the number of restraint and seclusion episodes significantly since the introduction of a No Force First approach.
  • The hospital provided a range of psychological therapies. Dedicated trained staff ran a dialectical behavioural therapy based helpline.
  • Patients participated in providing positive behavioural support training to staff.
  • An occupational therapy activity timetable and a dedicated recovery college provided a range of activities and courses.
  • Senior managers in the organisation were visible and accessible to patients and staff. Ward representatives attended weekly meetings to report ward performance to the senior management team.

Inspection carried out on 23 May 2017

During an inspection to make sure that the improvements required had been made

We found the following issues that the provider needs to improve:

  • The provider did not have effective systems and processes to identify issues in infection control and incident management. Staff displayed poor hand hygiene and infection control practices. They had not identified all risks in an infection control risk assessment and this did not contain sufficient information to manage and mitigate risks.
  • The provider had not taken timely and reasonable steps to assess, monitor and mitigate the risks to the physical health of a patient. Care and treatment records did not contain mental capacity assessments when making decisions about some aspects of physical health.
  • The patient risk assessment did not identify all risks and the risk management plan did not address and mitigate risks. Staff did not discuss risks at staff handover.
  • Care plans did not contain enough detail to reflect the care required and staff had not involved the patient in their development. Staff did not always follow the patient’s communication care plan. They did not have immediate access to the patient’s records, as these were stored in an office away from the suite.
  • In over half of the incidents of restraint used, it was not proportionate or in response to risk. Staff that reviewed incidents did not make recommendations, record actions or lessons learnt after incidents. The provider did not have effective systems to have oversight of incident management and did not identify these issues.
  • Not enough dedicated staff were available when needed and this meant that the patient had to wait staff to be available to enter the suite or get items that they needed. There continued to be limited input from some disciplines of the multi-disciplinary team.
  • The patient did not have privacy and dignity when using the bathroom or holding telephone calls.
  • The secure garden did not contain a shelter from adverse weather.
  • Senior management staff lacked understanding about the use and application of positive behavioural support. They acknowledged that they did not currently have any expertise in adaptive behavioural scales, applied behaviour analysis or positive behaviour support within their substantive staff.
  • The registered person did not speak respectfully when they described a patient and their needs.
  • Training in learning disability and personality disorder was not up to date.

However, we found the following areas of positive practice:

  • Since our last inspection in February 2017, the provider had installed a handwashing sink and a drain in the suite. They had arranged for an external hospital to review the long-term segregation every three months.
  • Staff entered the suite more frequently and for longer duration and the suite was more personalised and contained some furniture.
  • The provider had commissioned a sensory integration assessment.
  • Staff who regularly worked with the patient knew the patient well, treated them with respect, praised and encouraged them.

Inspection carried out on 4 - 6 August 2015

During a routine inspection

We rated Cheswold Park Hospital as requires improvement because:

The hospital was in a period of transition with a new managing director having implemented a new management structure to improve the quality of the service in the three months prior to the inspection. This included each ward having its own manager and a nursing operational manager overseeing all of the wards. However, the senior managers had not had sufficient time to review the service following the changes or embed the new systems at the time of our inspection.

Areas where improvements are required:

  • We found unclear information about when the provider would complete actions. For example, there were no timescales in place to remove ligature points or to improve visibility into patients’ rooms for staff at night. Minutes of the operational and clinical risk meetings had unclear information about when they would complete actions. Where staff had carried out the investigation of serious incidents and made recommendations, we did not find specific action plans in place.
  • The hospital did not have policies and procedures to inform staff about their responsibilities regarding the duty of candour. (Duty of candour is a legal duty on hospitals to inform and apologise to people if there have been mistakes in their care, which could have led to significant harm.)
  • The systems in place to prevent and control infectious diseases needed improving.
  • Staff kept patient information in a variety of places, which prevented them from having access to all the information from the multidisciplinary team members. This had the potential to affect the assessment and planning of patients’ care and treatment needs.
  • The hospital did not have enough qualified nursing staff on at night to cover the wards if an incident occurred, or when qualified nursing staff went for a break.
  • The hospital needed to improve the management of medication. For example, the hospital had not followed new guidance and checked patients’ physical health when administering high doses of medication. Nine patients on Foss ward did not have care plans in place to instruct staff about how the patients had to administer their own medication. Following induction, the hospital did not provide updates of medication training.
  • The hospital did not have a clear written protocol, or recording mechanism, to assess a patient’s physical needs following admission, which would have enabled the staff to provide a consistent approach to meeting care needs.
  • Although, managers had started to address attendance by staff at supervision meetings, on Brook, Foss, Calder and Don Wards only 53% of staff had attended supervision. Supervision is a method of checking the quality of staff’s work, recording action on training and cascading key information or learning to staff in the hospital.

  • Information about how to complain to the CQC about detention under the Mental Health Act was either not displayed or the information displayed was out of date across the wards Also, an average of 59% of staff had carried out their Mental Health training. This lack of information potentially prevented patients from being able to complain about their detention.

However, we also saw areas where the managers and staff had displayed good practice, or had made recent improvements. For example:

  • The provider held a morning meeting each day to review any issues relating to patient safety. The hospital directors, registered manager and ward managers attended the meeting. Following this, the managers met to review the staffing numbers on each ward to ensure that the wards had sufficient skilled staff to meet patients’ needs.
  • The hospital held a monthly governance meeting chaired by the clinical director.
  • The hospital had a newly implemented register detailing risks to the patient or staff that the management team reviewed regularly. This enabled the managers to prioritise risks and take action.
  • The hospital collated information about incidents, restraint and complaints to review any patterns.
  • The hospital had looked at staff employment contracts to make sure it improved recruitment of new staff and encouraged the retention of existing staff.
  • Patients had regular and well-organised multidisciplinary team meetings.
  • Records relating to the Mental Health Act were well kept and staff had a good awareness of the act.
  • The provider had carried out a staff survey in July 2015.
  • The managers had carried out a patient survey in March 2015, which they planned to act on.
  • Staff had commenced reviewing the treatment and care of patients who had been at Cheswold Park for a long period of time to see if the hospital was still appropriate for them. Staff had discharged 23 patients from August 2014 to August 2015.
  • The hospital had a fishing pond and animals within its grounds. There were a variety of activities available during weekdays.
  • Patients had regular leave from the hospital.
  • Managers and staff listened to the concerns and complaints of patients and responded to them.

  • The hospital had clear processes in place to safeguard patients and staff knew about these.
  • The hospital had trained eight staff to improve their practices when investigating complaints and incidents.
  • Following several absconding incidents, the hospital commissioned an independent review to look at ways of improving practices.
  • The hospital staff had a good range of skills. Staff had the qualifications needed and received specialist training specific to their roles.
  • Most patients said staff treated them with kindness, dignity and respect.
  • The hospital managers visited the wards regularly and staff informed us they were supportive. The senior managers had linked the vision and values of the organisation to the staff appraisal system.
  • The hospital had developed an individual service for one patient with complex needs and had trained the staff to support the patient.

The hospital had involved an independent specialist consultant to make sure the service provision was of a high standard for one patient with complex needs. This had improved the experience for this patient at the hospital.

Inspection carried out on 26 March 2014

During an inspection in response to concerns

During this inspection we visited Gill and Hebble wards, which are for patients with learning disabilities. We also visited Foss ward, which is for patients with a diagnosis of mental illness and personality disorder type illness. We spoke with six patients about their experiences of living in the hospital.

We carried out this inspection because concerns were identified to us by a whistle blower, in relation to care and welfare of people who use services, safeguarding people who use services from abuse, staffing and supporting workers.

At this inspection we found that people experienced care, treatment and support that met their needs and protected their rights. Most patients said their named nurses and key workers were helpful and supportive.

People who used 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. Most patients we spoke with told us that they felt safe. One patient said they didn't feel staff cared. However, they acknowledged that staff intervened to keep them and others safe.

There were enough qualified, skilled and experienced staff to meet people�s needs and staff received appropriate professional development and support.

Inspection carried out on 9 January 2014

During an inspection to make sure that the improvements required had been made

We carried out an inspection of Cheswold Park Hospital in October 2013. At that time we found the patients did not always experience treatment and support that met their needs and protected their rights. This was because there were some restrictions and interventions that were imposed on patients that were not based on individual risk assessments. We made a compliance action, which required the provider to make improvements in this area.

We undertook this inspection to review the provider's compliance with the compliance action made at the last inspection. At this inspection we found that improvements had been made and the provider had appropriate arrangements in place to ensure patients experienced treatment and support that met their needs and protected their rights.

Inspection carried out on 24 September 2013

During a routine inspection

We visited Brook and Foss wards, which are for people with mental health issues, Hebble ward, which is for patients with learning disabilities and Calder ward, which is for patients with a diagnosis of personality disorder type illness. We spoke with 12 patients about their experiences of the hospital. Comments included, �There is always plenty to do and staff around to talk to.�

Patients expressed their views and were involved in making decisions about their care and treatment. Patients said there were lots of opportunities for them to make choices and have a say in how their care and treatment was delivered.

There were some restrictions and interventions that were not based on individual risk assessments, such as monthly room searches, so patients did not always experience treatment and support that met their needs and protected their rights.

Patients 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. Patients said staff helped to keep them safe.

There were enough qualified, skilled and experienced staff to meet people�s needs.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

Reports under our old system of regulation (including those from before CQC was created)

Mental Health Act Commissioner reports

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.