The Care Quality Commission
  • Mental Health
  • Independent mental health service

The Retreat - York

Overall: Requires improvement read more about inspection ratings

107 Heslington Road, York, North Yorkshire, YO10 5BN (01904) 412551

Provided and run by:
The Retreat York

All Inspections

31 July 2019

During a routine inspection

We rated The Retreat York as requires improvement because:

  • Clinical premises where patients received care were not compliant with internal fire safety processes and did not maintain the confidentiality of patients. Clinic rooms were not soundproof so confidential conversations could be overheard.
  • Staff had not completed all the necessary checks on blood pressure monitoring and weighing equipment that was used in the service. The service did not have effective processes in place to safely manage a medical emergency.
  • Staffing levels were not high enough to meet the demands on the service. There was not a fully integrated system between primary care and the attention deficit hyperactivity disorder (ADHD) service to ensure patients received all care and treatment identified at the assessment.
  • Mandatory training was not well managed in the service. The service was unable to evidence if staff had met the service’s training requirements.
  • The service did not manage risks to patients or staff in line with organisational policies. Staff did not always use the format specified or update risk assessments in the timeframes stated.
  • Staff could not access all patient information quickly. Staff were not always able to locate paper or electronic files that held patient information.
  • Access to the service was difficult. Patients were not able to contact the service easily on the phone and staff didn’t always respond to patients that left messages.
  • Waiting times to access an assessment were 18 months and the referral criteria excluded patients that would have benefitted from care. The 'did not attend' policy and the process to expedite patients was not considerate of the challenges faced by this patient group.
  • Leaders lacked the skills and knowledge to oversee and implement daily operational tasks. There was a lack of clarity and ownership about the responsibilities of managers, clinical staff and business support staff.
  • Not all staff felt respected, supported and valued. They did not always feel able to feedback honestly to managers in the service. The service’s lone working protocols and policy were not fully implemented and did not offer support to all staff groups. The induction process did not meet staff needs.
  • Governance processes did not operate effectively, and processes were not always well managed.

However:

  • Clinical premises where patients received care were clean, well-furnished and well maintained. There were enough clinic rooms at the service and the service had made adjustments for disabled patients.
  • Staff worked with patients, families and carers to develop individual care assessments that were personalised, holistic, function-based and recovery-oriented. Staff supported patients to live healthier lives
  • 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.
  • The service used systems and processes to safely prescribe, secure and audit prescriptions. Staff reviewed the effects of medicines on each patient’s mental and physical health.
  • Staff from different disciplines worked together as a team to benefit patients. Staff were supportive of each other and understood the challenges the different roles faced.
  • Staff had the skills, or access to people with the skills, to communicate in the way that suited the patient. Reports were easily understood by patients. Staff supported patients to access additional treatment out with the contract. They recommended that patients seek additional funding from the local clinical commissioning groups via their GP for additional services.
  • The service managed complaints well and shared learning with staff. Managers supported staff with appraisals, probationary reviews, supervision and opportunities to update and further develop their skills.
  • Managers from the service worked with commissioners, local authorities and mental health providers to try to improve services for the local population.

7 November 2017 to 9 November 2017

During an inspection looking at part of the service

We rated The Retreat York as good because:

  • The organisation had made improvements following feedback from our previous inspections. Staff made changes to systems and processes across the organisation, and improvements meant patients received safe care and treatment. The unit managers had a good understanding of their units and shared good practice.
  • Staff were respectful and courteous at all times. Staff treated patients with dignity and respect and saw each patient as an individual. Staff involved patients, carers, and advocates in decisions about their care and treatment and took account of patients’ preferences and advance decisions. Staff helped patients engage with their environment and take part in meaningful activities.
  • Staff completed detailed, personalised care plans, which included crisis plans and information about their mental and physical health needs. Care plans took account of best practice guidance and patients and carers were involved in decisions about their care. Patients’ physical health care concerns were addressed.
  • Units held effective handovers and multidisciplinary team meetings to review and discuss patient care and treatment. Staff adherence to the Mental Health Act and Code of Practice was good overall and staff understood how to apply the Mental Capacity Act.
  • Staff were trained in safeguarding and incidents, they knew how and when to raise alerts. Staff completed and reviewed comprehensive individual and environmental risk assessments that kept patients safe. There were governance arrangements in place to monitor and respond to trends.
  • The units had good medicines management arrangements that meant staff stored, monitored, and administered medication safely. Medicines were managed in a safe way and patients were risk assessed to be self-medicating.
  • The leadership and culture of the units reflected the organisation’s vision and values. Staff knew who their senior managers were and spoke highly of the support they offered. Senior managers from the senior leadership team visited units and attended team meetings to listen to staff concerns and keep staff informed of service developments.
  • Morale on the units had improved following recent unit and senior management changes. Staff felt able to raise their concerns and that managers would listen to them and take appropriate action. Staff spoke positively of the senior management team and the positive changes they had made.

However,

  • The majority of staff lower than the middle management tier were not involved or aware of the emerging improvement strategy for the organisation.
  • Staff on Kemp unit did not appropriately use section 5(4) of the Mental Health Act to prevent patients leaving the hospital at a time when it was deemed unsafe for them to do so.
  • Staff on the older adult units were not clear what arrangements were in place for individual patients when authorisations for Deprivation of Liberty safeguards were delayed.
  • The provider did not have a consistent approach to the review of restrictive practices and we did not see processes that reviewed if lessons learnt had been embedded in the organisation following a complaint or incident.
  • The older adult service had no clear model of care or discharge pathway. The provider was aware of this and was reviewing the clinical model as part of its emerging strategy.
  • Patients from Naomi unit told us that there wasn’t a room on the unit where they could meet with visitors. The bedroom doors on older adult units compromised patients’ privacy, dignity, and confidentiality. The dining room on Katherine Allen was not large enough to accommodate all patients in one sitting.
  • Older adults units could not assure us that they checked all equipment to ensure it was safe to use. Both units had not carried out a recent fire drill to test that their procedures were safe.
  • Electronic records related to medication management had not been consistently documented by agency staff on older adult units.

13 February 2017

During an inspection looking at part of the service

We rated the Retreat York as inadequate because:

  • In January 2017 hospital managers decided to move six patients to the previously closed Allis unit for a six week period. When we visited there were no patients on the unit, however Allis unit appeared dirty, damp and cold. There was limited hot water and unsuitable kitchen, toilet and bathing facilities. We saw a lack of proper planning and staff allocation in relation to the cleanliness of Allis unit. We did not see, and were told by one nurse that worked on Allis unit, that there was no grab bag on the unit; a grab bag contains items to use in an emergency such as resuscitation equipment or emergency medications. The provider told us that the closest grab bag was on another older people's unit directly below the Allis unit. There was no clinic room on Allis unit and medicines storage was not in keeping with best practice when we visited. Neither unit had an environmental risk register to identify and prevent risks to the patients that could have occurred because of the changes relating to the flooring refurbishment of George Jepson.
  • We found there to be unsafe and unsuitable staffing levels and skill mix including the allocation and availability of qualified nursing staff on both Allis and George Jepson units. Staff were unable to spend meaningful time engaging with patients as they were responding to other patient needs.
  • Units had ligature risks and blind spots that were not continually managed with observations. On George Jepson unit, patients were unable to use the conservatory, quiet room or access the garden. Staff could not always see patients on the unit when they were on observations. Staff locked entrance doors to the units and patients were not individually risk assessed to be able to leave the units unescorted or without permission. Not all staff had swipe fobs to be able to leave the unit or access to the duty room.
  • We saw no record of timely discussions with patients or families in relation to the move to Allis unit. We saw that families had concerns regarding the Allis unit and did not find evidence that the provider had prioritised patient dignity in terms of the move. We saw evidence that families told the provider how their relatives had been disoriented on both units when the flooring work was being completed and gave examples of when staff had become distracted and had been unable to complete their personal care.
  • We saw no effective system for identifying, capturing and managing issues and risks at team and organisation level in relation to the flooring work on George Jepson during our inspection or in any of the information provided by the Retreat York. There were significant issues that threatened the delivery of safe and effective care and these were not identified.
  • We saw no documented evidence of a multidisciplinary discussion around suitability of patients to move or the impact on the patients that remained on the George Jepson unit. The provider was unable to locate and evidence details of personalised risk assessments, environmental risk assessments and personal evacuation plans.
  • Families told us that there were not enough activities for the patients on the unit and we saw this to be the case.

However:

  • George Jepson unit was clean and smelt fresh in both communal areas and patient bedrooms. Resuscitation equipment was available, medicines storage was well organised and we saw staff using correct equipment when moving patients as detailed in patient care plans.
  • We saw that the provider monitored incidents and acted on incidents reported. Families and carers of patients were informed of incidents when they occurred.
  • Patients who were able to communicate told us that they liked being on George Jepson unit and that staff were kind. Families described the staff as caring and supportive and George Jepson unit as a wonderful place in spite of the shortcomings.
  • All staff described their close working relationships and enjoyment of their roles. We observed staff to be friendly and caring to patients; staff considered patients’ needs; we saw that patients that needed help with personal care were clean.

29 November to 01 December 2016

During a routine inspection

We rated The Retreat York as requires improvement because:

  • We had concerns about medicines management practice. Issues found during the inspection included; staff not recording the reasons for missed doses of medication, medication not being dated when it was opened and medication care plans were not always thorough and updated. Staff did not correctly record the administration of covert medication.
  • Appraisal and supervision rates across the organisation were low. This meant that there was a reduced opportunity for staff to learn and develop their skills. Staff told us that they did not feel comfortable in raising concerns to the organisation’s senior management due to the historic blame culture in the organisation, although they were optimistic about the new chief executive officer's approach and felt this would improve under their leadership.
  • Patients on older people’s units had significantly long lengths of stay. On George Jepson unit the average was 6.8 years and on the Katherine Allen unit it was 6.1 years; for some patients, the placement was not appropriate.
  • There was one electrocardiograph machine for use by the whole hospital and staff sometimes took this off site to another unit 30 minutes drive away so it was not always available for the monitoring of patient’s physical health.
  • Units did not staff to establishment levels set by the provider. Activities were cancelled on units and patients told us that staff could not always respond to their requests. Staff told us they did not always receive an induction when they covered shifts on other units and were not familiar with different patient groups’ needs.
  • Risk assessments were not always completed in line with the provider’s policy. They did not always record the action they should take to lessen risk when patients refused physical healthcare checks and they were not completed within the time period in the provider’s policy. We found issues with the updating of blood test results in patient records and maintenance of estates not being completed in a timely fashion due to a staffing restructure.
  • Dining areas on older people’s units and the eating disorder unit were small. There was not enough space for patients at mealtimes with staff supporting patients on units. However a full range of rooms and equipment was available to support patient treatment and care.

However;

  • Staff on all units had received training in the Mental Health Act and Mental Capacity Act and showed their knowledge while caring for patients. They kept their understanding and skills up to date by meeting the provider’s combined mandatory training target.
  • The provider had safeguarding policies and procedures in place and staff knew how to use them and how to report incidents. Staff on all services used restraint as a last resort, and de-escalation techniques were clearly recorded in individual care and treatment plans. Where agency and bank staff were used, the units prioritised the use of familiar staff on the units.
  • Staff worked as a multidisciplinary team involving all professionals appropriate to support the patients. Attention to patients’ physical health care was also apparent. There was a range of therapeutic activities available on all units; although, on the George Jepson unit we saw limited meaningful engagement when patients were not in scheduled activities.
  • There was access to a range of spiritual and faith support hosted by the chaplain who included different patient’s faiths into interactions.
  • Patients and carers were involved in their care and the running of the service. They told us told us that staff were respectful and polite.
  • Staff felt supported by their line managers and spoke positively about them. Staff supported each other and offered help to ensure the best outcome for patients. Staff worked within the values of the provider, and we saw evidence of care provided in line with the organisational values.
  • All units were clean and tidy. Where blind spots and ligature points existed, risk had been lessened by the use of zonal observations.

1 December 2016

During a routine inspection

The inspection of The Retreat took place on 1 and 7 December 2016 and was announced. At the last inspection in June 2016 The Retreat – York was not given an overall rating for the domiciliary care service because only two key questions were inspected: ‘is the service safe’ and ‘is the service effective?’ These were separately rated as ‘inadequate’ and ‘requires improvement’, because the service did not meet all of the regulations we assessed under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was in breach of Regulations 12: safe care and treatment and 13: safeguarding service users from abuse and improper treatment.

These breaches were because the service had not followed the requirements of The Mental Capacity Act 2005 in using restraint to prevent people from harming themselves. Support workers were also unaware of people’s complex needs and had put people at risk of harm because of not knowing what action to take to meet those needs.

The Retreat is an independent specialist mental health care provider for up to 98 people with complex mental health needs. It also provides assessment or medical treatment for people detained under the Mental Health Act 1983. The service is located on the outskirts of York. Since September 2015 The Retreat has also been registered for the regulated activity of 'personal care' to provide domiciliary care services to people living in supported living schemes. This is provided on the site of the hospital location, in two units known as The Cottage and East Villa, which together have 11 shared accommodation places. At the time of this inspection there were eight people using the service.

The registered provider is required to have a registered manager in post. On the day of the inspection there was a manager that had been registered and in post for the last fifteen months with regard to 'personal care' and longer for the other regulated activities registered at the location. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we carried out a comprehensive assessment in which all five key questions were inspected. There was considerable improvement in the ‘safe’ and ‘effective’ key questions so they were rated as ‘good’. We found the overall rating for this service to be ‘good’. The rating is based on an aggregation of the ratings awarded for all 5 key questions.

People were protected from the risk of harm because the registered provider had systems in place to detect, monitor and report potential or actual safeguarding concerns. Support workers were appropriately trained in safeguarding adults from abuse and understood their responsibilities in respect of managing potential and actual safeguarding concerns. Risks were managed and reduced on an individual basis so that people avoided injury or harm.

The two shared tenancy premises occupied on the site were safely maintained and there was evidence in the form of maintenance certificates, contracts and records to show this. Support worker numbers were sufficient to meet people’s needs and we saw that rosters accurately cross referenced with the workers that were on duty. Recruitment policies, procedures and practices were carefully followed to ensure support workers were suitable to care for and support vulnerable people. We found that the management of medicines was safely carried out.

We saw that people were cared for and supported by qualified and competent workers who were regularly supervised and appraised regarding their personal performance. Communication was effective, people’s mental capacity was appropriately assessed and their rights were protected.

Support workers had knowledge and understanding of their roles and responsibilities in respect of the Mental Capacity Act (MCA) 2005 and they understood the importance of people being supported to make decisions for themselves. The service manager was able to explain how they worked with other health and social care professionals and family members to ensure a decision was made in a person’s best interests where they lacked capacity to make their own decisions.

People received adequate nutrition and hydration to maintain their levels of health and wellbeing and this was according to their individual preferences and routines.

We found that people received compassionate care from kind support workers who knew about people’s needs and preferences. People were supplied with the information they needed at the right time, were involved in all aspects of their care and were always asked for their consent before workers undertook care and support tasks.

People’s wellbeing, privacy, dignity and independence were monitored and respected and support workers worked hard to maintain these wherever possible. This ensured people were respected, that they felt satisfied and were enabled to take control of their lives wherever possible.

People were supported according to their person-centred support plans. These reflected their needs well and were regularly reviewed. People had the opportunity to engage in a variety of pastimes, activities and social events if they wished to and usually activities were to stimulate, entertain or maintain people’s skills. People had very good family connections and support networks.

We found that there was an effective complaint procedure in place and people were able to have any complaints investigated without bias. People that used the service, relatives and their friends were encouraged to maintain relationships by frequent visits, telephone calls and exchanging information about each others' daily events.

The service was well-led and people had the benefit of this because the culture and the management style of the service were positive. There was an effective system in place for checking the quality of the service using audits, satisfaction surveys and meetings.

People had opportunities to make their views known through their behaviour, conversations with support workers and through more formal complaint and quality monitoring formats if they wished to use these. People were assured that recording systems used in the service protected their privacy and confidentiality as records were well maintained and held securely.

7 June 2016

During an inspection looking at part of the service

The focused inspection of The Retreat took place on 7 June 2016 and was unannounced. We carried out an announced comprehensive inspection of this location in October 2015, against the regulated activities ‘Treatment of disease, disorder or injury’, ‘Assessment or medical treatment for persons detained under the Mental Health Act 1983’ and ‘ Diagnostic and screening procedures’. After that inspection we received concerns in relation to; the use of prone restraints on two tenants, the registered provider’s understanding of Mental Capacity Act 2005 (MCA) compliance, and emergency responses to incidents. These concerns related specifically to two supported living units at The Villa and The Cottage. As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to those topics and only in relation to the two supported living accommodation units. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Retreat - York on our website at www.cqc.org.uk

The Retreat is an independent specialist mental health care provider for up to 98 people with complex mental health needs. It also provides assessment or medical treatment for persons detained under the Mental Health Act 1983. The service is located on the outskirts of York. Since September 2015 The Retreat has also been registered for the regulated activity of ‘personal care’ to provide domiciliary care services to people renting their accommodation under supported living arrangements. This is also provided now on the site of the hospital location, in two units known as The Cottage and The Villa.

People that use this service are not detained under the Mental Health Act 1983 (MHA), and may have learning disabilities and autistic spectrum disorder. It is this regulated activity that sits more comfortably within Adult Social Care provision and so this directorate of CQC was involved in the focused inspection of the service. At the time of our focused inspection there were six people using the service: four females and one male at The Cottage and one male at The Villa.

The registered provider was required to have a registered manager in post. On the day of the inspection there was a manager that had been registered and in post for the last nine months with regard to ‘personal care’ and longer for the other regulated activities registered at the location. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that people were not always protected from harm and abuse because although the registered provider had systems in place to protect people from abuse and staff were aware of their responsibilities to protect people, the registered provider was carrying out restraints and depriving people of their liberty without the proper authorisations in place under the Mental Capacity Act 2005 (MCA) and following authorisations by The Court of Protection.

Several areas of practice at The Cottage and The Villa were being inappropriately carried out: admission of people to the service without ‘best interest’ decisions, use of restraint techniques for prolonged periods of time, seclusion behind locked bedroom doors, inappropriate use of equipment designed to reduce anxiousness for people with autism, such as wrist weights, hand held restraint for the purposes of providing personal care and people reliant on only two-to-one support to access the local community therefore under continuous supervision.

People that live in their own homes or in supported living accommodation can only be lawfully deprived of their liberty when following an order of the Court of Protection. Because people that used the service were not legally detained under the MHA and because the use of DoLS was not applicable to people living in their own homes we would expect that people unable to protect themselves from harm, for example, in the community, would only be subjected to restrictions on their liberty from orders made by the Court of Protection. These had not been applied for when we visited the service for all tenants.

This was a breach of regulation 13 (4) (b) and 13 (5) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It was also in contravention of the requirement to have an order in place from the Court of Protection. You can see what action we asked the registered provider to take at the end of this inspection report.

We found that while there were sufficient staff on duty each shift to meet people’s needs on a day-to-day basis there was a risk that, at times of emergency, insufficient staff were deployed to respond to the needs of people during those emergencies. This had been the case during one incident of restraint where all available staff had been deployed in the restraint and there was no staff member free to raise the alarm. There were alarms in place, however we found that these only linked between the two services, and not to the main Retreat site. This meant that summoning help was reliant on staff being able to access the land line. However, this was a failing of the registered provider’s procedures and practice to manage incidents where people that used the service were at risk of injury or harm and not a concern about sufficient staffing on duty. It was also a failing to ensure that people’s rights were protected. We made a recommendation to the registered provider about this to ensure staff followed robust procedures with regard to their deployment at times of emergency.

There were appropriate risk assessments in place to ensure people were not placed at risk, but at the beginning of the provision of the regulated activity ‘personal care’ there had been some careless omissions in identifying the risk that people presented and put themselves and others at, because of their behaviour.

The registered manager followed recruitment procedures to ensure staff were suitable to care for and support vulnerable adults and we found that staff had not been employed in the service until after their security checks and suitability to work had been cleared. However, we found that one staff member had started work before the provider had obtained their references from the previous employer.

There were appropriate and safe systems in place to manage medication and while some issues regarding medication concerns we saw had been highlighted in a May 2016 medication audit completed by a supplying pharmacist, the unit manager assured us these issues had been addressed and further changes were being considered to further improve on the systems used.

The registered provider had not always ensured that people’s risks relating to their health, safety and welfare had been properly assessed, monitored and mitigated. There was evidence that the staff were not made fully aware of the needs of people that had moved to The Cottage and The Villa in the first few months of the units opening. People had therefore been at risk of harm due to the lack of information and mitigation of risk.

While there was information in people’s care files that evidenced the range of records held about people the registered provider had not always maintained complete and accurate records about, for example, people’s past lives. There was information missing from some records and some documents were missing entirely from the files. We found that MCA assessments had not been fully completed, not all documents had been signed or dated and appropriate / relevant information was sometimes missing.

This was a breach of regulation 12 (1) (2) (a) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the registered manager to take at the end of the inspection report.

27 & 28 October 2015

During an inspection looking at part of the service

We rated The Retreat York as good because:

  • The feedback from people who used the services was generally very positive.
  • The services for people with an eating disorder and personality disorder were using evidence based good practice to help people make progress with their care.

  • The provider had made improvements to create a safe environment. Staffing levels enabled them to provide additional support for patients who were more vulnerable.
  • There was an on-site restaurant and people were positive about the catering arrangements.

  • Staff had access to training and supervision.

  • The provider was working towards improving governance and staff engagement and staff felt opportunities to provide feedback had improved.

However:

  • The medication management needed to improve. The measuring or monitoring of clinic room temperatures was not taking place on Naomi, Acorn and Katherine Allen wards. This meant that staff could not ensure that medicines were not exposed to temperatures higher than 25°C, as medications stored in rooms above this temperature could be less effective. Out of date medication and medicines for patients who had been discharged continued to be stored on the wards. Some patients were prescribed medication to be given as required, without a clear record of the reasons for this medication.

  • Older patients who were at risk of a fall did not have plans in place to ensure this was mitigated by wearing safe footwear. Activities for people with dementia needed to improve to meet their specific needs.

  •  Although there were systems in place for whistleblowing staff did not feel comfortable using them to be assured that their concerns would be addressed.

22 October 2013

During a routine inspection

During our visit we had the opportunity to speak with seven people who use the service. People were very positive about the care and treatment they had received. Comments included, "They have really supported me here and now I am so much better' and 'Staff are lovely. They listen to you. Unlike some places I've been before.'

We looked at the records and talked to the staff working in the hospital. We confirmed that people were supported to give their consent to care and treatment. People also told us they felt involved and included in decision making within the service. We confirmed that care records were person centred and reflected individual choices in their rehabilitation.

We talked with the staff and they confirmed they felt well supported and confident in their role with good training and development plans in place.

We saw that there were good systems in place to listen to people's concerns and everyone was supported to access advocacy services and other help networks. We also saw there were effective systems in place to monitor complaints. People who use the service told us that if they wanted to make a complaint they would know how to. We saw that the hospital recorded all complaints and resolved them where they could to the complainants' satisfaction.

During a check to make sure that the improvements required had been made

When we visited this service in August 2012 and we found that the electronic systems used to manage care were not effective. We were concerned that important information was not being communicated effectively and that people may be at risk of not having their needs safely met.

Following our visit the provider continually kept us informed of the action they were taking to address this. They also showed us the improvements that had been made.

We confirmed therefore that the provider had made improvements to the electronic systems and that important information was being communicated effectively.

7 August 2012

During an inspection looking at part of the service

During the morning of our visit we visited six units at the hospital and in the afternoon we focused on two particular units. The first unit was for elderly patients who were dependent on staff to meet their mental and physical health needs. The second unit was a 'therapeutic community' for women with, "self defeating behaviours, disordered eating and borderline personality disorders".

We spoke to patients on both units and those who were able told us that they were involved in making decisions about their care and support, they felt that the process was inclusive and one person explained 'I'm the first and last person to speak in my review'.

Other patients told us that the staff were, 'Professional' and 'excellent; supportive, challenging and committed'.

Patients also felt they were respected and included in wider decision making in the hospital, they said that they were involved in regular community meetings and they were also included in the recruitment of new staff to the service.

17 November 2011

During a routine inspection

We carried out a inspection of The Retreat over two days, on the 14 and 17 November. On the first day, a team of four inspectors visited the site and on the second day the 17 November two inspectors returned to complete the inspection.

Patients explained how they were informed about and involved in their care and treatment. They described how they attended both multi-disciplinary team and care programme approach meetings where their treatment and care is reviewed by the medical and nursing staff. Some described how they 'attended the whole meeting, from beginning to end'. They explained how they were informed and had been offered the use of the advocacy services.

Most patients told us they were listened to and treated with respect, they explained how staff 'knock on' their doors before entering and are always very 'polite'. Patients generally said they received the care and treatment which met their needs. On two of the units patients made the comments that care is 'excellent' and it is 'more than really good'. They made positive comments about the staff, they said they were 'excellent' and commented how the staff put their 'needs first'. They said the staff are 'supportive' and will 'help them to overcome their illnesses'.

Patients confirmed they attended regular meetings and received twice yearly questionnaires, which asked their views about the service.

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.