19 and 20 December 2023
During a routine inspection
This was the first inspection of this service. We rated it as requires improvement because:
- The ligature risk assessment was held electronically. Numerous staff had not seen this. There was no information on the wards to indicate high risk areas.
- Not all agency staff profiles detailed mandatory training received and so we could not be assured that all agency staff were appropriately trained.
- The service did not have an employed occupational therapist. We were concerned that patients were not receiving meaningful and therapeutic activities.
- Staff lacked knowledge around the Mental Capacity Act despite having received training. Records of capacity were not consistently detailed.
- Not all care plans were personalised and lacked individual goals, aims and interventions.
- Not all patients had been involved in their care planning.
- Some staff had difficulty accessing and navigating the electronic records system.
- Patients could not have access to fresh air as and when they wanted. Most windows across the hospital could not be opened.
- Governance processes needed to be strengthened to ensure ongoing monitoring of the quality of the service.
However:
- The ward environments were safe and clean. The wards had enough nurses and doctors. They minimised the use of restrictive practices and managed medicines safely.
- Staff developed a range of care plans which were updated regularly.
- Managers ensured staff received training, supervision and appraisals. The ward staff worked well together as a multidisciplinary team and with those outside of the hospital who would have a role in providing aftercare.
- Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
- The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.