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

Southleigh Community Independent Hospital

Overall: Good read more about inspection ratings

42 Brighton Road, South Croydon, Surrey, CR2 6AA (020) 8256 0906

Provided and run by:
Glancestyle Care Homes Limited

All Inspections

8 and 9 September 2022

During a routine inspection

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

  • Patients told us they felt safe. 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 cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The multidisciplinary team included or had access to a range of specialists required to meet the needs of patients. Managers ensured that these staff received training, supervision and appraisal. The staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service worked to a recognised model of mental health rehabilitation.

However,

  • NEWS2 charts were not being completed correctly and there were gaps in recording. There was no system in place for auditing the charts.
  • Cleaning records for the clinic room did not show when physical health equipment had been cleaned.
  • There were a high number of nursing and support vacancies that were covered by bank and agency staff.
  • There were some gaps in the provision of the specialist training that all staff needed to work with the current patient group, for example, on topics such as epilepsy and diabetes. Records of emergency scenario simulation training were not available.
  • The service did not always escalate concerns to clinical governance meetings and the risk register.

14 May 2019

During a routine inspection

We rated Southleigh Community Independent Hospital as good because:

  • The service was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Ligature risks had been assessed and fire safety arrangements were in place.
  • Staff assessed and managed risks to patients and themselves. Staff followed best practice in anticipating, de-escalating and managing behaviour which challenged. As a result, they used restraint only after attempts at de-escalation had failed and this was very rare. Staff participated in the provider’s restrictive interventions reduction programme.
  • Staff understood how to protect patients from abuse and/or exploitation and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and/or exploitation and they knew how to apply it.
  • The service had a good track record on safety. The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff provided care and treatment interventions suitable for the patient group, there was a good programme of rehabilitation in place. Staff ensured that patients had good access to physical healthcare.
  • Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The team had effective working.
  • Patients were partners in their care. All patients were involved in developing their care plans. Patients attended ward rounds and were supported to arrive at decisions. Patients’ views were incorporated, even when they differed from the clinical teams. No decisions were made about any aspect of care or treatment without the involvement of the patient. All patients had a copy of their care plan and care programme approach documents.
  • There was a strong, visible person-centred culture. Staff encouraged patients to take the lead on different activities as part of their progress. For example, one patient was lead on the art therapy group.
  • Staff empowered patients to have a voice and realise their potential. Patients were involved in decisions about the service. There was a patient representative for the service. The patient representative regularly attended the clinical governance meeting and also got involved in interviewing potential new staff for the service. When rooms were redecorated, patients decided on the colour. Patients also decided parts of the activity programme and the menu.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Staff helped patients with communication, advocacy and cultural and spiritual support. Advocates attended the service, and meetings, to support and represent patients.
  • Staff actively encouraged families and carers to be involved. The social worker took the lead on this and was in regular contact with families and carers. Patients were supported to maintain positive relationships with them during their time at the service.
  • The service treated concerns and complaints seriously, investigated them and invited patients and/or their carers to discuss their concerns with management.
  • The service had a model of care and staff understood how to put this into practice. There was a pathway for rehabilitation which outlined timeframes and what the patient could expect from the service.
  • Governance systems were in place which supported the delivery of high-quality care. Regular meetings took place within the service to discuss overall performance and learning from recent safeguarding and other incidents. Regular audits were undertaken, and improvements made as a result.
  • The team had access to the information they needed to provide safe and effective care and used that information to good effect.

However:

  • Staff had limited understanding about how to support the needs of patients with protected characteristics, for example sexual orientation, and there was little information available to these patients to make them feel included and welcomed into the service.
  • Whilst most patients had a length of stay of 1-2 years there were a small number of patients who had been admitted to the service for several years. The provider was actively working with commissioners to support them to move to more appropriate settings but it had proved a challenge to find another service that was willing to accept them.

19 and 20 August 2015

During a routine inspection

We rated Southleigh Community Independent Hospital as good because:

  • Patients were partners in their care. No decisions were made to any aspect of care or treatment without the involvement of the patient.
  • Patients’ care plans were written in plain English and were specific and detailed. There was a strong recovery focus to care plans. Care plans were evaluated thoroughly and demonstrated patients’ progress.
  • Patients were involved in decisions about the service, including redecoration, the activity programme and the menu. A patient representative attended some of the hospital management meetings.
  • The service had launched a family support service, tailored to the needs of relatives and carers. The service was flexible including home and evening visits.
  • When there were not enough ward staff to escort patients on leave, members of the mutli-disciplinary team escorted the patients.
  • Patients’ bedrooms were redecorated before they were admitted. Where required, a new carpet was fitted.
  • Where patients had progressed more quickly than expected, staff brought forward care programme approach meetings. This was to minimise the chance of the patient’s discharge being delayed.
  • Members of the MDT had their offices in patient areas. Patients were welcome to approach staff in their offices, unless a sign indicated they were busy.
  • The hospital management team had developed a culture focussed on safe, high quality care.
  • Staff morale was high. Staff felt able to do their job, and there was a strong sense that staff felt supported by the management team.
  • Staff said they could confidently raise concerns and were sure they would be responded to appropriately.
  • The governance system was robust with appropriate oversight from the quality and governance committee. There was an ongoing focus on quality and safety.

However:

  • There were some gaps in recording decisions regarding medicines management.
  • The majority of staff had little understanding of the Mental Capacity Act.
  • All patients were required to provide alcohol and drug tests as a standard practice.
  • There was one very small visiting room
  • Patients using the patient phone could not do so in privacy.

29 January 2014

During an inspection looking at part of the service

This visit was a follow up to an inspection visit we made on the 4th December 2013 with a Mental Health Commissioner. At that time we made a compliance action which related to quality assurance. This meant we had not considered the provider had enough checks in place to monitor the quality of their own service particularly with regards to medication and the paperwork which related to formal patients.

A compliance action meant the provider was non-compliant with the law. We required the provider to produce a report setting out how and when they would become compliant, which they did, and we visited again on the 29th January 2014. Following our visit to the service we considered they had done enough to comply with the law and have therefore removed the compliance action.

We would advise the reader to look at the much fuller report produced for the inspection carried out on the 4th December 2013.

4 December 2013

During a routine inspection

We carried out this unannounced inspection together with a Mental Health Commissioner who focussed on detained patients. The Commissioners findings are available on the CQC website as a separate report.

On the day of our inspection, Southleigh had twenty people who used the service, 14 of whom were formal patients detained by the Mental Health Act. This meant that there were some restrictions placed on them to do with their liberty.

We were able to talk to a number of people who used the service, they told us that they felt safe living at Southleigh. People felt that their views were listened to at the weekly community meetings, via the advocacy service and that if they wanted to make a complaint they knew how to.

We made a compliance action which related to quality assurance, this meant we did not consider the provider had enough checks to monitor the quality of their own service particularly with regards to medication and the paperwork which related to formal patients. A compliance action means that the provider was non-compliant with the law. We have required the provider to produce a report setting out how and when they will be complaint, and we will visit the service again to make sure that they are.

23 January 2013

During a routine inspection

We carried out this unannounced inspection alongside a Mental Health Commissioner who focussed on detained patients. The Commissioners findings are available on the CQC website as a separate report.

The inspector was able to speak to six out of the 22 people resident, numerous staff including ancillary staff, professionals attached to the service and the registered manager.

Three people who use the service were positive about Southleigh. We received comments such as, 'this is a nice place' and 'the staff are very helpful and reassuring'. In general, people made some very positive comments about the staff, singling out some for particular praise.

Three other people that we spoke to did not feel as positive about Southleigh. When we looked into this further, they commented that there was not good atmosphere which they put down to another resident. We discussed this with the manager who agreed that the hospital would look into this with the advocacy service that came into the home on a monthly basis.

All the paperwork that we looked at was up to date and relevant. People who use the service knew that they had care plans and what was written in them.

We received many positive comments about the choice and quality of food. People with special dietary requirements were catered for including vegetarians and diabetics.

24 November 2011

During a routine inspection

On balance the people we spoke to at Southleigh Community were satisfied with the standard of care and support they were receiving.

People felt that they could express their views and that they would be listened to; this was either via the patients meetings held three times a week or on an individual basis by talking to staff.

We received some very positive feed back about the staff including, 'staff are good, they are a team' and 'my primary worker looks after me.' Staff are supported to do their jobs with training and regular supervision. Some individual staff were singled out by people who use the service as being exceptional in the care that they gave, for their ability to listen and for treating people with dignity and respect.

Staff are well trained and supported to undertake their work.

Southleigh Community is a modern, well maintained environment, furnished to a high standard with many homely touches. One person told us, 'it a top quality hotel'.when I moved in they gave me a new carpet and bedding'.

We received many positive comments about the choice and quality of food on the wards. People with special dietary requirements are catered for including vegetarians. The hospital are in the process of building a kitchenette area where people can help themselves to drinks throughout the day.

The main area that the hospital needs to focus on is care planning; although the plans are well written, there needs to be evidence that people are involved in deciding what their needs are and how best they can be achieved. The plans need to be individualised, looked at regularly and changed when necessary. This will help to ensure that the care and/or treatment people using the services always meets their needs, as well as protects their rights.

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.