255 Lichfield Road

Updated 19 November 2025

255 Lichfield Road is a 28 bed long stay rehabilitation service for males and females. The service consists of two four bedded enhanced recovery and rehabilitation units for people who may require more intensive and structured support and twenty self contained bungalows that enable people to live independently with additional therapeutic structure where needed.

We carried out an on site assessment on the 29 and 30 July 2025 and asked for and reviewed data relating to the assessment.

We carried out this inspection as it had not been inspected since December 2017. At the last inspection we rated the service as good overall and good in all key questions.

We rated the service as good overall. The hospital was clean, well maintained and care was delivered in a suitable environment which focussed on rehabilitation and community living. Staff completed risk assessments for patients and updated these regularly. Care plans guided safe practice. People were supported to have choice and control and were involved in planning their care and could give feedback on their care.

However,

We found 1 breach of regulation in relation to good governance. The provider had not ensured CQC were notified of a change of manager, had not ensured that staff received appropriate supervision to enable them to carry out their duties and did not have effective communication systems and processes, that staff understood, to enable escalation of requests for additional staff.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 1 April 2025

255 Lichfield Road is a 28 bed long stay rehabilitation service for males and females. The service consists of two four bedded enhanced recovery and rehabilitation units for people who may require more intensive and structured support and twenty self contained bungalows that enable people to live independently with additional therapeutic structure where needed.

We carried out an on site assessment on the 29 and 30 July 2025 and asked for and reviewed data relating to the assessment.

We carried out this inspection as it had not been inspected since December 2017. At the last inspection we rated the service as good overall and good in all key questions.

We rated the service as good overall. The hospital was clean, well maintained and care was delivered in a suitable environment which focussed on rehabilitation and community living. Staff completed risk assessments for patients and updated these regularly. Care plans guided safe practice. People were supported to have choice and control and were involved in planning their care and could give feedback on their care.

However,

We found 1 breach of regulation in relation to good governance. The provider had not ensured CQC were notified of a change of manager, had not ensured that staff received appropriate supervision to enable them to carry out their duties and did not have effective communication systems and processes, that staff understood, to enable escalation of requests for additional staff.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

All staff were trained in the Mental Health Act, the Code of Practice and the guiding principles. When discussing some aspects of the Mental Health Act some staff did not demonstrate a full understanding of how it worked in practice.

The provider had relevant policies and procedures that reflected the most recent guidance.

Staff had access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were. Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

We were informed that there had been some recent organisational changes regarding access to advocates but patients told us that they had not been impacted by this.

Information on people's rights to advocacy was not clearly displayed in the hospital. However, patients were informed that they were entitled to advocacy and staff would support to contact the local advocacy if required. We were told by staff and patients that advocates did not always attend meetings even when requested.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded this clearly in patients’ notes.

We saw evidence of information documents on patients’ rights available in communal areas for both informal and detained patients. The provider displayed a notice to tell informal patients that they could leave the ward freely and how to do so.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted. We saw that staff clearly documented where this had been granted.

We saw evidence in care plans of staff requesting an opinion from a Second Opinion Appointed Doctor (SOAD) when they needed to. Staff told us that patients access to SOAD’s was challenging due to the length of time it could take to get a response to their request but they consistently used procedures to escalate this.

Staff stored copies of patients’ detention papers and associated records correctly and staff could access them when needed.

Mental Capacity Act

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

All staff were trained in the Mental Capacity Act and demonstrated understanding of how this worked in practice.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Care records show that there was a clear understanding around mental capacity and best interest decisions. People were appropriately supported to know their rights and make decisions that were safe and in the best interests of the person.

The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.