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

255 Lichfield Road

Overall: Good read more about inspection ratings

Bloxwich, Walsall, West Midlands, WS3 3DT (01922) 694766

Provided and run by:
Partnerships in Care 1 Limited

All Inspections

During an assessment of Long stay or rehabilitation mental health wards for working age adults

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.

During an assessment of the hospital overall

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.

25th to 26th September 2017

During a routine inspection

We rated 255 Lichfield Road as Good because:

  • The service routinely completed assessments of the environment to ensure the safety and wellbeing of staff and patients.
  • Risk assessments and care plans were detailed, reviewed frequently and identified patients strengths and goals. Patients and carers were involved in care planning and review meetings and we saw a focus on recovery and discharge planning by the clinical team.
  • Local and regional governance structures were in place to ensure that quality of service delivery was monitored by senior managers. The service reported on a range of key performance indicators and there was evidence of shared learning with other hospitals in the organisation.
  • Patients had access to a range of staff to meet their physical health, psychological and rehabilitation needs. The service used nationally recognised rating scales and assessments to identify patient need and monitor improvements in patients' wellbeing.
  • There were sufficient staff with suitable qualifications and skills to support patients. Sickness levels were low and the registered manager was able to access bank and agency staff where needed.
  • Attendance at mandatory training was high and was monitored by the registered manager. All eligible staff had received an annual appraisal and accessed regular supervision and peer support.
  • Staff were aware of their responsibility to report incidents and had received training in the safeguarding of children and adults.
  • Staff adhered to the Mental Health Act Code of Practice and restrictions placed on patients were based on an individual assessment of risk and need.
  • Staff described morale as excellent and reported a culture of mutual support and team working. The registered manager was described as accessible, responsive and patient focussed.

12th-13th October 2015

During a routine inspection

We rated 255 Lichfield Road as good because:

  • All areas were clean and well maintained and furniture was in good condition and comfortable.
  • Staff completed a risk assessment of every patient on admission and updated them regularly. All risk assessments included crisis plans.
  • All of the care plans we reviewed were thorough, holistic and recovery focussed.
  • Care plans were tailored specifically to the needs of the patient and included physical health and vocational goals
  • Staff were using the Lester tool to assess the cardio-metabolic health of patients experiencing psychosis and schizophrenia.
  • A psychologist recently joined the service and was developing a psychological intervention pathway for patients in line with the 2014 NICE guidance for the prevention and management of psychosis and schizophrenia in adults.
  • During the inspection we observed care from staff that was respectful and promoted dignity and choice.
  • A multi disciplinary approach to assessing the suitability of referrals to the service was taking place.
  • There was a full range of facilities to support treatment and care.
  • Patients told us that concerns were dealt with promptly and effectively by staff and that they received feedback following this process.
  • Regular supervision had not been happening in the service. The new manager had identified this and developed a supervision strategy, with other senior staff to resolve this

However:

  • The electronic records system had not been updated following the change in service provider. The manager had requested that the new providers' "care-notes" system be integrated within the service and training made available to staff.
  • Effective communication with local services providing physical healthcare for patients was not consistently happening. Medical and nursing staff from the service had met with the local GP practice to improve this but it had not been fully resolved at the time of our inspection.
  • Two staff raised concerns about poor exterior lighting in the self contained bungalow area, which made them feel vulnerable when working night shifts. This was fed back to the manager following our visit.