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Inspection Summary

Overall summary & rating


Updated 24 January 2018

We rated Three Valleys Hospital as good because:

  • Safety was a high priority for the service and the measurement and monitoring of safety was a robust and continual process of improvement. Patients had detailed and thorough risk assessments in place which staff updated regularly. There were clearly defined and embedded systems and processes in place to keep patients safe and safeguard them from abuse. People received their medicines as prescribed and medications and equipment were stored safely. When incidents occurred staff recorded them well, investigated them appropriately and they utilised the learning of lessons to ensure improvements in safety.
  • Staff planned and delivered care and treatment to patients in line with national best practice guidance. A clinical improvement schedule was in place to monitor practice and ensure improvements were made. Where audits identified a need for improvement we saw that staff made changes. Patients had comprehensive and holistic assessments of the entirety of their needs and the service gave high priority to the monitoring of patient’s physical healthcare needs. Staff used legislation such as the Mental Health Act and Mental Capacity Act appropriately and monitoring systems were in place to measure and improve their use. The service supported staff to deliver effective care and treatment by providing them with supervision, appraisal and opportunities for reflective practice. The service had a strong multi-disciplinary team who worked together to produce holistic care and treatment plans for patients.
  • Feedback from patients and carers was positive about the why staff treated people. We observed care that was kind and compassionate and saw that staff knew the patient group well. Patients on the rehabilitation wards were encouraged to become active partners in their own care and in the running of the service. In the rehabilitation services staff used a variety of ways to encourage patients to give feedback about their care and treatment. In the specialist dementia service we saw examples of exceptional care where staff had gone the extra mile to provide comfort and care to patients.

  • The service was responsive to the individual needs of patients and made reasonable adjustments for patients with specific needs. People had discharge and recovery plans in place to support effective discharge and the service was focussing on a renewed focus for discharging patients more quickly where it was appropriate to do so. The service needed to continue to ensure this focus was embedded to enable us to see sustained improvement in the discharge of patients from the hospital. Patients on the rehabilitation wards were not restricted and staff gave them opportunities to enhance their skills for independence. Patients on all wards were able to access a variety of activities, which were planned to meet their individual needs, interests and support their recovery plans.

  • The service was well led. The senior leadership team were experienced and qualified and had robust governance systems in place to manage, monitor and maintain the safety of the service. The service had a clear statement of its vision, values and its strategy for the future. Senior leaders were aware of the challenges faced by the service and had implemented plans to meet these challenges and prevent them from having an impact on the care and treatment of patients. The leadership team modelled the culture of the service which was one of openness and transparency. They embedded least restrictive practice for patients and a sustained focus on driving improvement by learning lessons from incidents and complaints. There was a clear pathway from ward level governance to organisation wide governance and a clear system for reporting from ward to board and back to the staff teams. Staff told us that their managers were approachable and that morale within the service was increasing. The management team had responded quickly to staff morale concerns on Oakwroth ward and made significant improvements.


  • The service was not always able to provide facilities which promoted the comfort, dignity and privacy of patients. However, the hospital director explained that the service was due to start a period of renovation which the provider supported and that these renovation plans would address all of these concerns within the next twelve months. Work had already begun on the replacement of doors on Oldfield ward.
  • The service did not always follow best practice guidance in relation to the use of do not attempt cardio pulmonary resuscitation forms on Oakworth ward. They were also unable to provide adequate psychological therapy services due to an ongoing vacant post for a qualified psychologist. Staff used a risk assessment tool which did not meet the needs of the patient groups.
  • Patients in the specialist dementia service were not asked to give feedback about their care and it was difficult to ascertain how they and their families had been involved in the planning of their care. Oakworth ward was not discussed in the service’s admission leaflet and therefore specific information was not available to patients and their carers.
  • Although the service was safe we found that staff needed to make improvements in their recording. Particularly in relation to the planning of leave, and the recording of patient physical health observations. service needed to ensure that local and national policy in the provision of emergency drugs on site were clear to staff to reduce the risk of error.
Inspection areas



Updated 24 January 2018

We rated safe as good because:

  • Staff adhered to infection control and hand hygiene procedures. Staff had undertaken environmental and ligature risk assessments and the service managed fire safety well, undertaking regular fire evacuation tests.

  • All wards had access to emergency and disaster grab bags and staff had access to emergency equipment such as defibrillators and ligature cutters.

  • Although staffing had been a challenge for the service, shifts ran at safe establishment levels the majority of the time, and the clinical governance lead had a robust system in place to monitor this.

  • Patients were able to have regular one to one with staff and there was adequate cover from doctors and to respond to incidents.

  • Medication management and record keeping and storage was good, other than one medication omission on Oldfield ward. Pharmacists visited all wards regularly and carried out detailed audits and we saw improvements as a result of these audits.

  • All patients had risk assessments in place which staff updated regularly and the system for assessing and mitigating patient risk was clear and well managed.

  • Staff were up to date with mandatory training.

  • The use of restrictive interventions was low across all wards. Staff did not use prone (chest down restraint) and all other restraints we reviewed used only low level restraint such as low level arm holds. Staff had not used seclusion or rapid tranquilisation with any patients. The hospital had a least restrictive culture and staff were skilled in de-escalation. When staff used restrictive or physical intervention they recorded it appropriately and the management team reviewed all incidents.

  • All staff knew how to report incidents, and senior members of the team reviewed these. Senior managers always shared lessons learned with staff and following a serious incident we saw that staff had implemented changes to practice. The system which the provider used for reporting incidents merged with the patient daily record which meant that patient records and risks were continually updated and could be reviewed by staff.

  • The senior leadership team had responded promptly when staff raised concerns about morale and patient care being affected by staffing levels.


  • The clinic room on Oakworth ward was not entirely clean and was also disorganised. Clinic rooms on all wards were small and did not contain examination couches for patients.

  • The hospital did not entirely follow guidance regarding the management of do not attempt cardio pulmonary resuscitation notices because they were photocopies which did not contain the original signature.

  • Ligatures risks in communal bathrooms were not included in the ward’s ligature risk assessment.

  • The service used the historical clinical risk (20) assessment tool with all patients. This tool did not support the risk assessment of the patient group and is widely used in forensic services.

  • The service had a local policy for the use of emergency drugs with patients, which did not entirely match with the provider’s national policy. This may cause confusion for staff in emergency situations.

  • Less than 75% of staff on Oakworth ward had been trained in the management of violence and aggression. However, the provider had a plan to manage and improve this, and an interim management plan to ensure the safety of patients.



Updated 24 January 2018

We rated effective as good because:

  • The service employed a registered general nurse who was responsible for ensuring patients’ physical healthcare needs were met. The physical health of patients was high priority for staff and underpinned by a physical health strategy.

  • The service provided patients with care in line with national best practice guidance, and monitored patient outcomes using recognised ratings scales.

  • Staff had up to date appraisals and received regular clinical supervision. They were also able to participate in regular reflective practice sessions on all wards.

  • The service had a good system in place for the management of the Mental Health Act and Mental Capacity Act and Deprivation of Liberty Safeguards. All staff had received training in both Acts and were able to explain their principles.

  • Staff had completed capacity assessments and undertaken best interests discussions when patients did not have capacity to make specific decisions about their care and treatment.

  • A highly skilled on site multi-disciplinary team worked collaboratively with patients to produce detailed care plans for patients.


  • Care plans did not always reflect the involvement of relatives and carers in the patient’s care and treatment.

  • The air locked door on Oakworth ward meant that not all informal patients were able to leave at will and the provider had introduced this as an additional safety measure but were not entirely clear that this was the least restrictive option for all patients.

  • There was a vacant post for a lead psychologist at the service, this meant that patients were unable to access all psychological therapies and the service lacked a long term psychology model. However, the provider continued to make efforts to employ a qualified lead psychologist.



Updated 24 January 2018

We rated caring as good because:

  • Patients, and their relatives and carers spoke positively about the care staff provided and described them as kind, compassionate and responsive.

  • Staff were caring, and we saw kind and compassionate interactions between patients and staff. Staff treated and spoke about patients in a dignified manner.

  • Care delivered ensured the entirety of patients’ needs was equally important.

  • Patients had access to the support of advocacy. Advocates were highly visible around the hospital and visited all wards at least once per week.

  • Where patients had made advance decisions about their care and treatment staff had worked with these patients to ensure they could meet their needs and wishes.


  • Community meetings on Oakworth ward for older people with mental health problems were not in place at the time of the inspection.

  • Carers told us that they did not always feel involved in the care of their relative, particularly on the rehabilitation wards, and communication from staff outside of planned meetings was not always good and impacted by the use of temporary staff on Oakworth ward.

  • The hospital admission leaflet did not include information about Oakworth ward to support patients and their carers.



Updated 24 January 2018

We rated responsive as good because:

  • Staff planned all discharges and admissions to the service thoroughly and involved the input of the patients, their commissioner and the entire multi-disciplinary team.

  • Patients were not restricted; they were able to access facilities such as skills kitchens and communal patient laundries on the rehabilitation wards in order to prepare them to build their skills for independence.

  • Patients were able to make drinks and snacks throughout the day and night and had personalised bedrooms.

  • The service was able to meet the needs of all people who used the service by providing access to outside spaces, access for those with mobility needs and onsite catering facilities which could meet the needs of patients with specific dietary needs.

  • Staff had gone the extra mile on Oakworth ward to meet patient’s individual needs by considering their history, needs and wishes to ensure they were able to maintain a good quality of life and be cared for in a manner in which they chose.

  • Patients had access to a wide range of activities which were highly individualised to meet their needs with the support of the occupational therapy team.


  • The facilities available to patients at the hospital did not always promote comfort, dignity and confidentiality. Four patient bedroom windows did not have privacy film. However the hospital director showed us a plan for renovations at the hospital to take place within the next twelve months, which they confirmed would address all of these issues identified and which they senior leadership were already aware of.

  • Although patients and carers knew how to make complaints and the service had a clear system for managing them. Staff did not always keep patients updated about delays, and did not always ensure that were investigated fairly and independently.



Updated 24 January 2018

We rated well-led as good because:

  • The overall governance of the service ensured the safe management of the hospital. There was a clear pathway between ward level governance, hospital level governance and provider wide governance.

  • The leadership team had a clear strategy for the service, and were aware of concerns and risks within the service. Where we identified issues during the inspection, the service had already recognised these areas and had plans in place to manage them.

  • Staff felt supported and valued and spoke positively about the leadership team and the provider as a whole. Staff felt able to raise concerns without fear of victimisation.

  • The service used a variety of tools and audits to measure the quality of the service and identified themes and trends from this data to continually improve the service.

  • The service was aware of their own risks and challenges. All areas of concern drawn from the measurement of data and key performance indicators had action plans in place to improve quality and safety.


  • Accurate and contemporaneous records were not always kept for all patients, such as in regards to their physical health observations and in leave planning.

Checks on specific services

Long stay or rehabilitation mental health wards for working age adults


Updated 24 January 2018

Wards for older people with mental health problems


Updated 24 January 2018