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We are carrying out a review of quality at Roseberry Park. We will publish a report when our review is complete. Find out more about our inspection reports.


Other CQC inspections of services

Community & mental health inspection reports for Roseberry Park can be found at Tees, Esk and Wear Valleys NHS Foundation Trust.

Inspection carried out on 22 February 2016

During an inspection to make sure that the improvements required had been made

We did not rate this inspection.

During the inspection we reviewed the provider’s action plan relating to restrictive practice.

  • At the inspection in March 2014, we found people had restrictions in place regarding the use of telephones and visits; these were not in response to individual risk. During this inspection we found that patients were no longer supervised during phone calls and visits unless indicated on their risk assessments

  • At the inspection in March 2014, people told us about their meal time experience and said that if they did not attend for meals on time they were not offered a hot meal and would be given a sandwich. During this inspection we found that patients always had access to a hot meal even if they had missed the meal time.

  • At the inspection in March 2014 we found that the hospital did not always treat people in the least restrictive manner and often enforced boundaries with actions that could be seen to be punitive. For example staff told us that aggressive behaviour spitting and hitting staff was regarded as physical assault and would lead to a person having their leave cancelled. During this inspection we found that there was a positive culture on the wards and actions were no longer seen as punitive.

  • At the last inspection in January 2015 we found that blanket restrictions continued to be in place on some wards. For example, on Merlin, Linnet, Lark and Newtondale wards, patients were subject to routine rub down searches following a period of unescorted leave. These were not carried out on the basis of the risks presented by individual circumstances. During this inspection we found searches were no longer carried out routinely.

  • During the inspection of the learning disability forensic inpatient/secure wards at Roseberry Park Hospital in March 2014 we found there was a breach of Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2010: Safeguarding people who use services from abuse. During this inspection we found learning disability forensic inpatient/secure wards were no longer in breach of this regulation.

Inspection carried out on 26, 27, 28 March 2014

During an inspection to make sure that the improvements required had been made

The visit to Roseberry Park Hospital took place over three days. We looked at seven wards during our inspection and the activities centre.

We spoke with approximately 24 people who use the service, unfortunately people did not have any visitors during our inspection and therefore we were unable to talk with family members and advocates, however we observed how people were cared for, talked with staff and other health professionals and looked at people's records to ensure people were appropriately cared for.

People who use the service talked positively about their experience at Roseberry Park. People told us they were involved in the planning of their care and were also involved in reviews of their progress. People made comments to us such as " the staff are supportive and make the best decisions for me", "The staff are really good I get on with most of them" and "I am involved in my care and feel like my opinions matter." Some people did not make positive comments about the service and told us “staff are overprotective” and “It’s like a prison.”

We looked at how people's care needs were met and considered whether care was safe and appropriate. Although we found many good practices such as people being involved in their care and being supported with alternative methods of communication where this was required, we did find that care was not always planned effectively and staff did not always follow the instructions in people's care plans.

We focused our inspection in areas where we identified concerns during our visit, such as seclusion and restrictions. We found that seclusion was used on occasions to manage complex behaviours rather than manage disturbed behaviour, which could cause serious harm to others or the person concerned. We also found there were a number of excessive and unjustified restrictions in place such as staff monitoring personal visits and phone calls on a routine rather than case by case basis. Appropriate risk assessments had not been completed to demonstrate why restrictions were in place and what the person needed to do to have restrictions removed.

We looked at how people were protected from the risks of abuse and found that the provider had not taken steps to ensure people were protected from the risks of abuse. We found processes to ensure seclusion was not used excessively were inadequate, and we also found restrictions placed on people were not adequately reviewed to ensure people were protected from abuse.

We spoke with people who use the service and asked if they felt safe in Roseberry Park. People told us that they knew how to report incidents of abuse and also knew how to raise any concerns if they had too. People were aware of the services they could contact if they felt abused or vulnerable, such as local advocacy services, the local safeguarding team and the CQC.

Inspection carried out on 14, 21 November 2012

During an inspection in response to concerns

During November and December 2012 we visited a sample of locations for Tees, Esk and Wear Valley NHS Foundation Trust. This was in response to feedback from people who used services, a range of safeguarding concerns, complaints and other serious incidents that had occurred within the trust. We visited Roseberry Park as a part of this sample of locations.

We spoke with the majority of patients on the two wards we visited offering forensic low secure services for people on the autism spectrum. In addition we spoke with the relatives of two people who used the service. We also spoke with three people who had been discharged from the service within the last year.

Overall, we found people’s views and experiences were taken into account in the way the service was provided and delivered in relation to their care. People’s privacy, dignity and independence were respected.

We found that people were cared for in accordance with their needs. Risk assessments were carried out and appropriate care plans were written to manage risks. These were kept up to date because they were reviewed regularly. We found that people had their comments and complaints listened to and acted on, without the fear that they would be discriminated against for making a complaint.

Inspection carried out on 12, 13 March 2012

During an inspection to make sure that the improvements required had been made

The visit took place because we were following up concerns we had raised during the last inspection in October 2011. Prior to the inspection, we had also identified some concerns from information we hold about the service, relating to dignity and respect. We also looked at the governance and quality assurance processes in place to ensure people benefited from safe quality care, treatment and support.

During this visit, we inspected a number of units within the hospital covering low secure forensic learning disability, adult mental health and forensic low secure adult mental health services.

We visited Harrier; Hawk; Kite; Kestrel; Robin; Clover; Ivy and Thistle units from the forensic low secure learning disability service. From the adult mental health service, we visited Beadale, Bilsdale and Overdale. We also visited Newtondale from the forensic low secure adult mental health service.

Low Secure Forensic Learning Disabilities Service

The people we spoke with reported that they were involved in the development of their care plans and that staff offered them a copy should they wish. People said the hospital offered them access to advocacy services, and where people did not have an advocate in place, they told us that they knew whom to contact if they wanted to get one.

Three people told us that they felt that sometimes the staff did not respect their dignity. However, they understood that the risks they presented meant this had to happen to maintain their own safety. Some people reported that they did not feel safe on the ward, because of the risks from other people staying on the unit. People told us “staff talk to me regularly” and “staff listen to me.”

People we spoke with said that their leave and activities were sometimes cancelled. When asked if staff gave a reason for any cancellations two people told us that they were not given a reason. Other people said to us that they were told staff shortages were the reason. Some people reported that they were escorted outside of the grounds, but that their visits were often shortened due to staff shortages.

Low Secure Forensic Mental Health Service

One person in the Newtondale ward was unhappy. They said leave was sometimes cancelled; they did not like the food; and, did not like the staff apart from their named nurse.

Adult Mental Health Service

The people we spoke with told us that staff talked to them about their care and treatment. “I’m looking forward now, I’m clear about the next steps and staff have talked to me about it” and “Staff talk to me about the care and explain any potential side effects.” People were very knowledgeable about their medications and treatment plans.

People told us about activities on units. One person told us “It’s a PICU (psychiatric intensive care unit) ward so there is not lots to do.” Another person told us “There are board games, quiet rooms and DVDs.”

One person told us “They try their best to facilitate what you want, sometimes staffing levels are difficult with leave, but they try to get cover to allow you to have your leave when you want it.” Another person said “I’ve got 2 hours escorted leave coming up, I want to get down to Middlesbrough town centre.”

People told us they are able to get up any time they like, and can have a shower or shave whenever they want to.

One person we spoke with reported that they had one to ones with staff and that “it’s nice to talk to someone, any issues or problems and the staff try to sort it out for you.” People also told reported that the staff are always there to speak to about any concerns.

Inspection carried out on 26, 27 October 2011

During a themed inspection looking at Learning Disability Services

Patients told us they knew what was written in their care plans. They had a chance to talk about their care plans at care planning approach (CPA) meetings.

Relatives told us that they were always invited to the CPA meeting and they felt that communication had greatly improved over the last twelve months. Staff always spoke to their relative with respect.

Patients told us their access to activities and home leave had been reduced because of staff shortages.

Patients thought that staff were fair and they felt safe at Roseberry Park.