• The management team checked and reviewed staffing levels. Managers could adjust staffing levels to meet the needs of the wards. However, when cover for shifts could not be arranged staff felt unable to meet all the needs of patients.

• When two qualified nurses were on duty during the day shift, staff felt under too much pressure to complete their workload and spend enough time in the apartments with patients and support workers.

• We observed staff who knew individual patients well, the staff and patient interaction we saw seemed familiar and comfortable.

• The patients we spoke to told us most staff cared, were kind and spoke to them nicely. However, two patients said that at times some staff looked for arguments and could be rude to them.

• Staff reported incidents. Staff reviewed and analysed incidents at a range of meetings across the hospital.

We rated Bradley Woodlands Low-secure Hospital as good because:

• The hospital had clear criteria for accepting referrals, ahead of admissions a pre-assessment was completed and reviewed by the team to ensure the provision would meet the needs of an individual.

• Following admission named nurses spent time with patients involving them in care planning within a recovery pathway. We saw examples of individualised care documents containing graphics and adapted language that made them accessible to patients.

• Individual care planning in relation to risk and staff awareness of patient’s current risk levels seemed high. There was evidence that clinical risk assessments were regularly updated, live documents that contained good examples of multidisciplinary team formulations.

• Staff knew how to report incidents and there was evidence of sharing lessons learned. Over long days, all staff believed teamwork was positive, with staff pulling together for support, especially following an incident.

• Patients were encouraged to chair their own multidisciplinary team meetings using prompt cards to follow the agenda. At the meeting we attended, the patient was empowered to speak about their concerns, and given time to say what they wanted to.

• Mental capacity assessments and paperwork relating to best interest decisions used language that reflected the patient group and showed questions revisited to assess the patients’ understanding and retention.

• Advocacy was available on site three days a week; staff in this service knew all the patients in the hospital and held a clear separation between their independent role and that of the hospital team.

• Visitors’ rooms were private and available for patients to use to make phone calls and see visitors. Relatives described staff as being supportive and accommodating when arranging for them to visit.

• Staff were aware of key messages from management about patient centred care and positive behaviour support showed commitment to work towards this.

• Before the end of the first inspection day all emergency equipment had been checked, was in date and returned to the clinic room with signage to indicate this. A laminated list of the contents of the emergency box was available.

However,

• Emergency equipment had not been consistently stored in the places indicated by notices so any staff unfamiliar with the hospital would not know where to find it. Emergency equipment needed checking regularly to ensure it remained suitable for use, until inspection on 9 August 2016, there was no evidence this had happened since March 2016. There was no content list with the emergency equipment box, a number of items had expired and some items appeared used and unsterile. It is important items are sterile and in date when used to ensure optimum performance and to prevent infection.

• There had been a gap from March to August 2016, in the regular monitoring of fridge temperatures to ensure the safety of medicines that could not be explained. Regular clinical audits took place to monitor a range of practice, although internal and external medicines audits had been completed neither had identified medication issues found on the first day of inspection.

• The patients we spoke with told us staff were polite and most spoke to them nicely, though others did not because they shouted.

• Staffing levels were checked and reviewed by the management team and could be adjusted however, on days with only two qualified nurses staff felt under too much pressure to complete their workload. There was a mismatch on a day shift between the stated establishment of qualified nurses required and the number determined by the providers staffing ladder.

• Over three months 36% of section 17 leave was cancelled, whilst this was rearranged whenever possible, at the time of cancellation this caused distress to both patients and relatives

• Complaints made by patients were listened to and recorded by managers, however; we saw no recording of investigations having taken place. Copies of letters written in response to patients complaints were formal and it was unclear how accessible this format would be to the patient on receipt.relatives

• Systems contracted by the hospital, for example the contract to deliver physical healthcare to the patients did not always work effectively, with issues raised by staff taking some time to be resolved.  

When we inspected the service on 10 October 2013 we found patient's legal paperwork was not always correct in relation to their consent to treatment under the Mental Health Act 1983 (MHA). We received an action plan which detailed all the improvements the provider planned to make.

We re-visited the service with the Mental Health Act commissioner to check that the necessary improvements had been made. We did not speak with any patients during this follow up inspection; the main focus of the visit was to review the quality of the records.

We found improvements had been made to the quality of the care records; we found staff were now completing assessments of patients' capacity to consent to their treatment. We also found the language used in the care plans was much less restrictive.

Records showed patients were given accurate information about their detention and these records were easily accessible and well maintained.

Improvements had been made to the recording of discussions between the responsible clinician and the patient about their treatment. However, we still found some inaccurate recording of treatment authorised under the MHA.

We visited the service to follow up improvements since our last scheduled visit in June 2013.

We saw evidence of warm, respectful relationships between staff and patients as we walked around the hospital and observed that many patients participated in a range of activities. Patients we spoke with were positive about the support they received from the service. One patient said, "I like it here, staff help me." Another told us they felt safe and said they felt they had made good progress whilst using the service.

Patient's legal paperwork was not always correct in relation to their consent to treatment.

Some patients told us that activities and formal leave arrangements had improved a lot, but that there continued to be some occasions when things were cancelled due to low staffing levels. Comments included, “Activities have changed because we get out more,” “I get my leave” and “I’ve had one lot of leave cancelled because of staff shortages, but it was a while ago.”

We found staff had received more specialist training and supervision to support them to carry out their work.

Improvements had been made to risk management in the hospital to support positive outcomes for patients.

In this report the name of the registered manager appeared who was not in post and not managing regulatory activities at this location at the time of the inspection. Their name appeared because they were still on our register at the time. A new manager had been appointed.

We spoke with people who used the service and they told us that they were satisfied with the care and treatment they received. They also said they felt safe at Bradley Woodlands. Comments included, “I agree with my care plan and I have chaired my own review”, “Staff treat me with respect and keep me calm” and “I feel safe here.”

However, several people also said there were some things they were not happy with and told us, “When the nurse call is pressed, care staff switch it off and walk away”, “I feel that no-one listens to us” and “If I’m unsettled they take my TV away and I feel like I’m being punished.”

We saw that restrictions were in place and some practices were controlling and felt punitive. Although the care and treatment was planned, delivered and overall met the basic needs of people who used the service, we were concerned about the high numbers of physical interventions or ‘restraint’ used. We saw records that showed incidents were recorded. However, we found that not all incidents had been reported appropriately and there was a lack of evidence to show these had been analysed and this showed us the service was not effectively monitored.

We saw that the environment was clean and hygienic and some bedrooms were personalised.

People told us that activities did take place, but were often cancelled due to staff shortages.

We have not spoken directly to people who use services in assessing the outcome areas for this review. The Mental Health Act Commissioner spoke to people using the service during the visit and people told him that they felt safe.

We rated Bradley Woodlands Low Secure Hospital as good because:

• The hospital had systems in place to protect patients from harm. Staff identified and managed risks appropriately. They recognised safeguarding concerns and had effective engagement with the local safeguarding procedures.
• The hospital met good practice standards described in relevant national guidance for prescribing medications safely. Patients received their medications as prescribed and attendeded regular reviews. Staff kept accurate records of medicines.
• There was a full range of disciplines to input into the hospital. Staff received the appropriate training and regular supervision to provide safe and effective care to patients. There was effective multi-disciplinary team working with respect for each role.
• Patients received a comprehensive assessment of their needs, which included physical health. Staff ensured care plans were up to date, holistic and recovery focussed.
• Staff had effective systems in place to ensure the hospital adhered to the Mental Health Act 1983, the Mental Health Act Code of Practice and applied good practice with regards to the Mental Capacity Act 2005.
• Patients were involved and encouraged to be partners in their care. The hospital used appropriate language and easy read material to aid the patient’s understanding. They were involved in their care plans and contributed to, or chaired their review meetings.
• The hospital was clean and tidy with comfortable facilities that promoted independence. There was a full range of rooms and equipment to support treatment. Staff supported patients in the planning and preparation of their meals taking into account specific dietary needs.
• Patients knew how to give feedback about the hospital and felt confident to complain if required. Staff explored complaints appropriately and informed patients of the outcome.
• The organisation’s governance structure ensured effective communication from the hospital to board level and vice versa. There were effective systems in place to monitor performance, share good practice and manage risks.

However:

• Staff occasionally cancelled or postponed planned or escorted leave due to lack of resources.
• Staff did not always monitor the keys for the clinic fridge appropriately.
• Staff did not have specific care plans or protocols in place to manage bathing for patients with epilepsy or for carrying out restraint on asthmatic patients.
• Staff did not always consider confidentiality when discussing patients in communal areas.
• Some staff were unclear about the new provider’s vision and values.