We rated Burton Park as requires improvement because:

• Staff did not follow the provider medicines management policy. We found three tubes of topical creams in the fridge on Warwick Lodge which staff had opened but had not labelled with the patient’s name.

• Managers did not ensure there was adequate medical cover to prescribe essential medication. One patient had been admitted to the hospital when no medical cover was available. Therefore, essential medication had not been prescribed and the provider could not ensure the patient was safe.

• Managers had not ensured all ligatures on Cleves Lodge had been included on the ligature risk assessment. We found ligature points in three bedrooms. Ligature points are places to which patient’s intent on self-harm might tie something to strangle themselves. Staff did not always adhere to the infection control policy regarding separating clinical waste from general laundry.
• There were insufficient numbers of substantive staff which resulted in the provider using large numbers of temporary staff. The average vacancy rate for qualified staff across the hospital was 48% the vacancy rate for unqualified staff was 43%.

• Staff did not follow the providers incident reporting policy. We found that one patient had not received their medication on five consecutive occasions. This was not reported at the time, we raised this with the ward manager who assured us that it would be reported immediately.

• Managers did not ensure information to deliver care was available to all relevant staff. Temporary staff had read only access to the electronic patient record, which meant they could not update records.

• Clinical documentation was not always reviewed and clearly recorded. Staff had not reviewed 10 out of 17 (59%) risk assessments inspected within the timescales set out in the providers policy. Staff did not always clearly demonstrate whether patients had received a copy of their care plan.

• Practice did not promote the least restrictive environment. We found a blanket restriction in place at the time of inspection. The minutes of the hospital clinical governance meeting which stated that patients would not be allowed to drink caffeinated products from September 2018.

• There was poor communication and governance structures in place. There was a lack of regular staff meetings taking place. Staff told us there had been no staff meetings for several months due to staff shortages, Staff were not aware of the governance structures in place to support best practice. We found a lack of regular community meetings and poor processes for sharing lessons learned.

However:

• Clinic rooms were visibly clean and had enough space to prepare medications, physical health observations were undertaken in patient bedrooms. Physical health monitoring equipment had been calibrated and staff carried out weekly checks to ensure it was in good working order. Staff checked emergency resuscitation equipment on a daily basis and recorded this appropriately.

• Patients had their own bedroom with an en suite shower room. Patients had personalised their room with pictures and soft furnishings and had access to lockable cupboards in which they could store valuable possessions. Patients were individually risk assessed for their suitability to have a key to their bedroom door.

• The hospital had a range of rooms and equipment to support treatment and care. This included quiet rooms for family visits, activity rooms, therapy rooms and a gym. Patients had access to outside space. Patients could make phone calls in private in their bedroom using their mobile or the ward cordless phone.

• The hospital kitchen provided a wide choice of meals for patients which included catering for specific dietary requirements. Healthy options were available and these were clearly displayed in dining rooms. Snacks and drinks were available 24 hours a day. Staff encouraged patients to make them for themselves wherever possible.
• Staff treated patients with kindness, compassion and respect. We observed interactions between staff and patients during the inspection and saw that staff were responsive to patient's needs and were respectful. Staff treated patients with dignity and remained interested when engaging patients in meaningful activities. Staff interacted with patients at a level that was appropriate to individual needs.
• We spoke with eight carers of people staying at Burton Park, six of which spoke highly of the care their relative received. Carers told us they were generally involved in their relative’s care planning reviews and received regular updates to any changes in their care plans, where the patient had consented to their information being shared.