We carried out a focused, unannounced inspection of Chesterholme to review the remedial actions taken by the provider in relation to two regulatory breaches. These breaches were identified at the last comprehensive inspection of the hospital in August 2015. This report was published in February 2016. As the focused inspection took place within six months from publication of the comprehensive inspection report, we have re-rated the safe domain.

The regulatory breaches related to the lack of a female only lounge and out of date clinical equipment.

At this inspection we found that:

• A female only lounge was available for female patients. Patients confirmed that this room was always available for female patients to use and that male patients did not use this facility.
• Staff were completing daily checks of clinical equipment. The registered manager reviewed these on a weekly basis to ensure they were completed.

However:

• The checklist used for daily checks of clinical equipment did not include oxygen masks. We found oxygen masks in the clinic room that had expired.
• The weekly check by the registered manager did not include an audit of the accuracy of the daily check of clinical equipment.

We rated Chesterholme as requires improvement because;

• There were insufficient staff on duty to ensure patients were able to have dedicated one to one time with their named nurse. Staffing figures did not allow staff to respond to incidents and maintain the required observation levels for patients at all times. Staff were regularly injured as a result of incidents.
• Patients were not provided with the level of meaningful activity as described in the provider’s policy each week. Staff who were observing patients did not make efforts to engage patients in activities.
• There was a failure to deal with specific risk issues like falls. Staff did not review and update risk assessments and risk management plans regularly. Agency staff were not familiar with the patients and this resulted in incorrect treatment.
• Incident forms were not completed correctly and there were often several incidents recorded on the same form. Statutory notifications were not always completed as required by the Health and Social Care Act. Senior staff were not always aware of what incidents required reporting.
• The internal teams did not work effectively and required the activity co-ordinator to pass information between the teams.
• Staff did not receive regular clinical supervisions in line with the provider’s policy. Staff did not feel respected, valued and supported. Staff were fearful of reporting concerns and incidents due to concerns about their jobs. Staff were not always provided with debriefs or support after incidents.

However;

• Permanent staff displayed a caring approach to patients and encouraged them to participate in activities outside the service.
• Staff participated in an annual audit schedule to ensure the safety and quality of the service provision.
• Access to the service was well managed and there were always beds available when patients returned from leave.
• The service was clean and tidy with good furnishings.