We rated the Cygnet Elms as outstanding because:

• Positive risk taking and least restrictive practice was embedded within the culture of the unit. Patients were actively involved in managing their own risks using risk assessments, positive behavioural support plans and worked collaboratively with staff. There were systems in place to ensure safe medicines management. Patients told us they felt safe.

• Elms had enough staff with right qualifications, skills and training and experience to keep people safe and to provide high quality care and treatment. Patients told us they felt safe at Elms. The manager proactively recruited to ensure there were no gaps in service provision and staff could undertake handover of work to ensure consistency for patients.

• Elms had a good track record on safety. Staff learning from incidents was based on a thorough analysis and investigation. Staff knew what and how to report. All incidents were shared daily, analysed by staff and patients. Learning was shared within the hospital, regionally and nationally.

• The managers at Elms had introduced a model of care that promoted patients’ recovery, comfort and dignity. Staff worked with patients to create excellent care plans that were, holistic, recovery focussed and person centred. They wrote these care plans in the voice of the patient. Staff reproduced care plans and other documentation in easy read formats for each patient. The multidisciplinary team provided a clear care pathway through the service from admission to discharge.

• Staff provided high quality care and treatment. All patients had access to psychological therapies, occupational therapy and speech and language therapy. Different professionals worked well together to assess and plan for the needs of the patients. Patients were fully supported to be involved in care planning and setting their own recovery goals. Staff used outcome measures to assess the effectiveness of treatment interventions. Staff routinely supported patients to address their physical health care needs.
• Staff understood and focussed on least restrictive practice. Elms had a least restrictive practice group, completed restrictive practice audits and sought to use the least restrictive approaches when managing challenging behaviour. Patients were involved in shaping least restrictive practice through governance and community groups. We found no evidence of blanket restrictions. The providers had a transparent policy on the use of restrictive interventions, with an overarching restrictive intervention reduction programme with board-level lead.

• Doctors sought to reduce the use of medications. Staff supported the STOMP pledge to reduce the long-term use of anti-psychotic medicines without the appropriate clinical justification. All patients who were on anti-psychotic medicines had a care plan in place with the rationale for prescribing, reduction plan and side effect monitoring.

• We saw evidence of best practice in the application of the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). All staff we spoke with had a comprehensive understanding of the MHA, the MCA, Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice.

• All staff were kind, caring, passionate and optimistic about their work. They fully involved patients in decisions about their care. We saw positive, professional and respectful interactions between staff and patients during our inspection. Staff showed patience and warmth. Staff and patients shared humour and were relaxed with each other whilst maintaining professional boundaries. Patients knew the staff well and were complimentary about all the staff at the Elms.

• Governance structures were clear, well documented, followed and reported accurately. There were controls for managers to assure themselves that the service was effective and being provided to a good standard. Managers and their teams were fully committed to making positive changes. We saw changes had been made to maintain improvements in quality using audits. The service had clear mechanisms for reporting incidents of harm or risk of harm and we saw evidence the service learnt from when things had gone wrong.

• The staff team were committed to providing active support to patients. Helping patients to be actively, consistently and meaning fully engaged in their own lives regardless of their support needs. One example of this was staff supporting patients exercise their civil rights to vote and become active member of society. They supported patients to get involved with projects at the hospital and wider community. For example, helping staff with clinical audits and undertaking voluntary work in the local community.

• Staff ensured that all information was accessible to patients. This involved the use of a variety tools to enable patients to understand, regular staff training, taking a personalised approach to every patient. We saw excellent examples of easy read boards with additional talking buttons and personalised communication plans to enable staff to support patients with capacity assessments.

• The staff team were committed to improving and taking part in innovative practice. Some staff had agreed to be a ‘patient’ for the day. This project was evaluated and adapted and outcomes used to improve the experience for patients. We saw excellent evidence of learning and developing projects throughout the provider region and sharing of ideas and good practice across sister units.

• Elms invested in and was responsive to the needs of staff, which resulted in excellent staff morale. Staff routinely received supervision, annual appraisals and reflective practice. Staff compliance with mandatory training was 100%, they were supported to develop their skills and career by the provision of additional specialist training. For example, support staff were fully supported to complete care certificate training or join a nurse apprenticeship scheme.

• Elms routinely sought feedback from patients, carers and staff. They made changes to reflect feedback. An example of this was the development of the sensory room. During the inspection patients told us the only thing missing from the Elms was WIFI and broad band television. Mangers had listened to this and were reviewing available options.

• Elms was well led. The manager monitored systems in place to ensure effective service delivery, whilst being accessible and supportive to all staff. All staff we spoke to commented positively about senior management and told us they were visible and accessible. Staff felt valued.

We rated Cambian Elms as good because:

• The hospital environment was safe, clean, well maintained and furnished. It provided a variety of rooms and environments to carry out therapeutic and leisure activities. The hospital had a homely feel to it. Patients were able to personalise their bedrooms and felt comfortable within the environment.
• There was a comprehensive programme of individual and group activities to help patients achieve their recovery goals. Activities were available seven days a week and during the evenings.
• There were robust risk assessments and management plans in place for each patient. Positive behaviour support plans were in place for all patients. Staff had a good understanding of each patients needs.
• Care plans were personalised, recovery focused and holistic. All patients had a copy of their care plan. Care plans were presented in a way that was accessible to each individual patient.
• Patients and carers were fully involved in the planning and review of their care and treatment.
• All patients were supported to self-administer medication. There was a culture to continually review the need for medication to be prescribed and there was good monitoring of physical health care.
• Patients had access to a range of health care professionals who were skilled and received regular training to develop clinical skills.
• All staff received supervision and appraisal.
• The local management of the hospital provided effective leadership and support to the staff team. The staff team was supportive of each other and worked collaboratively to meet the needs of patients effectively.
• There were good governance systems in place which linked smoothly with regional and provider level governance systems. A patient representative participated in the hospital governance meeting. The hospital manager told us that they promoted an atmosphere of transparency and candour. Staff we spoke to reflected this and we observed many examples throughout the inspection.
• The Mental Health Act policy had been updated to reflect the changes within the MHA Code of Practice 2015. All staff had received training on blanket restrictions and promotion of least restrictive practice.

There were nine people who used the service on the day of our inspection. All people had been detained there under the Mental Health Act 1983. We spoke with seven people, one of their relatives, ten members of staff and the registered manager.

People were involved in their care planning and were asked how they wanted to be supported to meet their needs.

Staff had the information they needed to know how to support people to meet their individual needs. We saw that people's needs had been assessed by a range of healthcare professionals and people's healthcare needs had been monitored and met. One person said, “Staff are good here, it’s really nice here and doesn’t feel like a hospital.”

All people spoken with told us that they felt safe at the hospital. Systems were in place to ensure that people who used the service were safeguarded from harm. We observed that people were at ease in the company of staff.

Appropriate staffing levels were maintained to ensure people’s needs were met. Staff had the skills and knowledge to know how to safely support people who used the service to meet their needs. One person said, “Staff are always around to help you, I like all the staff here.”

People were asked for their views about the hospital and these were listened to. We saw that audits were completed and action was taken to make improvements where needed.