We rated St Augustine’s Hospital as good because:

• Patients told us that they felt safe. Staff carried out environmental risk assessments in areas such as health and safety, fire safety, access to therapy rooms, the gym, use of any equipment and infection control and prevention.

• Staff were trained in safeguarding and demonstrated a good understanding of how to identify and report any abuse. They had established links with the local authority safeguarding leads.

• The ward had appropriate arrangements for the management of medicines. We found good links between St Augustine’s hospital and the local Lloyds pharmacy.

• The hospital practised excellent monitoring of physical health and healthy lifestyle promotion. Patients had regular physical health checks that included heart checks carried out on site and blood taken by staff for tests. Staff encouraged patients to participate in physical exercises and attend healthy lifestyle group. The hospital maintained close links with a local general practitioner (GP).
• Patients had access to psychological therapies as part of their treatment as individuals or group therapy. The doctors had access to information from National Institute for Health and Care Excellence (NICE) guidance updates that they shared with the clinical team.
• Staff carried out a range of clinical audits to monitor the effectiveness of the service provided. For example, care planning, risk management, information governance medicines and health and safety.
• Staff showed positive engagement and willingness to support patients. We saw that staff interacted with patients in a relaxed, kind and respectful way.
• Staff involved patients in their clinical reviews and care planning and encouraged them to involve relatives and friends if they wished.
• Staff encouraged patients to maintain independence. For example, patients were encouraged to self-administer their medicines.
• All discharges and transfers were discussed in the multi-disciplinary team meeting and were managed in a planned and co-ordinated way.
• There was a range of activities offered to patients. Each patient had an individual structured programme of activities.
• Staff offered and supported patients with the choice of food they wanted to meet their dietary requirements and their health, religious and ethnic needs when required.
• Staff told us that they felt supported by their managers. They said the manager was accessible to staff, approachable and had an open door policy.
• The hospital had effective governance processes to manage quality and safety.
• Staff were open and transparent and explained to patients if and when something went wrong. The manager discussed incidents with patients and their families.

However:

• The provider did not review and updated the Mental Health Act (MHA) policies and procedures to reflect the revised MHA code of practice. Training records reviewed indicated that 64% of staff had received training in MHA.

• Where the clinical team had reviewed levels of risk, they did not always update the management plans to reflect the changes in risk.

• The on call rota was at times covered by a doctor who covered a large geographical area of the organisation’s hospitals. This could have a significant delay for the doctor to arrive on site when required.
• Care plans did not document patients’ views about their care and treatment. The care plans were generic and not specific to patient’s individual needs.
• Patients’ confidentiality was not always maintained; two patients reported that at times some staff discussed other patients in communal areas.
• Our discussion with staff and records observed showed that there was no clear and formal process of learning from complaints and incidents.
• The door to the garden area was always locked and patients would ask staff to access the area. This garden had a smoking shed and patients had strict smoking times.
• The hospital did not have a clear formal way on how the information on performance of the service was shared with all staff and patients.

In this report the name of a registered manager, Mr John Keegan appears, who was not in post at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time. The provider has notified us of this and we are working to remove this name from our register.

People who used and visited the service told us that they were happy with the care at St Augustines Hospital. One person who used the service said, “So far, so good, I’m treated very well.” Another person said, “The staff are brilliant, they look after you and help you get yourself together.” One relative told us, “The staff listen and take on board what we say.” Another relative said, “X is involved in his care at ward rounds and monthly meetings. He can contribute and ask for things. He can push for things that haven’t happened.

We observed that people received the care and treatment they were required to meet their individual needs. Care and treatment was delivered in a professional and friendly manner which ensured people’s safety and welfare. One person told us, “The nurse does the dressing on my foot every time.”

We observed that the service worked with other providers to compliment the care and treatment that the people who used the service received. A visiting professional told us, “I’ve always felt that my opinions have been valued and they have been listened to.”

We saw that the provider did not have effective systems in place to ensure their staff members maintained up-to-date registration with the relevant professional body. We saw that records were; individualised, accurate and up-to-date. This ensured that the people received the care and treatment they required.

People told us they were happy staying at St Augustines Hospital. One person said, “My time here has been ok. I get to go out as much as I want to”. Another person said, “Its good care here. I have had no problems”. Relatives also told us they were happy with the care being provided. One relative said, “The staff are on the ball”. Another relative said, “I’m very happy with the care my relative has had”.

During our inspection we saw that people’s consent to care and treatment was gained in accordance with legislation.

We saw that people received the care and treatment they required to meet their individual needs. This care and treatment was delivered in a professional manner which protected people’s rights and kept them safe.

We saw that medicines were stored and administered safely, protecting people from the risks associated with them. People were encouraged to take responsibility for their own medicines when appropriate which meant that people’s independence was promoted.

We saw that there was enough skilled staff on duty at all times. This ensured that people received the care and treatment they required.

We saw that there was an effective system in place to respond to any comments or complaints and we saw that people had access to advocates to ensure that their rights were protected.

The hospital was purpose-built in the summer of 2009 and provides high-quality accommodation. Furnishings and equipment are to a very high standard and all bedrooms have en-suite shower facilities. The hospital was bright, comfortable and welcoming.

There are places for up to 32 male patients and the hospital is secure. When we visited there were 25 people in residence. All were detained under the Mental Health Act 1983.

A wide range of activities are lead by the occupational therapy team who work to produce a tailored programme providing individual support, with sufficient staff for people to achieve their personal goals. The main objective is to provide rehabilitation for patients. The average length of stay was 18-24 months.

During our visit some people were involved in external activities. Three had spent the morning horse-riding and one person was on overnight leave at home.

We spoke with at least half the patients who told us about their life at St. Augustine’s. They were keen to tell us how they spent their time. They understood fully their status as detained patients but most focussed upon the positive motivation to obtain “Section 17 leave.” People are only able to leave the hospital if leave is approved by the responsible clinician who must approve leave under Section 17 of the Mental Health Act 1983.

In practice the majority of people were accessing the community, people progressing through different levels of leave ranging from 1:1 escorted with a member of staff, unescorted group leave and ultimately unescorted leave as they made progress in their rehabilitation programme.

People gave us examples of activities in the community that included: attending local colleges, cinema, swimming, social club, football bowling and a range of other leisure activities through to local museums and Alton Towers.

A patient who had to return to the hospital following a trial in the community under a community treatment order told us why things had not worked out for him and why he now had restricted leave. We asked him about his care and treatment, he said, “The staff are really good to us, they treat us like they would their own family”.

Throughout the day of the inspection visit there was a very relaxed atmosphere. Some people were involved in activities, others were not. Some spending time in the main communal areas, talking, playing pool and other games. We observed good levels of engagement and communication between patients and staff at all levels. We saw that a potential for escalation of behaviours was identified swiftly by staff who sensitively defused the situation.

People we spoke with were generally positive about the service and the staff group. Comments included: “I have been here 18 months and want to stay.” “Yes, I like the staff, they always listen and do their best for me.” “I go out a lot into the community and do the things I like, staff used to come with me but now I can go alone, they obviously trust me.”

We rated St. Augustine’s Hospital as good because:

• Since the last inspection, the provider had updated its policies to reflect the changes in the revised Mental Health Act Code of Practice issued in April 2015.
• The hospital was purpose built and had a clean and safe environment. Staff mitigated any risks presented by blind spots and ligature points through individual patient risk assessments and close observations.
• The hospital was modern, spacious and purpose built with a wide range of facilities to meet patients’ needs, for example, ensuite bedrooms, an IT room, an occupational therapy kitchen, a gym, a prayer room, and ample outdoor space. The hospital also had well equipped clinic rooms that held the appropriate emergency equipment.
• The hospital had a wide range of skilled staff who were suitably qualified and experienced for their roles. The hospital had good staffing levels and a stable staff team. Staff reported good morale, team working and mutual support. Staff described the hospital manager as a strong leader with an open door policy.
• Staff completed comprehensive physical and mental health assessments to identify patients’ needs and risks. Staff completed holistic care plans that fully captured their patients’ needs, and risk management plans underpinned by a positive behavioural support model.
• Staff encouraged patients to develop and maintain independence. Patients had rehabilitation-focused activity plans that promoted self-care and helped them develop their daily living skills.
• Staff treated patients with dignity and respect. Staff showed a strong commitment to person-centred care and knew their patients well. Patients felt staff listened to them and provided them with appropriate emotional and practical support.
• The catering staff offered patients food that met their specific needs and preferences. This included special diets such as vegetarian or halal and consideration of health issues such as nut allergies or diabetes.
• Staff reported incidents and safeguarding concerns appropriately. Staff received feedback and lessons learned from investigations of complaints and incidents. Staff received debriefs and support following serious incidents.

However:

• Capacity to consent to treatment assessments and clinical notes did not always include records of the detail of the discussions between the clinician and the patient.
• Care plans did not always show clinical goals and outcomes specifically related to each patient’s recovery and rehabilitation.
• Staff did not always record when patients refused physical health checks for conditions such as diabetes.