We rated Thors Park as inadequate because:

• Safety was not a priority. The provider did not have sufficient oversight to ensure the clinic room was maintained safely. Staff did not ensure the clinic room was organised, clean or tidy. Staff did not manage medications appropriately, dispose of expired medications and numerous miscellaneous items or replace equipment. The provider had not ensured the replacement of an oxygen cylinder despite being aware that it had remained empty since November 2018 or an ambu bag (a manual resuscitation bag) that had expired in 2011. The provider had not ensured the repair of the clinic room door. This compromised the security of the clinic room which led to a patient forcibly accessing the room during our inspection. As the clinic room door remained faulty and no temporary solution had been put in place, this remained a risk to patients and staff. The provider did not ensure the timely maintenance of the alarm systems. Staff were unable to know the location of a raised alarm without viewing the alarm panel in the nursing office as the panel in the ward area was inaccurate. Not all staff responded to the alarm when it was pulled. Staff reported personal alarms as faulty since August 2018. Although the provider had repaired and replaced staff personal alarms, staff continued to raise concerns that their alarms did not always work effectively. We were not assured of the provider’s oversight and responsiveness to the safety of staff and patients. There were no effective system for identifying, capturing and managing issues and risks.

• Staff did not manage risks to people who use the services. Managers and staff missed opportunities to prevent or minimise harm. During the inspection, staff did not maintain enhanced observation levels for two patients as specified in their care plans and in line with the provider’s observation policy. This issue had been identified in a recent focused inspection but the provider had not addressed our concern. We were therefore not assured that the provider had managed the risks posed by or to people using the service. Staff did not intervene in situations of challenging behaviour towards the inspection staff during the inspection. Managers were aware of staff’s reluctance to intervene during incidents involving one patient and said they were providing training on this patient’s positive behaviour support plans and provided training on how to maintain boundaries. Restraint records were not accurate. The provider had not ensured that staff were recording physical restraints used during incidents. We found three incidents where staff did not record the type of physical restraints used during an incident. Managers were unable to know the type and frequency of physical restraints used.

• The provider had not ensured they maintained parts of the environment adequately. Some parts of the environment were dull and required re-painting. Two patients’ bedrooms had damaged radiator covers that had not been repaired and one bedroom was very worn and damaged. The activity room was bare, required redecoration and was not conducive to therapeutic activities.

• The provider had not ensured that staff were up to date with all mandatory training including safeguarding children training which 74% of staff had completed and Mental Health Act training which 67% of staff had completed. The provider had not ensured their staff had met their target of 80%. Managers did not provide staff with regular supervision or appraisals. Data showed that 50% of staff received supervision and 21% of eligible staff received an appraisal in the twelve months prior to the inspection.

• The service did not always meet people’s needs. Staff did not ensure they had records of care and treatment reviews. This meant they had limited records of actions required to support patients’ discharge. When people complained about the service, the response was poor and the quality of investigations into complaints were poor. The provider did not always use their terms of reference for investigating. We reviewed four investigation reports, they lacked clarity about what was being investigated and investigators had not used all evidence available to form a judgement.

• Managers had no oversight of significant issues that threatened the delivery of safe and effective care. Issues were not always identified and adequate action to manage them was not always taken. Managers had not identified issues in the clinic room and staff continued to report personal alarms as faulty despite the provider repairing these. Staff continued to leave patients who required constant enhanced observations despite this being raised in a recent focused inspection. These issues compromised staff and patient safety.

We rated Thors Park as good because:

• The provider ensured there were sufficient staff on duty for safe care and treatment of patients. The provider had significant vacancies for support workers; however, agency staff were block booked, where possible, to ensure continuity of care for patients. Data provided showed no shifts were left unfilled. New staff, including agency staff, received an induction to the service before working with patients. Staff were in receipt of mandatory training, clinical supervision and appraisals. The manager had introduced a new supervision model.
• We observed kind and compassionate interactions between staff and patients. Staff showed a good understanding of the individual needs of the patients and treated them with respect and dignity. Staff showed passion for their work with patients.
• Patients had access to advocacy services and staff involved families and carers in discussions around care and treatment. Staff supported patients to access information about local services, patients’ rights and how to complain.
• Staff were aware of safeguarding procedures and made referrals when necessary for the protection of patients. Patients told us they felt safe in the service. Staff completed holistic and recovery focused care plans and positive behaviour support plans. Staff completed risk assessments on admission and updated regularly and after incidents. Staff knew how to report incidents and managers completed investigations. Staff were aware of their responsibilities under duty of candour and we saw evidence that these principals were followed, when required.
• Staff prescribed medication in accordance with National Institute for Health and Care Excellence guidelines. Medication was stored and administered appropriately and in accordance with the appropriate legal authority. Staff completed and stored Mental Health Act paperwork correctly.
• Staff completed capacity assessments in accordance with the Mental Capacity Act 2005 and held best interest decision meetings for significant decisions.
• The provider had a full range of rooms and equipment to support care and treatment for patients. Patients were able to personalise their bedrooms if they wished and had access to lockable storage within their bedrooms. The provider had a seven day activity programme displayed in ward areas and in patient notes. Patients had access to outside activities, such as a climbing wall and swimming. Work placements were also available.
• The service was well led at local and regional level. Senior managers demonstrated a commitment towards continual improvement and innovation and had worked hard to improve the culture of the hospital and morale of staff. The provider had a robust rolling audit programme to monitor the effectiveness of the service. The provider had ongoing plans for refurbishment at the hospital to improve the quality of the estate.

However:

• The provider had not fully completed the services ligature risk assessment. Staff did not have all the detail for the safe management of patients at risk of self-harm.
• The provider had not ensured the emergency equipment was fully accessible. The sink in the clinic room was stained and did not meet infection protection and control guidance. The provider had not ensured all emergency equipment was in good working order. One defibrillator did not have the required pads and the suction machine was broken.
• Staff had not ensured all areas of the hospital were clean and some damaged areas had not been repaired.
• Staff did not always fully complete records of physical health care monitoring for patients.
• Patients remained in the service for long periods. The provider reported an average length of stay for patients of 1825 days.
• The provider did not always ensure all staff received feedback of outcomes of investigations from within the service or from other sites.

We rated Thors Park as requires improvement because:

• There was little evidence seen in regional meeting minutes regarding lessons learned from incidents or complaints.

• The window handles in the conservatories were not anti-ligature and there were some exposed wires by the fascias in the garden on Thorrington ward.
• The provider used a large number of agency staff and from 01 June 2016 to 31 August 2016; 29 shifts had not been covered. This meant that the wards did not have safe staffing levels on these days.
• Patients had not signed their care plans. Staff and not recorded whether a copy had been given to the patient.

• Staff had not recognised or recorded two episodes of seclusion in accordance with the Mental Health Act Code of Practice.
• The provider had not ensured that when a patient lacked capacity to make decisions, decisions made on their behalf were not documented appropriately.
• Staff compliance with mandatory training was low at 64% of staff up to date with mandatory training. The providers target was 80%.

However:

• Since the last inspection Thorrington ward had been renovated; the bedrooms, lounge, dining area and corridors had been decorated and there was new furniture and sanitary ware. The provider was due to bring Brightlingsea ward up to a similar standard, although no date was given when the works would be completed.
• The provider held staff profiles on agency staff members that worked on the wards. These contained qualifications, disclosure and barring service (DBS) records, references and training records.
• The provider used an electronic recording system to update patient records in the weekly multi-disciplinary team meeting.
• Staff showed a good understanding of the individual needs of the patients, and we observed good interactions between staff and patients.
• The provider provided easy read multi-disciplinary meeting forms for patients to complete prior to them attending the meeting to give feedback to the team.
• We saw good evidence of patient involvement in the recruitment of staff, for example being a part of the interview panel.
• We observed proactive discharge planning in the multi-disciplinary meeting. The provider ensured patients’ beds remained available following return from periods of leave.
• The provider was a member of the Award Scheme Development and Accreditation Network, which was designed to develop alternative education provision.
• Notes were observed to be patient centred and holistic.
• We saw six medication charts which all had consent to treatment forms attached.

We saw that people were actively encouraged to participate in their individual treatment programme and that they accessed specialist therapies and other support from staff. This demonstrated to us that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Staff reported that there were good opportunities for training and career development. This demonstrated to us that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

There were appropriate arrangements in place for ensuring that people were safeguarded against harm or abuse.

There were appropriate arrangements in place to ensure that people were protected from the risks associated with receiving mediciation.

The provider had effective systems in place to monitor the quality and safety of service that people received.

We did not directly speak with people about the outcome that we inspected during this follow up inspection, however we observed that people were happy and at ease within their environment.

People told us that the care they receive is generally good and told us that they liked the staff and thought that they understood their needs well. We saw that the rapport between the people and staff was positive. We saw people laughing and joking around, all of the interactions we saw looked to be completely genuine.

We did not rate the provider during this focused inspection as we did not cover all aspects of each domain. CQC last rated the provider at the comprehensive inspection, published 16 January 2018, when the service was rated as ‘good.'

We found the following issues that the provider needs to improve:

• The provider had not ensured that there were sufficient staff on duty for safe care and treatment of patients. There were insufficient staff on duty and staff were not always able to take breaks during their shift. Information provided about staff allocations showed that the provider often used staff intended to relieve others for activities such as driving.
• Staff did not always complete enhanced observations correctly. They did not follow observations in accordance with patients’ care plans, the provider’s policy or the strategies identified in positive behavioural support plans. Staff did not always engage with patients whilst on observation and did not always use physical intervention techniques in line with their training.
• Staff did not ensure that they updated care plans and risk assessments according to their own procedure. The provider had not ensured that best interest decisions made for patients who lacked capacity under the Mental Capacity Act were decision specific.
• The provider did not complete investigations according to their agreed procedure. Descriptions on incident report forms did not always match closed circuit television footage. Two closed circuit television cameras were not working correctly. The provider did not always respond to complaints in a timely manner and the provider did not always apologise when their own investigation found them to be at fault.
• Staff did not always ensure that they monitored patients’ physical health. We found that staff completed physical health monitoring of patients on admission however, they did not always update this.
• Three of the eight staff we spoke with stated that they would not feel comfortable to raise concerns without fear of victimisation, and did not feel listened to.

However, we found the following areas of good practice:

• We observed some positive interactions with patients. Staff used several different methods to communicate with patients. Patients had access to advocacy services. Patients had access to activities, escorted leave and could keep in contact with their families.
• Staff completed a two-week induction period, including shadowing other staff members, prior to working directly with patients on the wards.