We rated Wast Hills as good because:

• Staff carried out environmental risk assessments in areas such as health and safety, access to therapy rooms, use of any equipment and infection control and prevention.
• All units carried out comprehensive assessment of needs when patients were admitted. This included a detailed risk assessment and risk management plan that were updated regularly after every incident. These were based on positive behaviour support approach.
• Staff were trained in safeguarding and demonstrated a good understanding of how to identify and report abuse. Staff knew how to recognise and report incidents through the reporting system. Learning from incidents was shared with staff.
• In the records we checked we saw details of regular physical health checks and that staff continued to monitor health. Staff were trained in different areas of physical health such as dysphagia, postural positioning and epilepsy.
• Patients could access psychological therapies as part of their treatment. For example, anxiety management and therapeutic support programme recommended by the National Institute for Health and Care Excellence.
• Staff treated patient with respect and dignity and they were polite, kind and willing to help. Patients and families were happy with the support they received from the staff and felt that they got the help they needed.
• Staff involved patients in their clinical reviews and care planning and encouraged them to involve relatives and friends if they wished. Patients and their families told us that they could access advocacy services when needed.
• All discharges and transfers were discussed in the multi-disciplinary team meeting and were managed in a planned and co-ordinated way.
• Patients told us that the quality of food was good and meal times were flexible. Patients were supported in maintaining contacts with families by use of Skype and other information technologies. Care was personalised to meet individual needs.
• Staff used a variety of communication tools to help individuals communicate their needs. Families and carers told us that they could raise any concerns and complaints freely.
• Staff told us that they knew how to use the whistleblowing process and felt free to raise any concerns. Staff were offered the opportunity to give feedback on services through the annual staff surveys.
• The unit used performance indicators to gauge the performance of the team. The managers put action plans in place where performance did not meet the expected standard.
• Staff were open and transparent when things went wrong. Incidents were discussed with patients, their families and care managers. Staff felt supported by their managers.

However:

• Not all electrical equipment was checked regularly to ensure it continued to be safe to use.
• The unit did not have arrangements with the pharmacist to specifically audit or monitor prescriptions to ensure doses were safe. The Pharmacist had no direct input into clinical care.
• Staff did not record patients’ advance decisions. These are decisions made by patients earlier about how they wanted to be treated at some time in future.
• Patients were not actively engaged in meaningful activities that promoted their independent living skills. Not all patients in the Main house had access to the kitchen and laundry room. The activities appeared to focus more on leisure.
• Wast Hills had information on the number of incidents reported, episodes of restraint and safeguarding, which they analysed for trends and themes. They did not share this information with staff or patients so they could know how the unit was performing.

There were five people staying at The Annexe, five people at Wast Hills House and two people at The Lodge on the day of our inspection. Three people were detained at the hospital under the Mental Health Act 1983. We spoke with three people who used the service, nine members of staff and one relative who visited during our inspection.

Since our last inspection the provider and the registered manager had changed. Due to these changes and safeguarding investigations that had been undertaken by the local authority the provider had chosen to limit the number of new admissions. This meant that the hospital was under occupied because the provider wanted to ensure they met the needs of the current people who used the service before they admitted others.

We saw that people who used the service and their relatives were involved in their care. People were supported to have an advocate to help them to be involved.

People's mental capacity was assessed. This ensured that if people did not have the capacity to consent to their care and treatment this was given in their best interests.

Staff had the information they needed in order to support people to meet their individual needs. We saw that people's needs had been assessed by a range of health professionals and their healthcare needs were monitored and met.

People spoken with told us that they felt safe there. Systems were in place to ensure that people were safeguarded from harm.

We saw that people were given their medicines safely and to ensure that their healthcare needs were met.

We rated Wast Hills House as outstanding because:

Staff minimised risk to patients by ensuring the environment was clean and tidy, equipment was safe and effective to use and appropriate measures were put in place when risks to patients and staff were identified.

The service managed incidents well. Clinical and non-clinical staff were trained in conflict resolution and positive behavioural support and managed challenging behaviour in the least restrictive way. Managers investigated incidents and analysed themes and trends, which ensured staff could adapt and modify patient care when required to reduce the frequency of further incidents.

Skilled and experienced staff worked exceptionally well together as a team, using a variety of nationally recognised assessment tools to create holistic, individualised, person centred care plans. They focused on positive behavioural support and these were written in patients preferred communication style.

The service used the ‘Personal PATHS’ model of care which we saw adopted across the service. This shaped the way the service provided care and treatment, and ensured they monitored their effectiveness by sharing the findings and making improvements to maintain quality of care and treatment.

All staff employed by the service received specialist training and worked together with mutual support and respect to provide good quality care and treatment. Staff worked closely and proactively with families, external agencies and partners to ensure the patients best interests were always prioritised when decisions were made.

Staff had good knowledge of the Mental Capacity Act, which was embedded within the service. Staff supported patients to make decisions, and when they could not, staff recorded detailed reasons why decisions were made on their behalf. Staff understood their roles and responsibilities under the Mental Health Act 1983 and this was effectively applied across the service.

There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted patients’ dignity. Patients told us that staff treated them well, with kindness and respect. Staff had excellent knowledge of their patients, their likes and dislikes and their preferred communication style. This meant they understood their individual needs.

Carers, families and external agencies were extremely positive about the service and believed the service always managed challenging behaviour well. They were confident their relatives were receiving great care and treatment in a safe environment. They felt involved and included in their relatives care and the service was open and honest, providing regular feedback on their relatives care and when things went wrong.

The service encouraged feedback and saw it as an opportunity to improve. Patients and carers had opportunities to provide feedback to the service and staff listened and made improvements when required.

The service worked proactively with external agencies and families to ensure the patients were treated in line with the NHS Transforming Care agenda. Staff adapted the service to meet the needs of individual patients and ensured that appropriate care packages were in place before they were discharged from the service. The service ensured a smooth transition between services by providing an intensive face to face handover over many weeks before and after discharge.

Patients engaged in wide ranging meaningful activity plans which were individualised to meet their needs, encouraged independence and improve their skills. Staff used communication ‘grab sheets’ so patients’ interactions were consistently understood. Staff understood what was important to patients and provided them with information to make informed choices.

The service had a robust governance structure in place to monitor its effectiveness and sought to continually improve the quality of the service they provided. The service was committed to quality improvement and had signed up to a national project, making changes to the service when required. They provided training in autism for external agencies and partners. Staff were nominated for nationally recognised awards and they were accredited with the National Autistic Society.

The service promoted a positive culture that supported and valued staff. Staff enjoyed working with their patients and the majority thought that staff morale was high. Staff had opportunities to develop their skills and were provided with specialist training.