We rated Yew Trees good because:

• The ward environment was clean, tidy, and well maintained. Cleaning records were up to date and demonstrated that staff regularly cleaned the ward environment.
• The provider maintained safe staffing levels. We reviewed eight weeks of duty rotas which showed that the provider had covered all shifts with sufficient numbers of staff.
• Staff had received, and were up to date with mandatory training. Mandatory training compliance was 99%.
• Staff completed a comprehensive assessment of patients’ needs following admission. Staff used the information gained during these assessments to create care plans and risk assessments.
• Staff received regular supervision and annual appraisals. We reviewed supervision and appraisal records which showed staff were compliant with the provider's policy for supervisions per year.
• Patients were involved in the planning of their care. We reviewed four care records that showed staff had documented patients’ views on their care plan.
• Staff provided activities seven days a week. Occupational therapist and activities coordinator managed activities during weekdays and care staff would provide activities at weekends.
• The provider had systems in place to monitor staff training, supervision, and appraisals. The manager maintained spreadsheets which they updated and monitored regularly.
• Staff followed the providers safeguarding procedures. Staff made safeguarding referrals when appropriate contact the local authority for updates.

However:

• The provider did not always share lessons learnt from incidents and complaints with staff. We reviewed four team-meeting minutes. Only one of these minutes contained evidence that staff had discussed lessons learnt from incidents and two contained evidence of discussion of complaints.
• The provider had a high rate of agency staff use. This was due to high staff turnover and difficulty with recruitment. 

We rated Yew Trees as good because:

• Clinical areas were clean with appropriate equipment to ensure safety. Cleaning records were up to date and staff followed infection control principles. Staff completed health and safety risk assessments of the environment and carried personal alarms, which were tested regularly.
• Staffing levels were safe. The provider used regular bank and agency staff who were familiar with the hospital. The manager adjusted staffing levels according to the needs of the patients and staffing ratios were one staff to three patients.
• Staff analysed incident data and used this to review and update individual risk assessments and behaviour support plans. Staff held twice daily de-briefs to review the day and incidents. The hospital responded to incidents, complaints, patient, and relative feedback and shared lessons learnt.
• Staff read patients their legal rights and assessed patients’ capacity to make individual decisions. Staff made best interest decisions for patients who did not have capacity to do so.
• The provider had good medicines management practices with safe prescribing and administration. Staff completed consent to treatment and capacity requirements and staff attached forms to medication charts.
• Staff recorded patient and staff contact with relatives in a communication book and patients used skype to contact families. Staff invited families to a yearly family forum and patients attended local and regional service user forums. The hospital were visited by patients from other hospitals within the Danshell group as ‘experts by experience’, to provide feedback about Yew Trees.
• All staff were up to date with training in the Mental Health Act 1983 (MHA), the Mental Capacity Act 2005 (MCA), safeguarding, physical restraint and other mandatory training. Staff had regular clinical supervision, team meetings, annual appraisals and had opportunities for professional development.
• Staff completed holistic nursing assessments, annual and on-going physical health monitoring. Staff created person centred care plans, completed and signed by all patients. These were all in easy read versions. Staff followed the framework of the care programme approach (CPA) and invited community teams and families to attend and provide input. The hospital discussed discharge planning and had comprehensive discharge care plans, which involved patients.
• Staff had recently built a practice kitchen to enable patients to develop their cooking skills. Patients had access to hot drinks, snacks on request, pictorial menus, private telephone calls and could access fresh air in the garden when they wanted to. Patients could personalise their rooms and some patients had keys to their bedrooms.

However:

• The hospital building was a house across two floors that had blind spots where staff could not observe all areas of the environment. Staff managed this by carrying out regular observations of patients and used mirrors in corridors.
• The hospital’s ligature risk assessment was out of date. Staff did not identify some ligature points (anything that can be used to self-harm with) in bedrooms, the disabled toilet, in the administration corridor and the garden on their ligature risk assessment. Staff mitigated this risk with increased observations for all patients or supervising high-risk patients in areas with ligature points. We observed items on the ligature risk assessment that were no longer on site. We raised these issues with the provider who acknowledged that the assessment was inaccurate and they would address this.
• The provider observed all patients at least every 15 minutes. Observation levels were not necessarily linked to individual risk assessments and were, therefore restrictive.
• There were no nurse call alarms in patient bedrooms or in corridors. Staff mitigated this risk by regularly observing patients.
• The lift had been broken for over a year although this did not currently affect any patients. Staff told us they were waiting for this to be repaired.
• Staff kept resuscitation equipment and ligature cutters in a locked cupboard in the nursing office, which could cause a delay accessing these in an emergency. Staff addressed this when we raised it with them by moving the equipment in to the nursing office.

We used a number of different methods to help us understand the experiences of people who used the service. This was because the people who used the service had complex needs which meant that they did not all feel able to tell us their experiences. We spoke to most people who lived at the service and were able to observe staff supporting people.

We saw that people were supported and encouraged to exercise choice in their day to day lives. Independence was also promoted and staff worked with people to achieve this. People received the care, support and treatment they needed and this was provided in an individual way.

During the course of our inspection we saw that people were supported to express their views and choices by whatever means they were able to and staff clearly understood each person’s behaviours and their way of communicating their needs.

Staff looked after people's healthcare needs in a proactive way. The staff team were well trained and supported to carry out their role.

None of the people we spoke with expressed any concerns about their safety. One person said: “They look after you here it is difficult sometimes but at least they keep you safe."

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