We rated Edith Shaw Hospital as Good overall because:

• During this inspection, we found that the service had addressed the issues that had caused us to rate Safe as requires improvement following the November 2016 inspection. The hospital was now meeting Regulation 18 HSCA (RA) Regulations 2014 Staffing.
• At this inspection, we found that the provider had ensured that all staff received mandatory training and all staff knew how to report safeguarding incidents appropriately. All staff had received regular supervision and appraisal, and were competent in their roles and responsibilities.
• We found that staff used restraint as a last resort and had positive behavioural plans in place for all their patients. This meant that following assessment staff helped patients to develop strategies to recognise triggers of behaviours that challenge to find ways to manage it better.
• Risk assessments at Edith Shaw Hospital positively involved patients and built on their strengths. All risk assessments contained agreed plans to reduce identified risks and both medical and nursing staff were involved in developing them. This involvement ensured the inclusion of different clinical perspectives in the risk reduction plans for patients. Staff also made holistic assessments that included both physical and psychological factors.
• Edith Shaw Hospital was a clean and safe environment and the provider had invested in a continuing refurbishment program that included redecoration, new furniture and flooring. 
• The hospital continued to have good working relationships with the local GP, practice nurse and pharmacist. These relationships were important to support the safe care and treatment of Edith Shaw Hospital patients.
• Care planning for patients at Edith Shaw Hospital included comprehensive and personalised plans for patients. Staff were caring towards patients, treated them with dignity and respect, and demonstrated a high level of understanding of individual patients needs and wishes.
• Staff encouraged patients’ involvement in activities and ensured patient consultation on the type and frequency of activity they would like to join. The hospitals activity program had improved since our last inspection in 2016.

However:

• We observed that a nurse was interrupted several times by other members of staff when administering drugs to patients.
• Edith Shaw hospital staff learned lessons at a local level with support from clinical colleagues. However, learning from incidents decided on at governance meetings and to be shared from the sister hospital was sometimes not formally communicated to Edith Shaw Hospital staff.
• No patient satisfaction survey had been conducted in several years.
• There were of lapses in effective communication within Edith Shaw Hospital’s governance systems. In one case senior managers did not effectively communicate the learning from a drug administration error.
• There was limited occupational therapy (OT) input to patients.

We rated Edith Shaw Hospital people as good overall because:

• During this most recent inspection, we found that the service had addressed the issues that had caused us to rate effective and well led as requires improvement following the December 2015 inspection. The hospital was now meeting Regulation 17 HSCA (RA) Regulations 2014 Good governance.
• The provider had robust recruitment processes in place for directors. All board members human resources files had completed fit and proper person declaration forms, professional references, and disclosure and barring service (DBS) checks.
• The provider had updated all Mental Health Act (MHA) Code of Practice policies and procedures in line with the revised Code of Practice dated April 2015.
• During this most recent inspection, we also found that daily checks on staffing levels ensured the safe staffing of the hospital. These arrangements included contingency plans to manage unplanned staff sickness and absence.
• Patients had a comprehensive physical and mental health assessment on admission to the hospital and a full multidisciplinary team was responsible for their care. Staff attended regular review meetings to formulate positive behaviour support plans and ensure that care plans focused on patients’ physical and mental health.
• The hospital had good working relationships with the local GP and practice nurse and had access to an experienced therapies team and occupational therapy service.
• Staff were caring towards patients and treated them with dignity and respect. Patients could attend their care review meetings, were encouraged to be involved with their care plans, and agreed their discharge and follow-up care in consultation with their family and carers.
• Patients’ bedrooms were personalised and had adjacent bathroom suites for individual use. Patients also displayed pictures, in their rooms, that they had painted during activity sessions.
• Processes were in place to monitor and learn from incidents. Staff also received regular supervision and were of the right grade and experience.

However:

• Staff compliance with mandatory training was low. Training rates were low for safeguarding, food safety, and Mental Health Act, Mental Capacity Act and Deprivation of Liberty Safeguards.
• Staff did not always report all safeguarding incidents appropriately.
• Hospital staff were restricted in their observation of patients due to the layout of the building.
• The patients’ quiet room was frequently unavailable to patients because of its dual use as a multidisciplinary team meeting room.
• Staff were not consulted on the review of the John Munroe Group’s vision and values statement.

We rated Edith Shaw as requires improvement because:

• The unit did not fully meet the rehabilitation needs of patients due to the lack of a full onsite multidisciplinary team to deliver a recovery focus service. Staff and patients reported there was insufficient occupational therapy (OT) support to meet the needs of the patients. OT staff numbers and input as well as the lack of recovery focus in care plans also indicated this.

• The units planned establishment of nursing staff on a shift was two qualified staff to meet the needs of the patient group. We heard from staff and saw in rotas that only one qualified staff member was on shift routinely between Thursday and Sunday due to current vacancies.

• Staff under-reported incidents that were potential safeguarding concerns to external agencies.

• Care records did not consistently show patients’ views on and involvement in their care.

• The staff recruitment processes were not consistent applied to staff at a senior level. Employment files for board members did not contain evidence how they were selected, references or disclosure and barring service checks.

• The portable wooden steps used to help patients onto the unit’s minibus were not sufficiently sturdy to steady and support patients safely.

• The unit had blind spots in the bedroom corridors. Staff reduced the potential danger from these by taking into account individual patient risk factors when allocating bedrooms, and using staff observations.
• The provider generally managed the application of the Mental Health Act well. However, we found errors in completion of forms relating to the MHA and the unit had not updated its Mental Health Act policy in line with the changes in Mental Health Act code of practice. Both of which have been addressed since inspection.
• There were gaps in some of the medicines charts even though the provider had tried to address the issue. Documentation on the medicine charts was unclear if the doctor had reviewed some PRN medication (‘as required’) within a two week period.

However:

• The unit was safe, clean, well maintained and allowed patients a degree of autonomy. The hospital had identified ligature points in the ligature risk assessment and put measures in place to reduce the danger from these. Ligature points are places to which patients intent on self-harm might tie something to attempt to strangle them. All staff followed infection control procedures. The unit was well adapted for disabled access. All patients personalised their rooms and held their own bedroom keys.

• Electronic and paper records systems were well co-ordinated and easy to access. Staff carried out appropriate checks on medicines storage and emergency equipment to ensure high standards of safety.

• Patients received good physical healthcare support from staff, the local GP and a practice nurse who visited the unit weekly. There were effective arrangements for out-of-hours medical cover and staff confirmed they could have medical support day and night. Staff we talked to spoke positively about the unit describing a good team working ethos, and said that management were supportive.

• Patients received meals that met their health needs and personal preferences and had access to drinks and snacks throughout the day.

• Staff used the least restrictive options to manage challenging behaviour including de-escalation (calming down) techniques. Staff rarely used physical restraint or rapid tranquillisation. Staff told us they received training in physical restraint and knew how to report incidents and safeguarding concerns, and received debriefs following all adverse events.

• Staff received induction, training, supervision and appraisals. They also had access to regular team meetings. There was good interaction between staff, patients and relatives; patients felt listened to and relatives felt involved.