We carried out this inspection to check whether improvements had been made since our last inspection of the service. At our inspection in January 2014 we found that the provider did not have suitable arrangements in place for obtaining and acting in accordance with the consent of patients or those persons able lawfully to consent on their behalf. In addition, systems designed to regularly assess and monitor the quality of service were not always effective. In view of our concerns we served two warning notices informing the provider that they needed to take action to address the areas of non-compliance identified by 31 March 2014.

At our inspection of the service on 24 April 2014 we found that significant improvements had been made and the provider had complied with both warning notices.

A young person using the service described staff as “really nice and supportive” and said the service was flexible in meeting their individual needs. They said they found the lack of privacy in service “difficult” but had been made aware they would be sharing a room with another young person before they were admitted.

We found that the provider had reviewed and revised all consent forms used by the service to ensure that clear explanations were provided to patients and parents in respect of consent to care and treatment. Staff showed good understanding of the law and its application to children and young people in respect of obtaining lawful consent to treatment, including assessments of competence and capacity depending upon the age of the patient.

In addition, the service had reviewed and revised a number of key policies related to issues of consent to treatment, including the nasogastric feeding policy. The revised policies were easier for staff to understand and the content we reviewed was consistent with legal requirements.

Clinical governance arrangements for the service had been strengthened. The service had introduced regular meetings of senior managers to consider issues of quality, safety and standards. There was evidence of learning from incidents, feedback from parents and young people and clinical audits. Outcomes for young people were measured to ensure care and treatment was effective.

We carried out this inspection to check whether improvements had been made since our last inspection of the service in April 2013. At that inspection we found that several patient care plans had not been reviewed for long periods of time and no longer reflected patient’s needs. Some risk assessments conducted by nurses and by the multidisciplinary team were contradictory. As a result there was a risk that patients’ individual needs were not being met. Senior managers monitored the service to ensure appropriate standards of care and treatment were maintained but the system in place was not always effective. In addition, we found that there was a risk that not all patients had been treated in accordance with the provisions of the Mental Health Act 1983. Arrangements for obtaining and acting in accordance with the consent of patients were not always effective.

On the day of the inspection on 17 January 2014 there were 21 young people under the age of 19 admitted to the ward, eight of whom were detained under the Mental Health Act 1983. We were accompanied on the inspection by a Mental Health Act Commissioner and a specialist advisor.

We found that improvements had been made in the risk assessment and planning of care for the young people admitted to the unit. Care plans were much more detailed than on our last inspection and a single risk assessment was reviewed and updated weekly.

However, although we found some improvements had been made in relation to our concerns about consent and systems designed to monitor the quality of the service we identified a number of concerns in these areas. Arrangements for obtaining and acting in accordance with the consent of patients were still not always effective. Systems for reviewing the accuracy and clarity of key policies that underpinned the quality and lawfulness of care and treatment that patients received had not identified a number of inaccuracies and shortfalls. In view of our concerns in these areas we served warning notices on the registered provider on 4 February 2014.

We spoke with four young people who were admitted to service, all of whom were detained under the Mental Health Act 1983. They told us they were mostly satisfied with the care and treatment provided to them. Patients had mixed views on the way staff interacted with them although we observed many positive interactions between patients and staff on the day of our visit.

Appropriate arrangements were in place to ensure that medicines were managed safely. Staff received appropriate training and support to enable them to deliver the care to patients that they needed.

However, we found that several patient nursing care plans had not been reviewed and no longer reflected patient’s needs. Some risk assessments conducted by nurses and by the multidisciplinary team were contradictory. As a result there was a risk that patients’ individual needs were not being met and they were not protected against the risks of unsafe or inappropriate care. Senior managers monitored the service to make sure that risks to patients were minimised and an appropriate standard of care and treatment was provided but the system in place was not always effective. We found that there was a risk that not all patients had been treated in accordance with the provisions of the Mental Health Act 1983.

We spoke with a group of four of the six young people using the service. They told us that they were able to express their views and were involved in making decisions about their care and treatment. They were satisfied with the care they received and felt their needs were being met. The unit was described as ‘comfortable’ and ‘homely’. One young person said the unit was ‘cosy, in the evening everyone gets together and it is like normal life’. The young people attended a school on-site and took part in activities they were able to choose. They felt safe on the unit and one typical comment we received was, ‘you feel safe, because it’s secure’. There were suitable arrangements in place to protect the young people from the risk of harm.

Not all staff received regular individual clinical supervision but had the opportunity to attend externally facilitated group supervision. There were systems in place to assess and monitor the quality of service being delivered to young people and their families.

We rated the service as good because:

• The service had addressed several areas of concern since the last inspection in March 2016. This included having sufficient emergency resuscitation equipment that staff checked regularly, ensuring staff accessed monthly individual supervision, and ensuring compliance with mandatory training in safeguarding, breakaway and physical intervention. The service had also reviewed and improved their processes for responding to complaints. Patient bedrooms now had wall alarms so patients could more easily alert staff if needed.

• Patients gave positive feedback about most staff and said they felt their individual needs were met. Parents gave very positive feedback about the service and felt very involved in their child’s care.

• Staff carried out timely and comprehensive assessments of physical and mental health needs and risks for each patient and developed care plans to meet these needs. Staff updated risks assessments and care plans regularly.

• Some patients care involved physical restraint during naso gastric feeding. The service had developed a written tool to be able to include the patient in the planning of this. This was to ensure the patient had as much involvement in their care as possible. The service was also involved in the re-design of a chair for naso gastric feeding that could be used nationally.

• There were effective governance processes in place. Staff knew how to report incidents and learning was disseminated and discussed at ward level. The service carried out regular audits and senior staff met regularly to review the running of the service.

• The service were committed to and involved in several pieces of work in quality improvement and innovation.

However:

• Although patients were involved in giving feedback about their care, several said they would like to see or keep copies of care plans and would like to be involved in developing them from the start.

• Patients said some staff were impatient with them and inconsistent in how they enforced rules.

• Patients said food was not as well prepared on the weekends compared to weekdays.

• Space on the wards and in the cottages was limited. As patients shared bedrooms and bathrooms, there was a lack of private space.

• There were limited activities available on the weekend. Male patients said they would like more sports activities to engage in.