We observed positive interaction between staff and people who used services on the day of our inspection. Staff responded to people’s requests for support and appeared respectful and offered clear explanations to questions.

People were not always enabled to make or participate in making decisions relating to their care or treatment.

We spoke to five people who used the service. Some people told us that the occupational activities really helped them. One person we spoke with told us “Going to the gym really helps me manage my anger when I am cross”. Another person told us “We chose the new colours for the occupational bit and painted it ourselves. That was good to do”.

We saw that staff had access to the contact details for the local safeguarding team. We also saw that the service had quarterly safeguarding meetings that included attendance by their local safeguarding officer.

On the day of our inspection Farmfield was clean, tidy and in a good state of repair. The design and layout ensured that people who used the service could move around easily and there was adequate space for participating in activities, eating and socialising or finding a quiet space.

Staff we spoke with told us that they did not feel that there was always a good skill mix of staff on duty each day or that there were enough staff for them to cover all their duties. One person we spoke with told us “There were only 3 of us on the ward the other day; I didn’t feel safe”.

We saw that the provider completed yearly surveys for people who used the services/their representatives. We saw that the results had been collated, analysed and reviewed and that action had been taken based on the feedback.

At our last inspection on 21st of February 2013 we found that people were not protected from the risks of unsafe or inappropriate care and treatment as accurate records were not always kept. At this inspection we found an improvement in the quality of the records maintained. However, some information was still not recorded accurately.

We found that there were sufficient numbers of suitably trained staff available to meet the needs of patients. One patient we spoke to told us that the staff were "excellent" and that "there are always enough staff on shift so I do not need to wait for anything".

Staff told us that there were sufficient levels of staff available most of the time and that bank and agency could be used when there was an identified shortage.

We saw that care records were available but that information within the care note system were not available in a format which was accessible in a prompt manner due to staff not knowing how to locate the documents; this was attributed to an upgrade of the electronic carenotes system which staff were still "getting to grips with". The manager has provided the Care Quality Commission with assurances that additional training would be made available to staff and we will monitor this to ensure that records can be accessed by those staff who require access to records promptly.

We spoke to four patients about their views of the care and treatment they received, where we were unable to speak to patients we relied on our observations on the day to form our judgements.

We saw that there were many examples of positive interactions between patients and staff and noted that patients were relaxed and at ease.

We saw several examples of staff treating patients with dignity and respect by knocking on doors and speaking appropriately. Patients told us that the staff were “Good” and that they felt able to speak to them about how they felt.

Patients also told us they liked the food that was provided and that it was “Good”. One patient told us that the food was “Okay” and another said it was “Fine”.

We found that patients sometimes were not able to do things like go out on leave as there were not always enough staff available to escort or assist them. One patient told us it was “Frustrating” when this happened and we saw examples of this during our inspection.

Patients told us they knew their rights and told us that they felt safe, they told us that if they had a problem or concern they knew who to speak to about it. One patient told us that the hospital was “Better than the last place I was in.”

We rated Farmfield as requires improvement because:

• There was insufficient clarity in the guidance for staff to safely manage the physical healthcare needs of patients with insulin dependent diabetes.
• There was a variance in the ligature risks in the patient bedrooms on the low secure wards. This meant that some patients with similar risks of using ligatures could be accommodated in a less safe bedroom.
• The hot water boilers in the kitchens of all the wards were unsafe for patients to use.
• The water temperature in the showers on the low secure wards was extremely hot as the temperature regulator was not working. Patients had no way of regulating the temperature themselves and therefore were at risk of scalding themselves.
• Staff raised concerns about the relationship between ward staff and the senior team at the hospital. Their concerns included not feeling that their views were considered by the senior team and also concerns about new employment contracts and how new policies were being implemented by the hospital management.
• There were significant vacancies for occupational therapy. This meant that the range of structured activity offered to patients had reduced. 

However:

• The five wards were bright and clean and had been well-maintained.
• Patient records showed that they had received good assessments and had holistic care plans and up to date risk assessments.
• Incidents, complaints and safeguarding issues were effectively recorded and investigated.
• All staff had completed mandatory training and were supported by their line managers and had received an annual appraisal.
• Patients said that staff were caring and considerate and that they were confident in raising any concern. There were forums for patients to raise issues and suggestions about the running of the hospital.
• There were good systems in place providing ward managers with up to date information on how their ward was performing.
• The senior team met in a monthly governance meeting to review and make decisions on risk, quality and staffing issues.