We rated Field House as requires improvement because:

• Although Field House was a community based rehabilitation unit, staff had not put a full therapeutic timetable in place for patients.
• Staff had not completed a systematic audit of ligature points across the whole hospital. There were poor lines of sight to aid staff observations of patients and staff did not follow the policy for completing patient observations.
• Staff had not recorded the correct form of medication in the controlled drug register and had not completed all health and safety checks in line with the provider’s policy.
• There were restrictions on patients in place at the hospital. Patients did not have keys to their bedrooms, or other areas that they would be expected to in a community-based rehabilitation unit. Patients were randomly searched when returning from leave.
• Nurses had not always followed the procedure for administering medication to patients under the Mental Health Act and had not always followed their duty of candour following errors in a patient’s care. This meant a patient was given medication without consent or following the safeguards to ensure it was in their best interest.
• Families and carers were not involved in planning patient care. Not all patients were happy to raise concerns about their care with staff.
• The hospital governance structure had failed to identify issues relating to the administration of medication and safety checks. Not all local risks were on the hospital’s risk register.

However:

• The hospital was clean and tidy and staff had checked emergency equipment and medication in line with the provider’s policy.
• There was enough staff on duty and all staff had completed their mandatory training. Staff only used physical interventions as a last resort and made safeguarding referrals as needed. Patients had a full assessment of their needs. Staff supported patients to access physical healthcare services and informed them of their rights under the Mental Health Act.

• There was a fortnightly community meeting for patients to express their view of the service. Staff encouraged patients to help develop their care plans and to access the community. There was an informal complaints log that showed how staff had responded to patients concerns. Staff felt listened to by the manager.

• The manager had a vision for the hospital and patients and staff had input into the development of the hospital.

We carried out an unannounced focused inspection of Field House in response to concerns raised by the registration inspectors following their visit in April 2016. We reviewed the aspects of the service associated with the concerns raised.

We found that:

• Care plans and risk assessments were detailed and up to date.
• Staff were readily able to access key documents on the electronic care record system.
• Staff monitored patients’ physical health regularly and hospital staff had good relationships with other healthcare professionals, including GPs.
• Staff interactions with patients were warm, genuine and person-centred. Staff treated patients with kindness and dignity.
• Staff used radios effectively to communicate with each other.
• Patients were engaged in a range of activities within the community and the hospital environment. Activity planners were individualised and completed in collaboration with the patients.
• Staff spoke positively about the leadership within the organisation. There were plans in place to manage the recruitment process for a new registered manager.
• Staff felt supported in their role and had good access to specialist training where necessary.
• Field House had a robust admission process that carefully considered the mix of patients and skill set of staff.
• All staff had completed their mandatory training, which included The Mental Health Act (MHA) and The Mental Capacity Act (MCA).
• Patients had access to an Independent Mental Health Advocate (IMHA).

However:

• Not all staff could recall whether they had completed training in Mental Health Act or Mental Capacity Act.
• No patients were allowed unsupervised access to the small kitchen. There had been no risk assessment completed for this decision.
• Not all patients were given copies of their ‘personal planning books’ to keep in their bedrooms. There was no evidence to support the reason behind this restriction.
• There was no Independent Mental Capacity Advocate available to patients (IMCA).

We rated Field House as good because:

• it provided a homely environment that promoted the safety and wellbeing of patients
• patients’ bedrooms were personalised to reflect the taste and preference of individual patients
• staff supported and encouraged friends and relatives to be involved in their relatives’ care
• the Department of Health “Positive and Safe” (2014) programme had been adopted and implemented, nursing staff carried out regular physical health monitoring, and set out any identified physical health needs in detailed care plans
• patients were registered with a local GP and were able to be seen by the GP at the local surgery or at Field House
• patients had access to a speech and language therapist (SALT) who assessed needs and planned care accordingly
• the cook ensured that all patients’ dietary needs were met, and nursing staff provided any support required for eating and drinking safely
• the multidisciplinary team (MDT) assessed actual or potential risks using recognised risk assessment tools
• staff measured patients’ progress using a recognised outcome measure called the health of the nation outcome score for learning disability (HoNOS LD)
• patients received input from a psychologist who helped them with any communication difficulties and contributed to the multidisciplinary team (MDT)
• medicines were managed safely
• managers supported and encouraged staff to attend specialist training relevant to the patient group
• staffing levels were safe and the use of temporary staff was low
• staff raised safeguarding alerts appropriately, knew how to record and report any risk incidents or near misses, and there was evidence of learning lessons from incidents
• patients had regular access to an independent mental health advocate (IMHA).

However:

• Mental Health Act documentation was not always accurate, and Mental Capacity Act documentation did not always contain sufficient detail
• it could sometimes be difficult to access specific key information quickly because the care record system was in the process of transition from paper records to an electronic record system
• ligature risks were not recorded on the risk register
• the narrow corridors made it difficult for wheelchair users to navigate independently.
• the narrow corridors could not accommodate three people walking abreast in the event of a patient being re-located under physical restraint
• psychiatric cover consisted of attendance at the fortnightly multidisciplinary team (MDT) meetings, and on-call or telephone cover at all other times.

There were 7 people receiving care and treatment at the time of this review. During our visit we spoke with the manager, 3 staff and one person receiving care. Some people were not able to tell us about their experience of the hospital.

We saw interacting positively and patiently with people. One person told us about their interests and how they liked to go out with staff.

There were suitable arrangements in place to ensure that people were consulted and involved in making decisions about their care. Where people could not make decisions there were systems in place to ensure decisions were being made in people’s best interests.

We found that people experienced care and support that mostly met their needs and protected their rights. People had regular access to advocates and were informed of their rights.

The environment of the home was maintained to a comfortable standard and people’s bedrooms were individual reflecting their tastes. However actions have not yet been taken to respond to the findings of the fire officer’s report from July 2013.

Suitable pre-recruitment checks were made before staff commenced in post. However there was a fragmented decision making process in place as regards offering employment to staff.

Some people in the home had limited communication abilities and so we could not interview them to find out their views. However, we were able to observe their mood and behaviour and how they interacted with staff. We spoke with the manager, three staff members, two people who used the service and two relatives.

People and their relatives told us they were involved in making decisions about their care. The care plans were signed by people, or their relatives, to show their involvement and agreement.

We found that whilst there were systems in place to ensure that most of people's healthcare needs were being met there was no provision to provide speech and language therapy (SALT) to people. As this was an identified need for some people due to communication and swallowing difficulties this could place them at risk.

Relatives told us that staff were “Nice and kind” to people, another relative told service user staff were “Very good”. People knew who their key workers were and said that staff did “sit and talk” to them regularly.

There were systems in place to monitor the quality of the service as meetings and surveys were regularly conducted. This ensured people, their relatives and staff could share their views about the service.

There were eight people living at Field House when we visited. We met all of the people living at Field House throughout our two day inspection visit. The majority of people were able to verbally communicate with us. However the level of people’s communication skills was limited.

People were very welcoming to us and some people were keen to show us their bedrooms. Due to people’s communication skills they were unable to talk to us in detail about the service they received. Overall the staff appeared very friendly however staff tended to speak for people or prompted people to answer. Some people were able to confirm that they were supported by staff and told us about some of the activities they had done. People confirmed that they liked living at Field House.