We rated Forest Hospital as requires improvement because:

• Governance systems were not in place to ensure managers were assured about all aspects of the care and treatment of patients. There was no system to monitor individual patient’s activities and leave. Staff and carers said activity was low and not focused on maintaining independence and we observed low levels of activity on Maltby ward. Staff did not always complete effective audits and care records were not always complete and accurate records. Observation practices were not always safe; on occasion domestic staff, without suitable training completed them. When staff completed observations, they did not record the observation at the actual time it occurred.

• Staff did not complete detailed discharge plans and these were not present for all patients. Support plans were not strength based and staff did not always make sure they wrote support plans in the patient’s voice, describing their preferences. Staff could not describe the rehabilitation model for the hospital and had not completed training in rehabilitation.

• Staff did not consistently complete records to demonstrate they had checked or cleaned equipment. Staff had not regularly checked resuscitation equipment, including a defibrillator to check it was safe to use. There were no records to evidence cleaning of portable physical health equipment, the hoist and clinic room.

• Staff did not always ensure records were complete and detailed. Staff did not always keep detailed handover records and care records did not always contain all relevant information for patient care.

• Staff told us morale was low, they worried about staff turnover and found the change in managers destabilising. Staff did not think all managers were visible and did not feel well supported or encouraged. There was no local staff survey for staff to feedback to managers.

• Risk was not always well managed. Four of eight risk assessments did not provide a full description of the risk identified. Two staff did not know where ligature risks were on the ward and a nurse did not know where to locate ligature cutters. Staff did not consistently complete all the physical health observations and record risks using the National Early Warning Scores.

• Staff could not describe the model that the service used. Psychological interventions for patients were limited; there were no psychological interventions for patients on Maltby ward.

• Staff did not ensure that patient community meetings took place regularly. Staff did not know who provided advocacy in the community and details of local advocacy services were not available on Horsfall ward.

However:

• Staff completed mandatory training for their roles and compliance with training was high. Staff received supervision and appraisals from their managers and engaged in team meetings.

• Staff demonstrated that they knew how to protect patients and had completed safeguarding children and adults training. Staff knew how to raise a safeguarding concern and identify abuse. Staff ensured they only used restraint as a last resort and levels of restraint were low. There was evidence staff only used restraint if de-escalation had not worked and that staff successfully de-escalated without using restraint most of the time.

• Staff were kind and responsive towards patients, they supported patients appropriately and demonstrated they knew patients well, they understood patients’ likes and dislikes and cultural and religious needs. Staff communicated with patients in a way that suited them.

• The recently appointed interim hospital director and divisional director understood the hospital and challenges that the hospital faced and ensured all staff were familiar with the vision and values of the wider organisation. Managers ensured nurses could complete leadership training, new staff had enrolled on this. There was a care practitioner leadership course available for recovery assistants.

• Staff ensured patients had access to physical health care and worked with external professionals including a local GP to ensure this was accessible to patients. Staff followed good practice in medicines management. Medicines were well organised, recorded effectively and stored safely.

• Staff supported patients to make contact with their family and carers including home visits. The hospital offered flexible visiting times for families and friends. Staff responded to complaints effectively and in line with policy. Staff made appropriate changes following complaints.

• The service held multidisciplinary ward round meetings. Discussions at ward round involved the patient and were thorough and staff recorded these.

During this inspection, we looked at the three questions, of safe, effective and well-led where we had previously identified concerns. We did not inspect caring and responsive.

We rated Forest Hospital as good because found the provider made the following improvements:

• All staff and patients were offered debriefing sessions and informed of feedback from incidents they were involved in. Staff received feedback of lessons learned occurring internally and externally to the hospital. We saw written evidence of lessons learned on incident reporting forms.

• The percentage of staff receiving an annual appraisal was in line with the organisation’s targets. All staff we spoke with said they received an annual appraisal.

• The provider developed an audit process to monitor the use of the Mental Capacity Act within the hospital and staff knew who to approach for advice.

However:

• The quality of mental capacity assessments we saw were inconsistent and specific decisions were not recorded.

• Care plans we saw did not focus on the patient’s strengths and goals and were not recovery orientated. The language used in care plans did not reflect that used by patients.

• There was no indication in patient care notes to remind staff to consider a further Deprivation of Liberty Safeguards (DoLS) authorisation when the current authorisation was due to end.

Forest Hospital provides accommodation, care and support to up to 35 people caring for younger adults and older people who have dementia, mental health conditions, physical disabilities and people who misuse drugs and alcohol. People whose rights are restricted under the Mental Health Act 1983 may be accommodated there.

Our last inspection on 10 and 11 March 2015 resulted in a warning notice being issued on 31 March 2015 for failing to comply with the relevant requirements of the Health and Social Care Act 2008 (Regulated Activities). The service failed to comply with:

Regulation 9 (1) (a) (b) (i) (ii) and (iii) They were not taking proper steps to ensure that each service user was protected against the risks of receiving care or treatment that is inappropriate or unsafe, by means of the planning and the delivery of care to meet people’s individual needs.

Regulation 10 The systems in operation at the service were failing to be effective because they did not adequately assess and monitor the quality of the services against the requirements of the regulations.

We inspected this service again on 24 June 2015 in response to our last inspection. This was an unannounced visit. The inspection team included four CQC inspectors, a CQC Mental Health Act Reviewer, a Specialist Advisor and an Expert by Experience. There were 11 patients using the service. We spoke with six patients and six members of staff including the interim manager and divisional director.

The hospital was being managed by an interim manager, who started at the hospital in March 2015. However he has a substantive post with the provider in another hospital. The interim manager was supported by the divisional director. A nurse prescriber based at another service provided additional support,. There was evidence in the form of regular audits that they had made regular contributions to the overall effectiveness of the service. The hospital awere recruiting a substantive manager however arewere yet to find an appropriate candidate.

The hospital had adopted a self-embargo. This meant they had agreed to put a hold on any further admissions until they had actioned all the requirements from CQC following our last inspection.

The hospital was a relatively new build and opened for admissions in March 2013. The hospital was clean and in very good repair. It had well maintained gardens which could be accessed by patients. All bedrooms were en suite. Air conditioning was provided. The reception area was homely and welcoming with comfortable seating and a pay phone for use. There was a well equipped café style lounge area and a family friendly visitor area. There were dementia friendly activity boards and patients had names or personal indicators on their doors to aid them in clearly identifying their rooms. The hospital had a designated mini bus for patient outings. Overall, we felt the hospital was a safe and clean environment. There were still some ligature risks identified and the manager told us that they would make changes to ensure patient safety.

• The hospital were consistent in their approach to training, supervision and appraisal. We found a commitment to the vision of the hospital. The right candidate to manage the hospital was being sought using the recruitment process. The divisional director assured us that there would be a thorough handover and on-going mentorship for the new manager when the interim manager leaves. The manager was to interview the following week for a nurse lead from within the current team to encourage better leadership and good practice.
• There were regular audits and a consistent commitment to ensure good practice. Areas for improvement were identified and recommendations followed and recorded.
• The manager told us that they had 'mock CQC visits', an internal initiative, with all staff within the hospital to keep the team focussed on improving and developing. There were staff briefings daily to share concerns and planning.
• The hospital utilised resources from within the organisation. For example, the nurse prescriber had implemented a good governance framework that involved regular audits. There was a wide range of audits and monitoring systems. There was evidence of learning and action on recommendations. The records were organised and there were policies and procedures to hand.
• The manager acknowledged that staff felt insecure in light of the self embargo and our previous inspection.However he had adopted an open door policy to improve morale and encourage staff engagement. Staff felt there had been improvements made.
• There were systems and processes in place to report incidents and concerns. All patients spoken with told us they knew how to complain and they would if they had to. There was a folder of complaints however it was not up to date.
• There were patient meetings and minutes of these were kept. These were attended by three patients, an occupational therapist and an occupational therapist assistant. Menus, housekeeping and activities were discussed. Posters were displayed advertising IMHA services, whistle blowing and complaints. Staff attended a daily meeting to discuss any concerns. We observed this meeting and there were clear points raised and plans of action.
• There were improvements in multi-disciplinary and inter-agency team working. There were weekly multi-disciplinary team (MDT) meetings which included a doctor, the staff team and psychologist when they were able to. There was evidence to support learning from discussions from the MDT were shared with the rest of the team. Handovers were completed. One member of staff told us that they had not attended an MDT but they were provided with written feedback and had discussions during handovers.
• We looked at five patients records relating to their Mental Health Act (MHA) paperwork. We found that this was in good order and patients section 17 leave was up to date. There was a MHA administrator on site. We observed there were good systems and processes in place to support staff in adhering to the MHA and MHA Code of Practice. Files looked at showed that tribunals and managers hearings took place. Reports of these were available. Capacity assessments had been completed. Care programme approach reviews were evident. Family, community teams and commissioners had attended these.
• We saw a wide range of care plans in place for patients. They included personal care needs, mental health and communication needs and were specific to the individual's assessed needs. There was evidence of the patient’s views and participation. Care plans were reviewed. Mental capacity assessments were decision specific. In one file a patient had capacity assessments attached to all their care plans.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We used a number of different methods to help us understand the experiences of patients because patients had complex needs which meant they were not able to tell us their experiences. On the day of our inspection there were two patients using the service. We observed care being delivered and checked both patients care and support records. We spoke with nurses and rehabilitation assistants along with the hospital director and hospital matron.

One patient told us they were happy with the care they received and they were able to tell us they felt safe and cared for.

We found that patients received care and treatment for their physical and mental health needs that was effective, safe and appropriate.

We saw that care was being delivered in a way that was intended to ensure patients safety and welfare because appropriate levels of observation were maintained at all times.

We found that patients were protected from abuse, or the risk of abuse, and their human rights were respected and upheld. Patients could be confident that staff required to use restrictive physical interventions had received specialist training. Restraint was only used as a last resort, and the type of restraint used was the least restrictive and for the minimum amount of time to ensure that harm was prevented and that the patient, and others around them, were safe.

Patients were safe and their health and welfare needs are met by staff who were fit and appropriately qualified because effective recruitment procedures including relevant checks were being undertaken before staff were employed.

We rated Forest Hospital as requires improvement because:

• We saw written evidence of lessons learned on incident reporting forms; but four staff members we spoke with did not receive feedback of lessons learned from incidents and debrief sessions occurring at this hospital.
• Staff inconsistently recorded mental capacity assessments. The provider did not have an audit process to monitor the use of the Mental Capacity Act. Staff were unaware of the person within the organisation to contact for advice on the Mental Capacity Act.
• Care plans we saw did not focus on the patient’s strengths and goals. The language used in care plan did not reflect language used by patients. Patients were not present nor invited to care programme approach meetings with no reasons given for this.
• Not all staff received an annual appraisal.

However:

• The provider had an up to date environmental risk assessment and ligature audits. Staff updated these audits annually and when patients were admitted and discharged from the hospital.
• Although we smelt urine on both wards, the cleanliness of the ward environment was maintained, cleaning schedules and audits were up to date.
• The provider had good medicines management practices.
• The provider responded to and investigated complaints. Patients and relatives were provided with responses to complaints and staff were provided with lessons learnt from these.
• The hospital had developed an agency reduction strategy. To reduce the use of agency staff, the hospital had recruited permanent bank staff to cover shifts
• Staff understood their responsibility in using the provider’s incident reporting system.
• The staff induction programme used by Forest Hospital followed the Care Certificate.
• The hospital implemented the provider’s admissions and discharge policies, which enabled staff to admit and discharge patients safely.
• Staff demonstrated a good understanding of the guiding principles of the Mental Health Act and made appropriate referrals to advocacy services.
• Interactions we saw between staff and patients were caring, positive and friendly. Feedback we received from carers said staff had a good understanding of the patients they cared for.
• Patients had good access to physical healthcare. Staff at Forest Hospital used various risk assessment tools to manage patient’s physical healthcare.