We looked at the processes, and records held by the service relating to the use and management of medicines.

We reviewed the supply process, supporting information and administration records. Most medicines were obtained in a timely manner. Staff showed us where and how medicines were stored and the expiry date and temperature records they kept. Therefore we were assured that the medicines were safe to be administered.

We reviewed the prescribing and administration records including additional monitoring records that were required when medicines were administered. Whilst the prescribing and administration records were complete; there was a lack of additional monitoring records.

We spoke to three people who use the service. They explained to us how they were given their medicines. People were given written information about medication. If people had questions about their medication they said staff provided answers.

During this inspection we spoke with five patients, seven members of staff and the service manager. We looked at five records of patients who were detained under the Mental Health Act (MHA) 1983 and one record for an informal patient. We undertook this inspection to determine whether concerns we identified during the last inspection had been addressed.

We found arrangements for obtaining consent were appropriate. Patients signed their treatment records and care plans. Patients told us they were involved in decisions about their treatment. The service had the necessary documentation to demonstrate patients detained under the MHA were assessed appropriately and reassessed when necessary. Patients were made aware of their rights.

New systems were in place to assess risk to patients and ensure changes to any risks posed by patients to themselves and others were recorded and managed. Staff told us they had regular handover meetings to share concerns about patients and update each other on the risks associated with patients' care and treatment.

We found section 17 leave (leave for patients detained under the MHA) assessments had been changed. Staff told us the new system for section 17 leave made them more aware of the associated risks.

We found incidents were recorded, investigated and findings were shared with staff to ensure they were aware of any learning from investigations.

Patient records contained up to date information on patient assessments and their care and treatment.

During the inspection we spoke with five patients, eight members of staff and the registered manager. We looked at nine patients' records and other documents related to the management of the service. We observed the care provided to patients, where this was appropriate.

Patients told us they were able to communicate well with staff and that staff responded to their needs. Patients had a high regard for the therapy provided by the service. One patient told us "Therapy is amazing. They talk to you as a whole person." Patients we spoke with felt involved in decisions about their care and treatment. However one patient told us they felt the service did not respond effectively to risks before they became crises.

All the staff we spoke with felt they were involved in decisions about patients and the service. Staff said they received training relevant to the needs of patients they cared for. Staff had training in safeguarding, the Mental Capacity Act and the Mental Health Act.

The service had systems to monitor the quality of its service. However the provider did not effectively analyse and learn from incidents and events in order to reduce the risk of harm to patients. The service did not effectively assess and manage risks in order to protect patients from the risk of harm.

Patient records were not completed appropriately. Legal documentation required to detain patients or seek their consent were not always available.

People told us they felt cared for by trained and experienced staff. They valued their relationships with key workers and participated in organised activities. There were some areas where the people we spoke with felt the hospital could improve. These areas included providing more time with key workers; improving the quality of food; and organising structured activities at the weekend.

We found people using the service were provided with appropriate care to meet their needs. They were involved in making decisions about their care and understood their rights under Mental Health Act 1983. There was information on all the wards about advocacy services and people told us advocates regularly visited the wards. National clinical guidelines and recommendations were understood and implemented by the hospital. Infection prevention and control measures were in place. There were systems in place for monitoring the quality and safety of services provided to people including a system for reviewing complaints.

Patients and their parents were involved in making decision. Staff treated patients with respect and dignity. They said there was a suitable balance and their privacy was respected. We were told that there was good communication between patients and doctors, therapists, social workers and teachers. Patients were encouraged to join in with groups and activities. Patients were informed of their rights and knew how to raise concerns.

A member of staff said that “it was a nice place to work, they looked after staff well and that training was good”. There also said that there was a good clinical team with good team dynamics.

We did not rate the Huntercombe Group following the well-led review as we only rate individual services for independent providers.

We found the following issues that the service provider needs to improve:

• The Huntercombe Group had been unable to recruit and retain a sufficient number of nurses with experience in CAMHS across the five services that were open at the time of our inspection. This resulted in services relying heavily on temporary staff to cover shifts. We concluded that this shortage of experienced nursing staff was one of the factors that impacted adversely on the safety of these services. Although the provider had made efforts to recruit, across the five services that were open at the time of the inspection, there were a total of 44 whole time equivalent (WTE) vacancies for registered nurses out of a total required workforce of 109 WTE - a vacancy rate of 40%. Meadow Lodge had the highest vacancy rate (50%); followed by Stafford (48%). The lowest vacancy rate for registered nurses in any of the five services was at Cotswold Spa (29%). These figures did not include long-term contracted nurses and block booked agency staff filling substantive roles as a means to mitigate against high vacancies.

• The Huntercombe Group had not put in place a programme of specialist training of its workforce to mitigate the low numbers of experienced staff.

• Although the Huntercombe Group had investigated and identified lessons to learn from the serious problems identified at Huntercombe Hospital Stafford, the system for ensuring that these lessons were put into practice was immature and not embedded across all of the hospital sites.

• There was no identified member of the senior leadership team accountable for the CAMHS service delivery across The Huntercombe Group. This hindered the organisation’s ability to standardise good practice across the specialism. This was reflected in our findings across the services of inconsistent implementation of policies, sharing of good practice and embedding of lessons learnt across teams.

• We identified a number of significant lapses in governance. There was no effective corporate oversight of the provision of mandatory and role-specific training for staff and no effective system in place to ensure that staff in all services received consistent and regular supervision and appraisal. We found a lack of detail in the minutes of the various provider level governance meetings including the delivery board and quality assurance group. The minutes did not capture the discussion of data relating to performance or adverse incidents. Although senior management were able to inform us what had been discussed at these meetings, the minutes and papers of the meetings did not record this detail.

• The staff engagement strategy was not consistently embedded across all CAMHS services. Staff, at some services, reported they did not feel consulted or engaged in changes to practice and service developments. They did not feel the systems and processes in place supported an open culture for whistle blowing.

We found the following areas of good practice:

• The Huntercombe Group had a clearly stated vision and objectives. Managers worked to ensure all staff at all levels understood them in relation to their daily roles. All staff, including temporary workers, received an induction to their service.

• There was evidence of some improvements in the governance of services since our inspections of Huntercombe Hospital Stafford and Watcombe Hall. The organisation’s early warning escalation system, quality dashboard, quality assurance framework and quality improvement forums provided a range of data.

• There was a programme of regular audits intended to identify issues and inform improvements.

• The provider had a number of initiatives that involved young people. For example, the ‘you said, we did’ initiative encouraged young people to be champions of their peers’ views; and the ‘glamour for your manor’ initiative encouraged young people (and staff) to submit proposals for improvements to their ward environment.

• Several wards had registered with the Royal College of Psychiatrists’ Quality Network for Inpatient Child and Adolescent Mental Health Services (QNIC), and some wards had already received QNIC accreditation.