• We carried out this unannounced focused inspection on the 3rd November 2017. This was to establish whether the provider had met the requirement notices served following our comprehensive inspection in September 2016. During the focused inspection we looked at three domains, safe, caring and well-led, these domains are where the requirement notices were issued. Following our inspection in September 2016, we had rated the service as good for effective and responsive. Since that inspection, we have received no information that would cause us to re-inspect these key questions.
• The service had made improvements in response to the requirement notices. As this was a follow up inspection the service was not re-rated as not all of the domains were inspected.
• The service met the breach of regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014. They had taken action to record when non-prescribed medication was administered to patients on medicine administration charts. Staff completed weekly spot checks and an external pharmacist attended to complete audits. The medicine fridge was kept in good order and fridge temperatures were monitored. Information on how to reset the fridge was available to staff. They were aware of how to reset the fridge temperature if required. The service had taken action and met the breaches of regulation 9 of the Health and Social Care Act (Regulated Activities) Regulations 2014. The service had implemented changes that meant patients were involved in the planning of their care. Staff completed care plans with patients, copies of care plans were offered to them. Care plans were holistic and included patients’ strengths, weaknesses and preferences.

Some people who used the service were unable to tell us their views because of their complex needs so we used a number of different methods to help us understand their experiences. We spoke to three people about their experience of the service, two nurses, one care assistant and three relatives. We also looked at records relating to treatment and other aspects of the service provided.

We saw that people were treated with warmth and kindness and were involved in influencing the care and welfare they received. A relative told us “Staff are very good, it is the best place for them.”

Care was planned and designed to meet the individual health and welfare needs of the people who used the service.

The people who use the service were at risk of not having their ongoing individual care and welfare needs met because all health care was not coordinated between providers and it was unclear who would provide other aspects of care.

People were not protected against the risks associated with medicines because the provider did not manage their recording or administer them properly.

We found that care workers were skilled, qualified and competent to provide the people who use the service with the care they required to meet their individual needs.

The provider did not have an effective system to assess and monitor the quality of the service provided to protect people against the risk of unsafe care and treatment.

People told us they had benefitted from the service, and had developed greater independence. We read on a feedback form," I liked the fact I could see myself making a lot of progress." People told us they need more interesting things to do each day. One person said, "We have some games, DVD's and walk locally, but I think a lot more could be done."

People told us the food had recently improved and this was generally now very good.

We rated the Olive Carter unit as Requires improvement because;

• Although the service operated safe medicines management; we found three unlabelled insulin vials and insulin pen. Insulin has a change of expiry date once it has left the fridge; dates were not documented on the insulin.
• The fridge in the clinic room was overstocked therefore blocking the fan and reducing the circulation of air to keep medicines cool. Not all staff knew how to reduce the temperature of the fridge in the clinic room. The fridge temperature was 16 degrees centigrade.
• Non-prescribed medication administered to patients did not include the patients’ name. There were no recordings on the medication administration records of when patients had been given these types of medication.
• There were four areas of mandatory training that fell below 75% one of which was medication training at 67%. Training for bank staff also fell below 75% such as deprivation of liberty safeguards and Mental Capacity Act training which was 57%.
• Although care plans were up to date and recovery orientated not all showed patient participation.

• Patients were involved in discussions about their care and treatment, most care plans were signed but it was not clear whether the patient was offered a copy of their plan.
• Patients were not routinely invited to ward reviews they were able to give and receive feedback through their key worker.

However,

• The unit was clean with well- maintained furnishings. There was a range of rooms and facilities to support treatment and care. The service could also access facilities at the adjacent Janet Barnes unit.
• There were sufficient staffing levels to cover all shifts to safely support patient’s observations. Staff had good understanding and development of skills in de-escalation techniques.
• There was a good range of skilled staff to deliver care and treatment to the patients. There was good multidisciplinary team working within the service that also extended to outside agencies.
• Staff were kind, patient and showed a good understanding of individual patient need.
• The NHS Safety Thermometer rated the unit as providing 100% harm free care to the patients. This was above the national average of 95%.
• There were good discharge plans in place that involved a range of professionals and consideration to aftercare treatment under section 117 of the Mental Health Act.
• Patients could personalise rooms and had access to keys therefore they could lock their rooms. There was access to snacks and drinks at any time.