• Governance systems at the service were not embedded or working to ensure continuous monitoring of quality and service improvement. Audits we reviewed  for care note quality, ligature point checks and cleaning of the service, in all examples requested there were significant gaps.
• Risk assessments of patient need were not routinely updated following every incident or significant change to their wellbeing.
• Bedrooms in use by patients were not always fitted with necessary security or observation facilities. We found that where anti-barricade systems were in place, staff were unfamiliar with their use and were unable to demonstrate how to operate them.
• There was inconsistent use of the electronic record keeping system. Some senior medical staff reported that they were unable to access the system and instead documented their clinical entries using other staffs log in details, or had them typed up on paper and placed in a paper file.
• We found limited evidence of the use of debriefs following significant incidents, or a process for sharing and learning lessons to reduce future risk. Staff reported that debriefs happened in isolation, followed an inconsistent format and were not routinely recorded.
• Practices for the storage and dispensation of medication did not always ensure patient safety. We were given an example of a patient who had recently accessed the clinic room and obtained un-prescribed medication. We were not provided with any details of actions taken by the service or lessons learnt as a result of the incident occurring.
• Blanket restrictions were in place across both wards. There had been no consideration of the use of individualised risk assessments to support patients access facilities for activities of daily living.
• Morale amongst staff at the service was varied. Staff did not always wear the appropriate uniform and we were given examples where staff groups had chosen to work hours that were not in line with their contracts or the needs of the service.

We rated Priory Lakeside View as requires improvement because:

• Governance systems at the service were not embedded to ensure continuous monitoring of quality and service improvement. We recognise that the provider had responded and acted upon concerns we raised during the focussed inspection for the two acute wards. However, on this inspection for the whole hospital we still found outstanding breaches and gaps in governance. The leadership at the hospital needs a period of stability and consistency to embed new systems and practices and to enable effective governance and to support to all staff.
• The service had suitable premises and equipment but they were not always kept clean or well maintained. We found unclean wards, empty hand gel dispensers and emergency and medical equipment that had not been checked on a regular basis.
• Staff did not always keep appropriate records of patients’ care and treatment. Care plans for patients on the acute wards were not personalised, holistic or recovery focused. They did not evidence agreed goals or discharge plans.
• The service did not have enough staff with the appropriate qualifications, skills and training and experience. For example, the personality disorder pathway wards did not have enough staff suitably trained to provide the therapy patients had been referred for. There was high use of bank and agency staff and the vacancy rate across all wards was high at 21%.
• All patients were subject to blanket restrictions which were disproportionate and not individually assessed.
• The service did not ensure that patient care and treatment was designed to make sure it meets all the patient needs. There were minimal therapeutic and recreational activities available for patients on the acute wards. Patients told us there was nothing to do and there were no activities available in the evenings or weekends.
• We were not assured that the service treated concerns and complaints seriously, investigated them and learned lessons from the results.
• The service did not always actively seek feedback or action feedback from the people using their service. We saw many examples of the service not acting upon feedback in the community meeting minutes. There was a lack of information available to patients about how they could feedback in other ways.

However:

• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• Staff understood how to safeguard patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The hospital had four safeguarding champions.
• The service had good medicines management processes.
• Staff undertook risk assessments and completed risk management plans with all patients on a regular basis.
• Patients had good access to physical health care.
• The service had an electronic system for recording and storing information about the care of patients. This meant that this information was available to doctors and nurses as patients moved between services.
• Staff used the Mental Health Act and the accompanying Code of Practice correctly.