We undertook this focussed, unannounced inspection to find if Ash House had made improvements to their service since our last unannounced comprehensive inspection in July 2017.

When we last inspected Ash House, we found that two of the five key domains, effective and well-led, were deemed to require improvement, whilst the other three domains were rated as good. In completing this latest inspection, we considered that, based on information gathered during the period between inspections, caring and responsive domains remained rated as good. We reviewed three domains on this inspection: safe, effective and well-led.

We rated Ash House Rehabilitation Unit as good because:

• The service had met requirements with regard to breaches of regulation found in the inspection, report published in July 2017.

• The building had blind spots that were adequately mitigated by mirrors and equipment to reduce risk of harm to staff and patients. The service had an environmental ligature risk assessment in place, as well as individual risk assessments for each patient. Induction training was deemed appropriate and was completed across the service by all staff. Leave documentation for patients was audited. Patient risk assessments were holistic and up to date. Safeguarding was in place and audited. Medication management was in place and audited. All staff had a disclosure and barring service check that was electronically maintained and a copy kept in personnel files.

• Care plans were up to date, personalised and holistic. There was documented evidence that patients were being given a copy of their care plan, or offered a copy. Physical health monitoring was on-going at the service. There were comprehensive pre-admission criteria in place that was being followed. Patients were given time to access the internet by computer, as well as having access to their own mobile telephones after individual assessment. Mandatory training was taking place, and was audited by the service. Mental Health Act documentation was in order, and the new Mental Health Act administrator for the service was clearly knowledgeable about the subject. Ash House had five lay hospital managers who were involved with the service. Mental capacity of patients was being monitored and considered across the service.

• Policies and procedures that had not been tested on the previous inspection were embedded and seen to be working. Senior management oversight was present and noticeable at the service. There was a full and comprehensive risk register at Ash House. Policies at Ash House were in place and were relevant to the service. Key performance indicators were in place, and we saw evidence in minutes of meetings that these were used to gauge and enhance performance. Staff felt that morale was much higher, and felt that they had a voice in the service.

However:

• while staff told us supervision was regularly taking place, data supplied by the service was not up to date.
• Proactive referral to the independent mental health advocate was not being recorded when patients did not understand their rights.

We undertook this comprehensive, unannounced inspection to find out whether Ash House had made improvements to their service since our last comprehensive inspection of November 2016.

When we inspected Ash House in November 2016, we rated the hospital as inadequate overall. We rated safe, effective, responsive and well-led as inadequate and caring as requires improvement. We placed Ash House into special measures.

At this comprehensive inspection in April 2017, we saw substantial improvement and it has been agreed that Ash House can exit special measures.

We have now rated Ash House as requires improvement because

:

• We saw that there were no associate hospital managers to the service, so if a patient decided to appeal against their section, there was no hospital manager to hear their appeal. This was in breach of the Mental Health Act Code of Practice.
• Mental Capacity Act training had been attended by only 25% of staff, and Mental Health Act Awareness training had been attended by only 25% of staff.
• Although policies and procedures had been drafted for the service, many of the policies had yet to be made available to staff at the time of the inspection.
• At the time of the inspection, there was no registered manager at the service.

However:

• The service had met requirements with regard to the breaches of regulation found in the November 2016 inspection.
• The building had blind spots that were adequately mitigated to reduce the risk of harm to staff and patients. Patient risk assessments accurately identified patients’ risk to self and others. Safeguarding referrals were being made when necessary to the local authority. Medication management was in place and audited. A full ligature risk assessment had been carried out on the building, and was maintained. Patients could access their rooms during the day, and electronic door access was available to bedroom areas so patients could access the area without needing staff assistance.
• We found care plans to be updated, personalised, and holistic. Patients were being given a copy of their care plan, or offered a copy. Physical health care needs were documented and recommendations made regarding actions. There was evidence that psychological interventions were available to patients, if required. The Mental Health Act administrator had developed and maintained a system to monitor and alert staff when actions were required under the Act.
• The service had a regular patient meeting that was attended by patients, and minutes were taken and shared. Patients were treated with kindness and respect. We saw positive interactions between patients and staff. There was regular access to an independent mental health advocate for patients. We were told by a patient that he was hoping to leave the service soon, and was involved in sessions preparing him for return to the community.

• There was provision of structured activities within the service to aid patient recovery and rehabilitation. The operational framework for the service gave clear admission criteria. Cultural and religious differences were recognised and given consideration. Activities within the service had improved since the inspection in November 2016. The use of an occupational therapy assistant meant planning and provision of activities was much more prevalent. The sessions provided were meaningful.
• During the inspection in November 2016, there was no evidence of any vision or values in place at the service. At this inspection, the new chief executive officer for the service had helped develop visions and values and had incorporated them into the new operational framework. A risk register had been introduced and was up to date and comprehensive. The governance structure that was in place appeared sound, although the limited number of patients in the service meant that the governance systems introduced had not been fully tested due to the lack of admissions.

This was an unannounced focused inspection. We inspected because people had contacted us to raise concerns about patient safety. Ratings have not been given for this inspection.

We previously inspected Ash House in November 2016. We found breaches of the following Health and Social Care Act (Regulated Activities) Regulations 2014:

• Regulation 9 person-centred care
• Regulation 12 safe care and treatment
• Regulation 16 receiving and acting on complaints
• Regulation 17 good governance
• Regulation 18 staffing
• Regulation 19 fit and proper persons employed

We took enforcement action and rated the service inadequate overall. The Chief Inspector of Hospitals placed the service into special measures.

At this inspection we did not review the provider’s progress against the breaches of regulation. We looked at the areas of concern that had been raised.

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

• Patient risk assessments did not include all relevant information or give clear guidance to staff on how to manage risks.
• Treatment goals were not recovery-oriented and patients were not involved in planning their care.
• Staff did not always feel able to raise concerns with managers and morale was low.

However we also found evidence of good practice in the following areas:

• Convex mirrors had been installed to improve lines of sight on the wards.
• Staff had access to telephones to be able to call for help in an emergency.
• Patients’ medication administration records and Mental Health Act detention paperwork were up to date and stored appropriately.
• Unstructured activities for patients were available on the ward.
• Senior managers had met with the team to discuss the requirements of staff roles and the future of the hospital.

The service will continue to be monitored while in special measures and a further comprehensive inspection will take place to assess the provider’s progress against all areas identified as inadequate or requires improvement.

The CQC is placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made, and there remains a rating of inadequate overall or for any key question, we will take action in line with our enforcement procedures. At this point, we would begin the process of preventing the provider from operating the service. This will lead to cancelling the providers' registration at this service, or varying the

terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six

months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We rated Ash House as inadequate because

:

• The building had blind spots that were not adequately mitigated to reduce the risk of harm to staff and patients. Staff did not know the location of emergency equipment that was available. The service did not have an environmental ligature risk assessment in place. Risk assessments and management plans were not sufficiently detailed, meaning staff did not have an adequate knowledge of patient risk. Staff were not aware of whether there was a service observation policy. Staff did not always complete safeguarding referrals to the local authority. The service had no systems or processes in place to support the safe management of medicines and their administration; staff inappropriately administered medication.

• Care plans were poor, with no long term goals or methods for achieving such goals. Psychological and occupational therapy interventions were not being delivered. Staff did not use rating scales to measure patient progress during their admission. Staff did not receive regular supervision. Staff handovers between nurses were not effective in ensuring key information regarding individual patients was shared. Multidisciplinary team meetings were insufficiently staffed to ensure holistic care was provided. Multidisciplinary meetings took place outside of normal working hours, limiting access to the meetings by relevant staff from both the service and from the community. The Mental Health Act was not adequately monitored, and no training was in place. Patients detained under the Mental Health Act did not have the relevant documentation in place in files or to hand. Patients were not read their rights whilst under detention, and advocacy services were not being accessed.

• There were no forums for patients or carers to provide input into how the service should be delivered. Staff had a limited knowledge of individual patients based on assessment shortfalls, partly due to senior management not sharing key information regarding risk with front line staff nor agency and bank staff. There were no leaflets or noticeboards outlining the treatments available to patients. There was no access to advocacy in place at the service.

• Patients did not know how to make a formal complaint. There was no information anywhere in the service outlining a complaint procedure. Activities for patients were very limited, and did not aid in patient recovery. Patients had difficulty accessing the outdoor garden area as the door was locked, and required staff to open it to go out and come in. The key-fob system utilised at the service meant that patients had to request access to corridors where their bedrooms were, and to leave the area. Admission criteria to the service was not clear, leading to the service admitting patients with complex physical and mental health needs, but staff were not adequately trained to meet those needs. The service did not consistently source an interpreter for a patient with difficulties communicating in English.

• The service did not have any vision or values. Leadership was lacking throughout the service, staff did not feel supported by the management team. Mandatory training was not monitored to ensure full compliance. Regular and appropriate staff supervision was not happening. There was a lack of medication management, as well as poor Mental Health Act Code of Practice application. The service did not use key performance indicators to gauge team performance. The service did not maintain a risk register or other system to capture significant risks that might arise. Staff meetings for all staff were not taking place, so there was little or no input from staff into the service. Staff morale was low.

However:

• We observed positive interactions between staff and patients, with staff treating patients with kindness and respect.
• Patients told us that staff were caring and genuinely took an interest in their needs.
• Carers told us that they and their family members were treated with dignity and respect.
• The service did cater for individual dietary requirements, having a separate refrigerator for halal food.