We rated Milestones Hospital as good because:

• The service employed a sufficient number and variety of staff to provide safe care and treatment for patients. Staffing levels ensured there was a qualified nurse on the ward at all times.
• Patients spoke highly of staff and felt safe and cared for.
• The service had up to date, thorough environmental risk assessments including ligature risks and health and safety assessments.
• Patients had a comprehensive risk assessment on admission that staff reviewed on a regular basis. Staff had agreed positive behaviour plans for each patient to manage individual risks.
• Patients received a physical health check on admission and at regular intervals throughout their treatment. The service employed a physical health nurse to complete health checks and observations.
• Staff provided clinical and therapeutic interventions in line with National Institute for Health and Care Excellence (NICE) guidelines.
• Patients were involved in deciding treatment options and making decisions about the care they received.
• The service offered a wide range of activities to patients including at weekends.
• Staff felt supported and were regularly supervised and appraised.

We rated Milestones Hospital as good because :

• The hospital was safe, visibly clean and well maintained. Each bedroom and the communal areas had nurse call systems and staff carried personal alarms to summon help. The clinic room was fully equipped with accessible resuscitation equipment and medications were stored correctly. The cleaning records were up to date and showed that staff cleaned the hospital regularly.
• The hospital was comfortably furnished and supported the patients’ recovery. Patients had a choice of lounge areas and staff encouraged patients to personalise their bedrooms. Food was of good quality with drinks available all day. A separate kitchen area was available where patients could cook their own choice of food under supervision. There was a designated activity centre that offered numerous activities with choices available. Patients and carers gave positive feedback about the hospital.
• The provider managed risks to patients well. It had a detailed policy about enhanced observation. There was a current ligature risk assessment dated 26 August 2015 that assisted staff to mitigate the potential risks from ligature points (fittings to which patients intent on self-injury might tie something to harm themselves). The provider also had environmental risk management plans. Staff made good assessments of risks for individual patients and the high ratio of staff to patients further mitigated any risks.
• The provider met the physical healthcare needs of its patients. Staff ensured that all patients registered with the local GP. Physical health check records were current and ongoing and showed that the care and treatment team regularly assessed patient progress. Records included outcome measures such as the health of the nation outcome scales and the recovery star.
• Managers and clinical staff engaged well with patients under their care. Staff interactions with patients were caring and senior management were approachable and friendly. Patient records contained evidence that patients were actively involved in decisions about their care and treatment. Staff ensured that patients had access to independent advocacy services and that patients knew how to make a complaint. The hospital had effective systems for managing complaints and concerns.
• The service employed a sufficient number of staff and covered vacancies by using regular bank or agency staff. Patients told us that staff rarely cancelled escorted leave, including taking them to their place of worship in the community. Qualified nurses were available at all times. Hospital staff knew who to contact for medical advice out of hours and in an emergency.
• The hospital managers ensured that staff were supported to provide high quality care. All staff had completed mandatory staff training. Each member of staff had received an annual appraisal. Staff attended weekly team supervision delivered by the psychologist. The provider held regular staff team meetings and there was effective team working and mutual support within the staff group. When needed, the provider offered de-briefing to individual staff by a psychologist.
• The hospital provided an innovative and proactive approach to the care and treatment of this client group. Instead of a traditional locked ward, patients were cared for in a small family like environment. In addition to traditional psychiatric interventions, patients could access a range of complementary therapies on site and in the community.

However:

• There were ligature points the hospital and staff could not easily see patients in some areas of the hospital. The inspection team brought this to the attention of the provider at the time of the inspection.
• Mental Health Act (MHA) paperwork reviewed in patient records was incomplete. We were able to find the missing information in the MHA administrator’s office.
• Although physical health checks were seen to be current and ongoing, of the care files reviewed, only one contained evidence that medical staff had completed a physical examination upon admission.
• Staff were not clear about patient access to the garden area and patients’ views about the level and choice of activities varied.

People spoken with told us that they were mostly happy in the service and that they were involved in their own care. For example one person told us, “I like the staff and they help me when l need it.” This and the other evidence reviewed showed us that people’s privacy, dignity and independence were respected.

We saw that people were actively encouraged to participate in their individual treatment programme and that they accessed specialist therapies and other support from staff. This demonstrated to us that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

We saw evidence of close and collaborative working with other mental health care services and other health professionals. This showed us that the provider worked in co-operation with others within the wider health economy.

Staff reported that there were good opportunities for training and career development. This demonstrated to us that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We noted that the service had received five complaints since January 2013 and the records seen showed us that these had been investigated appropriately and that people had been responded to in a timely manner. This showed us that there was an effective complaints system available.

During our review we spoke with four people who were detained within the service under the Mental Health Act 1983. Three out of the four people told us "I feel safe here and there is plenty of staff around if I feel I'm going off a bit". Another said "I like living here, but in my last place I had a job".

One person said "I go to the meetings but nothing's ever done, I asked for some plants for the garden and never got them". We checked why this had not been followed through at the time and we were told that the plants that had been bought had been left to perish, due to the person ignoring them. There were written records regarding this incident forming part of the evidence that feedback and opinions had been followed through.

Another person told us "We talked about having some massage as a part of relaxation at one of the meetings and we have a therapist that comes in to do that now".

Most people appeared resigned to be living in this low secure hospital and for that reason some comments sounded negative.

During the visit to the hospital five people who use the service spoke with us. Most of them were not happy with their general status and placement in this, low secure Mental health Hospital and most of their comments sounded negative for that reason.

Comments regarding their tribunals, or doctors decisions regarding their discharge were related to the work of the multidisciplinary team which included external professionals and not merely and directly hospital staff.

When talking about staff, they told us that there were a sufficient number of staff on duty, but that staff did not have enough time to talk to them, as they spent a lot of time in the office. One person stated the same for the manager of the service.

All of them praised some staff, in particular the ward manager and the chef.

They made comments about the environment, mainly addressing noise. One person who had already been moved to another bedroom to reduce the effects of the noisy central heating system was still unhappy. This was due to hearing noise from the pipes every time the heating system automatically switched on or off.

Another person commented on noise from people walking near her room. Her room was more exposed due to its location opposite the main entrance and close to the office. The staff had already introduced measures to reduce the noise level, at least at night.

One person told us that she was scared, but could not explain the source of the fear.

All people with whom we spoke stated that they would prefer to have a bath to a shower, although there was only one en-suite bedroom with a bath. The senior staff member, who was in charge during the visit, explained that this issue was known and that various options were being considered to accommodate at least one communal bath.

There were no negative comments related to direct care and treatment that people who use the service received and therefore there were no improvement or compliance conditions. The feedback provided to the person in charge and to the ward manager contained comments from people with whom we spoke and they both agreed to listen and review these comments in order to further improve conditions and the service for people living in the hospital.