We rated Montague Court as outstanding because:

• Managers ensured there was always a sufficient number of staff on duty who were suitably skilled, qualified and trained to meet the needs of patients. Staff received regular supervision and appraisals. There was good medicines management across the service. Staff used a recognised risk assessment tool which they had adapted to add colour coding so that it was easy for staff to identify the current risks for patients. Staff mitigated risks in the hospital such as those from ligatures by using risk assessments and being very aware of the triggers for each patient. This meant that patients could take positive risks in a safe environment.

• Patients could access a range of therapies depending on their needs. These included cognitive behavioural therapy, dialectical behaviour therapy and positive behaviour support. There was also a full range of sessions to engage patients in activities to promote physical and mental wellbeing. These included activities of daily living such as self-care, housework, laundry, catering and budgeting. Patients had the use of computers to undertake learning. There was a range of exercise equipment available and an instructor attended the unit several times a week. They worked with patients to create and supervise exercise programmes and run exercise sessions that were very well attended. Patients who had leave had planned community visits with occupational therapists that were focussed on the activities of daily living such as shopping and socialising. These were inclusive and mindful of patients’ limitations to ensure that all patients were included.

• Staff ensured that patient records had been completed in holistic and personalised way. The records were of a high quality and focussed on recovery and improvement for each patient, involving a wide-range of professionals. It was clear that patients were fully involved in their care plans. The hospital had developed a system that allowed staff and patients to follow progress easily. The hospital had a team of Mental Health Act administrators who provided support to the staff. The administrators ensured that all paperwork relating to the Mental Health Act was completed fully, including for new patients before they were transferred to the hospital, to ensure the patients were properly supported using the Act. They worked in a way that was thorough and detailed.

• Staff had developed strong and supportive relationships with patients that had been built on trust. They had an excellent understanding of the needs of patients and were aware of their histories, so they could provide highly person-centred care and support. Staff took a holistic approach and went the extra mile to ensure that patients’ emotional wellbeing was considered and support was arranged in considerate and innovative ways. They talked about patients being part of the Montague ‘family’ and patients all agreed that staff went above and beyond their paid role.
• Patients had access to a range of rooms on the hospital site so that they could participate fully in the activities and learning opportunities provided. The occupational therapists and activity workers ensured activities met the needs of the individuals and supported them towards greater independence.
• Governance of the hospital was of a very high standard. Managers demonstrated they were fully involved in all aspects of the hospital and they knew patients and staff well. Staff felt valued and stated they appreciated the opportunities that the service had provided for learning and development. Patients felt they could approach anyone in the hospital if they needed to no matter what their role was. The culture of the hospital was one of improvement. This was evident throughout the whole staff team. Managers encouraged staff to think creatively and gave them the opportunity to explore and develop their ideas so that the whole hospital could benefit from this.

We rated Montague Court as good because:

• Montague Court provided a safe and clean environment. Staffing levels met the needs of the patients and the unit only used agency staff who had received an induction and who knew the service well. Staff completed risk assessments for patients and ensured they updated them regularly.
• Staff completed care assessments and carried out regular physical health care monitoring. Management of medication followed national guidance and the service provided psychological therapies including cognitive behavioural therapy. Mental Health Act paperwork was completed and stored correctly.
• Staff treated patients with dignity and respect. They had used their knowledge of patients to build supportive and therapeutic relationships. Patients spoke positively about the care they received.
• Montague Court provided a full range of treatment and therapy rooms for patients to use. Each patient had their own room, which they could personalise as the wished. They could lock these rooms to keep personal items safe. Patients had access to drinks and snacks when they wanted and had use of outside space. The activity programme encouraged recovery and independence.
• Staff morale was high and they described working in a supportive environment where they felt well they could approach managers at any time. Montague Court had shown a commitment to improving the processes they used to improve the quality of the service patients received and all staff demonstrated that they used this during their daily work.

However

• Mandatory training levels were below the target set by Options for Care in areas such as safeguarding and the service had to address the issues it has had with accessing training. This meant the service could not be sure staff were competent in all areas of their work.

We rated Montague Court as good because:

• Options for Care had undertaken work since the last inspection to improve all areas of care delivery.
• Consideration had been given to the environment. The building was visibly clean and well presented. Areas had been set aside for therapies. These were well thought out and had a range of equipment to assist in sessions. The clinic room was well equipped, clean and fit for purpose. All equipment had been checked and had stickers detailing when the next checks were due.
• All patients had care plans that contained detailed risk assessments and risk management plans. These were patient centred and recovery orientated.
• Montague Court had employed a Mental Health Act (MHA) administrator and staff had received training in the Mental Health Act and the Mental Capacity Act (MCA). Given its patient group were predominantly detained under the Mental Health Act this has resulted in systems that ensured that Montague Court record and store information relating to the MHA and MCA correctly.
• There were systems in place to ensure the involvement of the patient group in the day to day running of the service. Weekly house meetings canvased the opinions of the patient group and this information was fed into staff meetings. Where appropriate improvements had been made because of this information.

However

• We found errors in medication recording. These related to the section 62 second opinion appointed doctor (SOAD) paperwork and recording of refusals.
• There was no clear advocacy pathway at the time of our inspection and Montague Court did not have access to independent mental health advocacy (IMHA) services.
• Substantive staffing levels were low. There were vacancies for both qualified nurses and health care assistants at the time of our inspection. There was regular use of contracted agency staff to mitigate this.

There were 14 patients there on the day of our inspection. All patients were detained under the Mental Health Act (MHA). We spoke with six patients, nine members of staff, looked at six patient’s records and observed a clinical/multi-disciplinary team meeting.

We found that improvements were needed to ensure the service was safe. We found the provider had policies and procedures in place to protect people from abuse or harm. However, we identified that records were not complete to ensure that staff knew how to manage risks to patients.

Improvements were needed to ensure the service was effective. We found that systems were not in place to assess the quality of the service provided and make improvements. The guidance in the Mental Health Act (MHA) code of practice was not always followed to ensure patients had the appropriate care and treatment.

We observed that staff interacted well with patients. Patients told us that staff showed them respect. However, patients were not involved in their care planning.

Staff responded to patients individual preferences and supported them to meet their religious and cultural needs. However, some patients were not confident that their views and complaints were listened to.

Improvement was needed to ensure the service was well led. Systems were not in place to ensure that regular audits were completed to measure the quality of care.