The service was rated as requires improvement overall in May 2017. It was not rated at this inspection.

The Care Quality Commission (CQC) carried out a follow up inspection of Annesley House on 17 July 2017 to ensure improvements were made following our inspection in May 2017. This followed CQC issuing a warning notice on 25 May 2017 to the provider requiring them to make sure patients received the required level of observation to maintain their safety and the safety of others.

We found the provider made the following improvements:

• Staff on Oxford ward completed patient observations in communal areas of the ward and documented patient observations on the provider’s observation and engagement record form.
• The provider had implemented a new observation and engagement policy, delivered a training programme for all staff based on this new policy and completed an audit that reported into the provider’s clinical governance processes.
• We saw completed and up to date care plans, risk and physical health assessments.

• Documentation relating to the Mental Health Act 1983 was in order, however we observed a patient was not read their rights under section 132 Mental Health Act in a timely manner. This was rectified by the nurse in charge.

However

• We saw three staff members were not following the provider’s observation and engagement policy as they had included information about the patients’ mental state. One staff member did not record patient observations intermittently but recorded patient observations every 15 and 30 minutes.
• One care plan we saw did not focus on patient discharge although the patient had unescorted section 17 leave.

This was a responsive inspection and we only looked at three of the five key questions, which were safe, effective and well led. At our previous inspection in August 2015, we rated the other two key questions of caring and responsive as good. We have received no further intelligence to suggest any issues that would change these ratings.

We issued a warning notice to the provider as we identified a breach of Regulation 12 in relation to patient observations.

We rated Annesley House as requires improvement because:

• Staff did not observe patients on Oxford Ward as often as needed to make sure patients were safe.

• Staff did not consistently store medicines at safe temperatures and emergency equipment was not always in date.

• There were eight vacancies for registered nurses and agency staff were used to cover. The provider did not make sure that the estimated number and grades of staff worked on each ward on every shift.

• The provider did not offer psychological therapies to each patient to meet their assessed need.

• The provider did not offer specialist training to all staff to help them support patients.

• There had been two changes of managers within the last nine months, which had unsettled the hospital. There was no registered manager in post at the time of our inspection. An acting manager was in post.

• Audits did not always identify the risks to the health, safety and welfare of patients.

However:

• The environment was clean and safe.

• Restraint and seclusion were used appropriately and in line with current guidance.

• Staff followed safeguarding, Mental Health Act and Mental Capacity Act procedures and policies.

• Staff assessed each patient’s risks and needs and developed a care plan with the patient.

• The provider made sure that staff had mandatory training.

The service provided was safe. People told us they felt safe in the hospital. People told us that staff were proactive in addressing any identified safety concerns. Safeguarding issues were being appropriately reported. The relevant records seen showed us that clinical risks were being managed safely.

The service was effective. Each person had an individual care record which included assessments of specific needs. Individualised care plans were in place This demonstrated to us that care and treatment was being effectively planned and delivered in a way that was intended to ensure people's safety and welfare.

The service was caring. People told us that staff had time for them and provided them with the appropriate levels of support. We noted that staff were supportive and caring with people. We found that individuals were having their rights protected under the 1983 Mental Health Act.

The service was responsive. Systems were in place to manage and investigate formal complaints made to the service. Three people who used the service confirmed that they felt able to share any of their concerns or complaints with front line staff.

The service was well led. We reviewed the action plan agreed with NHS England following the previous concerns identified by the Care Quality Commission. Evidence was seen of the actions taken by the provider to demonstrate their on-going compliance with the relevant regulations.

We spoke with five patients during our inspection. They all knew about the care and support that was planned for them and said they were consulted about this. They said if any changes were needed the staff would explain the reasons for this, and they said they were given the opportunity to share their own views about any changes.

Patients told us that they knew about their care plans and said they were involved in creating them. We observed that there was a relaxed and comfortable atmosphere on the ward where we sat; there was a good rapport between the staff and patients.

Most patients felt the staff would listen to them and take action if they had a problem; though they did comment that the staff did not always have enough time for them at the moment as a difficult situation was taking a lot of their time. This meant people did not always have the support they needed and as it was planned.

One patient commented that they felt the GP did not listen to them when they visited and did not take into account how they were feeling. We passed this information on to the manager for her to feed this back to the GP to ensure the patient received appropriate health care support.

Most of the patients we spoke with said they felt safe. However, one person told us they were being "bullied" by another patient. This person told us they did not feel safe on the ward at night because of this. We spoke with the manager about this. The manager had various ideas as to how to improve things for this patient, and had already put enhanced staffing levels in place as a means of protecting patients. The patients we spoke with all said when people were upset or agitated the staff tried to separate them from others and took them to a quiet area to calm down. None of the patients we spoke with ever felt that patients were at risk of being harmed by staff on these occasions and they told us they felt restraint was done in a controlled way.

The provider had a system in place to regularly assess and monitor the quality of services that people received but this was not always effective at protecting service users and others who may be at risk by identifying and managing all of the risks to their safety.

One person we spoke with told us they had not seen a complaints procedure. When we looked around the wards we could not see one on display. The manager told us this may have been lost or dislodged during the recent move and would make sure this was replaced. The other four people we spoke with told us they had not had any cause to complain. All of the people we spoke with told us there was an advocate who came in to see them regularly. They all said they could speak to the advocate at any time and said she was easy to approach. Other evidence suggested complaints were not always dealt with in line with the provider's policies.

This was a joint inspection visit by a Mental Health Act Commissioner (MHAC) and a compliance inspector. The visit was unannounced and the report includes findings from the MHAC where they indicate non compliance with the regulations.

We asked patients about their involvement and experiences at the service. One patient told us, “Annesley is a great place to be, it feels like home. There is a good atmosphere and staff are friendly. They very much support my needs and I am able to work towards my goal of attending college. Staff are respectful of my opinions and views and I feel valued. When I was at a previous place I was not involved at all, here the staff encourage me, I have a structured day and can access authorised leave.”

One patient commented, “I am progressing really well here, I can see the medical team regularly and they have explained my care pathway to me, I can see how well I am doing using the recovery star plan.”

Some patients we spoke with told us they felt safe. One patient commented, “Staff know how to provide treatment here, they know how to deal with any incidents of aggression to keep us safe.”

Another patient told us that they were not confident when they raised issues about staff attitudes. Comments included, “Some of the staff have bad attitudes; they can be dismissive and rude. When I complain I am told to write it in the ward complaint book but when you do that they all see it and collude with each other so there is little point in raising things.”

We rated Annesley House as good because:

• We observed positive interactions between staff and patients.
• Patients had access to physical healthcare appointments and staff monitored patients’ physical healthcare.
• Care plans and risk assessments were up to date and person centred and showed patient involvement. Patients and their families were involved in decisions about their care.
• Patients were supported to maintain their independence through real work opportunities and a variety of therapeutic activities facilitated by the occupational therapy team.
• The provider made sure there was the right amount of experienced staff to care for patients on all of the wards. Staff were inducted into the service, given regular supervision and appraisals and suitably trained.
• We saw evidence that showed all patients had access to individually tailored psychological treatments and were offered additional sessions if needed.
• Staff knew how to report incidents and we saw evidence that when this happened, managers shared the learning from these incidents with all staff.
• Staff morale had improved since the last inspection. Staff said they felt well supported by their managers and that change had been managed well throughout the service.
• There were effective systems in place to monitor key performance indicators for patient care and staff development.
• The hospital participated in national quality improvement programmes.

However:

• Not all staff were clear it was unsafe to access rooms that did not have a functioning alarm or nurse call system on a one-to-one basis with patients.
• Staff did not always implement individual risk assessments during periods of observation and this meant some staff were unclear as to how they should observe patients during the night if there was a risk they might harm themselves through hanging or strangulation.
• Staff were unsure about when and how often they should search a patient and their room.
• Some patients told us they did not feel supported by all staff on the ward and that the provider had not given them the opportunity to give feedback about the service.