We conducted this follow up inspection to satisfy ourselves that the changes introduced on the Ramsey unit during the latter months of 2013 were still being supported by the trust.

There were enough qualified, skilled and experienced staff to meet people’s needs. We found that staffing levels on the unit had been maintained to the higher ratios. The nurse in charge of the ward told us that staff numbers were monitored extremely closely to ensure that these corresponded with the assessed needs of the patients.

A housekeeper had also been recruited for five days per week to assist with household duties and there was ongoing support from physiotherapists, dieticians and occupational health to patients on the unit. When we spoke to the senior medical cover on the ward they confirmed they now undertook more sessions on the ward and they were also contactable by phone as necessary. They confirmed that there was now a more holistic approach to patient’s treatment and care which included the patient's relatives and representatives.

One member of staff told us, “Instead of ‘fire-fighting’ we are now able to prevent unacceptable behaviour and we know our patients better.” Another person told us that, “The changes have benefitted patient’s care and treatment in a significant way.”

We visited Ramsey Unit to follow up on the warning notices and compliance actions set from our inspection on 10 October 2013. On this inspection we found a much improved atmosphere which ranged from calm and restful to lively and stimulating depending on the activity and patient’s wishes. We saw that lunch time was calmer and well organised with patients receiving discreet support from staff when they needed it. Staff were allocated to individual patients at mealtimes to ensure they received the support they required with their meals. When we spoke with staff they were knowledgeable of patients’ dietary needs. We noted on the files that patient’s weights were being recorded on a regular basis and that each patient’s food and fluid intake was being recorded across the day. These records were in more detail when staff were gathering information as part of the dieticians requests and interventions for people identified as being at risk of weight loss.

We saw that staff had the time to stop and talk to patients and we noted positive interactions such as touches, prompting and encouraging patient’s to eat. We overheard some nice phrases used such as, “Would you like to make your way for lunch, take your time, there’s no rush” and “Oh dear are you a bit stiff? I’m like that some mornings.” This gained a warm and friendly exchange between the patient and the member of staff. One member of staff spoke to us and said, “Things have improved hugely since you last visited. I think you can tell just looking at the people here now.” They pointed to four patients sitting in the lounge who were alert, animated, engaged with staff enjoying lively conversation’s and exchanges.

The trust acted very quickly when staffing issues were raised on our last visit of 10 October 2013, with regards to staffing on the ward. Staffing levels were increased by 25% with eight additional posts being created and sustained. The increase in staffing meant that patients were properly supported particularly at mealtimes and helped with the more timely medication rounds. It also enabled appropriate observations and continued support for patients. The unit was now staffed so that people were receiving treatment from a multi-disciplinary team. This now included input from an experienced senior consultant psychiatrist and a consultant nurse as well as additional occupational and physiotherapy support. We judged that there was sufficient staff on duty to meet patient’s care and treatment needs.

Where people did not have the capacity to consent, the unit now acted in accordance with legal requirements. We found a much better understanding and use of the Mental Capacity Act to ensure people’s rights were protected.

From the evidence we saw, information we were given and collected we judged that people’s care and treatment needs were not being addressed. Staff told us, “The staffing levels are horrendous. We are running round like headless chickens especially on the evening shift. We don’t have the staff to put people on the level of observation they need or to give the level of support they need. There’s preventable falls happening and there’s no time whatsoever for stimulation.” Staff told us that they were aware there were some patients who were at high risk of weight loss. Medical staff who visited the unit told us, “We don’t see the patients very much. We assess them by remote control and we feel terrible that we don’t know the patients. We cannot do our job. We have complained about this so many times but we are just not listened to.”

Staff were very open and displayed a good degree of candour with the inspection team. At no time did we hear or see staff being anything but respectful and pleasant in their exchanges with people in the unit. We found staff took pride in their care of patients.

We carried out a specific type of observation on the unit designed for assessing the staff interaction with people who have dementia, called a short observation framework inspection (SOFI). From this we judged that it was clear that staff did not have the time to spend with people for both personal tasks, for supervision to keep them safe and also for stimulation and social interaction. All staff we spoke with told us they felt that the ward was short of staff. When we discussed this further we were told that they (the staff) had highlighted this to senior members of the locality management team but nothing had been done. We observed that there was little to no stimulation for patients and we were told by the manager that there was no therapeutic input. Staff told us that, “We always do more than our hours because we cannot leave the unit understaffed. Staff are fed-up. We do genuinely care for our patients.”

We interviewed three relatives, who were visiting, and they told us they were happy with the staff attitude and friendliness of making them welcome at visiting time. One relative said, “They (the staff) are certainly dedicated and hardworking.” However all reported that they thought staff were “rushed” and “stretched”.

We had concerns regarding the units understanding of patient’s legal status in relation to the Mental Health Act (MHA), the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DOLs). The unit was not applying the MCA protocols for patients who were not detained under the act.