We rated Richmond House as good because:

• Staff completed detailed risk assessments using recognised tools that included comprehensive risk management plans. Staff updated individual risk assessments following incidents. Staff knew what incidents should be reported, incidents were reviewed and feedback distributed to staff via the Friday meeting and during staff handovers. The levels of incidents and physical restraints had reduced since the last inspection.
• Overall service specific mandatory training compliance for staff was 100%. Safeguarding adult training compliance was 100% and for safeguarding children was 100%. Staff received supervision in line with the provider’s policy, attending both 1:1 supervision and group reflective practice sessions.
• The provider had estimated staffing levels for each shift and the numbers and mix of staff was adjusted to take into account of patient need and safety. The manager ensured the consistency of agency staff booked to provide continuity of care for patients.
• A comprehensive ligature risk assessment was in place. This was updated regularly. The provider had mitigated risks posed by obstructed lines of sight by the use of convex mirrors. New bedroom windows had been fitted to ensure that patients were safe and risks were mitigated. The provider had refurbished the bathrooms and wash hand basins in bedrooms with anti-ligature fixtures and fittings. Staff and patients kept the service clean.
• Patients accessed regular physical health care through visits to a local GP. Care records showed that staff monitored patients’ physical health needs throughout their admission.
• Staff encouraged and supported patients to access opportunities to aid reintegration with the local community.
• Staff held regular multi-disciplinary team meetings and encouraged patient attendance to contribute to their care and treatment programmes. Patient records contained detailed information relating to individual rehabilitation.
• We observed caring and compassionate interactions between staff and patients. Patients told us that staff were caring and approachable, and most said they felt safe on the unit. Patients were involved in developing care plan goals, and completed a document that included their goals, strengths and how they liked staff to support them.

We rated Richmond House as good because:

• The service had implemented four of the five recommendations from the previous inspection to improve safety and dignity for patients.
• The service employed enough staff for patients to have 1-1 time with staff and attend activities outside of the service, including evenings and weekends.
• Patients told us they liked the service and had a good range of activities.
• The service had good links with local health services to provide ongoing physical healthcare for patients.
• Patients were involved in writing their individual care plans and positive behaviour support plans which were provided in easy read and visual formats.
• The service provided a good range of activities including psychological therapies, life skills and social events.

However

• There were still ligature point risks that hadn’t been mitigated by the service that provided a risk to patients wishing to harm themselves that had not been addressed promptly following the last inspection.

We rated Richmond House as requires improvement because:

• There were multiple ligature points (things to which patients intent on self-injury might tie something to harm themselves), in the bathrooms and bedrooms. The provider completed ligature risk assessments, but had no plans to remove or update ligature risks in these areas. There were multiple blind spots around the unit and on all floors, which were not risk managed. There was no nurse call system in any bedrooms or bathrooms, and staff did not carry alarms.
• There was a breach of the Mental Health Act (MHA) code of practice and CQC regulations regarding single sex accommodation. There was no female only lounge.
• Staffing levels at weekends and evenings was not sufficient to manage any serious control and restraint procedures that may be required, or other emergencies.

However:

• The service employed appropriately trained staff and covered vacancies by using regular bank or agency staff. Most staff were up to date with mandatory training, and those who were not had training dates booked. All staff either had, or were studying for, the British Institute of Learning Disability (BILD) care certificate or a diploma in health care. Supervision and appraisals were all up to date.
• All staff had received MHA training. Staff understood the MHA, the revised code of practice and the guiding principles. Staff completed capacity and consent to treatment requirements and reviewed these regularly. Staff explained patients’ rights on admission, and they repeated this information at patients’ reviews. Patients had access to Independent Mental Health Advocates (IMHA’s). Richmond House had no incidents of seclusion, segregation, or deprivation of liberty safeguard applications.
• Robust arrangements were in place for staff to manage admissions and discharges in the hospital. Staff undertook pre-admission assessment visits and patients were encouraged to visit the service prior to admission.
• Patients’ risk assessments were up to date. Staff had completed crisis plans for all patients to address any mental health deteriorated. Care records showed that staff carried out comprehensive risk assessments including physical health care needs. Staff encouraged patients to contribute to their own recovery. Patients had access to an independent advocacy service.
• The hospital had a good track record for managing safeguarding and complaints. The manager used the partnerships in care dashboard to monitor activity on the unit including MHA reviews and section 17 leave. Clinical audits were regularly undertaken by the manager and outcomes shared with other staff. The provider’s policies met best practice guidance. Staff told us they were able to raise concerns without fear of victimisation. Staff told us they were unaware of any bullying or harassment cases.
• Staff knew about and agreed with the organisation vision and values. Staff used clinical practice as recommended by National Institute of Health and Care Excellence (NICE) guidelines. Multidisciplinary team working and information sharing was good. Staff worked closely with external agencies and existing care co-ordinators to identify suitable accommodation, employment, and voluntary opportunities for patients. The provider offered smoking cessation support.

During our inspection, we spoke with three of the five people who were using the service at that time.

They told us that they were well cared for. One person told us, "Its brilliant here, I like the food and always get a choice of things to eat." Another person told us that, "I have got on really well here and can now move to somewhere where I can be more independent.” This showed us that that people who used the service were able to move on to more independent living services where this was appropriate and safe for them to do so.

We looked at the care records for three people who used the service. These contained care plans and risk assessments and were up to date. They included details of people’s hopes for future moves. We also looked at medication and staff training records. These were accurate and up to date.

The training records detailed the training that had been provided and identified where further training was needed.

This was a follow up inspection to check that the service had taken the actions they told us they would take following our inspection on the 13th September 2012.

We spoke with two people who used the service who told us that there were sufficient staff to meet their needs and enable them to go out.

We found that the service were now compliant with Outcome 13.

During the inspection, we spoke with four of the five people who were using the service at that time. People we spoke with told us that there were strict routines in place. One person told us that staff had to observe them at all times even when they were in the shower. Another person told us about their "Lovely nurse" who was helping them to use a new phone.

People told us that they were able to lock their bedroom doors, and that the staff would lock things in the safe if they wished. Two people told us that they had involvement in their care planning. One person said the care plan "Gives me boundaries." Another said that they thought their care plan was "Just about rules."

People who used the service told about activities they were able to take part in including shopping, walks, college courses and employment schemes. They also told us that they had to help with household chores such as cooking and cleaning.

We looked at the environment. This showed areas that needed to be improved both inside and outside.

At the time of the review there were seven people receiving treatment at Richmond House. We spoke with five people at length during our visit to get their views on the service and the treatment they received.

The people we spoke with told us about their past and events that led to their admission to Richmond House. Three people told us they had been asked if they wanted to move to Richmond house. The others said that “the doctor decided”.

All five people knew that they had a care plan, and three people told us they had their own copy. Two people told us they had a Health Action Plan.

We asked people what they did during the day. One person told us they went “into the local town or to the shops.” Another person told us they “liked cooking and sometimes helped in the kitchen”. Another person told us that they “go on trips in the bus at weekends, to Great Yarmouth or Diss.”

The people we spoke with all said they felt safe and knew what to do if they were abused or saw someone else abused. One person said “nothing happens here so I don’t need to worry”. Three of the five people we spoke with had been given information on abuse.

We also spoke with the relatives of two people being treated at Richmond House and a family friend of another. They all knew about their relative’s care plan and two people told us of some other activities their relatives enjoyed, which included guitar lessons, music and needlework.