This visit was a follow up to an inspection visit we made on the 4th December 2013 with a Mental Health Commissioner. At that time we made a compliance action which related to quality assurance. This meant we had not considered the provider had enough checks in place to monitor the quality of their own service particularly with regards to medication and the paperwork which related to formal patients.

A compliance action meant the provider was non-compliant with the law. We required the provider to produce a report setting out how and when they would become compliant, which they did, and we visited again on the 29th January 2014. Following our visit to the service we considered they had done enough to comply with the law and have therefore removed the compliance action.

We would advise the reader to look at the much fuller report produced for the inspection carried out on the 4th December 2013.

We carried out this unannounced inspection together with a Mental Health Commissioner who focussed on detained patients. The Commissioners findings are available on the CQC website as a separate report.

On the day of our inspection, Southleigh had twenty people who used the service, 14 of whom were formal patients detained by the Mental Health Act. This meant that there were some restrictions placed on them to do with their liberty.

We were able to talk to a number of people who used the service, they told us that they felt safe living at Southleigh. People felt that their views were listened to at the weekly community meetings, via the advocacy service and that if they wanted to make a complaint they knew how to.

We made a compliance action which related to quality assurance, this meant we did not consider the provider had enough checks to monitor the quality of their own service particularly with regards to medication and the paperwork which related to formal patients. A compliance action means that the provider was non-compliant with the law. We have required the provider to produce a report setting out how and when they will be complaint, and we will visit the service again to make sure that they are.

We carried out this unannounced inspection alongside a Mental Health Commissioner who focussed on detained patients. The Commissioners findings are available on the CQC website as a separate report.

The inspector was able to speak to six out of the 22 people resident, numerous staff including ancillary staff, professionals attached to the service and the registered manager.

Three people who use the service were positive about Southleigh. We received comments such as, “this is a nice place” and “the staff are very helpful and reassuring”. In general, people made some very positive comments about the staff, singling out some for particular praise.

Three other people that we spoke to did not feel as positive about Southleigh. When we looked into this further, they commented that there was not good atmosphere which they put down to another resident. We discussed this with the manager who agreed that the hospital would look into this with the advocacy service that came into the home on a monthly basis.

All the paperwork that we looked at was up to date and relevant. People who use the service knew that they had care plans and what was written in them.

We received many positive comments about the choice and quality of food. People with special dietary requirements were catered for including vegetarians and diabetics.

On balance the people we spoke to at Southleigh Community were satisfied with the standard of care and support they were receiving.

People felt that they could express their views and that they would be listened to; this was either via the patients meetings held three times a week or on an individual basis by talking to staff.

We received some very positive feed back about the staff including, ‘staff are good, they are a team’ and ‘my primary worker looks after me.’ Staff are supported to do their jobs with training and regular supervision. Some individual staff were singled out by people who use the service as being exceptional in the care that they gave, for their ability to listen and for treating people with dignity and respect.

Staff are well trained and supported to undertake their work.

Southleigh Community is a modern, well maintained environment, furnished to a high standard with many homely touches. One person told us, ‘it a top quality hotel….when I moved in they gave me a new carpet and bedding’.

We received many positive comments about the choice and quality of food on the wards. People with special dietary requirements are catered for including vegetarians. The hospital are in the process of building a kitchenette area where people can help themselves to drinks throughout the day.

The main area that the hospital needs to focus on is care planning; although the plans are well written, there needs to be evidence that people are involved in deciding what their needs are and how best they can be achieved. The plans need to be individualised, looked at regularly and changed when necessary. This will help to ensure that the care and/or treatment people using the services always meets their needs, as well as protects their rights.

We rated Southleigh Community Independent Hospital as good because:

• Patients were partners in their care. No decisions were made to any aspect of care or treatment without the involvement of the patient.
• Patients’ care plans were written in plain English and were specific and detailed. There was a strong recovery focus to care plans. Care plans were evaluated thoroughly and demonstrated patients’ progress.
• Patients were involved in decisions about the service, including redecoration, the activity programme and the menu. A patient representative attended some of the hospital management meetings.
• The service had launched a family support service, tailored to the needs of relatives and carers. The service was flexible including home and evening visits.
• When there were not enough ward staff to escort patients on leave, members of the mutli-disciplinary team escorted the patients.
• Patients’ bedrooms were redecorated before they were admitted. Where required, a new carpet was fitted.
• Where patients had progressed more quickly than expected, staff brought forward care programme approach meetings. This was to minimise the chance of the patient’s discharge being delayed.
• Members of the MDT had their offices in patient areas. Patients were welcome to approach staff in their offices, unless a sign indicated they were busy.
• The hospital management team had developed a culture focussed on safe, high quality care.
• Staff morale was high. Staff felt able to do their job, and there was a strong sense that staff felt supported by the management team.
• Staff said they could confidently raise concerns and were sure they would be responded to appropriately.
• The governance system was robust with appropriate oversight from the quality and governance committee. There was an ongoing focus on quality and safety.

However:

• There were some gaps in recording decisions regarding medicines management.
• The majority of staff had little understanding of the Mental Capacity Act.
• All patients were required to provide alcohol and drug tests as a standard practice.
• There was one very small visiting room
• Patients using the patient phone could not do so in privacy.