We visited Fenwick ward only during this inspection. During our inspection visit, we spoke with six members of staff and seven people who used the service. We also spoke with the ward manager, and the registered manager of the Adolescent Service.

We observed some good interactions between staff and people who used the service.

People’s physical healthcare needs were met to ensure their wellbeing.

We found that the service was provided to people who had a range of needs which meant that some people could be at risk of not having their individual needs met.

People told us and we saw that staff supported them to attend their weekly meeting with the team of professionals that worked with them. People said this helped to reduce their anxiety when at their meeting.

We saw that people were not always engaged in meaningful activities, which could impact on their health and wellbeing.

People told us that they liked the food and there was enough food provided. Some people told us they would like more choice of food. People were offered a balanced and nutritious diet.

Robust systems were in place to ensure that people were safeguarded from harm and abuse.

At our previous two inspections to Fenwick ward we found that records were inaccurate. We found improvements had been made at this inspection, however, further improvements were needed to ensure that people were not at risk of receiving inappropriate care and treatment.

We went back to review the improvements that the provider had made following an

inspection visit to the John Clare unit and Fenwick ward during September 2013.

The John Clare unit is a 12 bedded assessment ward for patients with complex mental health needs who present a risk to themselves or others. The Fenwick ward is a 10 bedded ward for patients with a learning disability and mental health needs.

The inspection team comprised of a compliance inspector and a specialist mental health advisor.

During our inspection visit, we spoke with four members of staff and six patients. We also spoke with the ward managers for John Clare unit and Fenwick ward, and the registered manager of Adolescent Services. We looked at patients and staff records, which were available on the wards.

Most patients on the John Clare unit told us that the level of care and staffing levels had improved since our last visit. One patient said “It’s a lot better, and some staff have made good changes on the ward”. They told us that there were more permanent staff working on the ward. Another patient told us that the ward had a “calmer environment” and most of the patients got on well with each other. Patients on the Fenwick ward also told us that there had been improvements made to the ward. One patient told us “The art room is nice and I have been playing football in the courtyard everyday”.

We found that the provider had made improvements to care planning at the service and the staff on John Clare unit were using de-escalation techniques in order to keep people safe and maintain a calm environment. We also found that the provider had made improvements to the environment and had plans to make further improvements. We also found that a system of staff supervision was in place in order to support workers. We found that staff had maintained accurate seclusion records. However, some care records contained inconsistent and inaccurate information.

We conducted an inspection visit at St. Andrews Adolescents Service on 25 and 26 September 2013. We found that the provider was not meeting the essential standards of quality and safety in relation to cleanliness and infection control, the safety and suitability of premises, staffing, supporting workers and assessing and monitoring the quality of service provision. We issued warning notices and informed the provider they were required to be compliant with the relevant requirements by 13 November 2013.

We conducted a follow up unannounced site visit on 12 December 2013 to check the provider had made improvements to the relevant requirements.

The inspection team consisted of two CQC compliance inspectors, a specialist advisor and an expert by experience. We visited four wards. These were the John Clare unit, the Boardman ward, the Heritage ward and the Fenwick ward. We spoke with seven staff and 14 patients. We spoke with the ward managers for John Clare unit and the Fenwick ward, the registered manager of the Adolescent Service and the Nominated Individual for St Andrew’s Healthcare.

We found that the provider had taken account of our previous inspection findings and had introduced some additional quality monitoring measures. However further improvements were still needed to meet full compliance with the regulations.

During our inspection visit of St Andrews adolescence services, we visited the Fenwick ward, which is a ten bedded medium secure ward situated within the Malcolm Arnold House. On the day of the visit there were nine patients receiving care on Fenwick ward and one patient who was being nursed within the extra care facility on the ward.

The inspection team was led by a CQC inspector who was accompanied by a practicing specialist mental health professional. We used a variety of methods including observation skills to find out how patients needs were being met on the ward. We spoke with one patient, six members of staff and reviewed the care records of three patients.

One patient told us that the staff treated them nicely and that they had a named nurse and key worker who were responsible for their care. They told us that they had made progress while receiving treatment on the ward and that they went out into the local community and enjoyed doing a range of activities. However, they also told us that sometimes they were not able to access the local community because there were not enough staff on duty to accompany them on their visit.

During our inspection visit, we found that there were some concerns relating to the level of staffing on the ward, and the arrangements in place for supporting the staff. We also had some concerns about the level of cleanliness and infection control on some areas of the ward and the safety and suitability of premises.

Patients were happy about the ward environment and told us that it had been improved since our last visit to the service in 2011. They had enjoyed being involved with choosing the colours and some of the painting within the ward.

On the day of the visits compliance inspectors and a mental health act commissioner sought comments from patients on John Clare and Church wards

We spoke with six patients about their care and support. Patients said they felt respected and involved in decisions regarding their care and treatment. All of the patients we spoke to said that they recieved support to cope with behaviours that placed them or others at risk of harm. Patients said they knew how to make a complaint about their care, and they could speak to the unit manager if they felt unsafe.

People said that they were unhappy with the maintenance of the ward both cleanliness and state of carpets. One person said that the air conditioning and central heating was often not working well in their room. One person we spoke with on Church ward said that they were settled, involved in many of the activities available on site at the Northampton location and that staff treated them with respect. Patients also said that they were involved in reviewing their care plans and aware their care and treatment is closely monitored.

We did not rate this service because this was a focused inspection.

We found:

• The provider had identified that they were

  not able to meet the care needs of three patients with very complex problems and behaviours that staff found challenging. For all three, the provider had worked actively to facilitate discharge without success. In one of these cases, the patient had been subject to repeated and prolonged periods of seclusion and segregation for about 18 months before the inspection visit. The staff at St Andrew’s had decided that this was necessary to reduce risk to the patient concerned, to other patients and to staff.

• We found one example where staff had not worked with a patient in the least restrictive way. They had applied restrictions despite the patient demonstrating reduced risk behaviours. Staff justified this based on the historic risks of the patient as opposed to the patient’s current presentation.
• There were gaps in some observation records; one example being staff not recording hourly checks in two records. Staff also recorded one patient’s behaviour as being settled for sustained periods of time, without ending seclusion as required by the Mental Health Act Code of Practice.
• The provider had not facilitated independent reviews of patients' in long term segregation in line with the Mental Health Act Code of Practice which states that ‘where long-term segregation continues for three months or longer, regular three-monthly reviews of the patient’s circumstances and care should be undertaken by an external hospital’. Staff employed by St Andrews had carried out the ‘independent reviews’ of patients in long-term segregation on these wards. Although these staff members worked in a different St Andrew’s hospital, or were from a different service on the same site, in CQC’s view this is not consistent with the intention of the Mental Health Act Code of Practice.
• During the three months between 31 July 2018 and 31 October 2018, the service had recorded 57 incidents of staff injury. These included staff being punched, kicked, scratched and pushed to the floor and being stamped upon. During one incident, five different staff had to attend the local accident and emergency department for injuries to the face, head and abdomen.
• Some staff did not feel that the provider gave consistent support after incidents and that managers delivered de-briefs for ‘significant’ issues only. This affected their morale, particularly when incidents related to staff assaults.
• Four carers reported that staff had not informed them of incidents involving the person they cared for in a timely way. One carer told us that the provider did not offer them a de-brief after they had witnessed an incident involving their relative.
• Staffing levels and skill mix had sometimes contributed to the cancellation of planned activities.

However:

• Staff worked actively to protect patients from avoidable harm. They assessed patient risk and updated risk assessments regularly and following incidents. Staff conducted observations of patients in line with their care plans. Staff used de-escalation and distraction techniques to reduce the need to use physical restraint.
• Staff recorded the clinical justification for placing restrictions, for example, seclusion and long term segregation, on patients and made decisions based on the assessed risk to the patient, risk to other patients and risk to staff. Staff developed positive behaviour support plans and those who worked directly with the patients were aware of the contents of these plans and these directed the interventions used to care for patients.
• In eight out of nine cases that we reviewed, staff worked in collaboration with the patient concerned to reduce restrictions at the earliest opportunity.
• The care and treatment interventions provided by staff were in line with best practice and evidence based guidance. Care plans reflected the holistic needs of the patient. The service employed a range of staff to work with patients to meet their needs including occupational therapists, teaching staff and clinical psychologists. Staff of all disciplines regularly tried to engage patients in education, therapy sessions and activities. Staff recorded the outcomes of sessions or if the patients declined to take part.
• Patients told us that staff generally treated them with respect. Patients were involved actively in developing their care plans and knew their content. Those patients being cared for in seclusion or segregation had access to and understood their re-integration plans. All patients knew of the advocacy service and how they could access this should they need to. Staff displayed knowledge of individual patient need and the goals patients were working towards.
• Staff encouraged patients to keep in contact with people important to them. This took place via face to face visits or via telephone or video conferencing.
• The service provided premises appropriate to the age of the patient group. Staff encouraged patients to personalise their space. This included patients who were in long-term segregation. Staff encouraged patients to engage with sessions and activities when in seclusion and long-term segregation to continue to work towards their individual treatment goals.