We carried out an unannounced focused inspection of St Andrews Healthcare, Maldon Ward, on 31 March 2015 due to concerns that were raised with the Care Quality Commission. During the inspection we found that:

• The provider had high levels of staff vacancies. This meant the provider used a high rate of bank and agency staff. The provider did not employ regular bank and agency staff to ensure continuity of care for patients. A patient told us the permanent staff treated them with kindness, consideration, and compassion. However, the agency staff did not always treat them with dignity and respect

• The provider did not keep accurate or accessible duty rotas. Duty rotas were duplicated in three different records, some of which were not accessible to ward staff. This meant staff could not be sure who was expected on duty or whether shifts had sufficient staff for safe care and treatment for patients.
• Staff cancelled patient’s section 17 community leave due to staffing shortages. Section 17 leave is a controlled, discretionary period of leave given to a person detained in hospital under the MHA. Medical staff granted leave to patients to allow them to access activities, and appointments, and to support their recovery.
• Staff did not always update risk assessments following incidents. Staff recorded incidents on the electronic record system but did not update risk assessments and care plans when risk changed. This meant that staff did not have up to date information to provide safe care for patients. The provider had carried out an environmental risk assessment. However, this did not fully address risks presented by blind spots where staff could not observe patients

• The seclusion room was located on the first floor, which meant that staff have difficulty safely accessing this facility in an emergency.

However

• Patients had access to an advocacy service. There was information about the advocacy service displayed on posters in the ward area.
• Staff managed seclusions in line with The Mental Health Act code of practice. Doctors were attending within an hour to review patients.
• Patients were involved in developing their care plans. A patient told us they attended regular review meetings where their care plan was reviewed. They had received a copy of their care plan.
• The ward environment was clean and tidy and the furnishings were in good condition. Staff completed cleaning audits that were up to date.

We saw that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard and the provider had an effective system to regularly assess and monitor the quality of service that people received.

People were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. People told us that the staff were knowledgeable and that they generally felt safe in their hands.

A Mental Health Act (MHA) commissioner met with seven patients during the inspection and found no significant care issues of concern. We could see that people experienced care, treatment and support that met their needs and protected their rights.

We rated St Andrew’s Essex as good because:

• All ward areas were clean and well maintained; equipment was well maintained and safety tested, cleaning records were up to date and demonstrated regular cleaning of ward areas.

• There were designated quiet areas on all wards and there was a visitor’s room near the hospital entrance that could be used for patients to meet with family and friends.
• There was a phone room on all wards to facilitate patients making calls in private.
• Patients were given a welcome pack on the psychiatric intensive care wards, which contained essential items for hygiene and enhanced their wellbeing.
• Shifts were covered by sufficient numbers of staff with the right grades and experience.
• Staff told us that morale had improved recently and attributed this to new members of the leadership team.
• Staff told us they felt well supported by managers.
• There were flexible working arrangements available for staff.
• Staff and visitors had access to personal alarms. The provider had simplified their staff recording system since the last inspection and for the majority of shifts; staffing numbers matched those on the rota. Shifts were covered by sufficient numbers of staff with the right grades and experience. Staff told us that they were able to maximise their time on direct care activities as opposed to administration duties. There was a full range of mental health professionals available to deliver care.
• Staff we spoke with knew what incidents to report and used electronic recording system to report incidents. Staff were open and transparent and explained to patients when things went wrong. Staff told us they received feedback from investigation of incidents at team meetings and in managerial supervision. There was evidence that changes had been made as a result of feedback.
• Patients we spoke with told us staff were kind and treated them with dignity and respect. Carers we spoke with told us that they were pleased with the care their relative received.
• Care records were up to date, personalised, with holistic recovery-orientated care plans.
• Prescription charts showed that staff followed National Institute for Health and Care Excellence guidance for prescribing medication. The pharmacist had written the percentage of medication prescribed to help staff remain within British National Formulary limits and reduce the risk of multiple medications being prescribed for the same problem.

However we found the following areas that the provider needs to improve:

• There were high levels of the use of prone restraint across the hospital, particularly in the psychiatric intensive care services. Whilst the provider had set out measures to reduce levels of seclusion and restraint these measures had not yet had significant effect.
• The external door to the garden from the extra care suite on Audley ward was clear glass and therefore visible from the garden. This compromised patients’ privacy and dignity. This was raised with the provider who agreed to address the issue.
• The fridge lock in the clinical room on Audley ward had been broken. The provider had sourced a new lock and was awaiting fitting of the new lock at the time of the inspection.

• For two of the seclusion records reviewed the front sheets were incomplete. The nurse in charge had not signed them before uploading to the electronic record.
• For one patient the gap between medical reviews whilst in seclusion was longer than the four hours recommended by the Mental Health Act 1983: Code of Practice.