We rated St Andrew’s Healthcare Nottingham as good because:

• Our previous inspection raised concerns and a compliance action regarding the number of staff and the skill mix on the wards. On this inspection, we found the provider had systems in place to address this which were effective.
• Comprehensive assessment of needs were undertaken prior to admission. These were updated during the initial weeks of admission to ensure all care needs were met. Patients told us that they felt they were involved in decisions regarding their care and in the care planning process. They also told us that they were involved in discharge planning
• Each ward had a ligature risk audit and resultant action plan.
• The clinic rooms were clean, tidy and well equipped.
• A safety nurse role operated on all wards. There are two registered adult nurses who were employed to undertake physical healthcare assessments.
• Risk assessments were undertaken on all patients following admission and through regular multidisciplinary team meetings.
• Restraint was only used as a last resort when verbal de-escalation and other interventions failed to reduce the risk presenting within the situation.
• The number of seclusions used was low.
• There was a daily review meeting carried out by hospital coordinators to look at staffing, safeguarding, seclusion and incidents and where wards or staff needed support.
• We found good medication management which was consistent with the provider’s policy and procedural guidance.
• Under the Reporting of incidents, diseases and dangerous occurrence regulations, there were no incidents in the period March 2015 to May 2015.

• There was information available for patients around how to complain, their rights and information about treatments. A log of local complaints was kept. Local resolution of complaints occurred generally. Patients were encouraged to contribute and problem solves issues with support from each other and staff.

• A psychologist was based on the wards who offered one to one sessions to patients. Group’s sessions such as assertiveness, risk, and communication were also facilitated by the psychologist. Outcomes were identified and monitored.
• Staff had undertaken induction on the ward.
• Annual mandatory training figures for May 2015 showed that over 96 % of staff had completed training. 100 % of personal development reviews had been completed. Monthly managerial supervision was provided.
• The clinical team met weekly.
• Each patient was seen by the clinical team every four weeks.
• Information about treatments available was given following assessments.

• Staff were observed to behave in a respectful manner.
• A full range of rooms was available to support treatment and care.
• Patients had access to outside space.
• Patients could access a small kitchen on the wards during the day to make drinks and snacks.
• Patients were able to personalise their room if they choose and we could see that some had chosen to do this..
• Staff worked with patients to meet their cultural needs. The site had a multi faith room for people of all faiths to use.
• Hospital directors and senior management were visible to staff and the patients.
• Staff appeared to understand and own the values of the organisation.
• Governance procedures were in place for monitoring the progress and functioning of the hospital. Results were produced monthly and disseminated to ward managers via the dashboard. Staff said they were confident about using the whistleblowing, grievance and bullying and harassment policies.

However:

• The ward layouts were not conducive to observation of patients at all times. Each ward had acknowledged this and staff were seen to be in the communal areas and undertaking regular checks of the ward environment.
• Rufford ward seclusion room had blind spots where observation of patients was not possible. This was a concern on our last visit.
• The de-escalation areas on the wards were in differing states of repair.
• The de-escalation environments were unclean with a lack of furniture, stained carpets and a lack of ventilation. This was of particular concern on Newstead ward.
• Concerns were raised by staff and patients about the length of time maintenance repairs took to be rectified.
• We had concerns from our intelligence and ongoing monitoring of the service over the inter-agency working with regard to safeguarding concerns. There were reported difficulties in St Andrew’s making appropriate referrals, providing timely and good quality information, and making reports to the Multi-Agency Safeguarding Hub (MASH) and the Community Learning Disability Team (CLDT). It is not clear what consideration was given to providing interim updates to patients where there are delays in the safeguarding process

• We had concerns with care plans and found inconsistent evidence that plans were regularly reviewed and evaluated.
• Care records were stored on an electronic system accessed by substantive staff across the hospital. We found that agency staff were unable to access this system meaning they did not have access to the latest accurate information around care and risk.

• Our previous visit raised concerns about the use of inappropriate language by staff on Rufford ward. During this inspection, we noted improvement in the approach on Rufford ward. We were concerned about behaviour of four members of staff we witnessed on Wollaton ward.
• Two patients were identified as having significant delays in their transfer of care to a more appropriate setting.
• On Rufford ward, there was a lack of easy read literature available.

When we previously visited on 18 September 2013, we found there were not enough staff on the wards to meet all patient's needs at all times. We returned on this occasion to review if enough action had been taken to provide sufficient staff on the wards.

Before our visit we reviewed all the information we had received since our previous visit and found seven people had raised concerns about staffing levels.

We spoke with senior managers who told us of changes and improvements made, particularly since the beginning of December 2013. This included greater forward planning so that replacement staff could be booked to cover shifts, but we found not all shifts were covered, especially at short notice. This had occurred on the day we visited and some wards were short staffed on five of the previous nine days.

One patient told us, "There's enough when the ward manager is here, but not always at other times."

We found there were occasions when activities could not take place due to shortage of staff, but not all cancellations were due to staff shortages, as each situation had to be assessed according to risks posed by an individual patient's behaviour.

Staff often missed their breaks due to shortage of staff on one ward, but on another this rarely happened.

The senior managers stated there was minimal use of agency staff, but for the day we visited over 42 per cent of staff were from an agency. We saw evidence of continual staff recruitment.

When we visited on 8 May 2013, we were concerned that full information was not available to confirm all staff were suitable.We received a report from the provider and this stated that had taken action to ensure all relevant information was held at the service.

When we visited on this occasion, we found an improvement in the information held in staffing files and evidence that arrangements were made to monitor records retained by the main staffing agency used by the hospital. This meant that patients were cared for by suitable staff, who were fit to work with vulnerable people.

Since our previous inspection visit in May 2013, we had received some concerns about the number of staff available on the wards, particularly at night and weekends. During this visit we spoke with staff and patients on two of the four wards. We also referred to staffing rotas, morning reports and other records about staffing numbers and breaks taken.

We found there were usually just enough staff on duty if there were no untoward incidents. One nurse told us, ”There are enough staff in the daytime, but it’s a juggling act sometimes." Another said, “It’s not easy, but it is workable.” However, there were occasions when it had not been possible to provide enough staff at all times. One patient told us, “Staffing is hit and miss. One weekend, I couldn’t go to the café because there were so many people kicking off.” A nurse told us the staff were stretched if there were incidents on other wards.

Our team included a specialist advisor with previous experience of working in similar services. We spoke with four patients on a ward for patients that needed low secure care and we spoke with five patients on a ward for those that needed medium secure care. We looked at some of the care records and spoke with a range of staff working in the hospital.

We found that patients were involved in making decisions about their care and treatment and their views were respected. One patient told us, "I can say what I think about things and they listen."

Patients we spoke with were aware of the continual presence of staff and one patient told us this was to "keep people calm". Another patient told us they felt safe when staff were around. Patients told us they liked the way the wards were designed and we found everything was designed to keep people safe.

We spoke with various staff and found that patients were supported by some suitably qualified, skilled and experienced staff, but the staffing records we saw at the hospital were incomplete. This meant we could not confirm the suitability of all staff working within the hospital.

We saw the quality improvement plan for the service and this showed how areas of the service were monitored.

We spoke with four people who were patients at the hospital. We observed staff working with people and saw the facilities available. One person requested to go outside with staff and we accompanied them to a secure garden area. It was clear that this person enjoyed the opportunity to be in this area and felt safe there. Another person said, "It's good here. I like the space."

Two people we spoke with said the staff helped them to feel safe. Another person told us he felt more safe than he had previously and that he liked the staff he was with.

Other patients told us they were satisfied with the standard of care they received and that they had choices. One said, "I can choose what I want to do while I'm here on the ward." During our visit we observed people to be engaged in a variety of activities. Some people were seen to be visiting the on site café, playing snooker, playing a game of cricket. People told us that they were asked for their comments about the hospital care and activities in ward meetings.

People we spoke with told us there were always a lot of staff around. We saw two people who had two staff each with them due to their needs.

We did not observe people or speak to them about this outcome.

We spoke with patients living at the service. Patients that we spoke with were positive about the support they received from staff. One patient told us: "The staff do care plans with me, they ask my views and opinions. Staff speak to me about moving forward. We also have a meeting every morning to talk about plans for the day." Another patient told us that they understood what section of the Mental Health Act 1983 they were detained under. We were also told by one other patient that staff respected their religious needs and that they attended a meeting called 'our voice' with an independent advocate.

One patient that we spoke with told us that staff were very good at asking for their consent. Another patient told us they had concerns that agency staff talked inappropriately about other patients that they worked with.

We spoke with a number of patients who told us that they were happy with the standards of care they received from staff. Most of the patients that we spoke with told us that they felt safe and were protected by staff. However, one patient was concerned about restraint practices. One patient told us that they thought too many agency staff were used. Another patient told us that the staff were good at doing their job and provided them with “good support.” We were also told that, “Staff regularly ask for my feedback about how things are going.”

Two inspectors and an expert by experience undertook the inspection. Most of the patients we spoke with told us that they liked living at St Andrew’s Nottinghamshire. One patient we spoke with told us: “The staff are good they listen and understand, they encourage us to do things.”

One patient said they were involved in developing a multi agency learning disability recovery tool. The patient felt very involved and valued within this process and was able to voice their views on what worked well and what needed to improve.

One member of staff told us that they were concerned with the poor attitude of some staff and how they spoke with patients who resided on the medium secure wards.

Some patients told us that they were happy with the quality of food. However, one patient told us that they felt the menus needed to improve, they told us: “Food is not very good, there is not enough.”

We found that staff at the service regularly involved other agencies who were involved in patients’ care. One patient told us: “I regularly see my social worker and probation officer.”

Most of the patients that we spoke with told us that they were appropriately cared for and protected by staff. One patient told us: “I like it here I feel safe.” In contrast to this one patient was not so positive about their experience and expressed concerns about how they had been treated by a particular staff member.

One patient told us that they had made a written complaint about the food and it was responded to by staff, but they had not received a written response. Another patient told us that they knew how to make a complaint and that they had been provided with a copy of the complaints procedure.

We rated St Andrew's Healthcare Nottinghamshire as inadequate because:

• Staff did not protect patients from avoidable harm or abuse. Managers did not ensure care environments were safe. Our inspectors identified potential ligature anchor points on Newstead ward that were not included in the ward ligature risk assessment. Also, the ligature risk assessments that were available to staff on Thoresby ward were out of date. There was a blind spot and a scratched viewing lens in the en suite areas of seclusion rooms. Staff on Wollaton ward did not adhere to infection control principles.
• Patient's privacy and dignity were not always respected. Patient's basic needs were not always met. Staff searched a patient in a communal area in front of peers. Staff were not responding to patients' requests when they were in seclusion. This included requests to go to the toilet, to use the shower, for food, medicines and for blankets. This resulted in distress and embarrassment for patients. Staff used inappropriate and disrespectful language in a patient's record. Patients told us on some wards that staff ignored them, took a punitive approach and spoke to them in a disrespectful way.
• Staff did not adhere to the Mental Health Act Code of Practice when using seclusion. There were gaps in seclusion reviews, staff did not end seclusion at the earliest opportunity or complete observations correctly. Staff permitted patients on Thoresby ward to vote on whether to end or continue with other patients’ seclusion. Senior managers told us that this was normal practice as part of the therapeutic community model. This was not acceptable practice.
• Staff did not seek the consent of patients to have other patients involved in decision making about their general care on Thoresby ward (a therapeutic community). In ten out of 24 records staff had not recorded that they had considered a patient’s mental capacity to understand and consent to treatment.
• Leaders and governance arrangements had not assured the delivery of high quality care. Managers had not ensured that all staff worked within the legal frameworks of the Mental Health Act and Mental Capacity Act. Quality audits had not identified the use of inappropriate and disrespectful language in a patient's record. Leaders had not ensured services worked towards recognised standards. Thoresby ward did not meet the service standards required to be accredited by the Royal college of Psychiatrists for therapeutic communities.

However:

• Staff were assessing and managing risks for individuals. We examined 24 patient records, all showed that staff undertook a risk assessment of every patient on admission and updated this regularly and after every incident. More than 90% of staff had completed safeguarding training and demonstrated understanding of how to assess safeguarding risks and make appropriate referrals.
• The provider employed the full range of disciplines needed to deliver care. This included autism specialists, nurses, occupational therapists, psychologists, social workers, healthcare assistants and activities coordinators. Staff ensured that patients had access to advocacy services for support.
• Patients told us that some staff were friendly and approachable and supported them to progress in their treatment. Patients told us that staff involved them in planning their care and assessing their risks. Staff recorded patient involvement in records.