We visited Spring Hill House, a treatment and recovery unit for women with borderline personality disorders. On the day of our visit the provider informed us there were 21 people residing at Spring Hill House. We spoke with eight people who used the service and six staff.

In response to a compliance action issued following our last inspection in November 2012 the provider was able to demonstrate that necessary maintenance works had taken place to the wards heating and cooling systems to ensure they were in working order.

In response to a compliance action issued following our last inspection in November 2012, the provider demonstrated they were actively recruiting staff. However people using the service and staff spoke of their frustrations when staff were taken off Spring Hill House to work on other wards within the Women’s Service. They told us this affected the quality of the service they received and restricted their engagement in planned therapeutic activities. This meant that due to staff redeployment to work on other wards the arrangements in place to ensure people were supported by appropriately qualified and skilled staff were not being effectively managed.

We visited Thornton Ward and Spring Hill House within St Andrew’s Healthcare Women’s Service, Northampton. The patients we spoke with told us they liked the staff and were satisfied with the standard of care they received.

We found that each patient had a daily schedule of therapeutic activities. During our visit we saw some patients engaged in their daily activities, such as participating in current affairs sessions and playing board games with other patients and staff. We were told that ward community meetings took place and we saw records of the meetings were kept. One patient told us they really enjoyed being involved in the community meetings and looked forward to them.

Some patients told us they were concerned that sometimes their planned activities, such as outings in the community had been cancelled due to low staffing levels at Spring Hill House.

At both Thornton Ward and Spring Hill House the patients had expressed concerns about the heating not being suitable, for example bedrooms and communal rooms being either too hot or too cold. At Spring Hill House, we saw that refurbishments were taking place to the shower and bathing facilities.

We spoke to the majority of patients throughout our two day visit. All of the people that we spoke with were able to verbally communicate with us.

We received mixed comments from the patients that we spoke with over our two day visit. In total we spoke with ten patients. The majority of patients felt they were supported well by the staff team on the ward. One patient said,” ‘yes the staff are good here they are always ready to have a chat with you”. Another patient told us “they try to give you a healthy diet and we do a lot of exercise groups”.

Some people were not happy about being on the ward because they were detained their under the Mental Health Act 1983. Although this was done to keep them and other people safe it meant that there were restrictions on what they were able to do and where they were able to go.

Two patients told us that their families did not live locally and they were not happy because their families were unable to visit on a regular basis.

We did not rate this service.

We carried out this inspection in response to concerning information received through our monitoring processes.

We found the following areas the provider needs to improve:

• Managers did not ensure established staffing levels on all shifts. The provider reported that 1,698 shifts out of 15,788 were unfilled for the period 1 February 2018 to 30 June 2018. This equated to a fill rate of 89% against the provider target of 90%. There were not always enough staff to safely carry out physical interventions and provide the required level of patient observations on Sunley ward. We reviewed seven incident reports. Staffing levels at the time of the incidents were recorded in each report. Staffing was below the establishment number for five incidents reviewed.
• The provider was not compliant with the Mental Health Act Code of Practice. We reviewed 22 out of 115 seclusion records from 1 April 2018 to 30 June 2018. Doctors and nurses did not complete records for all of the reviews as required by the Mental Health Act code of practice. Staff had not completed seclusion and long-term segregation care plans for all patients. The multi-disciplinary team had not conducted reviews as required. Sunley and Bayley ward seclusion rooms had blind spots in the ensuite areas, although the provider reported these immediately. Staff did not always provide patients with information about their rights under the Mental Health Act.
• Managers had not ensured a safe environment at the learning disabilities service. Whilst managers and the health and safety lead had completed ligature audits for Spencer North and Sitwell wards within the last six months prior to inspection, there was no hard copy of the ligature audit and assessment available. Staff on Spencer North did not know where to find the ligature audit. Staff had not received the necessary specialist training for their roles on Sunley ward. There had been an incident one weekend where there were no nasogastric trained staff available to administer the nasogastric feeds to a patient requiring this intervention.
• Staff had not followed the dysphagia care plan for one patient on Sitwell ward, which had resulted in a choking incident. Staff administered backslaps and dislodged the food.
• Managers did not share learning from incidents with their teams in the forensic and learning disabilities services. We reviewed ten team meeting minutes from January 2018 and weekly memos from 1 June 2018 sent by managers to staff and there was evidence of one incident being discussed in one meeting. The provider told us they shared learning from incidents via alerts sent by email. However, staff told us that they would hear of incidents on other wards by word of mouth rather than through any formal means.
• Staff did not always follow National Institute for Health and Care Excellence guidance for the use of rapid tranquillisation on Sunley ward. Staff told us that rapid tranquillisation medication was administered most days. We reviewed one patient’s records who had been administered rapid tranquillisation medication twice in one day. Staff had not completed the required physical health checks following both administrations.
• There were blanket restrictions on Sunley ward. Staff told us patients’ snack times on the ward were 11am and 4pm. Staff did not allow patients to have snacks outside these times.

However, we found the following areas of good practice:

• Staff told us that they received de briefs and support after serious incidents. This included visits from senior managers, support from the provider’s trauma manager and free access to a confidential helpline. We reviewed minutes from a de brief session, which confirmed this.
• Managers had implemented additional safety measures following serious incidents, these included updating the ligature audit and assessment following a ligature incident, ensuring staff with specific training were available to provide specialist support to patients and a review of patients’ access to contraband items.
• Staff ensured most patient’s needs were assessed and met within care plans. We reviewed 21 care and treatment records for patients. Staff had completed person centred and holistic care plans for 20 patients reviewed. Staff had completed physical health assessments for patients on admission accessed specialist healthcare providers when needed.
• Patients had good access to physical healthcare when needed. A physical healthcare team, based on site, were available during the week to offer support with patients’ physical healthcare needs. Staff could access emergency physical health care from the provider’s emergency response teams and the local general hospital to cover out of hours emergencies.