Three inspectors visited Haringey Ward at St Ann's Hospital on 11th April to check if actions had been taken to meet the requirements made following the previous inspection in November 2013 when the trust continued to be non-compliant with regulation 9 of the Health and Social Care Act 2008 because patients had been admitted to seclusion rooms and the designated place of safety (known as the "s136 suite") when there had been no available beds in the trust.

During this inspection, we spoke with people who were on the ward receiving care and treatment. We also spoke with nursing, medical and therapy staff. We also spoke with the Executive Director of Nursing, Quality and Governance and the Chief Operating Officer. We received information from the trust which we reviewed. We found that the provider was only using the seclusion rooms and the designated place of safety (known as the "s136 suite") when it was clinically appropriate to do so.

One person who was receiving care and treatment on the ward told us "It has been pretty good [on the ward]" and another person told us "If I could have a checklist for here, I would give it ten ticks out of ten". Most of the feedback we received from people on the ward was positive. We observed staff responding with kindness and consideration to people who were receiving care and treatment on the ward.

We checked seven records of people on the ward and found that they were up to date. Everyone had an initial care plan and risk assessment. We saw that sometimes capacity and consent was not explicitly referenced in the electronic notes.

Staff told us that there had been positive changes on the ward since our last inspection and they felt supported to do their jobs.

Two inspectors and a Mental Health Act Commissioner visited Haringey Ward and the s136 suite which is a designated ‘place of safety’ where people who are detained under s136 or s135(1) of the Mental Health Act are brought while awaiting a formal assessment at St Ann’s Hospital to see if improvements following the inspection of 19 June where we found that people were not experiencing care, treatment and support that met their needs and protected their rights.

We spoke with seven members of nursing and medical staff on Haringey Assessment Ward, one member of staff on duty on the s136 suite, we checked the records of six patients on the ward at the time of the inspection and spoke with seven patients. We also requested further information from the Trust after the inspection.

We found that some care was provided in an environment that did not meet the needs of individual patients. We found that people were cared for by staff who knew and understood their responsibilities. We found that most patients had care plans which were recorded and had up to date risk assessments although some patients told us they were not aware that they had care plans.

People told us that they did not have enough activities on the ward and staff told us that the activities which were timetabled to take place did not always take place. Some people also told us that they did not always know their rights and whether they were detained under the Mental Health Act (1983) or whether they had been admitted to the ward informally.

We checked the two seclusion rooms on the ward and looked at the general ward environment. We found that the two seclusion rooms on Haringey Assessment Ward and the s136 suite had been used to admit patients when there were not enough bedrooms in the Trust. This meant that the provider had not made the changes which were indicated in the action plan which was sent to us following the inspection in June 2013 and continued to be non-compliant.

Six inspectors and a Mental Health Act Commissioner visited Haringey Assessment Ward, Finsbury Ward for male patients and Downhills Ward for female patients at St Ann's Hospital. Most people told us they were given information on their arrival and that they were helped to make choices while they were on the ward.

Most people we spoke with told us they received care which they found helpful. We spoke with two relatives of people on Downhills Ward who told us they had not been told when their family members had moved wards or hospitals. One person told us they had been given no advance warning about moving between hospitals in the Trust. Three members of staff raised concerns with us about the Trust's use of seclusion rooms to admit patients to when there were no beds available. We found one patient who was admitted informally had been told that "a section would be activated" if they tried to leave. We found that people who were not detained may be at risk of experiencing the same restrictions as detained patients without any legal protection.

We found that most people told us they felt safe on the wards and that staff had a good understanding of safeguarding and the procedures which they needed to take when there were concerns raised.

We found that the Trust had adopted improved recording and auditing systems when restraint and seclusion was used. We found people and staff were able to feedback information to improve the running of the service.

We visited all four wards in the hospital. We spoke to patients individually and in small groups, and we spent time observing what was happening on each ward that day. We also spoke to a range of staff; ward managers, psychologist, nurses and nursing assistants.

People staying in St Ann's hospital told us they were treated with respect by nursing staff and were consulted about their care and treatment. Most people were satisfied with the care they received. Comments included; "We ask for something we get it, " "When you want something they keep you waiting a bit too long but you get it eventually, "I work quite well with them" and "They saved my life here."

People said the hospital looked after their physical health as well as treating their mental heath. One person told us, "They did my ECG and they take my blood pressure, they make sure I am ticking along alright." People said hospital staff supported them to go to health appointments outside the hospital when they needed specialist care for a physical health need. Most people said there were activities they could take part in. Some people said they appreciated treatment from a psychologist, especially those who did not agree with their psychiatrist that they had a mental illness. Two people said they were concerned about people bringing illicit drugs onto the wards.

The majority of people told us the food provided was good. One person said the meals were "delicious" and others said the food "good" or "alright."

People thought there were usually enough staff on duty to meet people's needs. Some patients on Downhills and Finsbury wards said they liked the ward manager and felt they looked after them well.

We spoke to thirteen patients on three wards. They said they were encouraged to attend daily community meetings to discuss issues, give their views and hear about the activities on offer to them that day. Patients on Downhills ward said they felt listened to. Three patients on Finsbury ward said that the meetings were not helpful as they felt staff did not act on the concerns they raised so they did not feel staff listened. Overall people felt they were involved in decisions about their treatment and care.

The majority of patients said they were aware of their rights and had given their consent to their treatment. Two patients on Finsbury ward said they did not know their rights. When we told the Trust this, they explained their rights to them again.

We spoke to thirteen patients on the three wards about the quality of care in this hospital. The majority said that staff had welcomed them and helped them settle into the ward. The majority also said they were satisifed with their medical care and were involved in planning their treatment and care. There were mixed views about the activities on offer to help patients with their recovery. General feedback from patients about staff was good.

We asked twelve patients for their views on the food. The feedback was mixed.

Comments included; "excellent," "second rate," and "I don't eat the food. My family bring me food every day." Women tended to be more satisfied with the food. A number of men said the portion sizes were too small for them.

Patients told us that the ward staff talk to other professionals involved in their care to help plan for when they leave hospital. They said staff talk to their GP and to their care coordinator.

We asked all thirteen patients that we interviewed whether they felt safe on the ward. The majority said they always felt safe.

We asked a selection of patients in three wards whether they felt their ward was clean and hygienic. They all said it was clean or "clean enough."

The majority of patients said they were satisfied with their medication. They said staff took the time to explain their medication to them including possible side effects. Patients said that the hospital pharmacist visits the ward and talks to them about the effects of their medication. They said they felt involved in decisions about which medication they should take. One patient said "I couldn't ask for better" (involvement). Patients said they received their medication on time.

Patients on all three wards felt there were enough staff on duty.

The majority of patients said staff listened to them and encouraged them to express their views.