We found;-

• An audit of ligature points had been carried out . There were potential ligature points in bathroom and bedroom observed on Walsham and Waveney wards relating to taps and doors. The provider had rated these as low risk. Patients assessed as at risk of self harm or suicide had specific care plans to address this risk.   

• The Patients' Council and three other patients reported feeling unsafe because of the number of incidents, patient on patient physical assaults and sexual harassment. The patients’ council did not consider that the issues it raised were responded to by the hospital.   
• Staff at St. John's House used physical restraint to control the behaviour of patients on 684 occasions in the six months leading up to the inspection visit. On 290 of these 684 occasions the patient was restrained in the prone (face-down) position. 56% of the prone restraints related to one patient. Staff told us that prone restraint was used as part of planned packages of care. An audit report dated 10 April 2015 showed that number of restraints were reducing each month during 2014.
• Department of Health guidance published in April 2014 is that planned or intentional prone restraint should not be used. The guidance also calls for providers to implement restrictive intervention reduction programmes. The managers of St. John's house had established such a programme.
• 98% ward staff had been trained in using positive behavioural support (PBS) to minimise and manage challenging behaviour. However, care plans did not consistently include the functional assessments of behaviour that underpin PBS. Also, staff did not use proactive strategies to reduce the likelihood of disturbed behaviour such as anticipating and meeting patients’ needs.
• The dignity of patients was affected by the lack of seclusion furniture in two seclusion rooms.   
• There was a lack of regard to the Mental Health Act Code of Practice in failing to record discussions relating to second opinion appointed doctors’ reviews, and the prescribing of medication in relation to statutory treatment certificates. 
• Performance information was collected and reported from “ward to board" which had been recently introduced. This information was not fully embedded in ward areas as staff were not able to say how the data informed decision making to drive improvement and inform ward objectives.
• Staff were trained in risk management and emergency care. Staff felt safe on the wards. Staff knew how to report incidents and safeguarding issues.

• National Institute for Health and Care Excellence (NICE) guidance was followed in relation to medication. Clinical audits were being undertaken, that showed positive results. The hospital had published research into interventions it was used such as mindfulness and positive behaviour support.

• The majority of patients said that they could talk to staff and were listened to. They received one to one sessions and felt supported by the clinical team.
• There was a care pathway that patients followed and co-ordinated discharges were organised.
• Most staff felt supported by senior managers. Healthcare support workers were and exception. This group of staff did not feel listened to. There was good team working, and staff received managerial supervision.

During our inspection we spoke in detail with six people who used the service. They told us how the service involved them in decisions about their day to day lives and about their care and treatment.

They told us that there were regular 'in house meetings' held on their ward. One person said that this gave them, "The chance to talk up." However, they added that,” Meetings don’t always make a difference." Another person told us, “We always speak up at in-service meetings." They also told us they had used the advocacy service and said, "They're good." Another person we spoke with told us the advocate came to their review meetings and said, "They speak up for me." This showed that people had the chance to discuss concerns with an independent advocate who would speak up on their behalf where appropriate.

People we spoke with told us about activities that they were able to take part in. these were vocational as well as leisure activities. Three people told how much they enjoyed horticultural sessions.

We looked at how the service responded to incidents and at the safeguarding procedures in use. This showed that measures were in place to ensure people were safe and that any incidents were quickly responded to and dealt with.

We looked at care, staff recruitment, maintenance and training records. These were well maintained and ensured that information was accurate and fit for purpose.

During our visit we spoke with eight of the 31 people who were receiving treatment at the time. They told us they were well treated and supported with their day to day living. One person told us that staff "Go out of their way to help us" and another person said "Staff support me as much as they can."

We were told by five people who used the service that they had care plans although one person told us that some of the other people who used the service "Did not always follow them (the care plans.)"

We were told about recreational activities which included art, gardening and sailing and also about numeracy and literacy sessions. We were told by one person that their chosen activities were "Sometimes cancelled" and that "No one tells me why."

We were also told that plans for the future had been discussed with most of the people we spoke with. One person told us that they knew what they had to do first. They said that they had to "Do all my psychology work first" and added that it was "Hard work but helpful."

Most of the people we spoke with told us they knew what to do if they were being abused or witnessed abuse, but only one person said that they "Felt safe."

During our visit on 31 August 2011 we spoke with a number of people about their views and experiences of Bure ward.

People told us that they were involved in planning and reviewing their care. We were told that people had opportunities to ask questions about their treatment and one person told us, "People listen here, we get lots of support from staff."

We were told that there was a good balance of activities, including educational sessions, arts and crafts, cooking and games. Most people also had escorted leave and made use of community facilities.

Two of the people we spoke with were complimentary about the staff.

One told us that if things were difficult staff helped them. Another said, "I have communications with the staff and I would tell them if I wasn't happy." People named specific staff whom they felt comfortable speaking to about their concerns.

People using the service told us that they received the support they needed from the staff. Two people said they liked the staff and got along well with them. People had opportunities to participate in therapeutic and recreational activities, which they said they enjoyed. People had different views about whether the sessions were voluntary and some people told us there were consequences if they did not attend. We asked the manager to look into this and ensure that everyone was clear about what was expected of them.

We were able to ask people about their views and experiences relating to all of the outcomes we looked at. We spoke at some length with five people from two of the wards.

People gave us examples of how they were able to make decisions and consent to their care and treatment, unless this was part of their treatment under the Mental Health Act. One person told us that they had asked staff for information about the medicines they took, which helped them to give informed consent. Another person said that staff tried to encourage her to accept help but no-one tried to force her if she said no.

Four of the people with whom we spoke had been subject to restraint at some time during their stay at St Johns House. They held the view that restraint was used too quickly by staff. However, two people then went on to give us examples of how staff had tried to help to calm them by talking and it was only when this did not work they needed to resort to restraint. Two of the people with whom we spoke raised concerns for their safety because the staff call system was not working properly.

Four of the people with whom we spoke said they thought the cleanliness of St Johns could be better. Two people told us that the hot water on one of the wards was not working properly. We later found out from the manager that this issue had been resolved. Another person we spoke with said they thought the cleaning products in use could be better, but this was their personal opinion.

People were not really clear about what training staff had or whether staff always understood their needs. One person told us, "Sometimes when I get upset I feel they don’t understand but when I talk to them they do."

We asked three people about how complaints were dealt with. It was their perception that nothing was done about complaints. We looked into this and found that this was not the case.

We rated St Johns House as good because

• The provider had established the staffing levels required to meet the needs of the patients. Ward managers had the autonomy to increase staffing levels if required. Staff training was 94% complaint. Staff received regular supervision and annual appraisal in line with the company policy. The provider had completed a ligature assessment and took steps to reduce the risk as required. All wards complied with the Department of Health guidance on same sex accommodation. Medical cover was available day and night.
• We reviewed 16 care and treatments records and found evidence that patients received a comprehensive risk and physical health assessment on admission. Patients were involved in developing their care plans and were outcome focused. The hospital offered a range of psychological interventions recommended in the National Institute for Health and Care Excellence guidelines. For example, offence specific interventions such as fire setting intervention programme for mental disordered offenders, motivational work and emotional regulation interventions such as cognitive behavioural therapy and anger management therapy.
• Patients knew the complaints process and had access to an independent mental health advocate if requested. Staff were aware of the provider’s whistle blowing policy and knew their responsibilities in relation to safeguarding. Staff spoken with told us they felt confident raising concerns to senior managers without being victimised.

• Ward managers and senior managers had oversight of the hospital. Ward performance was monitored by completing regular audits and the outcomes were recorded on key performance indicator dashboards. This meant that managers could monitor performance over a period of time to ensure continuous improvement.