We rated St Mary’s Hospital as requires improvement because we rated four key questions as requires improvement (effective, caring, responsive and well led) and one key question (safe) as inadequate. This was because:

• Staff did not always act to review or record patient blood results. We issued a warning notice to the provider to make sure they improved their systems for medicines management. Staff did not systematically record checks on patients on high dose antipsychotics. Staff did not always complete a risk assessment of each patient at admission or review risk assessments on an ongoing basis. There were not sufficient numbers of nursing staff trained at the required level of British Sign language working on the four-bed ward for deaf patients. Most patients on Cavendish, Dalston and Adams wards did not have a written positive behavioural support plan to provide staff with guidance on how best to support patients to reduce disturbed behaviour. Where these plans were in place, they had not been informed by functional assessment.

• There had not been a substantive Mental Health Act administrator in post so there were limited systems in place and variable adherence to the Mental Health Act Code of Practice and oversight of Deprivation of Liberty authorisations. Staff did not always record when patients received care and treatment from other health professionals from outside the hospital.
• During our observations, staff on two wards (Dalston and Cavendish wards) were not always respectful and responsive when caring for patients and we observed a small number of poor interactions. While most patients and carers were happy with the support they received from staff, three patients and one carer told us their general concerns about the attitude of some staff members on these same wards.
• Managers did not always fully address the issues raised by patients when they complained. Patients on the deaf unit were not always supported to engage in meaningful activities. Patients on Cavendish ward did not have access to information as there was very little information displayed on the ward about the services available and their rights as patients.

• Some of the shortfalls we found on inspection had not been identified or addressed fully by managers. The audits were not clearly identifying the action staff needed to take to address any identified shortfalls. The acting ward manager on Cavendish ward had not received supervision while taking on the additional responsibilities on an interim basis.

However:

• Leo and Hopkins wards had exemplary positive behavioural support plans. Managers were working to improve staff vacancy rates and mandatory training uptake rates following the transition to Elysium Healthcare. Patients were not subject to blanket restrictions; where restrictions were in place, these were individually assessed. Managers used a computerised dashboard which provided them with very detailed safety incident data for each ward.
• Staff ensured that patients had good access to physical healthcare and supported patients to live healthier lives. Staff supported patients to make decisions about their own care and treatment and assessed and recorded patients’ capacity and best interest decisions clearly. The ward multi-disciplinary team worked well together and included the full range of specialists to meet the needs of patients.
• Most of the carers we spoke with were very complimentary about the progress and care that their relatives had received. Where patients could engage in their care and treatment, records showed they were involved in decisions about their care and treatment. The hospital had a monthly patient forum run by patients and most issues raised by the patient forum had been addressed.
• Patients were progressing to conditions of lesser security where it was appropriate; where patients discharge was delayed, the delay was due to factors outside the hospitals’ full control. Patients had en suite rooms which they could personalise. Patients had communication passports and information across most wards was displayed in easy read formats.

• Senior managers were visible and approachable. Since Elysium Healthcare took over the running of the hospital, there had been significant improvements including introducing electronic records and environmental improvements. Managers had workable plans so staff worked under Elysium Healthcare policies, systems and processes. Managers had begun to monitor the service through detailed dashboards. The ward manager of Leo and Hopkins ward had carried out research and spoken nationally and internationally about reducing restraint and restrictive practices. The secure wards were accredited by the Royal College of Psychiatrists’ quality network for forensic mental health services.