•   The provider had made significant improvements to the safety and cleanliness of the   environment.

• The provider had refurbished and refurnished two wards and planned to complete this in all wards.

• The provider had installed air conditioning units and fans in medication dispensary rooms so that medicines were stored safely.

• The provider had redecorated and refurnished the visitors room. This was available for more patients to use and safe for children to visit.

• Staff took action following audits and from listening to patients views to make the hospital safer for patients, staff and visitors.

However:

• Some registered nurses did not know how to dispose of medicines safely.

• Some staff were not aware of how improvements had been made to the care of patients following learning from incidents.

• Some staff and patients did not feel supported following incidents.

• On ward A, the ensuite bathrooms were dirty and in need of refurbishment.
• On-going staffing issues affected the hospital’s ability to meet patients' needs, especially around access to leave and activities.
• Six out of 11 patients we spoke with told us that access to activities, including the resource room and gym, was limited due to the number of staff available. One patient told us they had only been able to access the resource room twice and could never use the gym.
• The hospital had experienced difficulties recruiting staff but it had an active recruitment plan. The hospital used a high number of agency and bank staff.
• Staff did not always give emergency alarms a timely and appropriate response, which put patients and staff at risk.
• Care plans did not show clear involvement of the patients and were not personalised. We found care plans that staff had not re-written since 2013 and 2014. We identified this issue on our last inspection, but the service had not addressed it.
• We found areas of concern around practices relating to the implementation of the Mental Health Act.
• Medication was authorised at high doses up to 150% and 200% of British National Formulary limits on authorisation forms. The responsible clinician (RC) had not prescribed medication at these levels on all medicine charts.

However,

• No staff had worked for a continuous 24-hour period. This had been an issue at the last inspection.
• The hospital had introduced a staffing assurance tool to try to manage staffing issues.
• The hospital had reviewed and updated its policies and procedures following two serious incidents.
• The hospital had developed an audit to assess emergency responses. As this was very new, outcomes of the audit were not yet available.
• Staff completed physical health checks in line with national guidance. We found that patients received a physical health check on admission and annually thereafter.
• We observed positive interactions between staff and patients during our visit.
• Patients told us that the staff were approachable, good and caring.

We inspected this service following concerns raised by a CQC Mental Health Act Reviewer who visited ward A on 30 October 2014. We visited wards A and B only during this inspection. We spoke with 17 people who used the service and eight staff on the wards. We also met with the hospital director, deputy hospital director, the responsible clinician, the clinical director and the Mental Health Act administrator.

We found that improvements were needed to ensure the service was safe. We found the provider had policies and procedures in place to protect people from abuse or harm. However, we identified some ligature risks on ward A and found that people who used the service did not feel safe.

Improvements were needed to ensure the service was effective. We found that restrictions were placed on all people who used the service.

We observed that most staff interacted well with people who used the service and people told us that staff were caring. However, the privacy and dignity of people who used the service was not always respected.

During this inspection we did not assess whether the service was responsive or not.

Improvement was needed to ensure the service was well led. Systems were in place to ensure that regular audits were completed to measure the quality of care. However, this was not always reflected in the service that people received or the support given to staff.

Before we conducted this inspection visit, we looked at all the information we had about the service. We also requested that a professional advisor assist us to complete the inspection.

Following our visit we spoke with a person who had recently conducted a Mental Health Act 1983 monitoring visit. They will produce a separate report.

We briefly visited all the wards and spoke with people. Some people expressed a wish to speak with us in more detail on a one to one basis. The professional advisor spoke with some people and we also spoke with some.

During our visit we spoke with 9 patients individually, 3 members of ward staff, a consultant psychologist and 3 members of the management team.

Most of the patients told us that they were happy with the care and support they received. One patient told us, "The staff do help me and sometimes seem to go out of their way to make things better for me." Another patient told us: "I was given information about my rights and I understand why there are things I can’t do.”

One patient told us they did not like being in the hospital because they were feeling well. They added, “When I am ill, this is the best place to be.”

Some patients we spoke with told us that they did not like it if their Section 17 leave was cancelled especially if others still got it. Section 17 of the Mental Health Act 1983 makes provision for certain patients who are detained in hospital under the Mental Health Act 1983 to be granted leave of absence.

Patients told us that there were a range of activities they could engage in and they had activities staff as well as occupational therapists. The favourite activity appeared to be visiting the café on site. This was open for a limited amount of time according to staff availability.

Most of the patients we spoke with told us that they did feel safe and they had no concerns about their welfare. One patient told us "I feel safe here." However, another person said they felt worried being on their ward because several other people were unsettled.

People told us they were given the opportunity to give formal feedback at ward meetings and patient group meetings.

As part of our inspection we visited two wards and spoke with six patients, six staff and looked at records of incident monitoring, staff deployment and Section 17 leave frequency.

We found that there were sufficient numbers of suitably qualified, skilled and experienced persons employed In order to safeguard the health, safety and welfare of patients.

One patient commented, “I have leave every week, my activity sessions are never cancelled.” Another patient told us, “There is a good balance of male and female staff, they go out of their way to help you here.”

During our visit we spoke with five patients. Four out of the five patients told us that they were happy with the care and support they received. One patient told us, “Staff are very caring.”

Patients told us that staff supported their health and personal care needs and took prompt action to get them medical attention when it was needed.

Four out of the five patients we spoke with said they felt safe in the hospital and knew how to raise any concerns they might have. One patient told us, “Staff do a really good job.”

Two patients told us that when restraint techniques were used they had been used appropriately and safely. Another patient told us, “When I need restraining the staff help me feel safe.”

Four patients we spoke with told us that often there was not enough staff on duty on their wards. Two of the five patients we spoke with told us that at times unplanned activities got cancelled due to other staff commitments.

During our visit we spoke with a number of patients. Most of the patients told us that they were happy with the care and support they received. One patient told us: “Staff are good they understand where you are coming from”. Another patient told us: “I have been given information about my rights.” One person said that this was the best place she had been to for care and treatment.

Some patients we spoke with told us that they did not like it when their Section 17 leave was cancelled. Section 17 of the Mental Health Act 1983 makes provision for certain patients who are detained in hospital under the Mental Health Act 1983 to be granted leave of absence. One person had made a complaint about this and another patient told us: “I hope they don’t change my leave again this week.”

When we asked patients about the quality of food we received a mixed response. Some patients told us that the food was fine. Other patients that we spoke with told us that they were not happy with the food and the portion size. Patients told us that there was a range of activities that they could engage in.

Most of the patients we spoke with told us that they did feel safe and they had no concerns about their welfare. One patient told us “I feel safe here.” One person told us that they are given the opportunity to give formal feedback.

Our rating of this service went down. We rated The Farndon Unit as Requires Improvement because:

• The hospital continued to have challenges in recruiting enough permanent staff and so had a high reliance on agency staff. These staff were not always familiar with the patients and their needs and this presented a clinical risk.
• The provider did not consistently follow best practice in the safe storage, control and administration of medicines and clinical equipment or infection control principles.
• Staff did not adhere to the provider’s policy around the use of safe and supportive observation practice. Staff did not consistently record or escalate a deterioration in patients’ physical health and staff had not received training in sepsis identification or management.
• Staff did not consistently know how and when to report a safeguarding concern or referral to external agencies and we saw variation in how and when staff reported safeguarding concerns.
• Patients told us not all staff treated them with compassion and kindness and did not consistently respect their privacy and dignity or understand the individual needs of patients. The hospital did not actively involve families and carers in care decisions.
• The hospital did not consistently provide patients with access to information about their care and treatment, how to complain, access to advocacy and appropriate spiritual support.
• The hospital did not have robust governance processes in place to support the safe care and treatment of patients within the hospital.

However:

• Staff minimised the use of restrictive practice wherever possible and patients were engaged in decisions about their care and treatment.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.