We rated Priory Hospital Hemel Hempstead as good because:

• There were robust environmental risk assessments, and the hospital complied with single sex accommodation. Wards were clean and tidy, furnishings were high quality and well maintained. There were adequate rooms and space for a full range of activities to take place including quiet rooms for patients to relax in and have family visits.

• Patients and staff told us that staffing levels were good across the hospital, and escorted leave and ward activities rarely cancelled. Where bank and agency staff had to be used staff and patients knew them well.

• Bed management was effective.

• The service employed a full range of experienced staff and communication between staff members was effective. There was good medicines management with a visiting pharmacist providing staff with training and advice

• Staff treated patients with kindness, respect, and showed commitment to providing high quality care.

• Staff routinely reviewed and updated risk assessments and care, including physical health care needs. Patients were encouraged to be involved in their care panning. All information required to deliver good care was stored safely on an electronic database.

• Patients told us the food was good, a dietician, and speech and language therapist ensured patients’ nutritional needs and special diets were catered for.

• Prior to admission prospective patients and their carers were invited to visit the hospital.

• There were regular ward community meetings, and patient forums, patients were invited to contribute their ideas about the day-to-day running of the wards.

• Patients had their rights under the Mental Health Act explained regularly, and were helped to access independent mental health advocates and general advocacy services.

• There was disabled access around the hospital. Patients received a comprehensive information pack including access to advocacy, how to make a complaint, and an explanation of patients’ rights under the mental health act.

• There was information in the communal areas showing how to access local amenities, and a wards activity program.

• Managers dealt with incidents and complaints promptly. Managers shared the lessons learned from investigations with staff across the hospital. There were no incidents of seclusion and staff had received training to use de-escalation strategies.

• The hospital was well led and had a clear vision and values. Staff morale was good and the provider used key performance measures to monitor and maintain high standards of care.

• There was an extensive training programme to develop and maintain staff leadership and clinical skills. There was a commitment from managers and staff towards continual improvement and innovation through learning.

However:

• A blanket restriction was in place on Dove ward to enable staff to mitigate the risk for two patients when using the kitchen. However, it was evident that senior managers had not reviewed this restriction in line with the code of conduct.
• While care plans and risk assessments were personalised, staff had not used a recognised recovery approach model. Care plans did not reflect patients’ strengths, and the risk assessments did not reflect positive risk taking.
• 85% of staff had completed Mental Capacity Act (MCA) training, and 91% of staff had trained in Mental Health Act (MHA). This was short of the providers target of 95%.

At our last inspection of Priory Grange Hemel Hempstead in March 2013, we identified a range of concerns about the care people received, and the poor care practices we observed. Staff lacked compassion in the way they cared for people and the monitoring of quality and safety was ineffective. We told the provider they must make improvements.

When we returned to inspect this service on 1 August 2013, a new manager had been appointed and we found significant improvements had been made.

We looked at care documentation for 4 of the 28 people who used this service, and spoke with 11 of them during this inspection. There were care plans in place which accurately reflected people's needs. Their personal preferences, aspirations and cultural backgrounds had been considered and respected by staff. One person said. “My care plan includes that I have Tasbee for praying and the staff respect this."

We observed staff were respectful and courteous in their approach to people, and were knowledgeable about people's needs and how they should be met.

New systems had been introduced to ensure the quality and safety of service provision was effectively monitored, and people told us they felt listened to.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

We spoke with some of the people who used the service and most of them told us that they were not happy living at the hospital. A high number of the people said they would prefer to live somewhere else. They said that the staff did not listen to them and when they asked staff for something they were ignored. We saw an example of this where a person was talking to a staff member and the staff member did not look at them or acknowledge them.

Relatives we spoke with were unhappy with how the staff treated them as visitors and how the staff treated their relatives.

We saw that the staff were disconnected from the people they were caring for. One staff member was sitting sideways and turned away from the person they were assisting.

Staff were unaware of people’s detention status in the hospital or what it meant in relation to the person’s rights.

We saw that the ward communal areas did not contain enough dining chairs or table settings for the people who lived there. There were not enough easy chairs for the people to sit together in the communal sitting room if they chose to.

We looked at how the people’s dignity was promoted, how their health needs were recognised and met, how people were safeguarded, how the staff were trained and the number of staff on duty. We also looked at the leadership in the home and how the home was managed. We found all of these areas were non compliant.

We rated the Priory Hospital Hemel Hempstead as good because:

• The wards were clean, presentable and very well maintained.
• Rotas examined showed that the actual nurse numbers matched the estimated number on most shifts.
• Staff undertook a risk assessment of every patient on admission and updated this every six months and after every incident.
• Staff could explain what a safeguarding incident was and how to raise an alert.
• We found that staff received feedback from investigation of incidents and that staff were aware of lessons learnt.
• Staff completed comprehensive and timely assessments and physical examinations for all patients on admission.
• The percentage of non-medical staff that had an appraisal in the last 12 months was 100%.
• We saw positive caring interactions between the staff and patients in the service.
• Patients were involved in their care planning. All patients were given copies of their care plans unless they said that they did not want a copy.
• Patients had open access to outside space during the day, in line with the Mental Health Act Code of Practice guidance.
• The provider had set visions and values. We saw that the vision and values were displayed across the service and embedded into staff day to day practice.
• Staff knew the senior managers in the organisation and confirmed that they were often visible on the wards were accessible, and listened to staff when needed.
• Managers had a strong influence and good oversight of the wards.
• The provider submitted training data prior to inspection of mandatory training, which showed compliance of 82%. Overall training figures on the day of inspection for mandatory training, was 96% for permanent staff and 88% for bank staff.

However:

• There was not always a sufficient number of staff on Wren ward. We found that the number of staff did not reflect care needs.
• Of the 30 medication charts reviewed two (eight percent), did not have an up to date treatment form attached.
• The quality of some of the Mental Capacity Act assessments were not comprehensive.
• We found that not all staff were in receipt of regular supervision. The data given by the provider showed that 81% of staff were in receipt of supervision, against a provider target of 93%.
• There was no disabled access to Dovecote.