We rated the Retreat York as inadequate because:

• In January 2017 hospital managers decided to move six patients to the previously closed Allis unit for a six week period. When we visited there were no patients on the unit, however Allis unit appeared dirty, damp and cold. There was limited hot water and unsuitable kitchen, toilet and bathing facilities. We saw a lack of proper planning and staff allocation in relation to the cleanliness of Allis unit. We did not see, and were told by one nurse that worked on Allis unit, that there was no grab bag on the unit; a grab bag contains items to use in an emergency such as resuscitation equipment or emergency medications. The provider told us that the closest grab bag was on another older people's unit directly below the Allis unit. There was no clinic room on Allis unit and medicines storage was not in keeping with best practice when we visited. Neither unit had an environmental risk register to identify and prevent risks to the patients that could have occurred because of the changes relating to the flooring refurbishment of George Jepson.
• We found there to be unsafe and unsuitable staffing levels and skill mix including the allocation and availability of qualified nursing staff on both Allis and George Jepson units. Staff were unable to spend meaningful time engaging with patients as they were responding to other patient needs.
• Units had ligature risks and blind spots that were not continually managed with observations. On George Jepson unit, patients were unable to use the conservatory, quiet room or access the garden. Staff could not always see patients on the unit when they were on observations. Staff locked entrance doors to the units and patients were not individually risk assessed to be able to leave the units unescorted or without permission. Not all staff had swipe fobs to be able to leave the unit or access to the duty room.
• We saw no record of timely discussions with patients or families in relation to the move to Allis unit. We saw that families had concerns regarding the Allis unit and did not find evidence that the provider had prioritised patient dignity in terms of the move. We saw evidence that families told the provider how their relatives had been disoriented on both units when the flooring work was being completed and gave examples of when staff had become distracted and had been unable to complete their personal care.
• We saw no effective system for identifying, capturing and managing issues and risks at team and organisation level in relation to the flooring work on George Jepson during our inspection or in any of the information provided by the Retreat York. There were significant issues that threatened the delivery of safe and effective care and these were not identified.
• We saw no documented evidence of a multidisciplinary discussion around suitability of patients to move or the impact on the patients that remained on the George Jepson unit. The provider was unable to locate and evidence details of personalised risk assessments, environmental risk assessments and personal evacuation plans.
• Families told us that there were not enough activities for the patients on the unit and we saw this to be the case.

However:

• George Jepson unit was clean and smelt fresh in both communal areas and patient bedrooms. Resuscitation equipment was available, medicines storage was well organised and we saw staff using correct equipment when moving patients as detailed in patient care plans.
• We saw that the provider monitored incidents and acted on incidents reported. Families and carers of patients were informed of incidents when they occurred.
• Patients who were able to communicate told us that they liked being on George Jepson unit and that staff were kind. Families described the staff as caring and supportive and George Jepson unit as a wonderful place in spite of the shortcomings.
• All staff described their close working relationships and enjoyment of their roles. We observed staff to be friendly and caring to patients; staff considered patients’ needs; we saw that patients that needed help with personal care were clean.

The inspection of The Retreat took place on 1 and 7 December 2016 and was announced. At the last inspection in June 2016 The Retreat – York was not given an overall rating for the domiciliary care service because only two key questions were inspected: ‘is the service safe’ and ‘is the service effective?’ These were separately rated as ‘inadequate’ and ‘requires improvement’, because the service did not meet all of the regulations we assessed under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was in breach of Regulations 12: safe care and treatment and 13: safeguarding service users from abuse and improper treatment.

These breaches were because the service had not followed the requirements of The Mental Capacity Act 2005 in using restraint to prevent people from harming themselves. Support workers were also unaware of people’s complex needs and had put people at risk of harm because of not knowing what action to take to meet those needs.

The Retreat is an independent specialist mental health care provider for up to 98 people with complex mental health needs. It also provides assessment or medical treatment for people detained under the Mental Health Act 1983. The service is located on the outskirts of York. Since September 2015 The Retreat has also been registered for the regulated activity of 'personal care' to provide domiciliary care services to people living in supported living schemes. This is provided on the site of the hospital location, in two units known as The Cottage and East Villa, which together have 11 shared accommodation places. At the time of this inspection there were eight people using the service.

The registered provider is required to have a registered manager in post. On the day of the inspection there was a manager that had been registered and in post for the last fifteen months with regard to 'personal care' and longer for the other regulated activities registered at the location. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we carried out a comprehensive assessment in which all five key questions were inspected. There was considerable improvement in the ‘safe’ and ‘effective’ key questions so they were rated as ‘good’. We found the overall rating for this service to be ‘good’. The rating is based on an aggregation of the ratings awarded for all 5 key questions.

People were protected from the risk of harm because the registered provider had systems in place to detect, monitor and report potential or actual safeguarding concerns. Support workers were appropriately trained in safeguarding adults from abuse and understood their responsibilities in respect of managing potential and actual safeguarding concerns. Risks were managed and reduced on an individual basis so that people avoided injury or harm.

The two shared tenancy premises occupied on the site were safely maintained and there was evidence in the form of maintenance certificates, contracts and records to show this. Support worker numbers were sufficient to meet people’s needs and we saw that rosters accurately cross referenced with the workers that were on duty. Recruitment policies, procedures and practices were carefully followed to ensure support workers were suitable to care for and support vulnerable people. We found that the management of medicines was safely carried out.

We saw that people were cared for and supported by qualified and competent workers who were regularly supervised and appraised regarding their personal performance. Communication was effective, people’s mental capacity was appropriately assessed and their rights were protected.

Support

The focused inspection of The Retreat took place on 7 June 2016 and was unannounced. We carried out an announced comprehensive inspection of this location in October 2015, against the regulated activities ‘Treatment of disease, disorder or injury’, ‘Assessment or medical treatment for persons detained under the Mental Health Act 1983’ and ‘ Diagnostic and screening procedures’. After that inspection we received concerns in relation to; the use of prone restraints on two tenants, the registered provider’s understanding of Mental Capacity Act 2005 (MCA) compliance, and emergency responses to incidents. These concerns related specifically to two supported living units at The Villa and The Cottage. As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to those topics and only in relation to the two supported living accommodation units. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Retreat - York on our website at www.cqc.org.uk

The Retreat is an independent specialist mental health care provider for up to 98 people with complex mental health needs. It also provides assessment or medical treatment for persons detained under the Mental Health Act 1983. The service is located on the outskirts of York. Since September 2015 The Retreat has also been registered for the regulated activity of ‘personal care’ to provide domiciliary care services to people renting their accommodation under supported living arrangements. This is also provided now on the site of the hospital location, in two units known as The Cottage and The Villa.

People that use this service are not detained under the Mental Health Act 1983 (MHA), and may have learning disabilities and autistic spectrum disorder. It is this regulated activity that sits more comfortably within Adult Social Care provision and so this directorate of CQC was involved in the focused inspection of the service. At the time of our focused inspection there were six people using the service: four females and one male at The Cottage and one male at The Villa.

The registered provider was required to have a registered manager in post. On the day of the inspection there was a manager that had been registered and in post for the last nine months with regard to ‘personal care’ and longer for the other regulated activities registered at the location. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that people were not always protected from harm and abuse because although the registered provider had systems in place to protect people from abuse and staff were aware of their responsibilities to protect people, the registered provider was carrying out restraints and depriving people of their liberty without the proper authorisations in place under the Mental Capacity Act 2005 (MCA) and following authorisations by The Court of Protection.

Several areas of practice at The Cottage and The Villa were being inappropriately carried out: admission of people to the service without ‘best interest’ decisions, use of restraint techniques for prolonged periods of time, seclusion behind locked bedroom doors, inappropriate use of equipment designed to reduce anxiousness for people with autism, such as wrist weights, hand held restraint for the purposes of providing personal care and people reliant on only two-to-one support to access the local community therefore under continuous supervision.

People that live in their own homes or in supported living accommodation can only be lawfully deprived of their liberty when following an order of the Court of Protection. Bec

During our visit we had the opportunity to speak with seven people who use the service. People were very positive about the care and treatment they had received. Comments included, "They have really supported me here and now I am so much better’’ and ‘’Staff are lovely. They listen to you. Unlike some places I’ve been before.’’

We looked at the records and talked to the staff working in the hospital. We confirmed that people were supported to give their consent to care and treatment. People also told us they felt involved and included in decision making within the service. We confirmed that care records were person centred and reflected individual choices in their rehabilitation.

We talked with the staff and they confirmed they felt well supported and confident in their role with good training and development plans in place.

We saw that there were good systems in place to listen to people’s concerns and everyone was supported to access advocacy services and other help networks. We also saw there were effective systems in place to monitor complaints. People who use the service told us that if they wanted to make a complaint they would know how to. We saw that the hospital recorded all complaints and resolved them where they could to the complainants’ satisfaction.

During the morning of our visit we visited six units at the hospital and in the afternoon we focused on two particular units. The first unit was for elderly patients who were dependent on staff to meet their mental and physical health needs. The second unit was a ‘therapeutic community’ for women with, "self defeating behaviours, disordered eating and borderline personality disorders".

We spoke to patients on both units and those who were able told us that they were involved in making decisions about their care and support, they felt that the process was inclusive and one person explained ‘I’m the first and last person to speak in my review’.

Other patients told us that the staff were, “Professional” and “excellent; supportive, challenging and committed”.

Patients also felt they were respected and included in wider decision making in the hospital, they said that they were involved in regular community meetings and they were also included in the recruitment of new staff to the service.

We carried out a inspection of The Retreat over two days, on the 14 and 17 November. On the first day, a team of four inspectors visited the site and on the second day the 17 November two inspectors returned to complete the inspection.

Patients explained how they were informed about and involved in their care and treatment. They described how they attended both multi-disciplinary team and care programme approach meetings where their treatment and care is reviewed by the medical and nursing staff. Some described how they “attended the whole meeting, from beginning to end”. They explained how they were informed and had been offered the use of the advocacy services.

Most patients told us they were listened to and treated with respect, they explained how staff “knock on” their doors before entering and are always very “polite”. Patients generally said they received the care and treatment which met their needs. On two of the units patients made the comments that care is “excellent” and it is “more than really good”. They made positive comments about the staff, they said they were “excellent” and commented how the staff put their “needs first”. They said the staff are “supportive” and will “help them to overcome their illnesses”.

Patients confirmed they attended regular meetings and received twice yearly questionnaires, which asked their views about the service.

We rated The Retreat York as good because:

• The organisation had made improvements following feedback from our previous inspections. Staff made changes to systems and processes across the organisation, and improvements meant patients received safe care and treatment. The unit managers had a good understanding of their units and shared good practice.
• Staff were respectful and courteous at all times. Staff treated patients with dignity and respect and saw each patient as an individual. Staff involved patients, carers, and advocates in decisions about their care and treatment and took account of patients’ preferences and advance decisions. Staff helped patients engage with their environment and take part in meaningful activities.
• Staff completed detailed, personalised care plans, which included crisis plans and information about their mental and physical health needs. Care plans took account of best practice guidance and patients and carers were involved in decisions about their care. Patients’ physical health care concerns were addressed.
• Units held effective handovers and multidisciplinary team meetings to review and discuss patient care and treatment. Staff adherence to the Mental Health Act and Code of Practice was good overall and staff understood how to apply the Mental Capacity Act.
• Staff were trained in safeguarding and incidents, they knew how and when to raise alerts. Staff completed and reviewed comprehensive individual and environmental risk assessments that kept patients safe. There were governance arrangements in place to monitor and respond to trends.
• The units had good medicines management arrangements that meant staff stored, monitored, and administered medication safely. Medicines were managed in a safe way and patients were risk assessed to be self-medicating.
• The leadership and culture of the units reflected the organisation’s vision and values. Staff knew who their senior managers were and spoke highly of the support they offered. Senior managers from the senior leadership team visited units and attended team meetings to listen to staff concerns and keep staff informed of service developments.
• Morale on the units had improved following recent unit and senior management changes. Staff felt able to raise their concerns and that managers would listen to them and take appropriate action. Staff spoke positively of the senior management team and the positive changes they had made.

However,

• The majority of staff lower than the middle management tier were not involved or aware of the emerging improvement strategy for the organisation.
• Staff on Kemp unit did not appropriately use section 5(4) of the Mental Health Act to prevent patients leaving the hospital at a time when it was deemed unsafe for them to do so.
• Staff on the older adult units were not clear what arrangements were in place for individual patients when authorisations for Deprivation of Liberty safeguards were delayed.
• The provider did not have a consistent approach to the review of restrictive practices and we did not see processes that reviewed if lessons learnt had been embedded in the organisation following a complaint or incident.
• The older adult service had no clear model of care or discharge pathway. The provider was aware of this and was reviewing the clinical model as part of its emerging strategy.
• Patients from Naomi unit told us that there wasn’t a room on the unit where they could meet with visitors. The bedroom doors on older adult units compromised patients’ privacy, dignity, and confidentiality. The dining room on Katherine Allen was not large enough to accommodate all patients in one sitting.
• Older adults units could not assure us that they checked all equipment to ensure it was safe to use. Both units had not carried out a recent fire drill to test that their procedures were safe.
• Electronic records related to medication management had not been consistently documented by agency staff on older adult units.