We rated The Woodhouse Independent Hospital as good for the Safe domain because:

• During the most recent inspection, we found that the service had addressed the issues that led us to rate the Safe domain as requires improvement following the January 2017 inspection.

• We found that when staff gave oral medication for the purposes of rapid tranquillisation, they completed the necessary physical observations. The provider had removed restrictions that meant that it no longer had a patient living in long-term segregation. The provider had a floating nurse to support the wards for people with learning disabilities or autism, in addition to the staffing establishment for each of the wards. Moneystone ward had sufficient staffing levels to meet patients’ needs.

• We found that the provider had allocated a lead nurse for infection prevention and control to the wards for people with learning disability or autism. Staff completed checks on emergency bags on all the wards. Staff completed records to show they had cleaned portable clinical equipment on all the wards. Staff had de-cluttered and tidied the storeroom, and cleaned, redecorated and re-floored the sluice room on Moneystone ward.
• The provider offered overtime to its staff and had a bank staff system to help fill shifts. The provider used agency staff frequently, and wherever possible, they tried to use staff who were familiar with the service. Most staff in the core service had received training in autism.

However:

• Staff did not always record the time of the physical observations they completed after they gave oral rapid tranquillisation.
• There were different processes for recording physical observations on the wards.
• The provider’s rapid tranquillisation policy lacked guidance on monitoring physical observations after oral rapid tranquillisation. 

We undertook this visit to follow up on issues raised at our previous inspection. Wehad also received some concerns about the service. We undertook a joint visit with the Mental Health Act Commission. We shared information although the Mental Health Act Commissioner will provide a separate report. The visit concentrated on two of the eight units at The Woodhouse. We looked at six outcome areas. These included people's health and welfare, their involvement in decisions about their care, medication, the systems in place to make sure people were kept safe and staff support and training. We also looked at how the provider was making sure people were receiving appropriate care.

When we visited last time we noted that some people were not involved in planning their own care. On this occasion we saw during this visit that the service had started to make some progress in achieving this although further work was needed. We identified that the service had started to work with people to look at their needs and to identify their preferences and important things in their lives.

On our last visit we identified improvements that the service could make in how it gave staff information about plans of restraints and restrictions. We saw that the service had made progress in this area. We had also identified that some people were not being supported sufficiently with undertaking activities. Most people we spoke with on this visit told us that they took part in activities although in some instances the records did not fully support this.

We and the Mental Health Act Commissioner (MHAC) spoke to some people about their care. Some people were not able to tell us about their care. People we spoke with told us that they were satisfied with the support they received. We saw that in one of the units we visited that patient involvement meetings were held where people could raise issues and any concerns. On another unit we were told that staff met with people individually to gain their views but the records did not fully show that these were always held. An advocate visited all the units to support people to express their views.

We saw evidence that the service had started to develop information in a more user friendly manner. A part time speech and language therapist had been apppointed and was working with people on communication passports and was starting to train staff in developing a range of key signs to develop more effective communication.

We identified areas for improvement in the way some medication was being stored and administered.

We saw that the service had introduced additional systems to keep people safe and to respond to any incidents of concern. We saw that staff were trained in recognising and reporting safeguarding issues and the service had developed an easy to read leaflet about abuse, although this had not yet been introduced. We felt that staff needed to be more aware of issues relating to the Mental Capacity Act 2005 and the manager confirmed this would be included in staff's annual training. We saw that some of the annual updates on physical intervention were overdue.

The service had systems in place to review and monitor the care people received.

We rated The Woodhouse Independent Hospital as good overall because:

• During this inspection, we found that the provider had addressed most of the issues that made us rate forensic inpatients/secure wards and wards for people with learning disabilities or autism as requires improvement for the safe, effective and well led domains in our last inspection in October 2015.
• All wards had access to emergency equipment such as automated external defibrillators and oxygen cylinders. Staff practised good infection control and food hygiene.
• Wards did not have nurse call systems but the provider had a specific risk assessment that identified the risks and how they mitigated them. This was mainly through designated support levels for each patient, observation and supervised access to high-risk areas.
• Staff received training in, and had a good understanding of, the revised Mental Health Act Code of Practice and the Mental Capacity Act. The hospital had effective and robust arrangements to monitor adherence to the Mental Health Act and Mental Capacity Act.
• The provider had improved its focus on autism and set clear aims and objectives for the service. Wards had autism-friendly features, staff assessed and met patients’ individual communication needs, and staff had access to specialist training.
• The provider had developed two clear service pathways - learning disability (incorporating the forensic inpatient/secure ward service), and autism. It had strengthened its leadership with designated operational managers and clinical leads for each service, and recruited a consultant psychiatrist with specialist skills for the autism service.
• The provider had improved its governance systems and processes for monitoring all aspects of care. For example, the provider had robust incident monitoring processes and held regular meetings to review restrictive practices.

However:

• When staff on Moneystone and Highcroft wards gave oral medication for the purposes of rapid tranquillisation, they did not always complete the necessary physical observations.
• The hospital did not have an active clinical lead role (for example, a named nurse) allocated to infection prevention and control.
• There were short periods when there was no qualified nurse present on Moneystone ward, and there were occasions when staffing levels were insufficient to meet patients’ observation requirements.
• We found gaps in the checks on the emergency bags on Moneystone and Highcroft wards.
• There were no records that confirmed the cleaning of portable clinical equipment on Moneystone and Highcroft wards.
• There were inconsistencies in the completion of forms used for recording observations of the patient in long-term segregation.