We carried out an unannounced focused inspection of this service following concerns identified to the Care Quality Commission.

We do not rate services that we inspect as part of a responsive inspection. We found that action was required by the provider because:

• Staff could not observe patients effectively in all parts of the ward. The service had installed mirrors to aid observation, but staff had not placed where needed. As a result, lines of sight were not clear.
• Staff did not seek appropriate levels of medical attention when patients harmed themselves.
• Managers undertook ligature risk assessments and staff had identified ligature points throughout the service, where patients might be able to harm themselves.. However,staff had taken no action to minimise the risks to patients.
• The ward did not comply with mixed-sex accommodation guidelines, as there were no separate day spaces for women.
• Staff were nursing one patient in long-term segregation to prevent the risk of harm to other patients and to themselves. Staff had not completed management plans or multidisciplinary reviews of this to ensure the patient was safeguarded in line with the Mental Health Act code of practice.
• Cleaning records showed that cleaning took place regularly; however, some areas of the service were not clean. Three bedrooms inspected were dirty and had an unpleasant odour. Ensuite facilities in two bedrooms had stained toilets and flooring.
• The emergency drugs held in the clinic room were out of date. Staff did not check medication regularly or effectively as this error was unnoticed.
• The service did not manage stock medication or controlled drugs in line with Nursing and Midwifery Council standards. We found errors in both the dispensing of, and recording of, controlled drugs. Staff did appropriately manage the recording of stock medication.
• Medication was stored in a fridge, which staff records showed, had temperatures that were higher than the accepted range. The fridge also contained solid ice. This could have changed the effectiveness of the medication. Staff had taken no action to address this.
• The service used blanket restrictions, such as limiting patients’ access to mobile phones and to the internet. This was not individually risk assessed.
• Staff knew how to report incidents and used an electronic system to do this. However, those report records reviewed were incomplete and lacked information about the incident and the lessons learned.

However,

• There were alarm call bells in patients’ rooms, which meant they were able to call for help if they needed it.
• Staff completed risk assessments and updated them when the risk to patients changed.
• The hospital had enough staff on shifts to meet the needs of patients on the ward. Managers could adjust the staffing levels if required.
• Eighty-one percent of staff had completed mandatory training.
• Staff interacted with patients in a positive way and showed good understanding of individual needs.

We spoke with six of the 21 people who were being treated at Cornerstone Hospital. They told us that they had their treatment discussed with them and explained to them. Some told us that while they may not always agree with their treatment, they understood that it was to promote their health and welfare. One person told us that this was the best place they had been admitted to and they said that the staff were respectful and listened to you. They also said that they felt free and had a better quality of life. One person told us that the hospital had a system in place where there was a patient’s representative who took the people’s views to the management of the hospital. We were told that this system worked well.

We found the people to be cared for in a manner that promoted their dignity and was respectful. We saw care plans and risk assessments were in place and the people had access to therapies that promoted their mental health. The people we spoke with told us that they feel safe at Cornerstone.

We found that there was a sufficient mix of trained and qualified care staff to recognise and to meet the people’s needs.

During this review we spoke with six people who lived at Cornerstone House and four people being supported by Vision Mental Health staff in the community. While people expressed different feelings, about the reason for their stay at Cornerstone House, the consensus was that the staff provided the support they needed and people felt safe. People told us about the wide range of therapies and recreational activities that made up their individual treatment plans. These included opportunities to make use of community recreational and educational facilities as people’s mental health improved. One person told us they had been encouraged to take part in activities they had not experienced before. Another person told us their relatives felt this was the best place they had been to. People living in the community told us that they got on well with staff who were approachable and listened to them. One person, living in the community, said when they had a problem they told the manager who was very easy to get hold of and things were sorted out. Another person told us they were “very satisfied”. One person who lived at Cornerstone House remarked that they would have preferred to be nearer their own home.

We noted that people had good access to psychiatric and community health services.

It was the view of the Mental Health Act Commissioners who visited the service, on 21 February 2012 that Cornerstone House provided a successful rehabilitation service for vulnerable people.

We rated Vision MH – Cornerstone House as Outstanding because:

• The service had robust, detailed and comprehensive environmental and ligature risk assessments in place. Managers updated these regularly.
• The service had a range of rooms and equipment to support treatment and care. This included a clinic, treatment room, therapy kitchen, gym, art room and a group therapy room.The service had achieved a five star food hygiene rating. Patients could make hot and cold drinks when they wanted. Snacks were available throughout the day.
• All staff assessed risks to patients who used the service on a daily basis. This included physical health, mental health and behaviours that challenged.
• There was good medications management, which included regular audits of equipment and records.
• Staff reported all incidents in line with policy. The senior management team reviewed every incident. Openness and transparency in relation to safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns. Senior staff discussed lessons learnt with the staff and patients in different forums, to minimise a re-occurrence. 
• All staff had a holistic approach to assessing, planning and delivering care and treatment to patients. Every patient had a comprehensive assessment upon admission to the service. Staff placed real emphasis upon the physical healthcare of patients. Nursing and medical staff monitored the physical health of all patients from the point of admission. 
• All staff undertook a comprehensive induction to the service. Staff received annual appraisals. Staff received supervision in line with policy. Senior managers encouraged the continuing development of staff skills, competence and knowledge. Managers recognised that this was integral to ensuring high quality care.
• All staff had a good working knowledge of the Mental Health Act. Where patients were subject to Mental Health Act detention, their rights were protected. Staff complied with the Mental Health Act Code of Practice. All staff had a good working knowledge of the Mental Capacity Act and the Deprivation of Liberty Safeguards. Senior staff regularly monitored consent practices and records. Staff completed capacity assessments for patients who might have had impaired capacity in relation to specific decisions.
• Staff who were exceptionally caring, extremely compassionate and very kind supported patients. Staff demonstrated considerable pride in their work and supported patients in the most appropriate manner to meet their needs. Patients and families shared with us their positive experiences of the care they received at the service. Staff consistently empowered patients to have a voice and realise their potential through different forums.
• Information on treatments, local services, advocacy and patients’ rights were visible in communal areas. Interpreters and signers were accessible as and when required.
• The service was led well by the senior management team. Staff, patients and carers told us that they were visible and accessible.
• A sufficient number of staff of the right grades and experience covered shifts.
• There was an open and transparent culture across the service. Staff were honest with patients when things went wrong.
• The service was proactive in capturing and responding to patients concerns and complaints. Patients and families knew how to make a complaint. Managers investigated all complaints fully in line with their policy and responded in a timely way.

However:

• We observed one ligature risk in the new building, which had not been identified. The manager took immediate action when we highlighted this.
• Some portable electrical equipment testing was just outside of the time frame for expected annual checks. These had been booked to be undertaken.