Prior to the inspection, in response to concerns raised by patients, staff and the local leadership team regarding the safety and quality of care at Antelope House the trust had made a number of key changes to the staffing structure including new leadership and additional checks on safety and support for staff. The trust introduced these key changes on 11 February 2019 so had only been in place nine days prior to our inspection.

Prior to the new staffing arrangements being implemented the senior management team spent time talking with staff, visiting the wards to ensure they understood the issues facing staff and consider what changes needed to be made to make improvements to the quality and safety of patient care.

Changes had been made to managerial and nursing roles and additional medical support was put in place to support staff. Daily safety huddles were also set up to discuss risks and concerns within Antelope House. Changes were communicated to staff in writing and in person. However, these were new and not fully embedded.

During the inspection, we found:

• Staff had not ensured that risks concerning a patient’s physical health had been fully addressed.

• Staffing levels were not always sufficient and fell below the trust ‘safer staffing levels’ on both wards approximately once per week. There were a number of vacant posts on both wards and a high level of staff sickness. The wards were heavily reliant on bank and agency staff and some shifts were left short by one or two staff members once or twice per week.

• Staff morale on Hamtun ward was low, three staff were off sick and the remaining staff team were feeling under pressure. Staff said that prior to the changes they had felt undermined by senior management regarding admissions to the wards and felt that communication had been poor.

However:

• The trust had recognised that staff morale was low on Hamtun ward and had put in place arrangements to bring about improvements. During the inspection staff told us told us that they felt there had been more support from senior management recently.

• The trust had implemented daily safety huddles to discuss any concerns on the wards and provide additional support to staff and monitor patient safety.

• Staff on Saxon ward felt that morale was good.

We carried out an inspection in August 2013 when we identified concerns with care and welfare and medicine records. We made compliance actions asking the provider to take action in order that we were reassured that people were in receipt of safe and adequate care. The provider wrote to us and told us what action they were going to take and they sent us an update on their actions in October 2013.

We inspected on 2 December 2013 to review the progress the provider had made. We found that the provider had taken some steps to improve care planning and medicine records. However, although the care plans were individualised for mental health needs they did not always detail the support and care each patient required for physical health needs. Records such as risk assessments did not reflect concerns related to patients’ physical health.

We issued a warning notice to the provider stating our concerns with continued non-compliance, stating that they needed to have taken action by 31 January 2014.

We inspected on the 6 February 2014 to review the progress the provider had made with regard to the warning notice and the concerns we had with the care and welfare plans for patients.

At this visit we chose to inspect care plan records on all four wards at Antelope House: Trinity, Saxon, Hamtum and Abbey. Some patients were there informally (not detained under the Mental Health Act 1983) and some were detained under the Mental Health Act 1983. We were accompanied by the senior nurse lead for the directorate. We looked at 10 care plans spoke with eight staff, the acute care pathways manager who managed Antelope House and the senior medical clinicians for the service. We spoke with 3 patients about their care.

We met with the acute pathways manager and senior nurse lead before we started our inspection and they explained to us the action they had taken to meet the warning notice. This included an open discussion about how they were working to change the practice at Antelope House, for example, the learning department were more proactive with training and implementing multi-disciplinary team working with the staff having signed up to working collaboratively with each other and the patients. Staff confirmed that there was protected time for two hours in the morning and one hour in the afternoon, this allowed staff to mix/integrate with patients. Occupational therapists had been asked to support people using the service during the protected time. We were told consultants were assessing junior doctors clerking and assessing with use of an audit tool. The senior staff told us that there has been confirmation that staffing will be invested in to improve skill mix of staff for example investment in psychology, occupational therapy and general trained staff.

Senior staff told us that they were looking at staffing and how staff vacancies were covered. We were told that senior staff had chosen to close Trinity ward to new admissions rather than bring in agency staff, because there were a number of patients who required one to one staffing. A daily situation report for staffing, vacancies, sickness, concerns had been implemented in order to manage the staffing to meet patient needs. Senior staff explained about their plans for long term agency staff, to have a pool of appropriately trained agency staff. “We can’t be satisfied with unsatisfactory agency staff”. The pool of staff would receive same training as permanent staff in order that the management of Antelope House could be assured that all staff were trained to meet the needs of patients.

We found that three wards had taken sufficient action to meet the warning notice.

However, concerns remained regarding Hamtum ward. There continued to be a lack of information in risk assessments and care plans regarding patient’s physical health needs, placing patients at risk of not receiving care to meet their needs. We also identified that staff on this ward were not well supported in that they were not confident in planning care or taking action for patients with physical health needs. The other three wards had taken action, staff had been supported and there was collaboration amongst the staff groups to ensure that changes were made. However, there was a lack of collaboration and assessment of the work that was talking place to ensure all the wards at Antelope House were compliant.

During this inspection we visited Trinity ward for female patients and Hamtum ward, the intensive care unit which is a mixed sex ward. Some patients were there informally (not detained under the Mental Health Act 1983) and some were detained under the Mental Health Act 1983.

We spoke with six members of staff working in the ward environment and four patients. We also spoke to senior managers on site such as the acute care pathways manager and lead nurse.

We observed staff being respectful, asking people if they needed support. The atmosphere on Trinity ward was relaxed with a member of staff playing their guitar. Whilst on Hamtum ward the atmosphere was variable as there were patients’ expressing themselves loudly and they were not feeling well.

We carried out an inspection in August 2013 when we identified concerns with care and welfare and medicine records. We made compliance actions asking the provider to take action in order that we were reassured that people were in receipt of safe and adequate care. The provider wrote to us and told us what action they were going to take and they sent us an update on their actions in October 2013.

We inspected on 2 December 2013 to review the progress the provider had made. We found that the provider had taken some steps to improve care planning and medicine records. However, although the care plans were individualised for mental health needs they did not always detail the support and care each patient required for physical health needs. Records such as risk assessments did not reflect concerns related to patients’ physical health. The improvement in medicine records was not consistent. We identified concerns regarding keeping stock safe and the administration of medicines.

We identified concerns with the monitoring and assessment of the service in that audits carried out had not identified issues and work had not been carried out to ensure that all actions taken and changes made, had been embedded into practice.

During this inspection we visited Trinity ward for female patients and Hamtum the intensive care unit which is a mixed sex ward. We spoke with six members of staff working in the ward environment and four patients. We also spoke to senior managers on site such as the care pathways manager.

Patients we spoke with gave contradictory opinions. For example one was happy with the service and was involved in their care and treatment choices, they felt ‘listened to’. Another patient however did not feel heard and did not think their equality and diversity needs were respected. Overall we found that patients received the care they needed.

We observed a nurse discussing the medication needs of a patient with them and ensuring they were involved in the management of their medicines. We observed staff encouraging and supporting a patient who had put themselves on the floor, to get up. We observed staff being respectful, observing patient’s behaviours so they were aware of when they may need to intervene and offer support. This was balanced with offering choices and asking patients if they needed support and assisting when asked. However we found that medicines were not disposed of following the trust’s policy.

Staff told us about the training they have received and the support they had from senior staff. Senior managers work with staff to monitor and assess the quality of the service.

We carried out an inspection in August 2011 when we identified concerns with Outcome 4 care and welfare, Outcome 7 safeguarding and Outcome 14 supporting staff. The concerns were in relation to care planning, risk assessments, safeguarding of patients and staff training. We made compliance actions asking the provider to take action in order that we were reassured that patients were in receipt of safe and adequate care with regard to outcome 4 and 7; and that improvements were made to staff training.

We carried out an inspection on 14 November 2011 to review the progress the provider had made in taking action to be compliant in the areas where we had assessed them as non complaint or needing to make improvements.

We visited two wards, Trinity and Saxon, and spoke with eight staff. Staff we spoke with were generally happy the new working arrangements that had been put in place. One member of staff had introduced a new method of retaining information for handover between staff.

Staff told us about the training they attended since our visit and confirmed training plans had been developed for the first three months of 2012.

We were not able to fully assess the provider’s progress in improving training as some training will not be competed until 2012, we will continue to monitor the Trust’s progress in this area.

The inspection was a joint visit between a compliance inspector and a mental health act commissioner. The purpose of our visit was to follow up on a recent review of action taken following the death of a service user. On this occasion we spent our time on one of the wards and looked at records relating to the treatment of patients and arrangements for their care. During our visit we spoke with six staff and observed interaction on the ward between staff and patients.