We carried out this inspection to follow up on non-compliance from previous inspections on 10 October 2013 and 22 November 2013. After the inspections the provider wrote to us to tell us what action they had taken to address this. At this inspection we looked at the non-compliance from previous inspections and confirmed that the provider had taken action, and was now compliant in these areas.

At a previous inspection we found that staff were not always aware of how care should be provided to people using the service, and there were inconsistencies in how care and incidents were recorded. At this inspection we found that the provider had addressed this, that care had been reviewed, and that key information about the care of people using the service was easily accessible. The service had implemented a new system for recording and monitoring incidents.

At a previous inspection we found the safeguarding processes to be non-compliant with a major impact on people using the service, and issued a warning notice which told the service they must take urgent action to address this. The service had not reported or responded appropriately to some of the safeguarding concerns that had been raised. At this inspection we confirmed that they had taken action to address the areas of non-compliance found at the previous inspection, and there were effective processes for reporting and responding to safeguarding concerns.

At a previous inspection we found that the seclusion room did not meet the expected environmental standards. At this inspection we found that this had been addressed.

At a previous inspection we found that the provider had not carried out all the necessary recruitment checks of all staff before they started work in the service. At this inspection we found that the provider had reviewed their processes to ensure that all new staff had the necessary recruitment checks completed before they worked unsupervised with people using the service; and had updated the recruitment records of existing staff where there were gaps.

We undertook this responsive inspection as concerns had been raised about the patients nursed in segregation and patients nursed for periods in seclusion. Concerns had also been raised about how patients were protected from abuse at the hospital.

The inspection was undertaken with two Mental Health Act Commissioners.

At this inspection we went to four of the wards at the hospital. We looked at specific areas of care and support on these wards. We did not visit Poplar Ward or Tonbridge Ward.

The majority of patients who posed a risk to themselves or others had on-going multi - disciplinary assessments and plans of care in place. However, we found that the staff directly caring for one patient who was a high risk did not know the outcome of the MDT meetings and therefore did not have the guidance and support that they needed to care and support the patient in the best way.

Patients and staff told us that at times when incidents occurred on the ward they did not feel safe at the service.

The service had not taken the appropriate action to report some incidents of abuse. This meant that patients could not be sure were fully protected from all types of abuse or neglect.

Patients who use the service rights to privacy, dignity, choice, autonomy and safety were not protected by the environment in which they lived.

We inspected two wards at the service: Folkestone ward and Maidstone ward. We spent most of the time at this inspection on Folkestone as this was the part of the service where concerns were identified at the last inspection.

On Folkestone ward patients told us that on the whole they felt involved in their care planning and they told us about their goals and aims. They were able to tell us what was in their care plans and about their aims and goals. Patients were involved with their Care Programme Approach planning meeting (CPA ). This meant that patients had a say about how their care and support was planned and delivered.

The procedures for the recruitment were not always adhered to by the service. This meant that patients may be at risk of receiving care and support from staff who had not been suitably vetted.

More staff had received up to date training they needed to make sure they had the knowledge and skills to deliver care and treatment to the patients safely and to an appropriate standard. Staff told us and records showed that staff received regular supervision to make sure they had the support and direction to carry out their roles effectively and safely.

We did find that about 40% of care staff had not received and annual appraisal. This meant that some care staff had not received the support to help them develop and promote their skills and knowledge so that this could be used to benefit the patients and themselves.

We rated the service as good because:

• Overall, we observed lots of improvements since our last inspection. We noted that the culture had improved significantly and staff had worked hard to embed the behaviour support plans which staff told us had supported them to deliver person centred care.

• The service maintained a secure environment appropriate for a low secure setting. Environments were safe, clean and well-maintained.

• The service operated with sufficient numbers of appropriately qualified staff. They were trained and supervised to be able to support people with learning disabilities or autism.

• The service managed patients’ risks on an individual basis. The service contained seclusion facilities and staff were trained in physical interventions. These were used as a last resort and patients were debriefed and supported following episodes.

• Staff were aware how to report incidents, raise safeguarding concerns and manage complaints. All incidents were reviewed and investigated and the service used outcomes to learn lessons and improve practice.

• The service had a team of staff who oversaw patients’ physical health needs. They were appropriate qualified and could recognise and access specialist physical health support when necessary. This team upskilled colleagues with a programme of training.

• The service supported patients with care plans that covered all aspects of care and needs. They used a positive behavioural support approach and prescribed medicine in line with national guidance.

• The psychology team offered a range of individual and group interventions that were relevant to the patients at the service. The occupational therapy team ran a course which focussed on patients’ individual recovery needs.

• The service provided career progression opportunities. Support workers could gain nursing qualifications funded by the provider and nurses could attend leadership courses. All staff could access training in individual areas of interest, such as family work.

• Staff interacted with patients positively and patiently. They followed details plans to help them deliver care to patients in a consistent way. Patients were supported to understand and be involved in their care plans.

• The service had developed a family liaison nurse role to support communication between patients, their families and the service. They also had an onsite advocacy service that supported patients to give feedback and express their views.

• The provider actively looked for solutions to meet the challenge of accommodating their patients after they left hospital. They were converting property, on another local site, into bespoke bungalows where patients could be accommodated.

• The service provided an environment that promoted recovery and comfort, complete with information in an easy read format. Patients could personalise their rooms and choose their meals. Patients had access to the local community and this was encouraged to support their integration back into the community.

• The provider had a vision, values and strategy that was patient-centred and installed in staff during induction and supervision. Their audit framework was based on regulations, national guidance and extracting learning opportunities.

• Staff morale was high and the service had many initiatives to promote their well-being. The service participated in peer review schemes, contributed to research projects and used innovation to improve patient experience.

However,

• The service was routinely using seat belt clips for two patients to stop patients undoing their seat belts whilst driving. They did not recognise this as a form of restriction and, therefore, had not assessed patients to ensure they were agreeable to them being used.

• The service did not have care plans that fully promoted safe care and treatment for patients with symptoms and histories of epilepsy. However, the service acknowledged this and submitted an action plan to bring this area of care in line with national guidance.

• The service completed seclusion records in line with national guidance. However, we found one instance where a female member of staff was observing a secluded male who was exhibiting sexually inappropriate behaviour. The was contrary to the provider’s seclusion policy.

• We found some solution medicines had been opened without an opening date being recorded. This meant staff could not be assured they were safe to administer to patients.

• Agency staff, on occasions, were entering notes on the electronic patient’s record system under substantive staff’s login details. This was due to them not using the agency login protocol. Furthermore, training in general data protection regulation was lower than the provider’s target.

• We found that some forms, that documented patients’ consent to treatment, would have benefitted from being updated. Similarly, some financial capacity assessments would have benefitted from being reviewed.

• Two out of seven carers we spoke with were unhappy about the service. They felt that their relatives had been their too long with little progress and felt the service had been unsupportive of their efforts to form an external carers’ group.