During the inspection we visited three wards that support older people. We spent the whole day on The Oaks ward, which is an admission unit providing assessment and care for older adults over 65 with mental health problems (both functional and dementia patients), before visiting again in the evening to observe the night shift. We also visited Cornwall Villa ward in the morning and Silver Birches ward in the afternoon and evening. Both of these wards provide continuing care and rehabilitation to older adults with severe and enduring mental health needs.

Most patients and relatives we spoke with were positive about the care provided on the wards. Some felt that the communication between themselves and the ward staff could be improved.

We observed the staff supporting the patients and saw some examples of positive interaction but also noted some areas where these could be improved.

We found that people were generally having their care needs met. Some activities were taking place, but these were not always planned in a manner that met people’s individual needs. People did not always get the support they needed to eat and drink.

This was a themed inspection looking at seclusion, the practice of nursing somebody on their own in a locked seclusion room. We inspected four wards at this inspection; Suffolk ward for women, Sussex ward for men and Sage and Saffron wards, two forensic wards. We checked that practice on seclusion at these wards at Chase Farm hospital was in line with national guidelines and the provider's own policy and procedures.

We inspected the seclusion rooms and a sample of seclusion records on each ward. We were not able to talk to all the patients whose records we inspected. We did talk privately to one patient. We also talked to staff; two service managers, three ward managers, a deputy ward manager and the Director of Nursing, Quality and Governance.

We found people in seclusion were continuously monitored by ward staff and regular reports made on their condition. We found some good examples of patients' health being looked after while they were in seclusion and afterwards. There was one example where a patient alleged that they hurt themselves in seclusion and there was a lack of written evidence to find out if this was the case.

The provider had made recent improvements to the auditing and recording of seclusion. We found in most cases, people had an opportunity to comment on their experience after being secluded. There were safety issues with some seclusion rooms where there was a lack of written risk assessment on the ward to address the known risks.

We visited three wards for older people. We were able to speak to six patients privately. Overall, these people were satisfied with the care they receive. One patient said they enjoyed an activity organised on the ward by an Occupational Therapist. This patient said, "this is really good, very therapeutic. I do like it."

The majority of patients were not able to tell us their views on the care and treatment provided to them due to dementia or cognitive impairment. Because of this, we spent time observing on the wards to see what people's experience was like. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We found the the majority of people were in a positive or neutral state of mind during our inspection. We therefore did not have concerns about their wellbeing.

We also spoke with eighteen staff and five patients' relatives on this inspection. We looked at activity programmes and four weeks of activity records on each ward to see what activities had taken place. We also looked at six patients' individual care plans and records. We carried out nine structured SOFI observations as well as general observations on the wards. We also looked at the Trust's policy on the care of patients in seclusion, which means when a patient has to be nursed on their own in a locked room for a period of time. We looked at the Trust's audits of periods of seclusion and seclusion records for three patients on one ward.

We carried out this unannounced inspection on 8 and 10 January 2012. The reason for the inspection was to follow up on an improvement action and compliance actions made at the last inspection of Chase Farm hospital in September and October 2011.

We visited four wards. We visited Suffolk ward to look at care of patients in seclusion, medication, therapeutic activities and staffing levels. We visited Oaks and Cornwall Villa wards to look at therapeutic activities, staffing levels and medication. We visited Silver Birches ward to look at medication only. We also checked on staff's understanding of safeguarding procedures (what to do to protect patients from abuse and to how to report any suspected abuse) on Cornwall Villa, Oaks and Suffolk wards.

We talked with ten patients, six relatives of patients, and seven staff. The staff were of different grades and included nurses, nursing assistants and a ward manager. We looked at a few patients' care records on the Trust's electronic record keeping system, and some paper care records, activity programmes, staff rotas, medication records, staff supervision records and some maintenance records.

On Oaks and Cornwall Villa wards there were a number of patients who were not able to talk to us due to their condition, such as dementia, so we observed those patients. We carried out structured observations in the wards and used an observation tool to help us assess patients' wellbeing and the interaction between staff and patients. We saw that patients had limited choice about how to spend their time during the inspection.

Most people thought there were enough staff on the ward to meet patients' needs. Two people told us that a few staff on Cornwall villa ward talk too loudly to the patients. Most patients on Suffolk ward thought staff were kind, understanding and looked after them well.

We visited nine wards at Chase Farm hospital which provide a range of services. We visited the following wards;

Sussex, Suffolk, Saffron, Fennel, Paprika, Mint, Silver Birches, Oaks, Cornwall Villa.

We spoke with twenty five staff individually and this was a range of staff; ward managers, staff nurses, nursing assistants, cleaner, independent mental health advocate and a service manager.

We spoke with thirty two patients individually or in pairs both in private interviews and informally. We also spoke with six patients' relatives. We observed staff-patient interaction on all nine wards. On wards for older people with dementia where patients were less able to talk to us, we carried out periods of structured observation to see how well staff were interacting with these people and see what their experience on the ward is like.

People staying in nine wards as inpatients told us they were generally satisfied with the care and treatment at this hospital.

The majority of people said staff listened to them and take their opinion seriously.

People said they were involved in making decisions about their treatment and care and that staff listened to their views. They said staff treat them with respect.

The majority of patients knew how to contact an advocate.

Most people said they always felt safe on the ward.

Most people felt they had enough activities offered to them and patients on forensic wards, especially Mint ward, were most satisfied with the activities on offer.

There were mixed views about the food. Many patients felt the food could be improved.

People said the hospital was clean.

People on Saffron ward said they had equipment which needed repairing; an oven, washing machine and dishwasher.

Two people on Suffolk ward said they did not have as much fresh air as they would like as this ward did not have its own secure outside space.

The majority of people thought staffing levels were good enough to meet their needs. One person said, “there is always someone around to talk to and support you.” Another said, “they are amazing and all turn their hand to anything.”

Three inspectors, a Mental Health Act Reviewer, a Specialist Advisor and an Expert by Experience visited three wards registered to Chase Farm Hospital on the 27th and 31st October. This was a focussed inspection to follow up previous non-compliance in September 2013 with regulations 9 (Care and welfare of people who use services), 10 (Assessing and monitoring service provision), 15 (Safety and suitability of premises) and 20 (Records) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We spoke with staff on the wards and the management within the service line and the trust, as well as people who used the service and their relatives. We looked at a recent feedback survey which had been carried out on Cornwall Villa and we used a specific tool to observe the manner in which care was being delivered to people who were unable to give us direct feedback about their experiences on Silver Birches. We observed the meal period on each of the wards we visited. We also requested information from the trust which was provided to us.

We found that significant improvements had been made in the service since our last inspection. People and their relatives spoke positively about the care which they received and we observed positive and therapeutic nursing interventions. People's physical healthcare was monitored and work had been done, and was ongoing, to ensure that therapeutic activities met the needs of people with dementia.

We saw that some specific projects had been initiated to ensure that the specific needs of people using the service were met, such as a project on measuring compassionate care particularly where people were not able to communicate easily and a focus on therapeutic activities and occupation for people with dementia.

Understanding and application of the Mental Capacity Act (2005) was significantly improved. The ward environment was checked and the ward environments were clean and hygienic. Records relating to people's care were both complete and comprehensive.

The service had established meetings between the wards so that learning could be shared. We saw that this was evidenced and that the trust had embedded learning across the organisation from the improvement journey which had taken place in the older people's inpatient mental health services. We saw that leadership within the organisation was committed to continual improvement.