We found the following issues that the provider needs to improve:

• The provider did not have effective systems and processes to identify issues in infection control and incident management. Staff displayed poor hand hygiene and infection control practices. They had not identified all risks in an infection control risk assessment and this did not contain sufficient information to manage and mitigate risks.
• The provider had not taken timely and reasonable steps to assess, monitor and mitigate the risks to the physical health of a patient. Care and treatment records did not contain mental capacity assessments when making decisions about some aspects of physical health.
• The patient risk assessment did not identify all risks and the risk management plan did not address and mitigate risks. Staff did not discuss risks at staff handover.
• Care plans did not contain enough detail to reflect the care required and staff had not involved the patient in their development. Staff did not always follow the patient’s communication care plan. They did not have immediate access to the patient’s records, as these were stored in an office away from the suite.
• In over half of the incidents of restraint used, it was not proportionate or in response to risk. Staff that reviewed incidents did not make recommendations, record actions or lessons learnt after incidents. The provider did not have effective systems to have oversight of incident management and did not identify these issues.
• Not enough dedicated staff were available when needed and this meant that the patient had to wait staff to be available to enter the suite or get items that they needed. There continued to be limited input from some disciplines of the multi-disciplinary team.
• The patient did not have privacy and dignity when using the bathroom or holding telephone calls.
• The secure garden did not contain a shelter from adverse weather.
• Senior management staff lacked understanding about the use and application of positive behavioural support. They acknowledged that they did not currently have any expertise in adaptive behavioural scales, applied behaviour analysis or positive behaviour support within their substantive staff.
• The registered person did not speak respectfully when they described a patient and their needs.
• Training in learning disability and personality disorder was not up to date.

However, we found the following areas of positive practice:

• Since our last inspection in February 2017, the provider had installed a handwashing sink and a drain in the suite. They had arranged for an external hospital to review the long-term segregation every three months.
• Staff entered the suite more frequently and for longer duration and the suite was more personalised and contained some furniture.
• The provider had commissioned a sensory integration assessment.
• Staff who regularly worked with the patient knew the patient well, treated them with respect, praised and encouraged them.

During this inspection we visited Gill and Hebble wards, which are for patients with learning disabilities. We also visited Foss ward, which is for patients with a diagnosis of mental illness and personality disorder type illness. We spoke with six patients about their experiences of living in the hospital.

We carried out this inspection because concerns were identified to us by a whistle blower, in relation to care and welfare of people who use services, safeguarding people who use services from abuse, staffing and supporting workers.

At this inspection we found that people experienced care, treatment and support that met their needs and protected their rights. Most patients said their named nurses and key workers were helpful and supportive.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Most patients we spoke with told us that they felt safe. One patient said they didn't feel staff cared. However, they acknowledged that staff intervened to keep them and others safe.

There were enough qualified, skilled and experienced staff to meet people’s needs and staff received appropriate professional development and support.

We carried out an inspection of Cheswold Park Hospital in October 2013. At that time we found the patients did not always experience treatment and support that met their needs and protected their rights. This was because there were some restrictions and interventions that were imposed on patients that were not based on individual risk assessments. We made a compliance action, which required the provider to make improvements in this area.

We undertook this inspection to review the provider's compliance with the compliance action made at the last inspection. At this inspection we found that improvements had been made and the provider had appropriate arrangements in place to ensure patients experienced treatment and support that met their needs and protected their rights.

We visited Brook and Foss wards, which are for people with mental health issues, Hebble ward, which is for patients with learning disabilities and Calder ward, which is for patients with a diagnosis of personality disorder type illness. We spoke with 12 patients about their experiences of the hospital. Comments included, “There is always plenty to do and staff around to talk to.”

Patients expressed their views and were involved in making decisions about their care and treatment. Patients said there were lots of opportunities for them to make choices and have a say in how their care and treatment was delivered.

There were some restrictions and interventions that were not based on individual risk assessments, such as monthly room searches, so patients did not always experience treatment and support that met their needs and protected their rights.

Patients were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Patients said staff helped to keep them safe.

There were enough qualified, skilled and experienced staff to meet people’s needs.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

We visited two wards and we spoke with four patients. The patients we spoke with gave positive feedback about their experiences of the hospital. They praised the staff and said they were treated well.

We spoke with 17 patients on the eight wards and on one ward we sat in on a patients’ meeting that five patients attended. On five of the eight wards patients gave very positive feedback about their experiences of the hospital. They praised the staff, said they were involved in their care plans and said there were lots of activities. On Esk, Don and Calder wards five of the nine patients we spoke with expressed concern about there being staff vacancies. They said this had led to them missing out on activities. They said they found it unsettling that the agency staff who were used to cover staff vacancies were not familiar with their needs and preferences, particularly at night. One patient said there had been a lack of qualified staff on the wards on a number of occasions in recent months and this had an unsettling effect on the patients.

We visited Gill and, Hebble wards, which are for patients with learning disabilities. We also visited Calder ward, which is for patients with a diagnosis of personality disorder type illness. We spoke with six patients about their experiences of living in the hospital. Comments included, “The staff here are well trained” and “The staff are very pleasant.”

Patients said staff helped to keep them safe. They told us that there were lots of opportunities for them to make choices and have a say in how their care and treatment was delivered. We observed that there were lots of activities for patients; one patient told us there was always something going on.

To carry out this follow up inspection we did not seek the views of patients, however, we saw that they benefited from high quality facilities within the hospital. This included a well stocked shop which provided work opportunities for patients, a gym, recreational facilities and newly developed outdoor areas. When we inspected the hospital in September 2011 patients we spoke with told us that staff were “good” to them, although some told us that they were unhappy about being detained in hospital. They told us that when they had planned leave from the hospital this was important to them and they said that on the whole it took place as arranged.

People we spoke to told us that staff were “good” to them, although some told us that they were unhappy about being detained in hospital. People told us that when they have planned leave from the hospital this is important to them and they said that on the whole it takes place as arranged. Some people told us that they do not feel they have the opportunity to carry out spontaneous activities within the hospital due to them needing staff support to do so.

When we have visited this hospital prior to this review, patients have been extremely positive about their experience of Cheswold Park Hospital. They told us that they felt involved in decisions about their care and treatment, and that they felt staff gave them the support they needed.

Patients were extremely positive about their experience of Cheswold Park Hospital. They told us that they felt involved in decisions about their care and treatment, and that they felt staff gave them the support they needed. Patients told us that they could participate in decision making about how the hospital, and some patients who had experienced treatment in other hospitals told us that this was the best hospital they had experienced.

We rated this location as requires improvement because:

• For patients who lacked mental capacity to make key decisions about their care or other aspects of their life, staff did not follow best interest decision-making processes.
• Staff did not always ensure the needs of gay and transgendered patients were fully met and did not access specialist support to enable them to work effectively with patients with these needs.
• The provider’s resuscitation procedures and response times did not meet national guidance.
• Staff did not document the use of mechanical restraint in patient support plans.
• Staff did not carry out risk assessment for patients with mobility needs.
• Some of the patient records we looked at did not identify all the pertinent risks. There were some inconsistencies between risks identified in the patient’s health action plan and their risk assessment.
• Some of the hospital’s policies did not provide staff with the standards expected of them.
• The hospital’s procedures did not always identify when staff missed safety checks on equipment.
• The hospital did not do everything it could to protect patients’ privacy and dignity when using communal bathrooms.

However:

• The hospital had carried out the actions we told them they must at our last comprehensive inspection.
• The hospital had an effective cleaning schedule in place and staff had received training from the British Institute of Cleaning Science.
• Staff were up-to date with their mandatory training.
• The hospital carried out physical health checks and on-going monitoring with all patients.
• Managers provided staff with supervision and appraisal.
• Overall, patients and carers thought staff were caring and respectful.
• Patients had access to advocacy and knew how to make a complaint.
• Patients had access to a range of activities and a college aimed at promoting recovery
• Staff worked alongside patients to reduce restrictive practices across the hospital.
• Managers and members of the multidisciplinary team participated in monthly governance meetings to improve quality and safety.