We rated Cambian Appletree as good because:

• Cambian Appletree was staffed to safe levels. Staff were suitably trained and compliance with mandatory training was at 100%.
• Medicines management practice, including storage, dispensation, and administration was in line with the relevant guidelines. Staff regularly reviewed patients’ medication needs and undertook regular audits of medicines management practice.
• Cambian Appletree had a full range of rooms and equipment to support patients’ care and treatment. A range of activities were available throughout the week and staff took into account patients’ views in planning their day.
• Staff completed a comprehensive assessment of patients’ risk and need on a regular basis using standardised tools. Patients’ care plans were individual and holistic.
• Staff had received training in the revised Mental Health Act code of practice. Patients understood their rights and which section of the Act they were detained under. Staff were supported by a Mental Health Act administrator who completed audits and scrutinised documentation.
• Staff worked well together as a team and held daily multi-disciplinary meetings. Patients felt supported by staff and we observed staff treating patients with kindness, dignity and respect.

However:

• Cambian Healthcare Limited had not fully updated its policies to reflect the changes in the Mental Health Act revised code of practice.
• Staff understanding of their responsibilities under the Mental Capacity Act varied. Staff did not always reflect decisions made about patients’ capacity in their care plan.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Patients were given the opportunity to influence how the service was run. Patients had contributed to their care planning and assessments and these were written in the first person. The provider had a contract in place with a local advocacy service which included the provision of Independent Mental Health Advocates (IMHA) for qualifying patients.

We saw meetings with patients were held on a regular basis. This included daily activities planning meetings, weekly community meetings and monthly meetings chaired by the advocate.

Patients' needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We looked at the records held for three patients. We found each patient's assessment included detailed information about their needs and personal history. They also included information from other professionals who had been involved in the care and treatment of the patient.

The provider made every effort to maintain the safety and dignity of patients when any form of restraint was used. Patients told us they had been restrained by staff when it had been necessary for them to do so. They told us any restraint used had been appropriate, reasonable, proportionate and justifiable to them.

Patients were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. This included through the provision of training and supervision from line managers.

The provider had an effective system to regularly assess and monitor the quality of service that patients received.

We carried out a comprehensive inspection of Cygnet Appletree on 8th and 9th May 2018. At that time, we identified concerns with the safety of the hospital. In June 2018, we received three whistle-blowing's from staff raising serious concerns about the safety of patients and staff, staffing levels and staff training, the attitudes and behaviours of staff at all levels, and the management of the service. The whistle-blowers also stated that staff had felt unable to speak truthfully at the time of the comprehensive inspection, therefore we could not trust all of the evidence gathered at that time. We returned on 27th and 28th June 2018 to look at these specific concerns. As this was a focused inspection, we have insufficient evidence to rate this hospital. However, due to the seriousness of the issues found at this inspection, we have taken action against this provider in line with our enforcement powers.

• The service was not safe. Patients did not feel safe due to the high numbers of incidents of violence and aggression. Staff and patients were experiencing aggressive behaviours on a regular basis. The service did not have enough staff to provide safe care and treatment.
• The service was not effective. Staff did not provide care that met the needs of one patient with a learning disability and did not have the required skills and knowledge to support this patient group. Staff were not monitoring the effects of high dose anti-psychotic medication on one patient’s physical health.
• The service was not responsive. Staff were not meeting the needs of all patients being admitted to a rehabilitation environment. Staff did not manage complaints in line with the provider’s policies or support patients to raise concerns.
• The service was not well-led. Systems that were in place to ensure good governance of the service were not being operated effectively. Managers did not notify CQC of all incidents as required. Staff raised concerns about poor leadership, a bullying culture and low staff morale. There was a lack of visible clinical leadership and effective team working.
• Staff were not always caring. Staff did not always treat patients with dignity and respect. Staff and patients raised concerns about the attitudes and behaviours of staff towards patients.