We undertook this unannounced, focused inspection to find out whether the provider had made improvements to their long stay/rehabilitation mental health wards for working age adults since our last unannounced, follow up inspection on 21 and 29 September 2016. Following the inspection on 21 and 29 September 2016, we took enforcement action and issued the service provider with a warning notice due to breaches in regulation regarding patients’ care or treatment.

At this inspection, we found the service had made some significant improvements to the quality of care and treatment given to patients. However, further improvements were required.

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

• Care plans were still not rehabilitation or recovery focused. Care plans did not clearly reflect patients’ goals, and the steps needed to achieve these. Staff did not record in care plans how they intended to support patients in their rehabilitation or recovery. They did not specifically detail patients’ strengths and what level of support individual patients needed and how best to motivate and encourage them.
• Staff did not assess patients’ nutritional or hydration needs. High-risk patients who were receiving care or treatment for dietary or nutritional issues were not effectively being assessed and monitored to ensure ongoing good health. Care plans did not contain any detail about a patient’s nutritional intake or the level of support needed.
• For patients who were self-medicating, staff did not record the incremental steps needed to help them progress or what would happen should a patient not be able to adhere to the programme.

However, we also, we found the following areas of good practice:

• Staff undertook a range of assessments with patients. These included a comprehensive physical health assessment, occupational-functional assessment, transport and kitchen assessment. However, this was not always recorded in the patients care plans.
• Staff sought patients’ views and preferences and recorded these in the patients’ care plans.
• Staff completed activity interest checklists with patients to ensure that care or treatment was designed to meet patients’ individual needs and preferences. When patients had shown an interest in certain activities, they were supported to achieve these goals. Staff reviewed and discussed these goals and activities regularly to ensure they were still relevant to the patient. Each patient had an individual activity timetable.
• Staff had identified patients’ physical healthcare needs and incorporated details of these into patients’ care plans. On most occasions, staff recorded physical healthcare checks clearly and consistently so that they could quickly identify any changes or concerns and take the required action. Staff used a standardised approach called Modified Early Warning System. There was evidence of high scores being followed up. Staff were trained to use the Modified Early Warning System tool to observe changes in patient’s presentation. One of the nurses at the service took a lead on this and was available to all staff to provide support and advice when needed. However, we did find two records where staff had not dated a review or documented recordings correctly.
• Staff used the Glasgow Antipsychotic Side-effect Scale (GASS). Where concerns were raised these were followed up. They were reviewed by the multidisciplinary team fortnightly and discussed with the patient during their individual ward rounds, or sooner if required. However, the outcome of the GASS assessment was not always documented in the patient’s daily nursing notes.
• Each patient had a health action plan folder. Information relating to healthcare appointments, including copies of letters, were filed in the patient’s paper records and follow up appointments were well documented.
• Staff in the service worked actively in partnership with external healthcare professionals. The service worked collaboratively with several local GPs in the area to ensure that patients’ healthcare needs were met. We found that communication between the service and GPs had improved greatly since our initial inspection. Staff followed up information about clinical decisions and outcomes and recorded their actions clearly in the patients’ notes.

• The service provided a wider and improved range of therapeutic activities on the ward and outside the hospital. The service had established links with the local colleges and in the local community to help facilitate voluntary work and reintegrate any patient, who wished to, back into the community.

When we inspected the service in May 2014 we found them non-compliant in six areas: involving patients, care and welfare, safeguarding, environment, staff and training, and monitoring the quality of service. The provider wrote to us and told us that what actions they would take to address this, and said that they would be compliant by the end of September 2014. We carried out this inspection to check their compliance.

At this inspection we found that improvements had been made in some areas and there were further improvements planned. However, these changes had yet to be fully implemented and become established, and the service remained non-compliant in all six areas. We also identified concerns with infection control in the service.

Is the service safe?

There were processes in place for recording incidents and to identify areas that needed improvement, but there was limited evidence to demonstrate that information was effectively analysed and learnt from, and changes implemented as a result. Several areas of the building were dirty or in need of repair. The safeguarding policies were not up to date, and staff were not clear about how to make a safeguarding referral.

Is the service effective?

There was a multidisciplinary team of staff working within the unit. There were staff vacancies which the service filled with temporary agency staff, and the provider could not demonstrate that they had received the necessary training and support to work effectively with people in the service. Audits had been carried out, but there was limited evidence of changes being made as a result.

Is the service caring?

Some of the care we observed and feedback from people using the service was positive. However, there was limited involvement of people in their care planning, and staff were not always available to provide support to people when they needed it.

Is the service responsive?

All the people using the service had a care plan. In some cases this was tailored to the needs of the person, but in others it did not reflect their individual needs. There was limited evidence of discharge planning, although most people had had a care programme approach (CPA) meeting. There was not a clear rehabilitation pathway, or care plan/strategy for working with people who misused drugs or alcohol.

Is the service well led?

The service had policies, but it was not clear that these had been updated as necessary, and that the current policies were accessible to staff. There were processes in place for monitoring the service, but there was limited evidence to demonstrate that information was effectively analysed and learnt from, and changes implemented as a result.

We spent time with people who used the service and talked to them about their experiences. They made comments including “The staff here are wonderful”, “I’ve really made progress since I’ve been here” and “We are able to make choices about what we do each day”.

We spoke with people about their care and looked at care records. People told us that they were involved in making decisions about their care and were able to speak to healthcare professionals when they needed to.

We visited the service with pharmacist inspectors who looked at how medication was managed within the service. We saw that there were appropriate procedures in place for managing the way medication was stored, dispensed and disposed of.

We spoke to staff and looked at training and supervision records for the service.

We looked at records of audits that were completed by the service to monitor the quality of the care provided. We also spoke to people who told us that they were able to give their feedback on the service and put suggestions forward for improvements to be made.

We looked at care records, medication administration records and staffing records. We saw that records were clear and kept up to date.

We received a copy of a complaint that had been sent to the service which raised concerns about the staffing arrangements at the service. We spoke to people who used the service, staff and managers and looked at records including staffing rotas to investigate. We found that there was some confusion about the understanding of some roles and responsibilities, however there were enough suitable staff to meet people’s needs.

We spoke with people about the care and treatment they received. They told us that they liked the service and they were supported to become more independent. One person said “we have a meeting every morning where we decide what we want to do that day and staff support us to do the things that we want to”.

During the inspection we spoke with staff and looked at care records and staff records. Staff we spoke with told us that they enjoyed working at the service. One member of staff said “This is a really nice place to work”.

We spoke briefly with three people who were receiving services in the hospital during our visit. People told us they were generally happy with the service. They told us their privacy and dignity was respected. People said they felt safe at the hospital. They told us there were enough staff to help them when they needed it. One person was not happy with the service but did not wish to talk to the inspector about their concerns.

We rated Glenhurst Lodge as good because:

• The service provided a clean and safe environment that contained equipment and facilities that allowed staff to deliver all aspects of treatment and care. Appropriate staffing levels ensured patients were safe, supported and had access to a full range of interventions to support their recovery and rehabilitation.
• The service carried out comprehensive risk assessments on all patients. Staff were skilled in calming distressed patients and were trained and knowledgeable in safeguarding procedures. The service had good systems in place to ensure incidents were discussed and lessons were learnt.
• The service had a good approach to assessing, and responding to, patients’ physical health and nutritional needs. The service had a good approach to medicine management and supported patients to manage their medicine independently.
• Patients were actively involved in planning their care. Staff, from across the multi-disciplinary team, worked with patients to ensure that care was delivered based on individual need. They had comprehensive knowledge of patients’ recovery needs and had organised systems in place to ensure these were monitored and reviewed regularly.
• Patients had access to a wide range of occupational and psychological groups and activities that were recovery focussed and tailored to their needs. Staff audited these interventions and used recognised rating scales to monitor patient progress.
• Mental Health Act requirements were completed in line with the Code of Practice. The multi-disciplinary team assessed patients’ capacity to make decisions and arranged appropriate support if their capacity was lacking.
• Patients were treated with dignity and respect and had appropriate access to privacy. The service provided a calm and friendly environment for patients to be able to focus on their recovery. Patients had regular community meetings and patient forum where they had the opportunity to give feedback on the service.
• Patients’ families and carers were involved in their care and the service had recently introduced a carers’ forum.
• All patients had clear discharge plans and progress was reviewed by the multi-disciplinary team and shared with their community care coordinators. Patients had access to a wide range of activities and facilities to support their care and recovery.
• Patients were able to personalise their individual bedrooms and contribute to the wider hospital environment. Patients chose their own food to meet their dietary requirements. They had their own kitchen areas where they could make hot drinks and snacks 24 hours a day.
• The hospital responded to complaints and had a policy that staff and patients were aware of. Patients and staff received feedback on complaints and the hospital had a good approach to reflecting on complaints to improve standards of care.
• Staff were enthusiastic about the jobs, felt valued, and were kept up to date with developments in the service and wider organisation. Robust governance systems were in place and adhered to in line with organisational policy.
• The multi-disciplinary team were committed to quality improvement and delivering care and treatment in line with current evidence-based practice and national guidelines.

However:

• The service’s fire risk assessment needed updating and emergency resuscitation bags required more thorough checking.
• Staff supervision records did not always capture sufficient detail of supervision sessions. Some therapeutic care workers had limited knowledge of the Mental Health Act and Mental Capacity Act.
• One patient told us there could be delays in them receiving their money entitlements. The service was aware of this issue and had added it to the risk register and was looking into making the system more robust.