This was a focused inspection relating to issues identified at a previous inspection following which we served a warning notice. We have not rated services at this inspection.

We issued a warning notice following a comprehensive inspection in March 2016 relating to regulation 12: safe care and treatment.

We found:

• staff did not know about environmental risk assessments and what they needed to do to reduce risks.
• there was no effective system in place to ensure that patients were only given medicine that was authorised
• patients were not always getting their medicines as prescribed
• patients who were prescribed high doses of antipsychotic medication, above the limits recommended in the British National Formulary (BNF), were not receiving increased monitoring to check for any adverse effects. There were no guidelines for high dose antipsychotic treatment and monitoring in the medication policy
• medication was not stored appropriately, which meant that patients were at risk of being given medications which were not effective, and medicines were not being disposed of safely.

At this inspection, we assessed whether the service provider had put right issues identified in the warning notice. We found improvements in terms of safe care and treatment and that the provider had met the requirements of the warning notice.

We found:

• staff knew about risks on their ward, how to reduce risks and all three wards had ligature risk assessments in place
• forms for authorising treatment, certifications showing that a patient had consented to their treatment (T2) or that it had been properly authorised (T3) were completed and attached to medicine charts where required
• staff checked medication stock levels to ensure the correct medicine was available for patients and records showed staff gave medicines to patients as prescribed. Staff ensured that patients who went on leave had their medicine with them. This was in the form of blister packs
• the provider had reviewed the medicines policy, and it now included guidance on high dose antipsychotic monitoring and rapid tranquillisation monitoring. Staff completed a high dose antipsychotic monitoring form and patients’ care files had a sticker to indicate increased monitoring required
• all medicines were in date and appropriately stored.

We spoke with nine people who were being cared for in this hospital about their care and treatment. We also spoke with one relative of a person being cared for in this hospital. People we spoke with were generally felt positive about the care they received and felt safe most of the time. We were made aware that there had been instances of bullying by other patients on occassions. We discussed this with people who used services. We found that the service dealt with bullying and took active steps to deal with this issue.

We went with a Mental Health Act Commissioner. The Mental Health Act Commissioner considers whether the Mental Health Act and the Mental Health Act Code of Practice is being followed. They also proactively visit and interview people who are detained under the Mental Health Act. The Mental Health Act Commissioner interviewed a further six detained patients.

We found that the provider was meeting the standards we looked at during this inspection.

The people who use services we spoke with were positive about the care and support they received at the hospital. They told us they were getting the leave they were entitled to. People said that leave was only cancelled if they were not well enough to go out. They said that sometimes they had to wait to go out but staff always discussed any changes in arrangements with them. People who use services told us that staff looked after them well. They felt able to talk to staff and were confident that staff would help them. One person told us that they preferred being at Jigsaw than the previous hospital they had been at.

We rated Jigsaw independent hospital as good because:

• The service was clean and newly refurbished. Ligature risks were well managed.Staff had completed comprehensive risk assessments for patients and these were up to date and reviewed regularly. Practice in relation to moving and handling and falls assessment and management had improved. Moving and handling risk assessments were in place for all patients who needed these and included falls risk information and plans.
• Care records contained up to date, personalised, holistic care plans. Staff had created easy read or pictorial care plans for some patients who needed these. There was excellent psychology and occupational therapy provision. Physical healthcare needs were assessed and monitored, with care plans devised to capture this. A practice nurse had been appointed part time to assist staff with physical healthcare monitoring.
• We saw positive interactions between staff and patients during this inspection. Patients were positive about staff, describing them as kind, respectful, polite and caring. Two carers gave positive feedback about their relative’s care.

• All admissions to the hospital were planned. A pre-admission assessment was completed by clinicians before placement was offered and this included a detailed breakdown of proposed interventions and treatment and a timescale for admission. The hospital managers and commissioning lead had been proactive in identifying the next steps for some patients and in liaising closely with commissioners to plan successful patient discharges.

However:

• The service had made progress in identifying and reviewing blanket restrictions but there were still some blanket restrictions in place. These were in relation to rooms and outside space; which patients were not able to access.
• Not all staff had their own confidential email address and each ward had a mailbox which all staff accessed.
• The service has not ensured ongoing arrangements for recruitment and training of hospital managers in relation to the Mental Health Act 1983.
• Most patients were involved in activities but patients mentioned a lack of activities at evenings and weekends. This had been highlighted in a recent patient survey.
• Some patients told us they did not use the complaints system as they felt it was not effective.