We carried out this inspection in response to information of concern we had received. This information referred to the lack of regular staff on Hawthorn ward and indicated that, as a result of this, the ward was not functioning as a locked rehabilitation ward as was its stated purpose.

We spoke with two people who used the service. One person told us they felt the ward operated as a rehabilitation unit and there were opportunities to engage in activities both on and off the ward. They told us, “I know it’s a rehab ward. I feel I have achieved more through the multi-disciplinary team here than anywhere else”. Another person who used the service told us, “There’s not much to do here”. We discussed this with staff who told us the person concerned would often refuse to engage in activities.

Both people who used the service told us they felt there were sufficient staff on the ward and that these staff generally knew them well. They told us they were always able to have leave off the ward as planned.

We spoke with seven members of staff including the nurse in charge of the ward, an occupational therapist and a psychologist. All the staff we spoke with told us they understood the purpose of the ward was to offer rehabilitation to people in a locked setting. Staff told us they felt the skill mix of people employed to work on the ward was appropriate to meet the needs of people who used the service.

We found improvements and suitable arrangements had been made to ensure patients dignity and privacy was maintained. Patients were involved in their care and treatment and were consulted with.

We spoke with nine people who used the service and reviewed care records. Most people we spoke with were happy with their care and the treatment being provided. Two people we spoke with expressed concern that people on their ward had a mix of diagnoses and felt this impeded their recovery

We found that the hospital has effective operations and systems in place to protect patients and staff in relation to cleanliness and infection control.

We found that staff had access to appropriate supervision and appraisals in place and staff were given opportunities to update their training in line with their roles. One person told us, “I think the staff do well. As near as possible they try to treat everyone the same”. Another person commented, “Most staff are really good”.

We found there were effective systems in place to assess and monitor the quality of the service provided.

We found suitable arrangements had been made to obtain and act in accordance with the consent of patients in relation to the care and treatment provided for them. Advocates were readily available at the hospital for patients to access. One person told us that they knew about the care and support that had been planned and told us he was consulted with about this.

Most people we spoke to said they were satisfied with the care they received. One person told us, "I have discussed long term plans for my future that I am working toward”. Another person said, "I have no complaints at all, you couldn’t get better staff and a better place to live in they will do anything for you ".

Suitable arrangements had been made to ensure patients are safeguarded against risks of abuse.

Suitable arrangements had not been made to ensure the privacy and dignity of patients was maintained.

Regular checks and audits had been made by managers, ward staff and the visiting clinical pharmacist to make sure medicines had been prescribed, administered and recorded safely.

We found that the hospital had undergone a refurbishment of some of the wards and improvements had been made to the design and layout of the refurbished wards. Fire risk assessments we looked at for two of the six wards did not include updated information to inform us if the identified risks had been completed or reviewed.

We inspected Kemple View on 26-28 October 2015 as part of our ongoing comprehensive mental health inspection programme.

We rated Kemple View as outstanding because:

All the wards provided safe, secure environments. There were effective systems to maintain safety and security.

In April 2015, the low secure service had been reviewed by the Royal College of Psychiatrists quality network review team in April 2015 and fully met 95% of low secure standards, compared with a national benchmark of 81%.

The ward environments were generally clean and in good repair. There were some environmental issues but there was appropriate environmental assessment and mitigation.

Staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Managers responded to any staff shortages quickly.

All the wards operated some restrictive practices that applied to all patients. It was recognised that some restrictive practices were necessary for environmental security and patient safety purposes. The service was operating in accordance with company policies.There was a clear culture of least restrictive practice and positive risk taking that was embedded across the service.There was a “least restrictive practice” champion on each ward, and efforts had been made to relax restrictions in some areas.

There was a strong recovery focused ethos. The hospital worked within the principles of the recovery model. This meant they focused on helping patients to be in control of their lives and building their resilience so that they could regain a meaningful life. Staff worked collaboratively with patients to promote recovery and include them in every aspect of care delivery. Patients and staff worked together to plan care and treatment in line with current evidence-based guidance. A recovery champion on each ward was responsible for offering advice and support to other staff and disseminating information. Patients contributed to their own care records, including planning for their discharge.

Staff received training in de-escalation and management of violence and aggression techniques. They were using “reinforce appropriate, implode disruptive” (RAID) techniques that used positive behaviour reinforcement to deal with potentially violent situations. RAID training is accredited by the association for psychological therapies. Kemple View was recognised as a RAID centre of excellence. RAID is a recognised industry standard method of working with patients to help them manage their own behaviour, accredited by the association for psychological therapies. Being recognised as a RAID Centre of Excellence means that that the organisation is implementing RAID principles outstandingly well.

The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice. For example, following leadership training, staff were encouraged to develop a piece of innovative work to implement on their ward.

Case formulation and reflective practice groups were available for all staff at each ward. Most of the staff we spoke with said they found discussion of challenging clinical issues invaluable in exploring ways to improve the service they provided.

Staff respected and valued patients as individuals and empowered them as partners in their care. There was a strong, visible person-centred culture. Putting patients at the centre of the service, involving and empowering them was clearly embedded. Staff treated patients with dignity, respect and kindness and the relationships between them were positive. These relationships were highly valued by staff and promoted by leaders both at ward level and by the senior management team.

The emphasis on patient involvement was clearly evident across the hospital. We saw a genuine commitment from all staff. Patients were involved in recruiting staff and the patients’ council was represented at all levels including governance. Each ward was represented on the patients' council and a patient representative chaired the meetings supported by the hospital director. Issues raised and actions taken were fed back into community meetings on the wards and to the hospital governance meetings. Patients were actively involved in plans for service developments and improvements. They were involved in the review of complaints via the patients’ council.

Staff offered support to patients’ families and friends. For example, visitors were offered assistance with transport where they needed it in order to be able to visit their relatives. There was excellent support for patients and their families in the use of technology. Skype facilities were available so that patients could more easily maintain their relationships with the people close to them, particularly where there was significant distance. As well as assisting patients, the service had invested time in familiarising patients’ friends and families with the use of Skype.

Care and treatment was coordinated with other services and other providers. Staff used technology to help ensure this. For example, tele- and video-conferencing were being used so that external care co-ordinators who might otherwise be unable to attend could contribute to care programme approach meetings. Staff worked closely with care coordinators to ensure that patients were helped through their discharge. Discharges or transfers were discussed in the multidisciplinary team (MDT) meeting and managed in a planned and coordinated way.

The use of projectors during care programme approach meetings ensured patients had the opportunity to comment on the report as it was written and enhanced their involvement in their care and treatment.

Patients were encouraged and supported to use community facilities wherever possible, reflecting the focus on normalising behaviour and life in the wider community. This enabled patients to take part in the activities of the local community so that they could exercise their right to be a citizen as independently as they were able to. There were established positive working relationships with other service providers, such as GPs and community services and groups. The involvement of other organisations and the local community was integral to how care and treatment was planned and ensured that the hospital met patients’ needs. For example, they could attend neighbourhood groups, learning, vocational or volunteer opportunities. This reinforced the strong emphasis on improving access to education and employment opportunities, both within the hospital and in the community. Patients could access vocational and academic courses, plus basic skills such as numeracy and literacy.

Many patients had access to a range of “real work” opportunities, both on-site and in the community. Patients applied and were interviewed for these posts and received reimbursement for the work they carried out. This reinforced the strong emphasis on improving access to education and employment opportunities, both within the hospital and in the community. There was a clear culture of positive risk taking.

Patients were involved in the review of complaints via the patients’ council.

There was an effective governance structure to oversee the operation of the hospital and drive delivery of high quality person-centred care. Leaders prioritised safe, high quality, compassionate care and promoted equality and diversity. The hospital had developed services in line with national programmes of audit and quality.

The hospital operated a ‘ward to board’ model of governance that encouraged and supported staff involvement in the governance process.

Patients had opportunities to get involved in hospital governance and they were actively involved in plans for service developments and improvements. The patients’ council had a strong voice and was represented at all levels. Rigorous and constructive challenge from patients was welcomed and viewed as a way of holding services to account.

The hospital used feedback from patients from annual surveys, ward quality matters, and patient-reported outcomes to inform and prioritise improvements in patient experience and care.

Staff surveys indicated high levels of staff satisfaction. Staff we spoke with were proud of the organisation as a place to work.

Leaders encouraged continuous improvement and there was excellent commitment to quality improvement. Staff were motivated to deliver change.There was a culture of collective responsibility across the hospital.

However:

On Elmhurst ward, although the bathrooms and shower facilities were cleaned regularly, there was black mould around the silicone seals.

All the wards had enclosed garden areas but patients were only allowed access to them with a member of staff and the door to the garden was locked.

Some staff on Kenton ward were not aware of the reflective practice groups. This is a concern given the nature of the challenging work carried out on this ward.