When we inspected Milton Park Hospital in May 2013, we identified non compliance in relation to record keeping and recruitment. As a result of our findings we made compliance actions, and told the provider they must make improvements. The provider responded swiftly with an action plan and put new systems in place to ensure improvements were made.

When we carried out this inspection on 28 August 2013, we found new documentation relating to the delivery of care had been introduced and there were significant improvements in the standard of record keeping.

The provider had 'activated' a new electronic system to ensure recruitment processes were robust, and the renewal of professional and employment documents was managed efficiently.

During our visit to Milton Park hospital on the 09 June 2011 people that we spoke with told us that they were treated well and were involved in making choices about their day to day care and support and discharge planning.

One person said, “I think I have been treated well”, and another person said, “I do not have any complaints, the staff are all very supportive”.

Generally people were aware of what was in their records and they had been involved in the review of care plans and risk assessments relating to their care.

We spoke with numerous people during this visit on 09 June 2011, and those that were mentally well enough to discuss the matter of consent told us that they understood and agreed with the care that they were receiving. They told us that they appreciated that at times they had not been well enough to verbally give consent, but they knew that some procedures such as restraint had to be done in their best interests, and to safeguard themselves and others.

The only negative comments that we received were in relation to activities. Some people told us that their activities were sometimes cut short or cancelled because there were not enough staff available to drive the hospital vehicles and transport them into the community. However on the wards people generally felt well cared for.

We rated Lakeside as inadequate because:

• The provider did not manage environmental risks to patients effectively. Ligature risk assessments on all eight wards were not accurate and did not mitigate all risks. The service did not exclude admissions of patients with self-harming behaviours.
• Staff were not carrying out and documenting all checks on all patients. We found gaps in patient observation records on three wards. This placed patients at risk.
• Staff were not adhering to the Mental Health Act Code of Practice in regards to seclusion and long-term segregation. There were gaps in documentation and staff did not always follow the correct procedures. Staff did not complete seclusion records in full. Reviews of four patients in long-term segregation were not in line with the Mental Health Act Code of Practice.
• Staff did not manage equipment or medicines safely. Two clinic rooms contained out of date equipment. We found unlabelled, ‘patient-only’ medication in clinics on three wards. Staff did not accurately record patients’ allergies on medication charts on four of the eight wards.
• The wards were not always staffed safely. Between November 2016 and October 2017 Staff turnover was at 35%. As a result, the service had been running with low levels of registered staff . In addition, the service had a high level of new and inexperienced staff and relied heavily on agency staff. Managers did not ensure that all shifts were staffed to the required establishment.
• The provider did not ensure that staff had adequate training or supervision. Not all staff had completed the induction training. Compliance with mandatory training was low for bank staff and low in some areas for permanent staff. Managers were not reviewing staff performance and development needs. The overall compliance with appraisal was low at 36%. The provider did not ensure that bank staff received supervision.
• Staff did not ensure that all confidential patient information was stored safely. We found confidential patient information left unattended in communal areas on two wards. We found handover documentation left in a toilet.
• The quality of care planning was poor. Care plans were not always personalised, recovery focused or accurate. Staff did not capture patients’ views in care plans. We saw limited evidence in care records of staff supporting patients to make decisions.
• Engagement and activity levels were low. Patients spent long periods asleep or in their room alone. We saw little evidence of activities and therapy taking place. Staff were not prompting or supporting patients to improve their engagement. The service provided a limited range of psychological interventions that were recommended by the National Institute of Health and Care Excellence. Some but not all patients’ had sensory profiles and formulations in place.
• Not all staff were caring in their interactions with patients. Interactions between staff and patients were not positive and supportive on three wards. Staff did not always take action to ensure that patients’ dignity was maintained.
• Staff did not discuss actions and learning from complaints at clinical governance meetings.

However:

• The units complied with Department of Health guidance on eliminating mixed sex accommodation.
• All wards had emergency medical equipment in place.
• Staff discussed patients’ care and treatment at monthly multi-disciplinary meetings. Staff completed risk assessments upon admission and updated them at regular intervals.
• The provider held daily meetings where key staff would meet to review issues across the service including staffing and incidents.
• The ward environments had improved, they were clean and tidy, and some had been decorated.
• Most staff knew how to use the whistle-blowing process and felt able to raise concerns without fear of victimisation. Staff told us that morale was slowly improving.
• Staff were aware of and usually followed safeguarding procedures and the provider had a positive working relationship with the local safeguarding team.