During our visit we spoke with 15 people who use the service across the young people and adult wards. We spoke with a minimum of 14 staff, including the manager, quality compliance manager, doctor, nurses and healthcare assistants. We also spent time talking with the Independent Mental Health Advocate who met with people during the inspection.

We received divided feedback about the service that people received. People in the young persons and eating disorders units were more positive about their experience than people using the general psychiatry wards. Similarly, the input of people into their care and treatment plans varied across the wards, where some people felt fully involved and others did not feel involved in decisions about their care.

Staff knew about different types of abuse and the local procedures for reporting these, though were unclear of external agencies where they could report concerns.

However, the provider did not always act in accordance with legal requirements in relation to the continual supervision of people who use the service. We also found a number of areas in the environment that were potentially unsafe for people and staff. People were also at risk of unsafe care where there was a lack of appropriate risk management.

The provider had mechanisms in place to obtain consent from people who use the service. People who use the service told us that they consented to the care that was delivered to them and staff only carried out activities that they were "happy" for them to do.

Staff understood the requirements of the Mental Capacity Act 2005 and had attended relevant training. The provider carried out decision-specific Mental Capacity Assessments on people who it was felt lacked the capacity to make certain decisions. People who were detained under the Mental Health Act 1983 (the Act) gave their consent to treatment and had their capacity assessed to make specific decisions.

Staff assessed the needs and risks of people using the service. Each person had an individual care plan that was based on their assessed needs and risks. People using the service told us that they were "satisfied" with the quality of care they received. Staff were described as "caring", "wonderful" and "helpful".

People using the service told us that they felt safe at the home and if they had concerns they would report it to the nurse in charge. We observed that each floor was appropriately staffed on the day of our visit. Staff made records of people's care that were clear, concise and legible. People using the service files were kept in lockable filing cabinets in staff offices and were easily accessible to staff when required.

People were given adequate information about what to expect and were satisfied with their care and treatment. People felt safe in the hospital, had their privacy and dignity respected and felt involved in their treatment.

We rated the Nightingale Hospital as good overall because:

• When we inspected the Nightingale Hospital in January 2018, we rated the hospital as requires improvement. At the current inspection, we conducted a comprehensive inspection and rated all core services as Good. We did not inspect the children and adolescent mental health (CAMHS) ward, which had been closed since December 2017 as the provider submitted evidence that they were no longer providing this service. 
• The provider had made significant changes to address areas of concern highlighted at the previous inspection in January 2018. A new hospital director was in post and he had recently introduced the roles of staff and patient representatives. They met regularly with the senior management team to bring about improvements at the hospital.
• At the previous inspection in January 2018 we found that there were insufficiently robust governance and quality assurance processes in place to identify areas for improvement promptly. At the current inspection we found that the hospital director had identified immediate challenges relating to the facilities and nurse leadership, and had introduced the posts of head of facilities, and ward manager to address them. The hospital managers were undertaking more audits to monitor quality across the hospital. They had also undertaken a review of procedures and processes to improve systems to prevent illicit substances from being brought into the hospital. Improvements had been made to the frequency and quality of searches, including a visit by specially trained sniffer dogs. We also found improvements in ensuring were aware of the learning from incidents across the hospital, staff recruitment checks and protocols for risk assessment prior to opening, closing or relocating wards, as required at the previous inspection.

• At our previous inspections in January 2018 and February 2017, we found that the hospital did not have an effective system in place for staff to alert other staff when they needed urgent assistance, and staff were not aware of the ligature point risks on their wards. At the current inspection we found that staff had been provided with personal alarms, and significant maintenance work was being undertaken to reduce ligature risks. Staff were aware of ligature risks as specified in the ligature risk assessment for each ward, and how to mitigate these risks.

• At the previous inspections in January 2018 and February 2017, we found that staff had insufficient training in their roles supporting patients with addictions and eating disorders, and did not have annual appraisals. This had improved at the current inspection, and we found that staff were now clear about the validated tools to use for patients on detoxification from different substances. They were also receiving annual appraisals. Staff were also ensuring that patients were always prescribed and administered medicines in line with national guidance, as required at the previous inspection.

• At the previous inspection in January 2018, we found that clinic rooms were not always clean, and staff could not access the most recent infection control audit. There were also gaps in completing action identified at the most recent fire safety assessment. At the current inspection, we found that all clinic rooms that were in use were clean, and there were records of when routine cleaning tasks were undertaken. Staff had access to the most recent infection control audit, and all actions from the current fire risk assessment had been completed.

• At the previous inspection in January 2018, we found that patient care plans were generic and patients had not been involved in the development of their care plan. At the current inspection we found that care plans were individualised and had clear input from patients. We also found that on the specialist eating disorders ward, informal patients were now clear about their right to leave the ward, and patients were assessed for their risk of developing pressure ulcers, as required at the last inspection.

• At our previous inspections in January 2018, and February 2017, we found that, on the mixed sex acute ward, there was no provision for a female only lounge. During the current inspection, we found that patients on this ward were risk assessed, and could be relocated to a single sex ward if required. Female patients on the mixed sex ward were able to access a female only ward on the first floor.
• At the previous inspection in January 2018 we found that complaint responses were not consistently of a high standard. During the current inspection we found that complaint responses were appropriately worded, addressed each area of concern, and highlighted the next steps to take if the complainant was unsatisfied.
• Weekly timetables for patients on each ward included a range of activities that supported the recovery and wellbeing of patients. Patients gave very positive feedback about staff and we saw staff were supportive and kind when interacting with patients. There were enough medical, nursing and therapeutic staff to provide care and treatment to patients and meet with them regularly for one-to-one support.
• On the eating disorder ward relatives and carers were offered a fortnightly support and education group. On the substance misuse ward, monthly family days were arranged for patients’ relatives to attend, and a free aftercare weekly session was provided for patients on discharge from the ward.

However:

• Staff were not fully implementing procedures to prevent banned items such as plastic bags from being brought onto the wards. Plastic bags had been banned following a serious incident at the hospital. Staff told us that they were not always offered a debriefing session and support following a serious or challenging incident.
• Day patients on the eating disorders ward did not always have current risk assessments and care plans in place to ensure their safety and wellbeing. Discharge plans for patients with eating disorders did not always include sufficient detail including future options for support. There was also no system in place for reviewing any blanket restrictions on the wards, such as locking laundry and activity room facilities when not in use. The hospital did not have a smoke-free policy, in line with best practice guidance.
• Although staff had received specialist training in addictions and eating disorders, nursing competencies for staff working on the addiction unit and those for the eating disorder service were not specific to the care of patients with those particular needs to ensure that staff understood the specialist training they received. Staff did not have any training in working with patients who have autism, to ensure that patients with autism received appropriate support.
• There was no system in place to check mattresses and all soft furnishings in the hospital on a regular basis, and record when they were deep-cleaned to ensure appropriate infection control.
• The route taken by patients on the eating disorder ward to access the hospital restaurant, needed to be reviewed, to ensure that it did not impact on their comfort and dignity. Patient records were not always being stored in locked cabinets when they were not in use, which could potentially breach patient confidentiality
• Staff on the wards were unable to access the results of recent audits, and there was no clear evidence of changes made as a result. Staff meetings were not always held on a regular basis including standard agenda items related to quality and safety, and staff were not always able to access a clear record of the minutes of the last meeting. In addition, staff did not always have easy access to legible, accurate and up to date information about patients when they are admitted to the service, and at shift handovers.