We rated acute wards for adults of working age and psychiatric intensive care units, and forensic inpatient/secure wards as good overall because:

• Following our inspection in October 2016, we rated the service as good for effective, caring, responsive and well led. Since that inspection we have received no information that would cause us to re-inspect these key questions or change the ratings.

• During this inspection, we found that the service had addressed the issues that had caused us to rate safe as requires improvement following the October 2016 inspection.

• The acute wards for adults of working age and psychiatric intensive care units, and forensic inpatient/secure wards were now meeting Regulations 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

This overall rating has not changed from the rating given following the previous comprehensive inspection in October 2016.

• The three wards we visited (Michael Shepherd, Wendy Orr and Amy Johnson) had made improvements with physical health care of patients since the previous inspection.
• The hospital had a practice nurse in post to review physical health care across the hospital.
• All staff had completed mandatory training.
• Staff monitored patients’ physical health daily. All staff,including healthcare assistants, were trained to complete physical observations.
• Patients reported staff listened to them and involved them in their care planning.
• Care plans were holistic, person centred and recovery focused. Staff completed assessments within appropriate timescales.
• There were good medicines management processes in place and good links with the pharmacy service that provided medicines for the hospital.
• The hospital was 100% compliant with CQUIN (Commissioning for Quality and Innovation) for physical health care.

The purpose of this inspection was to follow up on widespread non-compliance identified during our last visit to The Dene on 30 April 2013.

It is noted that since that inspection, there has been an open and honest acknowledgement by the provider of the shortfalls and a commitment to address these issues. The Regional Executive Director told us there was “A need to facilitate a culture shift to improve both patient and staff engagement and this will take some time and sustained effort.”

The inspection team comprised four Compliance Inspectors, a Pharmacist Inspector, a Specialist Advisor and an Expert by Experience.

We visited all five wards, observed care practices, examined a range of documentation and spoke with patients, nursing and care staff and senior managers.

We found that a lot of hard work and significant improvements had taken place since our previous inspection. These included changes to the management structure, the relocating of the acute admission wards, more support and involvement of patients in their care and treatment planning and improved communication, staff support systems – and staff morale.

We found that before patients received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Consent forms had been completed appropriately.

We saw that patients’ privacy, dignity and independence were respected. We saw that staff were friendly and kind and responded to patients’ needs. We saw that people were supported to make choices, including how they spent their time, and that their choices were respected. A care worker told us “We ask patients instead of telling them and try to prompt rather than do things for them - it puts the power back to them. The managers are very hot on things like that.”

One patient told us “Generally all of the staff are very caring. They are trying to give us much more support. They’re here for me whenever I need them.” Another person told us, “It’s the best hospital I’ve been in. I have the support of the staff and the psychologist. There are people helping you all the time. I feel safe here.”

We found that improved systems were in place to ensure there were sufficient numbers of staff on duty to meet the assessed care and support needs of the patients. Staff were supported and received appropriate professional development.

Despite on-going issues with the electronic patients records, we found that significant improvements had been made regarding the accuracy and consistency of the records maintained.

On the day of our inspection we were accompanied by Mental Health Act commissioners (MHAC), a Pharmacist Inspector and an Expert by Experience. We visited three wards (Edith Cavell, Helen Keller and Michael Shepherd) to monitor compliance and the use of the Mental Health Act 1983 (MHA) to provide a safeguard for individual patients whose rights are restricted under the Act.

We found that informal patients on an admission ward alongside detained patients were subjected to the same restrictions, which consequently infringed their rights. Patients also raised concerns about the lack of privacy and dignity.

The registered manager told us that the service had transferred much of its documentation, including individual care and treatment plans to an electronic system of recording.

Record keeping, including care plans, risk assessments and staff interventions were found to be inconsistent and inadequately maintained. Consent to treatment forms were not always in place.

One patient we spoke with on Michael Shepherd Ward told us “It would be good to have a few more staff around so we can get out more. Other than that I haven’t got a bad word to say about the place”.

We found that the service did not protect patients against the risks associated with the unsafe use and management of medication.

We found that patients’ safety, welfare and their opportunity for leave was often compromised by insufficient staff on duty.

It is to be noted that on the day of our inspection we were accompanied by a Mental Health Act Commissioner (MHAC). They visited one ward (Amy Johnson) to monitor the use of the Mental Health Act 1983 (MHA) to provide a safeguard for individual patients whose rights are restricted under the Act. Their findings on this ward, including in relation to privacy and dignity and activities differed from our experience throughout the rest of the hospital. The MHAC identified issues which were specific to Amy Johnson Ward and these have been recorded and addressed under their own monitoring process.

We found that individual care plans included a section which incorporated the patient’s view and experience of various aspects of service provision.

We found that the service did not protect patients against the risks associated with the unsafe use and management of medication by means of appropriate arrangements for the obtaining, recording, using, safe keeping and safe administration of medicines.

The registered manager told us that staffing levels throughout The Dene were now closely monitored to ensure that they reflected the assessed treatment and support needs of patients.

We spoke to a Senior Support Worker who had worked at The Dene for many years who stated, “I feel supported by my managers, I have no issues and have regular supervisions. If I do need to raise an issue I will speak to my managers - or other staff on other wards.”

Residents generally felt safe and well cared for, and that consultations such as the recent meeting on smoking breaks had been helpful.

People felt staff worked hard but that at times there weren’t enough staff, which impacted on them and what they could and couldn’t do.

Privacy and dignity issues raised by residents included lack of access to their bedrooms during the day, food being cold and a lack of menu choice, and having to get up in the morning earlier than they would want to.

• Priory Hospital Burgess Hill was well maintained and cleaned to a good standard.

• Staff were aware of their roles and responsibilities and took appropriate measures to safeguard clients from avoidable harm and/or abuse.

• The hospital had identified staffing as a high-risk issue on the hospital risk register and were ensuring wards did not run under their safe staffing numbers by using locum agency staff, while full time positions were recruited to.

• Morale amongst staff was good. Staff felt proud and valued to work at the service. Relationships amongst staff were strong and supportive.

• Physical healthcare was integrated into the care plans and the practice nurse was closely involved across the hospital in supporting the patients.

• There was an induction and annual training programme for all staff that specifically addresses issues of relational security.

• There was a designated safeguarding lead for both children and adults

However:

• Staff were not aware they could refer a safeguarding matter straight to the local authority without requiring it to be reviewed by the Priory Hospital Burgess Hill Safeguarding Lead first.

• Senior support workers and nurses did not have the opportunity to meet regularly as a hospital wide clinical reflective group to review case studies and how situations were being managed across different wards within the hospital.