We rated Sherwood Lodge Independent Healthcare as good because:

• Significant improvements had been made since our inspection in 2015. This included taking action to address the issues we had raised in the previous report.

• The provider had carried out extensive refurbishments to ensure the environment was safer for the patients.

• Staff managed risk well. All staff knew the patients and shared risk issues with each other on a day to day basis.

• Male and female sleeping areas were now segregated in accordance with guidance on same gender accommodation.

• The provider ensured they carried out their statutory duties of informing the Care Quality Commission of when a safeguarding concern was raised.

• The service had updated policies and procedures related to the Mental Health Act (1983) Code of Practice. Staff monitored use of section 17 leave on an ongoing basis.

• Staff were caring, respectful and supportive, and we received positive feedback from patients, carers and stakeholders.

• There were governance processes in place to ensure more robust oversight of the service.

• The service was well-led. The clinical manager was visible and ensured the needs of the patients were a high priority at all times.

However:

• Some care plans did not contain risk information and some risk assessments were not regularly updated.

• Some clinical records, particularly belonging to those subject to detention under the Mental Health Act (1983), were full and difficult to navigate.

• Staff did not always inform patients of their right to an independent mental health advocate.

We looked at the files for five people who use the service. In four of the five we saw the new paperwork titled “about me” had been completed. This was easy to follow and gave a good account of the background and current needs of the person which they had signed to show agreement.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. Care plans were person centred and included information about all areas of the person's life including their health, personal and social care needs.

We spoke with all staff on duty during our visit and found a good level of knowledge about safeguarding and the ability to apply this knowledge to the people in their care. We observed staff intervening in a positive and respectful manner when people became agitated with each other. The language used by staff was kind and respectful.

People were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

Patients' health care needs had been monitored and responded to appropriately. Information about patients' health needs and contact with health care professionals had been recorded. We were informed that the service received “good support” from healthcare professionals and there were no problems obtaining their input for patients when required.

Patients were protected against the risks of receiving unsafe or inappropriate care. We read three care plans. These contained assessments of need and provided staff with information about the care and support patients required.

The staff we spoke with were knowledgeable about the procedures to follow should a patient go missing or, in the case of detained patients, fail to return to Sherwood Lodge within agreed timescales. We were shown the records for a detained patient who had gone absent without leave. Records demonstrated that staff had responded promptly and had informed appropriate authorities, which included the police.

We were informed that staff turnover was low and agency staff were only used “where absolutely necessary.” This meant that patients were supported by staff who knew them well. We spoke with three members of staff. None expressed any concerns about staffing levels or about their ability to meet patients’ needs. Comments included “I think staffing levels are good here. It’s never a problem” and “I’ve never experienced any problems and we get to take patients out a lot.”

Systems were in place to ensure that staff received appropriate levels of support. Staff were very positive about the support they received and they confirmed that they received regular supervision sessions.

Sherwood Lodge had been converted from two large Victorian houses many years ago. The design and layout of the home would not be appropriate for patients with limited mobility. Access to upstairs bedrooms was via stairs and the service did not have a lift.

Sherwood Lodge provided accommodation for up to 24 patients. Two years ago partition walls were built in four double rooms to provide patients with more privacy. This resulted in three bedrooms not having the provision of a window. These bedrooms only received natural light because the wall partitions were not to ceiling height. We found that these bedrooms provided limited space for patients. Patients did not raise any concerns with us about their accommodation and the provider informed us that patients had been involved in the decision to convert double bedrooms to single rooms. Patients had also been able to choose the decor for their rooms.

Patients were provided with opportunities to express a view about life at Sherwood Lodge. Patients attended regular meetings where they could discuss a range of topics. Patients had been able to discuss activities, social events and meal options.

Patients told us that they were involved in discussions about their care and support. We saw that patients had access to information about how they could access independent advocates. Patients were told of their rights of appeal under the Mental Health Act.

We found that staff had supportive, respectful and professional relationships with patients. Patients we spoke with confirmed that their right to privacy and independence were respected.

There were comprehensive assessments of patient's mental health needs. There were limited assessments which identified the patients health and social care needs and reflected a person centred approach. The provider had made sure that staff had accurate details about organisations they could get in touch with if they had concerns about the service.

We found that the provider had appropriate arrangements in place for management of medicines. There were accurate administering records. Patients rights were protected which made sure that their treatment was appropriate and safe.

Patients told us they felt able to make a complaint if they wished. There was a lack of information available to patients about how to make a complaint.

Staff we spoke with told us they were well supported. We found that managers and nurses were approachable so that staff felt able to ask for advice and support when they needed it.

Patients told us how well supported they were with their mental health needs by the staff team and the manager. We were told “It is lovely here the manager is a very nice person”. “It’s nice here they look after me”. “I don’t want to be here but its much better then the place I came from” and “Sherwood Lodge is a happy family environment”.

Patients were treated with respect and were supported in their recovery from long term mental health problems. We met some patients at Sherwood Lodge who were being cared for under a section of the Mental Health Act. This meant the Mental Health Act was being used to gain legal permission to give patients compulsory assessment or treatment. We found patients under a section were properly supported and they had their legal rights maintained.

Patients were involved in planning the care and support they needed. The care plan records explained what support patients needed clearly and were informative. There were risk assessments records about patients which clearly showed actions to be done to keep them safe as well as to protect other people. Patients under a section were helped to understand their treatment regime, as well as the reasons why it had been decided they must stay there for their safety and /or the safety of others.

Patients were cared for by staff who had a good understanding of complex mental health needs. This meant patients received care from staff who understood the support and treatment they needed.

There were systems in place to review and learn from all critical incidents and occurrences that may have impacted on patients’ wellbeing. Patients were involved in monitoring and reviewing the quality of treatment and the service they received.

We rated Sherwood Lodge Independent Mental Healthcare as requires improvement because:

• fixtures and fittings were in need of attention. Floors in some areas were slippery following cleaning during our visit and staff had recorded a high level of slips and trips through incident reporting

• staff documented and monitored risks poorly. This was particularly for patients detained under the Mental Health Act 1983 where a higher level of monitoring and risk management would be expected. There was no systematic means of recording risk or mental state when patients took or returned from daily Section 17 leave as the home had an open door policy

• male and female sleeping areas were not segregated in accordance with Department of Health guidance on same sex accommodation. Although a bathroom separated the genders they were in very close proximity on the upper floor.
• The provider were not providing statutory notifications of abuse or allegations of abuse to the Care Quality Commission
• There was very little acknowledgement of the potential for dignity to be compromised. Some windows facing an outside smoking area had open curtains. This displayed room contents and personal belongings
• the service had not updated all its policies and procedures in line with the revised Code of Practice related to the Mental Health Act 1983 so compliance with the Act was poor, including patients being allowed leave without daily risks or mental state being documented
• there was no formal governance framework or system to make sure staff learned lessons following investigation of incidents of harm or risk of harm.
• the risk register was very limited. It did not address operational or environmental risks.

However,

• we observed staff engaging in warm, caring and kind interactions with patients and staff appeared to be genuinely concerned for the welfare of their patients

• staff showed very good understanding and knowledge of the patients including individual risks
• We were told there was a good relationship with the community and management plans were in place with the police

• patients were able to raise issues and were involved in house meetings. Feedback from patients and carers was generally positive

• there was access to the acute mental health ward if patients experienced deterioration in mental state

• there were efforts made to provide a homely environment and atmosphere. Patients could access quiet areas in the home away from communal areas to relax if they wished

• we saw a full activity programme timetable. During our inspection we saw patients joining in with activities such as foot spas and artwork. Staff we spoke with were enthusiastic about their activity programme

• staff morale appeared good. Staff told us they enjoyed their work and were able to contribute to the service.