We went back to review the improvements that the provider had made following an inspection visit to Elgar ward during July 2013. Elgar ward is a 12 bedded ward for patients aged 13-18 years of age who have an acquired brain injury. The inspection team was comprised of a compliance inspector and a specialist mental health advisor.

We spoke with two patients, six members of staff and the ward manager. We also reviewed a variety of patient and staffing records which were available on the ward.

One patient told us they liked the staff that worked on the ward. They also told us that the staff were supporting them to go on a visit to the cinema later that day and they were looking forward to doing this activity. They also told us that the ward could be improved by “making it more homely” and that “they had put up some posters” which had improved the environment. Another patient told us that some staff had “shouted at me” and they had told the ward social worker and the advocate about this. The staff confirmed that the appropriate action had been taken to safeguard this young patient.

We found that staff had improved safeguarding procedures to safeguard patients from the risk of abuse and that improvements to staffing had been made on the ward. We also found that there were plans to improve the safety and suitability of premises. We also found that improvements were required to maintain accurate seclusion records on the ward.

During our inspection visit of St Andrews Neuropsychiatry services, we visited Elgar ward, which is a 12 bedded ward for younger people who have an acquired brain injury. On the day of the visit there were six young people receiving treatment and care. We spoke with three young people and four of their relatives. We also spoke with five staff, the ward manager and reviewed the care records of three young people.

Most young people and their relatives told us that they were happy with the treatment and care that they received. However, we found that some young people had made safeguarding allegations about some members of staff on the ward. We found that the young people had been supported by staff and an independent advocate to discuss their concerns. We also found that the provider had put in place safeguarding measures to ensure the safety of young people and staff whilst these concerns were being investigated.

We found that the young people were involved in their planning of care and that they received treatment and care that protected their health and wellbeing. We had concerns that there were not enough staff working on the ward, that safeguarding procedures were not always followed by staff and that improvements were needed to maintain the safety and suitability of the premises. We also had concerns that records on the ward were not always being maintained and updated.

The inspection was carried out by two inspectors from the Care Quality Commission (CQC). On this inspection we visited Tavener, Allitsen and Elgar wards over a period of two days.

We were supported by a Mental Health Act Commissioner who was contracted by CQC to undertake the monitoring of the Mental Health Act (MHA)1983 in hospitals who care for detained patients.

The Mental Health Act Commissioner met in private with detained patients, examined statutory documentation relating to their detention, reviewed the ward environment and spoke with ward staff.

We were also supported by an 'expert-by-experience'. They had personal experience of using or caring for someone who had used mental health services.

The patients we spoke with told us that they felt respected by staff. They told us that the staff listened to them when they had any queries. They also stated that their opinions about their care were valued and any concerns or complaints raised were investigated by management. Most patients said that they had been involved in decisions, which supported their care and treatment.

The care records of patients we looked at showed that they had their needs assessed prior to admission and their care and treatment was planned, and delivered in line with their individual care plans. The records also showed that appointments were routinely arranged for patients to see a number of health care professionals to ensure their health care needs were being met.

We rated wards for older people with mental health problems as good because:

• Patients received timely access to physical healthcare, including access to specialists when needed.
• Care records were up to date and included the patients personalised life story “This is me.” Care records showed positive behaviour plans and support.
• Technology and equipment were used to enhance delivery of care, for example a talking tile (which had a picture of patient’s family member and a recorded message) and a digital aquarium on the wall for patient‘s viewing. Staff accessed video calls for patients to see and speak with their carers and relatives. One patient spoke regularly with their relative abroad.
• Staff received the necessary specialist training for their role for example end of life training, dementia care mapping, and physical health care training.
• Staff were supervised with one to one meetings, group reflective practice meetings, appraised and had access to regular team meetings.
• We observed effective early morning handovers on O’Connell South and Compton wards.
• Staff participated in regular clinical audits such as infection control, cleanliness audit. Clinicians were provided with research evidence from recent publications via alerts.
• Staff told us managers were supportive, and were a visible presence on the ward. Staff knew how to use the whistle blowing process.
• • The clinical nurse lead on O’Connell South ward was the champion for the staff survey, encouraging staff to complete the survey “My Voice”.
• O’Connell North and South wards were working towards accreditation for the quality network older adults. An application had been submitted.

However:

• On O’Connell South ward, the visitor’s room on the first floor had two large sash windows with no restrictors. These meant widows could be fully opened and patients may not be safe when left unsupervised in this area. When we brought this to the attention of the clinical nurse lead they told us repairs would be made to the windows within three days. The door was locked after we brought the issue to their attention.
• The patients lift on the first floor of O’Connell South ward was not in use for one week. This was due to an infection control outbreak on an adjacent ward. We saw the lift was unclean with litter, and reported this to the clinical nurse lead. The lift was immediately cleaned. For a temporary period O’Connell South ward was accessed via another lift in the building.