We have changed the rating in the safe domain from requires improvement to good because:

• The hospital acted to meet the requirement notice we issued after our inspection in February 2016.
• Patients told us that staff treated them in a kind and respectful manner during a period of seclusion. Patients understood the reasons for their seclusion and what they needed to do for their seclusion to end. They felt supported by staff during and after their period of seclusion.
• Staff cared for patients physical and mental health needs when patients were secluded. All patients had care plans, which addressed the patient’s safety, comfort, privacy, and dignity throughout a period of seclusion.
• On the day of our visit, all the seclusion rooms we visited were clean and well maintained.
• Staff documented comprehensive seclusion records that met the requirements of the hospital policy and Mental Health Act Code of Practice.
• Staff used positive behavioural support plans and de-escalation techniques with patients and used the least restrictive practice when people were at risk of harm.
• Senior managers took action to ensure that the hospital continued to meet the requirements of the hospital seclusion policy and Mental Health Act Code of Practice.

We visited Stockton Hall as part of the annual review and also because we had received some concerns that staffing levels were not safe. When we looked at staffing overall we found that staffing levels were planned and flexible to meet needs as they occurred on each ward. However we recognised that the merging of the wards had meant that different mental health needs were now being cared for in the same area which has caused an increase of incidents on the ward.

Patients told us how they were involved in decision making both individually about their care and communally about issues that affected the hospital. They also told us that they were aware of how to raise concerns and make a complaint.

We looked at how patients were protected from the risk of abuse and found that the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. All staff had received training and demonstrated a good understanding of safeguarding adults from abuse. We also looked at how the staff were supported and found that staff had the right training in place to safely meet patients’ needs but that supervision and team meetings could be more frequently held.

We did find that the hospital needed to review practices, records keeping and the complaints process. We have therefore decided that we will continue to monitor these areas and return to the hospital to review the improvements made.

We visited Stockton Hall as part of the annual review and also because we had received some concerns that some patients were not accessing their section 17 leave due to staff shortages.

We visited the two wards Farndale and Dalby and spoke to ten patients and eleven staff. Some patients who were present on the ward at the time of our visit chose not to speak to us; however, we were able to observe patients within the ward setting and saw how staff interacted with them.

Those patients who wished to talked to us told us they knew about their care plan and said they were consulted about this. They also said if any changes were needed the staff would explain the reasons for this, and they said they were given the opportunity to share their own views about any changes.

Some patients were satisfied with the care, treatment and support they received at the hospital. They said they had care plans and were able to attend review meetings with advocates to support them. They told us; “I have a care plan and I am given a copy if I want it.” “I see my doctor, advocate and solicitor regularly.”

Patients told us they attended weekly community meetings with staff where daily activities and leave could be organised. Patients said they had access to meaningful activities and said; “I go to the gym and woodwork sessions.”

Some patients told us that the food generally was ok and that they had access to making a drink if they wished. Two patients told us that in their community meetings it had been agreed they would have a take away meal on one day per week, but they said they were not allowed any days in addition to this and could only choose one type of food.

Patients told us about restrictions placed on them by the smoking policy for the organisation. This meant that patients could smoke between the hours of 9am and 7pm in the smoking areas outdoors when accompanied by a member of staff. One patient told us, “that’s really hard when you can smell smoke on the staff after these times; it is also hard to wait for that morning cigarette.

One patient told us that they attended the User Involvement Group meetings and that they were given the opportunity to chair the meetings. They felt they were encouraged to have their say and represent the opinions of other patients on their ward.

Patients also told us they knew how to raise concerns or make a complaint and also confirmed that that they had access to advocacy and to their solicitors when required.

Patients explained to us that they valued their individual bedroom space and that they held a key for their room. They also told us that they could stay in bed and sleep in if they wished although staff encouraged them to engage in their programme during the week. However one patient said that they felt their privacy was compromised by their door blind being left open by staff and they were unable to close it.

We carried out a responsive review of Stockton Hall at 6:45 am on Saturday 17th December 2011; this was because we had received information that there was insufficient suitably qualified, skilled and experienced staff working at the weekends and at nights.

During out visit we went to Kyme, Fenton, Kirby, Farndale and Dalby units, we talked to ten patients and seventeen staff.

We asked the ten patients about whether they believed there was sufficient staff to meet their needs at the weekend and at nights, seven told us they believed there was “not enough” staff and they told us the ways this affected them. For example they were sometimes unable to have escorted leave in the grounds and in the community at weekends. They felt “ignored” and had been unable to take part in supervised activities at the weekend such as “pool or X box”.

Twelve male patients were living on Kyme ward. We met and introduced ourselves to 11 patients and spoke with six patients in more depth to get their views of the service.

When we first arrived one patient told said, “Staff are brilliant on this ward.” Overall, patients told us they were satisfied with the care and treatment at Kyme Ward. However, some patients said they didn’t feel safe because a new patient had been admitted who had attacked another patient and some of the staff. More than half of the patients we spoke with were not happy about some of the rules. They told us that they took part in activities, but were sometimes bored, especially at weekends.

Patients told us the staff supported them to be involved in putting their care plans together and going to review meetings, and that they had access to independent advocates. That was someone from outside of Kyme Ward who came in and spoke up for them.

We rated Stockton Hall requires improvement because:

• The audit systems in place were not always effective. The audits did not identify the issues we found during the inspection for example in relation to the restrictive practice meetings, discharge planning records, the inconsistent use of systems to record information about the patients and implementation of Priory policies.
• Patients did not routinely have access to a nurse call system but staff ensured on an individual basis that alarms were in place when required.
• Patients capacity was not always recorded clearly in the patient files and staff were not always able to find them when asked.
• Discharge planning was not always recorded clearly recorded in the patient files.
• The provider had informed the Commission in 2016 they were going to develop the hospital and reduce two wards each with 24 beds to four wards each with 12 beds. The development had not happened yet although the plans are with the planning authorities. The delay in developing the two wards means they are tired and would benefit from being refurbished if the development is not started in the near future.

However:

• The hospital was clean and equipment was available to assist staff in their role.
• Managers had an active recruitment programme for staff. All staff were supported in their identified training and development needs. Where bank staff were used they worked on the one ward so that they got to know the patients.
• Managers effectively planned staffing resources to ensure that staff were available to spend the time required on direct patient care such as escorted leaves and attending hospital appointments.
• The process for reporting incidents and safeguarding concerns was robust and lessons learned were shared with staff. Although staff were unclear about any recent lessons learnt.
• Patients had access to different disciplines within the hospital to aid their recovery.
• Patients were involved in their own care planning and they told us staff were supportive and treated them with respect. They accessed a variety of activities and received support from an independent mental health advocate.
• There was a robust complaints process and when the hospital was found to be at fault they were honest about their mistakes and how they had put right the issue.
• The service could meet the diverse needs of patients and accessed specialist services to ensure patients could be fully involved with their care.