Since the last inspection in April 2013, improvements had been made to the arrangements for training, supervision and appraisal of staff in order to meet regulations and keep patients safe.

We met with the registered manager and four staff. We also met the newly appointed training manager who was responsible for reviewing training policies and procedures. The induction for new staff had been reviewed and developed to include a departmental induction and core competence training.

The training records showed us that since the last inspection staff had received refresher training to enhance their knowledge and skills. The training included mandatory training in core subjects and additional training that focused on mental health issues.

Staff were being offered fortnightly clinical supervision sessions and annual appraisals. Nursing staff attended weekly team meetings to discuss patient’s on-going care and treatment needs.

People spoke very highly of the day nurses. One person said, "they make time to listen to you even if they are on their way somewhere else." We were told some of the night staff were "rude." Some people told us night staff made them feel "like a nuisance" when they approached them for help or support.

People felt involved in planning their own treatment and care but told us they were not always told about changes to their care plans. Without exception, people praised the quality, quantity and availability of food at the clinic. They were equally pleased with the clinic's housekeeping arrangements and told us they had no concerns about cleanliness. People we spoke with told us that the clinic was very responsive to any concerns they raised and, when they had a concern, it was addressed.

There were systems in place to ensure patient records were kept confidential. The patient records we saw had information relating to each person's care and treatment needs. With some minor exceptions, records were kept in accordance with national guidance on record keeping. However, we found the clinic remained non-compliant in the two areas we identified as a concern in our last inspection: infection control and supporting staff. While considerable progress was made to address the concerns relating to infection control, no improvements were made in relation to staff training.

People told us they felt cared for by trained and experienced staff. They valued their relationships with key workers and participated in organised activities. People we spoke with felt there were some areas in which the hospital could improve. They told us the hospital needed to be clearer about the outcomes people could expect to achieve by the end of their treatment. People also said the hospital did not give them the tools they needed to help them cope after they left the hospital.

We found people using the service were provided with appropriate care to meet their needs. They were involved in making decisions about their care. There were systems in place for monitoring the quality and safety of services provided to people including a system for reviewing complaints. When complaints were made, people told us they were dealt with promptly.

However, the hospital was non-compliant in two areas: infection control and supporting staff. There were inadequate systems in place for preventing and controlling the spread of infection. Policies and procedures we looked at made no reference to the Code of Practice on the prevention and control of infections and related guidance, under the Health and Social Care Act 2008. There were also insufficient arrangements in place to ensure staff had training, particularly in the Mental Capacity Act 2005, Mental Health Act 1983, and infection control.

We rated The Cardinal Clinic (the clinic) as good because:

• All three areas of service, the inpatient unit, the day service and outpatients were exceptionally clean and well maintained and without exception, patients told us that they felt safe.

• There were enough suitably qualified and trained staff to provide care to a very good standard.

• We found that patients’ risk assessments and plans were robust, recovery focussed and person centred. The assessment of patients’ needs and the planning of their care was thorough, individualised and had a focus on recovery. Staff considered and met the needs of patients at all times.

• Staff were confident in how to report incidents and they told us about changes they had made to service delivery as a result of feedback, following incidents.

• Patients had an excellent level of access to a good variety of psychological therapies either on a one to one basis or in a group setting.

• There was retrospective evidence of best practice. All staff had a good understanding of the Mental Health Act 1983 (MHA), the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice.

• Skilled staff delivered care and treatment. Throughout the clinic the multidisciplinary team was consistently and pro-actively involved in patient care and everyone’s contribution was considered of equal value.

• The staff were kind, caring and motivated and we saw good, professional and respectful interactions between staff and patients during our inspection.

• We saw evidence of initiatives implemented to involve patients in their care and treatment. Patients told us that the staff at the clinic consistently asked them for feedback about the service and how improvements could be made. The service was particularly responsive to listening to concerns or ideas made by patients and their relatives to improve services. We saw that staff took these ideas into account and used them when they could.

• The service model optimised patients’ recovery, comfort and dignity.

• There was a clear care pathway through the service with associated treatment and therapy options.

• All patients and staff told us that the quality and range of food offered was of a high standard.

• There was a varied, strong and recovery-orientated programme of therapeutic activities available every week.

• All staff had good morale and they felt well supported and engaged with by a visible and strong leadership team, which included both clinicians and managers. Staff were motivated to ensure the objectives of the organisation were achieved.

• Governance structures were clear, well documented, followed and reported accurately. These were controls for managers to assure themselves that the service was effective and being provided to a good standard. Managers and their team were fully committed to making positive changes. We saw that changes had been made to ensure that quality improvements were made, for example through the use of audits. The service had clear mechanisms for reporting incidents of harm or risk of harm and we saw evidence that the service learnt from when things had gone wrong.