Our overall rating of this service changed from inadequate to requires improvement. The service was removed from special measures following this inspection.

We rated it as requires improvement because:

• Further work was needed to safeguard against the risks associated with ligature anchor points on the wards. Not all staff were aware of the most up to date ligature risk assessment of the ward they worked on, where ligature anchor points were located, or the measures in place to mitigate and manage these. The hospital used a high number of bank and agency staff and ligature risks were not covered in their induction. However, the provider had ensured that an updated ligature risk assessment was in place for each ward, patients assessed as being at risk of fixing ligatures were subject to increased observations and a programme of anti ligature works was underway.

• Further work was needed to ensure governance arrangements were embedded as part of the hospitals ‘business as usual’ approach in assessing the quality and safety of the service. Some complaints had not been dealt with in line with the providers stated time frame.

• Further work was needed to strengthen the role of audits in ensuring the quality and safety of the service. The hospital had not ensured staff could use information from audits to improve individual records identified in the sample. On Upper Richmond Ward, staff were not routinely accessing the outcome of audits to drive improvement. Some audits, for example the risk assessment audit, were not comprehensive, as they did not consider whether identified risks had an associated management plan.

• There were limited opportunities for carers to give feedback on the service provided. Whilst the hospital had plans to develop different ways carers could feedback, no timescale for their implementation had been fixed.

• Although managers were maintaining safe staffing levels on each ward, and could increase staffing numbers as patient needs changed, a high number of nursing posts remained vacant. The provider had recruited some agency nurses to long term contracts, and the provider was actively looking to fill vacant posts, but the hospital’s continued reliance on bank and agency staff meant that there was an ongoing risk to the safety and consistency of care.

• Further work was needed regarding the use of restrictive interventions. A formal reducing restrictive interventions strategy had not been implemented and there had not been a reduction in the use of restrictive interventions such as restraint, seclusion and rapid tranquilisation since our last inspection. However, staff had received training in positive behaviour support and were confident to de-escalate. Initial steps had been taken to promote the least restrictive intervention including advance agreements with patients around how to safely administer medication without the need to restrain.

However:

• The service had made improvements since our inspection in May 2018 and had worked hard to address breaches of regulation and best practise recommendations. The service had implemented a clear framework of what should be discussed at team meetings. Staff were now aware of the service risk register and managers knew how to escalate issues to be considered in terms of risk to the service.

• The ward environments were clean and improvements had been made to ensure that patients could access drinking water freely.

• Staff assessed and managed risk well and improvements had been made to patient risk assessments. The service had improved its monitoring of physical health following administration of medication by rapid tranquilisation and now monitored the use of restrictive interventions including rapid tranquilisation.

• Staff followed good practice with respect to safeguarding and managed medications safely. Improvements had been made to ensure staff recorded rational for administering ‘as required’ medication.

• Improvements had been made since the last inspection to ensure staff completed daily physical health checks for all patients and that smoking cessation was available to all patients. The service was in the process of working towards smoke-free status at the time of the inspection.

• Reporting of incidents had improved since our last inspection and incidents were now routinely discussed and learning shared with staff during team meetings.

• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Care plans had improved since our last inspection and patients were more involved in their care. The service provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.

• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.

• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

• The quality of interactions between staff and patients had improved. Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.