We visited Keston Ward which treats people with Asperger’s and autistic spectrum disorders and Lower Court which provides acute mental health care and an addiction therapy programme. We spoke with seven staff and four people who were receiving a service, and the relative of one person who was receiving a service. We also observed care being provided to people who use the service on Keston Ward. We spoke with Keston Ward Manager, Lower Court Charge Nurse, the corporate Quality Improvement Lead, the Clinical Services Manager, and the Hospital Director. . We examined the personal files of 10 people using the service on the day of our visit and also looked at other records relating to the provision of service.

We found that where people did not have the capacity to consent, the provider acted in accordance with legal requirements. However the provider may find it useful to note that for some people their capacity assessments were inappropriately grouped together. Some staff were not familiar with the Mental Capacity Act 2005 or Deprivation of Liberty Safeguards (DOLS). Staff were also unable to tell us the frequency of advocacy visits to the hospital, or identify when the next advocacy visit would take place. These factors could mean that people who use the service are at risk of not being able to give valid consent to their care and treatment and not having their human rights respected.

People experienced care, treatment and support that met their needs and protected their rights. The provider may also find it useful to note that whilst people who use the service told us that they were aware of their care plans, the majority told us that they did not receive a copy of their care plan.

We found that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard and that people who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

We inspected the hospital with an Expert by Experience and a Mental Health Act Commissioner. We visited three units at the hospital during our inspection. People using the service told us they were happy with the care and treatment they received and one person said "I have improved since I came here". People using the service said staff were approachable and they could speak to staff whenever they wanted to. However, a small number of people told us they did not agree with their care plans and had not received information on advocacy services to support them in expressing their views. We found that the hospital had not followed the code of practice for depriving people of their liberty in at least one case, and that assessments of capacity had not always been completed. People's needs were assessed and care was delivered in line with their needs. We found that complaints were mainly handled in line with the provider's time scales.

The Mental Health Act Commissioner will produce a separate report which focuses on the experiences of people detained at the service.

People we spoke to said they felt that they were able to make choices and found the hospital provided good care in pleasant surroundings.

People were happy with the quality of food and their individual rooms; they said that they were provided with adequate refreshments throughout the day.

People we spoke to felt involved in their care and treatment programmes.

People we spoke to said that there were sufficient activities during the week although week-ends were very quiet if they didn’t have visitors.

People we spoke to felt that some areas in the grounds were not kept as tidy as they could be.

Some people we spoke to felt that there had been delays in starting their care treatment.

We rated the Priory Hospital Hayes Grove as good because:

The service had addressed the concerns raised following our last inspection in February 2017. For example, the service had updated all ligature risk assessments and included steps to mitigate risks in these assessments. On Keston Ward, occupational therapists had developed an activities timetable to suit the needs and interests of patients. This included activities at weekends. Discharge planning on Keston Ward has also improved.

All the services provided care and treatment recommended by national guidance including medicines and psychological therapies. Psychological therapies included cognitive behavioural therapy, mindfulness, family therapy and anxiety management.

The service had robust policies and procedures to ensure that medically assisted withdrawal from drugs or alcohol was done safely in accordance with national guidance. This included monitoring patients’ symptoms of withdrawal four times a day using a nationally recognised assessment tool. All permanent staff had completed training and competency checks in ensuring the safety of patients withdrawing from drugs or alcohol.

Patients across all the services said that staff were kind, friendly and supportive. Patients said they felt comfortable talking to staff and they valued the support they received.

Multidisciplinary teams across all the wards worked well together. These teams had extensive knowledge, skills and experience of planning and delivering care to their specific patient groups.

Staff on Keston Ward maintained safety on the ward whilst providing a least restrictive environment. Staff implemented positive behaviour support plans that followed best practice in anticipating, de-escalating and managing challenging behaviour.

Patients’ representatives attended monthly clinical governance meetings and were involved in decisions about the service.

Services were provided in a comfortable, well-maintained and welcoming environment. Patients said the food was very good. The restaurant offered good quality meals including a range of healthy options.

However,

Staff on Keston Ward did not always carry out and record physical observations and examinations of patients. For example, we found that daily blood test for a patient with diabetes were not being completed every day. We also found that daily monitoring of vital signs for a patient with a complex co-morbidity had not been completed for six consecutive days.

The vacancy level for permanent nurses was above 50% on all wards. This meant that the service relied on agency staff to ensure there were sufficient staff on all shifts. Patients on Keston Ward and the at eating disorders service said the use of agency staff led to inconsistency in the quality of nursing.

Supervision sessions with staff were not held consistently. Records showed that discussions in supervision sessions were not always sufficient to develop staff and improve services.

Incidents were not always investigated in a timely manner. Findings from investigations into incidents were not always shared with ward staff.

The provider could do more to separate the male and female sleeping areas in order to increase patient’s privacy and dignity.