Patients told us that the food quality and choice had “improved massively” since our last visit to the service in October. Every patient we spoke with told us that the food and access to food had got better.

We saw menus available on the wards with choices for each day and patients told us if something wasn’t on the menu that you could request an alternative and it would be sent over from the kitchens.

We saw for patients who had specific nutritional needs that this was recorded in their plan of care and patients’ nutritional intake and weights were recorded in a consistent format. We saw appropriate referrals had been made to dieticians were required.

There was plenty of fresh fruit available and kitchens on the three wards we visited were well stocked with food and snacks that were appropriately stored.

We carried out this responsive inspection to look at the recruitment and selection of staff who worked at Priory Hospital Middleton St George. The reason for our visit was because we had received concerning information about the recruitment of a care staff member who may not have been suitable to work with vulnerable adults.

We looked at the personnel files for seven members of care and nursing staff. We looked at the recruitment and selection checks of those staff. We spoke with human resources staff at the hospital.

We found there were gaps in the recruitment processes. We found the provider did not always check people’s conduct in a previous employment in services relating to children or vulnerable adults before employing them. This meant the provider could not fully demonstrate that some staff were suitable to work in an environment where they had direct contact with vulnerable people.

We visited one unit at the Priory Hospital to check whether improvements had been made to the two compliance actions and two improvement actions we made in November 2011.

We spent time talking with people and the staff to get their views about whether the service had improved since our last visit.

The people we spoke with were very positive about the change to the model of care provided. The service was now delivering care under the ‘star recovery’ model instead of the previous ‘stages’ model. One person told us, “The star recovery model is great because you can see how far you have progressed.”

One person said, “I write my own risk assessments and care plans and that’s good because I have started to recognise when my own mental health is not so good.”

Another person commented, “I like being so involved in my care, I write a journal every day about how I feel and I talk through it with the psychiatrist at the ward round. It helps me understand my thoughts and feelings.”

People were positive about the staff on the ward. They said, “I can talk to anyone if I’m worried” and “I do have my favourite staff but I think everyone has people they get on better with.”

We saw from records people were supported by staff to go out much more than previously. One person we spoke with said, “I go out of the ward a lot more than I used to.” Two people said their leave did not always happen. They felt this was because staff were busy because of other patients' behaviour on the ward.

One person said they had found the change in care model more difficult as they felt that some patients got more of the staff time if their behaviour was poor.

On one unit people told us that they were fully consulted every month about being a detained patient. They told us that their rights were fully explained and that they understood these.

One person commented, “Staff go through my rights every month and I sign them.”

People told us, “We have morning meetings every day. We have asked for the kitchen staff to come over to talk about the meals.”

People we talked with told us that they had been involved in their review meetings.

But they also commented on the restrictions. People told us:

“Bedrooms are locked during the day.”

“Starting from tonight we have to go to bed at 11.00pm.”

”You get more privileges in prison. It’s supposed to be homely but they enforce too many rules.”

The people we spoke with on Linden unit were all were very positive about the care, treatment and support they received. One person said, “They look after me alright.” Another person said, “It’s very good here, I am well looked after.”

On Thoburn unit people felt that the care was “ok” and that there was “enough to do”.

On Jasmine unit there was a different treatment programme (called ‘stages process’). People did not feel that this type of treatment supported them to get better. One person said, “I don’t agree with the stages. I have been in loads of hospitals and they don’t have stages. I have self harmed here because I feel like I have failed”.

Other people said, “If I don’t do activities during the day I might lose my stages” and ”There are not enough activities for the young ones.”

On two of the three wards we visited people said that they generally felt “safe”.

One person said he felt nervous being alone in areas where staff were not around. He said that he had never been verbally or physically abused by other patients, but he felt vulnerable at times.

On one ward people commented: “Staff take you to seclusion to calm you down. Sometimes you are asked to walk in and staff shut the door but they don’t lock it.”

“I feel safe sometimes. Staff sometimes help. Sometimes I’m led into seclusion, sometimes I’m asked to go in.”

One person said, “I don’t feel safe because of the young ones.”

One person said, “I would feel able to talk to (the manager of the ward) if I had to make complaints about the staff attitude.”

On Linden unit people said, “I think there are enough staff around most of the time”.

People on the Jasmine unit felt that there were not enough staff and that this affected their daily living choices. One person told us, “Our bedtime has had to be changed from 1.00am to 11.00pm as staff aren’t getting home until late.”

One person said, “I don’t feel I get enough support because staff are often restraining other people or observing them in the seclusion room.”

Another person said, “There are not enough staff. Sometime I don’t feel safe.”

We rated The Priory Hospital Middleton St George as outstanding because:

• Leaders at all levels demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. Staff felt respected and supported through all management levels. Staff of all grades and professions told us they felt part of a team, their opinion was valued and treated with equal respect. The company recognised the value of their staff and annual awards were given to staff members in recognition of their service and contribution.
• There was a demonstrated commitment to best practice performance and risk management systems and processes. The organisation reviewed how they functioned and ensured that staff at all levels had the skills and knowledge to use those systems and processes effectively. Problems were identified and addressed quickly and openly. Staff were proud of the organisation as a place to work and spoke highly of the culture. Staff at all levels were actively encouraged to speak up and raise concerns, and all policies and procedures positively supported this process. Plans were consistently implemented, and had a positive impact on quality and sustainability of services.

• The long stay/rehabilitation wards had a bright and homely feel with a calming and relaxing environment. Patients and carers told us that staff treated them well and were invested in the welfare of the patients.

• Staff and patients were kept safe and were able to get help when it was needed. Clinic rooms throughout the hospital were clean and tidy with all the necessary equipment. Equipment was well maintained and calibrated. Staffing levels throughout the hospitals were appropriate to the needs of the patients. Managers were able to increase the numbers of staff on the wards if needed. There was a good range of disciplines, knowledge and skills to care for the patients.
• Patient risks were identified on admission and updated as needed. Management of risks was dealt with in a way that was individual and least restrictive. Incidents were reported quickly and clearly and were discussed in both the daily multi-disciplinary and hospital operational meetings.
• There were a range of care and treatment interventions that were suitable for the patient groups. Multi-disciplinary working was planned and well structured with a clear and collaborative approach to patient care.
• Staff completed mandatory training in both the Mental Health Act and Mental Capacity Act. The on-site Mental Health Act administrator demonstrated a clear knowledge of the Act and of patients who were detained under the Mental Health Act. Both the Mental Health Act administrator and other staff working in the hospital reported close working relationships.
• Staff supported patients to understand and manage their care, spending time talking to them about their individual needs. Cultural, religious and social needs were discussed on admission and documented in care records. Patients were encouraged to download an application for their mobile telephones which could help them deal with situations they might find challenging. Staff involved patients in their care. Patients were able to attend meetings about their care and if they were not able to attend, could submit questions for staff to respond to. Patients were involved in the formulation of care plans and staff noted records to show which patients had accepted or refused copies of care plans. Staff donated items to ensure patients on the acute ward were provided with a bag of essential personal items on admission.
• In the last 12 months, there had been no delayed discharges from the services. Staff planned for patient discharges and established relationships with external stakeholders to ensure patients were appropriately supported. Discharge planning throughout the service helped to ensure patients had a positive experience when leaving the hospital.
• Patients were given information on how to make a complaint. There was information on display throughout the hospital on how to make a complaint and how to contact the Care Quality Commission. Staff and patients received feedback on complaints and investigations. Lessons learned were feedback and action points developed which were acted on as a result of these.
• The provider had an online career pathway which provided staff with information on career progression and the knowledge and experience required to attain the role. Advertised posts were open to all staff with the right level of knowledge and experience. The provider had ring-fenced upcoming roles within the service to allow existing staff progression opportunities.
• There was a clear framework of what was to be discussed during meetings. The hospital director was aware of all the meetings that took place in the hospital and reviewed the minutes of all meetings. Information was shared to teams in the hospital and where appropriate nationally throughout the organisation.
• Staff used quality improvement methods and knew how to apply them. The service identified a number of innovative practices to drive quality improvement. This included defensible documentation training which gave staff the knowledge and tools to write clear and concise care notes, using the most appropriate language in line with professional standards, completion of the reducing restrictive practice self-assessment tool and implementation of the local steering group.