We inspected this service in November 2017 as part of our on-going comprehensive mental health inspection programme. As a result of our findings at the inspection in November 2017, we served the provider with a letter of intent to take immediate enforcement action under section 31 of the Health and Social Care Act 2008 regarding the safety of patients receiving treatment for drug and alcohol use on West Wing.

The provider voluntarily suspended the admission of new patients requiring medically assisted withdrawal to the service and submitted an action plan to the CQC.

We carried out this focussed inspection on 17 January 2018 to check that the provider had followed their action plan and had addressed the issues outlined in the letter of intent.

Immediately following this inspection, we informed the provider that they had made sufficient progress to improve patient safety and they could start admitting patients who required medically assisted withdrawal from 18 January 2018.

At the November 2017 inspection we found the following concerns:

• Staff had not completed comprehensive physical health checks and drug testing prior to treatment commencing. This included staff carrying out relevant blood tests and pregnancy tests.

• Staff had not comprehensively assessed and appropriately managed patient risk on admission. This included assessing for alcohol related seizures and delirium tremens, completing cognitive assessments prior to treatment commencing and assessing whether the patient is in contact with dependent adults or children.

• Nursing staff had not received specialist training including substance misuse awareness training.

• Nursing staff did not have the correct skills, knowledge and competence to recognise withdrawal symptoms and complete relevant withdrawal tools accurately. This included staff recording how they come to a decision to administer a specific dose to a patient requiring PRN (as required) medication.

• The service did not have governance systems to assess, monitor and improve the quality and safety of the service.

At this inspection, we found that the service had made the following improvements:

• Staff completed drug testing on admission and then randomly on a twice weekly basis.

• Staff completed comprehensive physical health checks on admission including blood tests and pregnancy tests.

• The provider had developed a pre-admission in-patient risk screen and updated the nursing and doctor’s admission checklists. Doctors would complete a face-to-face assessment prior to admission. The provider had also developed an addictions nursing assessment aide memoir.

• The provider had developed “see the adult, see the child” guidance to assess safeguarding risks for patients in contact with children. The provider updated the pre-admission in-patient risk screening to assess whether the patient had children and any current safeguarding issues. In the three patient records we reviewed, staff had documented whether there were any safeguarding concerns; however, staff had not always completed the record on admission.

• Nursing staff completed one-day training on substance misuse. However, the provider must ensure they deliver training on a regular basis and includes specialist information on substance misuse.

• The provider had developed an algorithm to use with a withdrawal tool to provide nursing staff with guidance on the administration of PRN (as required) medication. Nursing staff completed a medically assisted withdrawal competency checklist and were knowledgeable about when to administer PRN medication.

• The provider completed regular emergency scenarios with staff on the ward.

• The provider had implemented governance systems to assess, monitor and improve the quality of the service including regular audits, internal compliance reviews, reviewing risk at the clinical governance meeting and quality at the weekly learning outcomes group.

We also found the service should continue to make the following improvements:

• As the provider had only recently ratified their updated withdrawal policy, the provider needed to ensure staff understood and applied the new policies and procedures in practice.

• As the provider had voluntarily stopped admitting new patients who required medically assisted withdrawal, the provider needed to embed the implementation of the new admission process and monitor the staff team’s ability to support patients undergoing the new withdrawal process.

• The provider also needed to embed the implementation of the new governance systems to assess, monitor and improve the quality of the service.

• Ensure learning and improvements are shared across the provider’s other residential detoxification services.

We carried out an inspection at The Priory Hospital, Roehampton and visited Emerald ward which is a ward for adults with personality disorders and was due to close the week after our inspection visit, Upper Garden Court which is an acute mental health admission and treatment ward, the Adolescent Eating Disorders Unit and West Wing which accommodated people receiving treatments for addictions and adults with eating disorders. We spoke with people who used the service and a range of staff across the units we visited as well as speaking with the hospital manager. We also requested information from the provider which was sent to us following the inspection.

People we spoke in all the areas we visited spoke positively about the support they received. We found that people were involved in the planning and organisation of their care. People told us that they had the opportunity to provide feedback and felt listened to. People told us that they felt staff were skilled and caring. Records, including medication charts were up to date and completed. We saw that medicines were stored appropriately.

There were sufficient numbers of staff on duty to support people with their needs. Staff received support and training to ensure that they were competent to meet people's needs. The provider had governance systems in place to ensure that learning took place from incidents, complaints and comments.

We spoke with two people using the service during our inspection. They told us that "staff are good", "the ward manager is brilliant", and that they had no problems with their medication.

We observed how medicines were administered to two people and saw that medicines were explained to them and that nurses observed that they were swallowed before recording that they had been given. We looked at seven drug charts and consent forms to give medication and saw that all medicines listed as given were signed and dated and correlated with the consent forms.

We observed that the prescription charts were checked by the pharmacist for accuracy and if a medicine was omitted the gap was identified and appropriate action taken. We saw that there was a regular audit of the charts and the results were recorded in an audit book.

Ward managers confirmed that there had been a recruitment drive in the past few months. One person told us "we have had new staff inducted to the ward". Another staff told us "we always call bank staff if possible, it's very rare that we use agency" and "you see familiar faces now".

The Human Resources (HR) department had taken steps to try and improve the recruitment process for new staff. Where agency or bank staff were used, core competencies and revised induction had been implemented to ensure that the quality of staffing was of an acceptable standard.

We spoke with people using the service on East Wing and Priory Court. People felt involved in their care and told us they met with their key worker regularly. One person said their families were kept involved. Some of the comments included "generally the care is very good" and "they are strict but they have to be". One person told us the admission process was smooth and straightforward.

Risk management plans were updated and clinical decisions recorded when people were moved from one to one to zonal observation. Care plans recorded issues around restraint, the risk of absconsion and self harm.

Permanent staff on East Wing were issued with basic emergency equipment such as ligature cutters and gloves. Staff were aware of the location of the emergency kit on the wards. Training records showed that staff received Basic Life Support and defibrillator training as a yearly classroom session.

Staff on both East Wing and Priory Court told us that on each shift there were at least two staff that were restraint trained. We saw these staff were allocated on the records that we saw.

Staff described their induction programme. One person said that HR staff went through policies in an interactive way. They said that more training had been booked for them in the future, including first aid and restraint training. New staff told us they had "settled in well" and staff were "supportive". Other comments included "got a good team here" and "I'm happy we have a core team".

During our visit we spoke to a number of people who use the service and staff on the addictions unit, garden wing and the child and adolescence mental health service unit (CAMHS). The feedback we received from people who use the service was positive, where they said they felt respected and involved in planning their care. One person said ‘’…this is a lovely unit, the staff are really great…’’, whereas another commented that ‘’…they do fantastic work here…’’.

People told us that they get a good service which meets their needs. They said that generally all of the staff were respectful and caring towards them.

People told us they felt supported by staff and that there was generally always someone available for them to talk to.

People told us that staff acted swiftly on occasions where they felt anxious and at risk.

People have varying experiences of the service. Some people feel that they are involved in identifying their needs and treatment, whereas others say that they are not involved in the care provided to them.

Similarly, people have differing experiences of the staff. Some people told us that they find the staff to be very skilled and knowledgeable, yet others felt that the staff had no understanding of their needs or of how to meet them.

People told us that they feel safe, and that there are some opportunities for them to raise any issues they have about the ward.

We rated The Priory Hospital Roehampton as good because:

• Staff provided emotional and practical support for patients. Staff took the time to understand patients and their needs and were sensitive, discreet and compassionate when providing care. Patients reported that staff were polite and helpful and treated them with kindness and respect.

• Staff undertook a comprehensive risk assessment of all patients when they were admitted. Specific areas of potential risk were highlighted and staff put in place effective risk management plans. Potential patient risks were reviewed during nursing handovers and multidisciplinary meetings. Patients had comprehensive mental and physical health assessments when they were admitted to the hospital. Patients mental and physical health were reviewed regularly during their admission.
• Patients’ treatment followed best practice guidance, including guidance from the National Institute for Health and Care Excellence (NICE). Patients had access to a range of evidence-based psychological treatment and therapy.
• Patients were involved in their care. They developed their own care plans and their individual needs were met. Staff involved patients’ relatives or carers in their care and treatment, if the patient consented.
• The hospital safeguarding lead was a qualified social worker. They met with the substance misuse therapy team each week to discuss patients. The aim of this meeting was to identify if any safeguarding issues had arisen during patient therapy groups.
• The acute wards provided support groups for the family members and carers of patients. These included sessions with and without the patient being present.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. We saw examples of where staff had made improvements to the service as a result of feedback from patients, families and carers.
• Senior leaders provided strong leadership. Two new senior managers had, in a short space of time, made a demonstrable impact to the safety and quality of care provided to patients. Staff found ward managers and senior managers accessible and approachable. Staff felt confident that they could raise concerns. Staff spoke highly of the management team and their colleagues, and felt respected, supported and valued. Senior managers met monthly with staff for breakfast. This provided an opportunity for informal conversations to generate ideas and discuss issues.
• There was a comprehensive governance system to monitor the quality and safety of services. This included a system of audits, procedures and practices which monitored the safety and quality of care. For example, the system of audits for patients having substance misuse detoxification was detailed and ensured best practice guidance was followed at each stage of treatment. Significant amounts of managers’ time was focused on identifying how the safety and quality of care could be improved. Incidents and mistakes were viewed as learning opportunities and there was shared learning across the services. There was a culture of openness and transparency.

However:

• Staff did not provide written information to patients that left alcohol or drug detoxification treatment early. Patients were verbally given advice from staff regarding their reduced tolerance and complications of alcohol withdrawal such as seizures. The ward manager planned to produce written information for patients shortly after the inspection.
• Although Lower Court filled shifts for registered nurses with bank and agency staff, there were five registered nurse posts vacant at the time of the inspection. There was potential for this to affect the consistency of care to young people.
• Some patients being admitted for alcohol or drug detoxification did not provide consent for hospital staff to contact their GPs. This meant information concerning potential risks in detoxification treatment was only based on information the patient provided. However, patients had a comprehensive assessment on admission and their detoxification was monitored closely. Any risks to the patient during treatment were identified quickly.
• For two hours a day, young people on Lower Court could only access their bedrooms with the support of staff using a fob system. This restriction meant young people could not get to their bedrooms without staff assisting.
• The garden on East Wing was bare with high fences. The garden lacked comfort and did not allow for a therapeutic atmosphere.

• Three young people on the child and adolescent eating disorders ward, Priory Court, said that some staff were rude and made inappropriate comments.
• Four young people on the child and adolescent mental health ward, Lower Court, said that staff did not always knock on their bedroom doors before entering.
• Some young people on Priory Court described a lack of activities at weekends which led to them becoming bored.