On 22 June 2018 we undertook a focussed inspection on Upper Court ward. Concerns had been raised with us about the care and treatment of young people who had been accommodated on Upper Court toward the end of 2017. The concerns related to incidents of young people self harming and an alleged lack of staff skills in responding to these incidents. It was alleged staff were not adequately inducted to undertake their role and as a consequence of this young people were put at risk of harm. As this was not a comprehensive inspection we focussed the inspection on the areas of concern.

We found the following issues the provider needs to improve upon:

• Young people’s physical health was not adequately monitored following the use of rapid tranquilisation. Records of the physical health checks were not always completed.
• Records about potential risks for each young person were not always consistent and this could result in them not receiving an appropriate level of observation.
• Permanent and agency staff had not received an induction appropriate to the roles they were to undertake on the ward.
• Records relating to agency staff inductions and staff rotas were poorly maintained.
• Not all staff had received regular supervision.
• The provider did have governance systems in place to monitor and assess the service but where areas needed to improve these were not fully implemented.
• The provider failed to notify CQC of notifiable events concerning the wellbeing of young people.

We found the provider to be in breach of regulation 12, safe care and treatment, regulation 18 staffing and regulation 18 (registration) notification of other incidents.

We looked at care records and found that they were person centred and well maintained with systems in place to audit and monitor the quality of care provided. Patients told us that their care and treatment needs were planned and delivered in line with their individual care plan. One patient told us "“I really like it here. The staff are amazing. It’s really good.”

We saw evidence to support that prior to receiving care, patients were given appropriate information that enabled them to make informed decisions. We saw that documentation showed that patients were being asked for their consent and that the provider had acted in accordance with their wishes.

The provider had systems in place to protect patients from abuse and to deal appropriately with concerns if they were raised. Staff had received training and were confident about how to recognise signs of abuse. They described the steps they needed to take to keep patients safe.

There were enough qualified, skilled and experienced staff to meet patient's needs in the event of sickness and to allow adequate time to support staff.

We found that there were suitable arrangements in place to support staff with meaningful supervision, appropriate professional development and training, and an inclusive appraisal mechanism.

The provider had systems to deal with and respond to complaints

We used a number of different methods to help us understand the experiences of patients who used the service, because some of the people who used the service had complex mental health needs which meant they were not able to tell us their experiences.

We saw that patients were treated with dignity and respect and that they were supported to retain their independence.

Patients were offered a choice of food which was nutritious and varied. We observed staff interacting positively with the people who used the service. We saw that patients had access to educational and social activities to meet their wishes and needs.

We saw that the provider has effective quality assurance systems in place to identify, assess and manage risks to the health, safety and welfare of the patients who used the service and others.

You can see our judgements on the front page of this report.

During our visit we spoke with patients at the hospital, the registered manager and staff members.

We also took information from other sources to help us understand the views of patients to include surveys and community meetings.

We primarily focussed on Highlands and Upper Grange Court units. However we had discussions with patients from Garden Court and Lower Grange units. We conducted the inspection with a Mental Health Act Commissioner present also from the Care Quality Commission. The Mental Health Act Commissioner completed a separate report on their findings under the Mental Health Act 1983.

The patients we spoke with had mixed views with regard to the care they received at the hospital.

Staff we spoke with knew the people living at the hospital well and had a good understanding of their support needs.

We spoke at length with the registered manager and found that a number of improvements had been made since the last inspection, to address outstanding compliance actions. The registered manager provided transparent feedback on outstanding actions requiring completion.

In addition, we have received regular monthly action plans from the provider advising us of ongoing improvements made in response to the findings from the last inspection in November 2011 and last review in April 2012.

We were told that “we get the support we need” “ Sometimes I feel like I am stuck in the middle of nowhere” “ Its great that I can study and I will be able to continue with my education when I leave” “ I have decided to stay voluntarily now as I feel really much better”.

We rated The Priory Ticehurst House as good because:

• The service provided safe care. The ward environments were safe and clean and wards met the requirements set out in national guidance on mixed sex accommodation.

• Staff assessed and managed risk well. All patient records that we reviewed had a current and up to date risk assessment in place. Staff demonstrated a good knowledge of their patients and their associated risks. The service minimised the use of restrictive practices and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Medicines were appropriately stored, administered and reconciled on all wards. All medicine was in date and labelled.
• Staff monitored patients’ physical health regularly and managed patients’ physical health needs well across all wards.
• The wards had enough staff on shifts. 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 appraisals. 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.
• Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed and were visible in the service and approachable for patients and staff.
• The service demonstrated that governance processes operated effectively at ward level and that performance and risk were managed well.

However:

• The provider failed to notify the CQC of incidents, including those that involved the police, as required by regulations set out in the Health and Social Care Act.
• Spare alarms were not consistently stored on the wards or accounted for on handover sheets. Staff alarms were not routinely tested to ensure their efficiency.
• The clinic room on Newington Court One had thick dust on medical appliances. The medicine cabinet in the child and adolescent ward clinic room was in reach of patients waiting outside.
• Whilst improvements were noted since the last inspection, not all agency health care assistants on the child and adolescent mental health wards had their induction checklists completed before working independently.
• On the child and adolescent mental health ward, some staff were unclear about what to do in the event of a fire.
• Whilst a comprehensive ligature point audit had been carried out and staff aware of the risks, the remedial works action plan did not indicate whether the work had been completed where the expected date of completion had passed.