We rated Waterloo Manor Independent Hospital as requires improvement overall because:

At this inspection, we found areas of concern in the safe and well-led domains.

• The provider had not risk assessed the impact on the patient environment and the patients where a boiler had broken and patients’ did not have access to hot water, or find alternative washing facilities.
• Some patient records were incomplete, including observation records and medication records, and documentation and storage of that documentation was inconsistent and not always in line with guidance provided.
• Not all systems and processes in place to ensure patients were safe and that treatment and care was effective were robust or effective. This included systems to ensure that accurate and complete records were maintained, cleaning schedules were completed, and contingency plans were in place.

However,

• During this most recent inspection, we found that the service had addressed the breach of regulation that had caused us to rate safe as requires improvement following the June 2016 inspection. All the wards were clean at the time of this inspection.
• Waterloo Manor was now meeting Regulations 15 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
• Following our inspection in June 2016, we rated the location as good for effective, caring and responsive. Since that inspection we have received no information that would cause us to re-inspect these key questions or change these ratings.
• Staffing levels across the hospital were adequate and ensured patient need was met. Recruitment was ongoing and the hospital continued to use bank and agency staff to fill any staffing shortfalls.
• The level of engagement and involvement of patients with regional involvement groups and the recovery college was encouraged and supported by staff. Patients attended meetings and contributed positively to projects within the hospital.
• Staff gave positive feedback about the management of the hospital. They said there had been some changes since our last inspection which they felt were positive. They told us management were approachable and they felt able to raise issues and concerns.

We spoke with three patients who told us they knew about the care and support that was planned for them and said they were consulted about this. They also told us they attended meetings to review their care plan and progress and were given the opportunity to share their own views about this.

Patients told us they were kept informed about the planned changes for the future service delivery at Waterloo Manor.

One patient said; “I like it a lot here. I get chance to go out and can now use public transport. Staff listen and generally care about your mental heath. Staff are very friendly and approachable and we have a laugh. I have not found this in other places where I have been.” Another patient said; “Staff are very helpful, especially the manager.”

Another patient told us the food was “fantastic” and they had the opportunity to have takeaway meals each week.

Patients were able to explain why they were taking certain medications and said that the medical team had explained to them about the possible side-effects from the medication prescribed and had sought their consent about taking the treatment.

Each patient spoken with said that there had never been any shortfalls in staffing levels that had resulted in cancellation of their section 17 leave.

Patients spoken with told us they felt able to make comments or complaints and believed they would be listened to and their concerns acted on, without the fear that they would be discriminated against for making a complaint.

One patient told us, “I think it is alright here. I am relaxed and know if I have any concerns I can go to the staff.

Patients told us that staff explain and discuss their care with them. A patient explained how they had been involved in discussion about staff interventions they preferred to be used if their behaviour put themselves or others at risk.

One patient said, “We are asked for our opinions and views and have a say in how the hospital can be improved.” Another patient explained their involvement with independent advocacy services.

All of the patients in Waterloo Manor are detained under the Mental Health Act 1983. Patients spoken with told us that staff had fully explained their rights in relation to their detention.

Both patients we spoke with were complimentary about the care they receive. One patient told us “The staff are excellent.” Another patient said that staff are ‘helpful.’

One patient told us “I was very unwell when I came here and without the staff I do not think I would be here today.”

Patients told us that they feel safe at Waterloo Manor and had confidence that any concerns would be properly dealt with. One patient said, “I raised a concern in the past and was satisfied with the outcome from this.”

Patients provided mixed comments about staffing levels. One patient said that staff could be accessed at all times. However, another patient said that there can sometimes be problems in the early evening.

One patient said, “Quite like it living here. The staff are friendly and have always got time for you.” Another patient explained that she was doing recovery work which would prepare her to live back into the community. A patient told us that she was writing her own report detailing how she was progressing. She was receiving staff support to help with this, and the report was to be presented to people attending her imminent MDT review.

During our visit we spoke with staff about the training they had done and looked at some training records.

All staff have completed mandatory training such as fire safety, first aid, infection control and safeguarding patients from abuse. Staff had also undertaken more specific training about resuscitation, the mental health act and managing violence and aggression. A member of staff told us “The training is very good.” A training matrix is used to record when staff have completed training and when updates are needed so that staff are kept up to date with good practices.

Permanent members of staff have regular supervision that is recorded. However, there is currently no supervision system in place for non-permanent staff such as those who work as bank staff.

Patients told us that they are asked for their views and opinions about how the hospital is run and complete information about this.

We rated Waterloo Manor Independent Hospital as good because:

• Staff had ensured that patients were fully involved as partners in their care. Feedback from patients about staff attitudes and behaviours was highly positive. Carers were positive about the hospital and told us that they felt appropriately involved in the care delivered by the hospital. Staff supported patients well and encouraged patient led initiatives and events.
• Environmental risks and individual patient risks were assessed and appropriate management plans were in place. Premises and equipment were clean and well looked after. Medications were managed well. Staff understood how to recognise, report and protect patients from abuse. Staff learned from incidents and worked to prevent incidents from happening again.
• There were clear admission criteria. Average lengths of stay were less than national averages for similar services. There was a range of activities available including a fully established and embedded recovery college. Complaints were responded to quickly and appropriately.
• The hospital was well-led. Managers and staff had worked to improve the culture of the hospital since the previous inspection. Managers were visible in the service. There were effective systems in place to ensure good governance. Key performance indicators were effectively used to monitor the service and make improvements. There was a clear commitment to improving the service from all staff.

However,

• There were not enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Lilac ward did not have a qualified nurse working on the ward to provide the right care and treatment.
• Staff were not always recording the level of consciousness of patients following the administration of rapid tranquilisation in line with the hospital policy.
• We found two patients on Maple ward had been administered medication which were not included on the relevant consent to treatment documentation.
• Whilst the hospital had recently introduced a new system for monitoring supervision, staff were not maintaining detailed records of supervision sessions.