We rated York House Independent Hospital as good overall because:

Following the last comprehensive inspection on 7 and 8 February 2017, we rated the hospital as good overall. We rated the service good for the effective, caring, responsive and well led domains and requires improvement for the safe domain. We issued a warning notice and a requirement notice under Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act (Regulated Activities) Regulations 2014. We told the hospital that staff must adhere to the hospital policy in relation to physical health monitoring following the administration of medication for rapid tranquillisation and ensure that all mandatory training meets the hospital compliance target. During this focused, follow up inspection, we found that the service had addressed the issues that had caused us to rate safe as requires improvement following the February 2017 inspection.

We rated the service requires improvement for safe because:

• There was no overall ward level ligature audit that identified all ligatures on the ward. This was not in accordance with National Patient Safety Agency guidance.
• Clinic rooms were too small to have examination couches and were cluttered. Medicines fridge temperatures were not always recorded daily in accordance with national guidance.
• There was limited multidisciplinary team support at weekends.
• Staff recorded incidents of harm as a result of patient assault, and prevention management of violence and aggression training was classified as desirable for nursing staff.
• York House hospital had not updated its local observation protocol to reflect the Disabilities Trust policy for corridor observations. This was identified at the last inspection. Staff were completing the observations but this did not reflect the local protocol.

However;

• Medicines management practice had improved. The provider had taken action to ensure that staff adhered to hospital policies in medicines management and staff acted in accordance with national guidance after they administered rapid tranquillisation to patients. The provider had introduced a prompt that explained rapid tranquilisation expectations and gave staff guidance on physical health checks and escalation. Risks associated with the administration of medicines for rapid tranquillisation were audited and reviewed.
• Mandatory training compliance for contracted staff had improved. First aid training was 5% below target however training was scheduled for November 2017. Wards identified staff with this training each shift and moved them to cover wards to ensure there was a suitable skill mix. Bank staff training was lower than the mandatory training compliance rates for eight courses but the service had implemented an online training platform to address this issue. Staff that did not have suitable training were not offered shifts on the wards.
• Staff now complied with infection prevention and control measures. The hospital’s infection control lead completed infection prevention and control checks of staff and the environment.
• The reporting system that staff completed when incidents occurred now indicated the level of harm sustained because of the incident. The provider was also in the process of implementing a new electronic recording system that was to be fully rolled out by December 2017.

We found people were included in decisions about how their care was provided and their preferences and wishes were respected. The provider was looking at ways to assist people to recall their inclusion in decision making and be provided with an accessible plan of care.

We observed that staff and patients had positive relationships and patients appeared relaxed and comfortable with their surroundings; staff and the activities they were engaged in.

We spoke with eleven patients; all expressed satisfaction with the care and support they received. One person said “I am looked after fantastically” another said’ “It’s brilliant here.”

Patients were cared for by staff who were properly trained and supported.

There was an accessible complaints procedure available. Complaints were investigated and taken seriously and information from complaints was used to improve the service patients received.

We met and introduced ourselves to four patients and spoke with one patient in depth, to get their views of the service. One patient didn’t want to answer any questions, but they did say that they were going to the pub and that they were happy.

Of the people we were able to speak to they told us that they were informed about and involved in their care and treatment. They confirmed that they were asked if they wanted to attend both their multidisciplinary team meeting reviews (MDT) and their care programme approach meetings (CPA).

They also told us about the community meeting that took place where all patients were invited to attend to discuss areas of concern or plan events for the future. They told us that there are been a Jubilee celebration recently and there was to be a Summer Garden Party at the weekend.

One person explained how they were involved in producing a newsletter about York House which was published for everyone to read.

All the patients we talked with told us that the staff treated them with respect and that they felt listened to. One person explained how the treatment programme had helped their recovery. All told us they had made choices about their daily lives, such as when they wanted to rise or retire and what activities they wished to be engaged in.

Some patient’s told us they were informed about and involved in their care and treatment. They were asked if they wanted to attend both their multidisciplinary team meeting reviews (MDT) and their care programme approach meetings (CPA).

All the patients we talked with told us the staff were “respectful” and “helpful”.

One explained how the treatment programme had helped their recovery.

Patient’s explained they had regular community meetings where they made their views known. One person explained how they were involved in producing a newsletter about York House.

All told us they had made choices about their daily lives, such as when they wanted to rise or retire. Although two explained there were specific times when they could have a hot drink or cigarette during the day.

Two patients explained they had agreed to the programme and had agreed to the restrictions placed on them. Although one patient told us they found the service “over protective.”

For some informal patients we found the patients’ capacity to make decisions about their care and treatment, access to the community, and the specific times they could have a cigarette or a hot drink had not always been assessed.

We rated York House Independent Hospital as good because:

• Staff protected patients from avoidable harm and abuse. Staff took a proactive approach to safeguard patients who were vulnerable and effectively managed risks on a daily basis. Staff ensured the environment was safe and clean and staffing levels were adequate to support patients safely.

• Staff planned patients’ care and treatment in line with current evidence based guidelines and used outcome measures to monitor patients’ progress. Staff considered the range and complexity of patients’ needs and worked collaboratively with each other and other services to support patients’ recovery. This included good access and outcomes in relation to physical health care. Staff were very mindful that they carried out least restrictive practice with their patients. They ensured they protected the rights of all patients concerning the Mental Health Act Code of Practice and the Mental Capacity Act and Deprivation of Liberty safeguards.

• The service demonstrated a very person-centred culture supported by organisational values and behaviours that kept patients at the heart of everything they did. Staff supported patients and their relatives with kindness, dignity, and respect. Staff sought feedback from patients and responded appropriately to meet their needs. The feedback we received from patients their relatives, and other people who used the service was overall positive.

• Staff ensured they met the needs of all patients who used the service. The facilities promoted comfort and confidentiality and included a range of suitable information to support their care and treatment. Staff used a range of communication methods to support patients to make choices about things that were important to them such as food and activities. Staff used the care programme approach to review patients’ progress and plan discharge.

• All staff knew who the senior managers were by name. Managers were aware of the issues that were important to staff and morale amongst staff was generally good. The service had acted to make improvements since our previous inspection in February 2016. The service developed good systems to improve the quality of care and was committed to making continual improvements to the service.

However,

• Staff had not made all the improvements needed to ensure they followed the hospital policies and procedures following the administration of rapid tranquillisation. We had concerns about the impact on patient safety and issued the hospital with a warning notice.

• Not all staff had completed the required training for life support. The training compliance was below 75% overall which meant that there might not be sufficient, adequately trained staff on duty and patients could be put at risk.

• Staff adherence to some aspects of medicines management and infection prevention and control measures did not comply with the hospital policies and procedures.

• Staff did not do all they could to keep all information that related to patients confidential.

• Managers did not include bank staff in the supervision and appraisal arrangements for staff.

• Some patients had been at York House for many years because of difficulties finding appropriate placement to meet their complex needs. There was reduced staffing available at evenings and weekends to support patient activities. Some patients told us they felt bored at these times.
• The hospital did not have a completed Workforce Race Equality Standard review to monitor and assure staff equality. The hospital observation protocol and the organisational smoking policy did not fully support staff and patients at York House.