The Care Quality Commission
  • Mental Health
  • Independent mental health service

Nightingale Hospital

Overall: Good read more about inspection ratings

11-19 Lisson Grove, Marylebone, London, NW1 6SH (020) 7535 7700

Provided and run by:
Florence Nightingale Hospitals Limited

All Inspections

During an assessment of Specialist eating disorder services

Nightingale Hospital is an independent hospital that provides mental health care and treatment for people who may or may not be detained under the Mental Health Act 1983. The hospital offers general psychiatry, eating disorders, obsessive compulsive disorder and addiction treatment for adults as both inpatients and outpatients. The service provides 3 acute wards for adults of working age, an obsessive compulsive disorder ward, a substance misuse and detoxification ward, and a specialist eating disorder service for adults. The eating disorder ward is located in a separate 9-bedded 3-storey building. Bendall Mews eating disorder unit provides eating disorder services for individuals aged 18 and above. Treatment can be accessed as part of an outpatient, day patient or inpatient programme. We carried out our on-site assessment of the service on 17 April and 13 June 2024 to check on compliance with requirements from the previous inspection in June 2022 and in response to feedback about the service received by CQC. At the previous inspection the eating disorder service was rated Requires Improvement in all key questions except Responsive which was rated Good, leading to an overall rating of Requires Improvement. Overall, we found significant improvements at the service. Patients felt safe in the service, and most relatives of people using the service were positive about staff care and treatment. The environment was clean, and well maintained. Patients said that staff were readily available and generally supported them with kindness. However, they raised concerns about the number and skills of bank or agency staff that worked with them. The ward manager was working to address these concerns. Patients were involved in producing their care plans and completed their own daily risk assessments alongside staff members. There had been an improvement in the governance systems and processes within the hospital following an unsettled period on the ward.

During an assessment of the hospital overall

Nightingale Hospital is an independent hospital that provides mental health care and treatment for people who may or may not be detained under the Mental Health Act 1983. The service provides 4 acute wards for adults of working age, 1 obsessive compulsive disorder ward, 1 substance misuse and detoxification ward, and 1 specialist eating disorder service for adults. The eating disorder ward is located in a separate nine-bedded three-storey building. Bendall Mews eating disorder unit provides eating disorder services for individuals aged 18 and above. Treatment can be accessed as part of an outpatient, day patient or inpatient programme. We carried out our on-site assessment of the service on 17 April and 13 June 2024. We carried out this assessment to check on compliance with requirements from the previous inspection in June 2022 and in response to feedback about the service received by CQC. At the previous inspection the eating disorder service was rated Requires Improvement in all key questions except Responsive which was rated Good, leading to an overall rating of Requires Improvement. As part of the assessment we spoke with 8 patients, 4 relatives/carers of patients, and an independent advocate who attend the service. We spoke with 11 staff members including the consultant psychiatrist, ward manager, dietitian, psychotherapist, and psychologist, 2 registered nurses, a student nurse, 3 non-registered nurses, and looked at 7 patients’ care records, 3 patients medication records, checked the clinic room and unit environment, and attended a staff handover meeting between shifts. We looked at health and safety records of the service and a selection of staff recruitment records, and training supervision and appraisal records. Overall, we found that patients felt safe in the service, and most relatives of people using the service were positive about staff care and treatment. However, some raised concerns about incidents that had occurred on or off the hospital premises. The environment was clean, and well maintained. Patients said that staff were readily available and generally supported them with kindness. However, they raised concerns about the number of bank or agency staff that worked with them, some of whom did not always support them sensitively. The ward manager was working to address these concerns about bank and agency staff, providing them with improved inductions and training. Patients were involved in producing their care plans and completed their own daily risk assessments alongside staff members. They were supported with medicines appropriately and provided with relevant information about their treatment. Patients said that staff helped them to prepare for stepping down to being day patients with appropriate advice and consideration of risks that they would face. They were positive about the range of psychological interventions available to them, describing staff as kind, empathetic, and going the extra mile to support them. As required at the previous inspection in June 2022, there had been an improvement in the governance systems and processes within the hospital. Management of the clinic room and medicines management had improved, a new and more appropriate chair was provided for nasogastric feeding. Staff were using a recognised risk assessment to ensure patients’ skin integrity. Managers had taken steps to improve consistency of staff compassion and empathy, although this was still an area to be addressed with the use of bank and agency staff. Patients and carers felt that the hospital looked into their complaints and made changes accordingly. However, prior to the inspection, a small number of patients and carers were unhappy with how responsive the service was to their concerns. Staff described a recent difficult period on the ward when many patients had significant needs, and they had struggled to manage their care effectively. They said that senior managers had stepped in to suport them.

7 June 2022 - 17 June 2022

During a routine inspection

We rated acute wards for adults of working age and specialist eating disorder wards as requires improvement overall. We rated the substance misuse ward as good overall.

We rated Nightingale Hospital as requires improvement because:

  • Staff completed ligature risk assessments for wards, but these were missing important details, confusing and lacked clear plans in place to mitigate risks identified. Some staff we spoke with did not know how to find the risk assessment.
  • Staff developed care plans but did not always reflect patient risks, needs and goals on the acute and eating disorder wards. We found that staff reviewed care plans on a regular basis but there was no evidence that these reviews were meaningful in terms of making appropriate changes in line with patients’ current presentation. Care plans for day patients in eating disorder had not been reviewed after they were discharged from the ward, so were not an up to date reflection of their care.
  • The service had systems and processes in place to provide assurance and deliver the organisation’s services safely, but these were not always effective. We found areas for improvement in their governance processes. Although performance data was collected, there was limited evidence of improvements. For example, the quality of some essential patient records were still not adequate and could lead to unsafe care and treatment.
  • The service had not documented a specific risk assessment for a patient under 18 years old admitted to an adult ward, including consideration of risk related to their age and vulnerability.
  • Staff did not use a recognised risk assessment for patients in terms of their tissue viability (to monitor their risk of developing pressure ulcers) on the eating disorders ward and the ward did not have a safe and appropriate chair for patients who needed feeding by naso-gastric tubing.
  • Patients in eating disorder ward described some variability in the way different staff treated them, with some staff not understanding their individual needs, and not treating them with compassion and kindness and respecting their privacy and dignity.
  • Although records showed that staff checked emergency equipment weekly some of it had expired, removed from the emergency kit and not been replaced. A defibrillator was noted to have had a low battery since May 2022. It was not clear from the paperwork or from talking to staff how this identified issue had been actioned.
  • Some prescription charts on the acute wards did not record the name of the patient or the name of the prescriber, which meant there was a risk of patients being given the incorrect medicines.
  • Staff did not always document discharge plans or approximate dates of discharge for all the care records we reviewed on the acute, obsessive compulsive ward and eating disorder wards. It was difficult to ascertain whether these discussions had happened with the patients by looking at their records.
  • The overall vacancy rate at the hospital for clinical staff was 29%. The hospital had used long term contracts with bank and agency staff to fill these roles. Staff vacancies had been filled with long term locum staff. This had the potential to affect continuity of patient care.
  • The service was not smoke-free in line with best practice.
  • The services used closed circuit television (CCTV) in all communal areas but did not have signs to make people aware of the use of CCTV. We raised this with the staff who promptly added the signs.
  • Female patients on the substance misuse service mixed sex ward did not have access to a female only lounge.
  • The provider had not developed staff competencies for key tasks specific to treating patients with eating disorders and autism.
  • Clinic room temperatures in the substance misuse ward were above 25 degrees, which is above the recommended temperature for the storage of medicines.

However:

  • Staff in substance misuse service, acute wards and obsessive compulsive disorder wards treated people with compassion and kindness and understood their individual needs.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary team.
  • The daily handover sheets were very informative and had key patient information that staff reported to be useful.
  • Patients on acute and substance misuse wards felt that nurses were responsive, any issues raised are promptly addressed and patients enjoyed therapy groups.
  • All records we reviewed in the substance misuse ward included a comprehensive assessment of patients’ drug and/or alcohol dependence level, healthcare and other needs.
  • The substance misuse ward met the needs of all patients – including those with a protected characteristic. The ward had recently held an LGBT+ event on the ward, where advice and information about services that support the LGBT+ community was shared.

4-5 March 2019

During a routine inspection

We rated the Nightingale Hospital as good overall because:

  • When we inspected the Nightingale Hospital in January 2018, we rated the hospital as requires improvement. At the current inspection, we conducted a comprehensive inspection and rated all core services as Good. We did not inspect the children and adolescent mental health (CAMHS) ward, which had been closed since December 2017 as the provider submitted evidence that they were no longer providing this service. 
  • The provider had made significant changes to address areas of concern highlighted at the previous inspection in January 2018. A new hospital director was in post and he had recently introduced the roles of staff and patient representatives. They met regularly with the senior management team to bring about improvements at the hospital.
  • At the previous inspection in January 2018 we found that there were insufficiently robust governance and quality assurance processes in place to identify areas for improvement promptly. At the current inspection we found that the hospital director had identified immediate challenges relating to the facilities and nurse leadership, and had introduced the posts of head of facilities, and ward manager to address them. The hospital managers were undertaking more audits to monitor quality across the hospital. They had also undertaken a review of procedures and processes to improve systems to prevent illicit substances from being brought into the hospital. Improvements had been made to the frequency and quality of searches, including a visit by specially trained sniffer dogs. We also found improvements in ensuring were aware of the learning from incidents across the hospital, staff recruitment checks and protocols for risk assessment prior to opening, closing or relocating wards, as required at the previous inspection.
  • At our previous inspections in January 2018 and February 2017, we found that the hospital did not have an effective system in place for staff to alert other staff when they needed urgent assistance, and staff were not aware of the ligature point risks on their wards. At the current inspection we found that staff had been provided with personal alarms, and significant maintenance work was being undertaken to reduce ligature risks. Staff were aware of ligature risks as specified in the ligature risk assessment for each ward, and how to mitigate these risks.
  • At the previous inspections in January 2018 and February 2017, we found that staff had insufficient training in their roles supporting patients with addictions and eating disorders, and did not have annual appraisals. This had improved at the current inspection, and we found that staff were now clear about the validated tools to use for patients on detoxification from different substances. They were also receiving annual appraisals. Staff were also ensuring that patients were always prescribed and administered medicines in line with national guidance, as required at the previous inspection.
  • At the previous inspection in January 2018, we found that clinic rooms were not always clean, and staff could not access the most recent infection control audit. There were also gaps in completing action identified at the most recent fire safety assessment. At the current inspection, we found that all clinic rooms that were in use were clean, and there were records of when routine cleaning tasks were undertaken. Staff had access to the most recent infection control audit, and all actions from the current fire risk assessment had been completed.
  • At the previous inspection in January 2018, we found that patient care plans were generic and patients had not been involved in the development of their care plan. At the current inspection we found that care plans were individualised and had clear input from patients. We also found that on the specialist eating disorders ward, informal patients were now clear about their right to leave the ward, and patients were assessed for their risk of developing pressure ulcers, as required at the last inspection.
  • At our previous inspections in January 2018, and February 2017, we found that, on the mixed sex acute ward, there was no provision for a female only lounge. During the current inspection, we found that patients on this ward were risk assessed, and could be relocated to a single sex ward if required. Female patients on the mixed sex ward were able to access a female only ward on the first floor.
  • At the previous inspection in January 2018 we found that complaint responses were not consistently of a high standard. During the current inspection we found that complaint responses were appropriately worded, addressed each area of concern, and highlighted the next steps to take if the complainant was unsatisfied.
  • Weekly timetables for patients on each ward included a range of activities that supported the recovery and wellbeing of patients. Patients gave very positive feedback about staff and we saw staff were supportive and kind when interacting with patients. There were enough medical, nursing and therapeutic staff to provide care and treatment to patients and meet with them regularly for one-to-one support.
  • On the eating disorder ward relatives and carers were offered a fortnightly support and education group. On the substance misuse ward, monthly family days were arranged for patients’ relatives to attend, and a free aftercare weekly session was provided for patients on discharge from the ward.

However:

  • Staff were not fully implementing procedures to prevent banned items such as plastic bags from being brought onto the wards. Plastic bags had been banned following a serious incident at the hospital. Staff told us that they were not always offered a debriefing session and support following a serious or challenging incident.
  • Day patients on the eating disorders ward did not always have current risk assessments and care plans in place to ensure their safety and wellbeing. Discharge plans for patients with eating disorders did not always include sufficient detail including future options for support. There was also no system in place for reviewing any blanket restrictions on the wards, such as locking laundry and activity room facilities when not in use. The hospital did not have a smoke-free policy, in line with best practice guidance.
  • Although staff had received specialist training in addictions and eating disorders, nursing competencies for staff working on the addiction unit and those for the eating disorder service were not specific to the care of patients with those particular needs to ensure that staff understood the specialist training they received. Staff did not have any training in working with patients who have autism, to ensure that patients with autism received appropriate support.
  • There was no system in place to check mattresses and all soft furnishings in the hospital on a regular basis, and record when they were deep-cleaned to ensure appropriate infection control.
  • The route taken by patients on the eating disorder ward to access the hospital restaurant, needed to be reviewed, to ensure that it did not impact on their comfort and dignity. Patient records were not always being stored in locked cabinets when they were not in use, which could potentially breach patient confidentiality
  • Staff on the wards were unable to access the results of recent audits, and there was no clear evidence of changes made as a result. Staff meetings were not always held on a regular basis including standard agenda items related to quality and safety, and staff were not always able to access a clear record of the minutes of the last meeting. In addition, staff did not always have easy access to legible, accurate and up to date information about patients when they are admitted to the service, and at shift handovers.

15, 16, 17, 19, 21 January 2018

During an inspection looking at part of the service

We conducted a comprehensive inspection and rated the specialist eating disorder service at the Nightingale Hospital as Requires Improvement.

We conducted focussed inspections of the other core services to check on progress with meeting the regulations. We did not re-rate these core services. We were unable to inspect the children and adolescent mental health (CAMHS) ward, as it was closed.

  • When we inspected the Nightingale Hospital in February 2017, we rated the hospital as requires improvement and found breaches of four regulations, two of which had still not been met at the current inspection. We found significant additional concerns relating to these two regulations, and breaches of a further four regulations at the current inspection.
  • At the previous inspection in February 2017, we found that staff were not provided with an alarm system for use to summon assistance in an emergency. This had not been addressed by the time of the current inspection, although alarms had been ordered.
  • At the previous inspection in February 2017, we found that staff were not clear about the ligature risks and the management plans on each ward to mitigate risks. This remained a concern at the current inspection, although work had been undertaken to reduce ligature risks across the hospital.
  • At the previous inspection in February 2017, we found that staff had insufficient training in their roles supporting patients with addictions, and eating disorders. This remained a concern at the current inspection. We also found that staff were not clear about the validated tools to use with patients on detoxification from different substances. Staff did not sufficiently protect patients undertaking detoxification from harm as they were unclear about action to take in the event of alcohol withdrawal seizures or opiate overdose.
  • At the previous inspection in February 2017, we found that staff were not having annual appraisals. This was still not happening at the time of the current inspection.
  • At our previous inspection in February 2017 we found that on the mixed sex acute ward, there was no female only lounge in line with recommendations from national guidance on same sex wards. During this inspection, we found that there was still no female only lounge on this ward or risk management plan in place to address this issue.
  • Staff were not storing, administering and monitoring patients’ medicines safely.
  • The provider had not fully addressed all actions from the most recent fire risk assessment within the deadline set.
  • There were insufficiently rigorous infection control systems in place to ensure that all areas of the wards were clean.
  • There were insufficiently robust governance and quality assurance processes in place to identify areas for improvement promptly. The provider had not carried out an appropriate level of planning and risk assessment before the eating disorder ward moved location.
  • A review was needed of procedures and processes to reduce illicit substances being brought into the hospital and to ensure these were followed by all staff.
  • Complaints were not always addressed appropriately, complainants were not told about the steps to take if they were not satisfied with the provider’s response.
  • The provider did not have an effective system in place to ensure staff knew about and learned from incidents. Staff team meetings were not held on a regular basis and there was no standard agenda covering learning from incidents.
  • Insufficiently rigorous recruitment checks were carried out for new staff, such as obtaining two written references.
  • Improvements were also needed in the following areas; recording mental capacity assessments, ensuring informal patients on the eating disorders ward had clear information about their right to leave the ward and access fresh air and in storing patient records securely.

However:

  • At the previous inspection in February 2017, we found that staff were not receiving regular supervision sessions. We found that this had improved at the current inspection. We also found an improvement in notifying the Care Quality Commission of safeguarding alerts raised with the local authority.
  • At the previous inspection in February 2017, we found that a generic assessment was in use on the substance misuse and detoxification ward, which meant they did not have detailed information about the patient’s history of drug or alcohol use. A detailed substance misuse risk assessment was in place at the time of the current inspection, including prompts to check safeguarding arrangements for any dependants, and permission to contact the patients’ GP.
  • At the previous inspection in February 2017, we found that in the substance misuse and detoxification ward, the staff did not routinely offer patients tests for blood borne viruses (BBV) and did not keep adrenaline on its emergency medication trolley. Adrenaline was available as appropriate at the current inspection and we found improvements in offering patients BBV screening.
  • Most patients were positive about the therapies available to them and spoke highly of the level of support provided by staff across the hospital.
  • There was a positive reporting culture for when things went wrong.

21-23 February 2017

During a routine inspection

We rated the Nightingale Hospital as requires improvement overall because:

  • We previously inspected the Nightingale Hospital in October 2015. At this inspection we found that the requirements from the inspection in October 2015 had been mostly met and improvements had been made.
  • However, some of the previous requirements from the inspection in October 2015 had been partly met and where needed, ongoing requirement notices have remained in place.
  • In October 2015, the provider had not addressed risks from ligature anchor points as part of its environmental risk assessment. Clear timescales were not available to remove ligature anchor points. At this inspection, building works to remove ligature anchor points had started and this work was due to be completed by December 2017, so some wards, including two acute wards, still had ligature anchor points in place. Each ward had a ligature risk assessment, but during the inspection these documents could not be found on some wards and staff could not clearly articulate how they minimise risks from ligature points and keep patients safe.
  • In October 2015, the provider was not ensuring that when rapid tranquilisation was administered, physical health checks were carried out and recorded. At this inspection we found that while rapid tranquilisation was used very rarely this recording still needed to improve.

There was an outstanding recommendation from the inspection in October 2015, which was now a requirement from this inspection:

  • In October 2015, the wards did not have wall-based fixed alarms and staff did not have personal alarms. At this inspection we found staff did not have access to an effective alarm system in all of the wards to alert other staff that they needed urgent assistance.

During this inspection we also found that:

  • Supervision levels and appraisal rates in all the services were not adequate..
  • Allegations of abuse were not routinely being notified to the Care Quality Commission.
  • Staff were not receiving specialist training to support them to be able to deliver effective care to patients on the CAMHS ward or the substance misuse and detoxification ward.
  • Children safeguarding training completion rates were low across the hospital and not all staff working on the CAMHS unit had received children’s safeguarding training.
  • Staff were not completing appropriate assessments on the substance misuse and detoxification ward and withdrawal and rating scales were not routinely used.
  • In the substance misuse and detoxification ward, the service did not always inform the patient’s GP that the patient had been admitted and to corroborate the patient’s medical history, and staff did not routinely ask patients about the safety of children they cared for.
  • Staff did not always know the whereabouts of patients as patients had access to a number of areas throughout the hospital, even when they were potentially at risk of harming themselves or others.
  • Systems were not in place to ensure all clinical staff had the opportunity to learn from incidents. Following the inspection in October 2015, the service no longer graded incidents.
  • The service did not implement the actions required as evidenced by its infection control audit in 2016.
  • Young people in the CAMHS unit did not have daily regular access to fresh air.
  • Young people were being asked to sign a document giving their consent to being restrained in the event of them having violent behaviour. This did not reflect their individual needs.

However we also found areas where the care provided was very positive:

  • The service delivered individualised care plans according to patients’ needs and patients spoke highly of the care and treatment from nursing staff and therapists.
  • Patients had access to a large range of rooms and equipment to support their treatment and therapy.
  • The service offered a range of psychological therapies and a dietician had input into the wards.
  • Morale was high and the staff group felt supported by their peers and their manager.

27-29 October 2015

During a routine inspection

We rated The Nightingale Hospital as good because:

  • Staff delivered individualised care plans according to patients’ needs. Patients had access to group therapy programmes and one-to-one sessions.
  • Staff showed a good understanding of the Mental Health Act Code of Practice and its guiding principles.
  • In the patient satisfaction survey, patients spoke highly of care and treatment from nursing staff and therapists.
  • Patients had access to a large range of rooms and equipment to support their treatment and therapy.
  • Staff supported patients with complaints. Information was available in the form of a leaflet or poster.
  • Patients had a good choice of meals. Patients we spoke with told us the quality of food was good and had no complaints.
  • Staff understood the values of the organisation. Staff were aware of senior managers in the organisation and told us they regularly visited the ward.

However:

  • The provider had not addressed ligature risks in its environmental risk assessment. Environmental risk assessments did not indicate timescales for work to address identified ligatures. Examples of ligatures included en suite bathrooms in patients’ bedrooms that had standard tap fittings.
  • We tested the defibrillator on the second floor and it was not charged. This was a risk to patients if they needed cardiac treatment as it could result in delays in patients receiving urgent care in an emergency.
  • Wards did not have wall-based fixed alarms and staff did not have personal alarms. Staff felt unsafe if there were challenging patients admitted to wards.
  • On three occasions staff had not carried out physical observations after administering rapid tranquilisation with no rapid tranquilisation audit system in place to monitor use.
  • Staff knew how to report an incident and senior management gave us examples on how they had learnt from incidents. When we asked staff on wards for instances of learning they did not provide any clear examples.
  • Staff mitigated risk of harm through hourly observation-based risk assessments but did not have access to an overview of updated risks in one place. Risks were stored and updated in different places in patient files, meaning staff had to look in several different places to find the information. How staff developed a plan to mitigate risk was unclear.
  • We reviewed documents that recorded multiple incidents of restraint (intervention that prevents a person from behaving in ways that threaten to cause harm to themselves, to others, or to property and/or equipment) on one form. Staff had not indicated the amount of time they had restrained patients held in the prone (placing a person face down) position.
  • Some informal patients did not always clearly understand their rights.
  • The privacy and dignity of patients was not maintained on the young persons unit. When conducting routine observations of patients, members of staff often were not considerate and woke patients in the middle of the night. Male members of staff who were completing observations on female patients were routinely entering female sleeping areas at night compromising privacy and dignity.
  • Two patients told us they did not have a copy of their care plan.

15 December 2014

During a routine inspection

During our visit we spoke with 15 people who use the service across the young people and adult wards. We spoke with a minimum of 14 staff, including the manager, quality compliance manager, doctor, nurses and healthcare assistants. We also spent time talking with the Independent Mental Health Advocate who met with people during the inspection.

We received divided feedback about the service that people received. People in the young persons and eating disorders units were more positive about their experience than people using the general psychiatry wards. Similarly, the input of people into their care and treatment plans varied across the wards, where some people felt fully involved and others did not feel involved in decisions about their care.

Staff knew about different types of abuse and the local procedures for reporting these, though were unclear of external agencies where they could report concerns.

However, the provider did not always act in accordance with legal requirements in relation to the continual supervision of people who use the service. We also found a number of areas in the environment that were potentially unsafe for people and staff. People were also at risk of unsafe care where there was a lack of appropriate risk management.

2 October 2012

During a routine inspection

The provider had mechanisms in place to obtain consent from people who use the service. People who use the service told us that they consented to the care that was delivered to them and staff only carried out activities that they were "happy" for them to do.

Staff understood the requirements of the Mental Capacity Act 2005 and had attended relevant training. The provider carried out decision-specific Mental Capacity Assessments on people who it was felt lacked the capacity to make certain decisions. People who were detained under the Mental Health Act 1983 (the Act) gave their consent to treatment and had their capacity assessed to make specific decisions.

Staff assessed the needs and risks of people using the service. Each person had an individual care plan that was based on their assessed needs and risks. People using the service told us that they were "satisfied" with the quality of care they received. Staff were described as "caring", "wonderful" and "helpful".

People using the service told us that they felt safe at the home and if they had concerns they would report it to the nurse in charge. We observed that each floor was appropriately staffed on the day of our visit. Staff made records of people's care that were clear, concise and legible. People using the service files were kept in lockable filing cabinets in staff offices and were easily accessible to staff when required.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.