• Mental Health
  • Independent mental health service

Archived: Cedar House

Overall: Inadequate read more about inspection ratings

Dover Road, Barham, Canterbury, Kent, CT4 6PW (01227) 833700

Provided and run by:
Huntercombe (Granby One) Limited

Important: The provider of this service changed. See old profile
Important: The provider of this service changed. See new profile

All Inspections

15 September 2020

During an inspection looking at part of the service

Cedar House hospital provides low secure inpatient services for adults with a learning disability or autism who have offending or challenging behaviour and complex mental health needs.

The purpose of this inspection was to follow up on the warning notice that was served by the Care Quality Commission immediately following the unannounced, focused inspection on 21 July 2020. We served the warning notice because the provider was failing to comply with Regulation 12 (Safe Care and Treatment) because of the following reasons:

  • Failure to deploy enough suitably qualified, experienced and competent staff to deliver safe care along with a failure by the leadership team at both the hospital and provider level to recognise this
  • Lack of robust risk assessment and management of risk resulting in a high number of assaults on staff and patients
  • Not carrying out observations appropriately and safely
  • Reliance on the use of ‘as required’ medication (PRN)
  • Confusion and lack of understanding about the use of emergency equipment and emergency medicines.

We told the provider it must take immediate action to meet the requirements of the regulation

This inspection was an unannounced, focused inspection. We did not rate the service on this inspection. The previous rating of inadequate overall still stands and the hospital remains in special measures.

At the inspection we found:

  • Staffing levels across the hospital had improved and the hospital managers were recruiting more staff and working towards maintaining maintain safe staff levels. An additional member of staff had been allocated for teams on Folkestone ward and the Enhanced Low Secure Service. This meant more staff were available to support observations and manage incidents. The staffing level on Poplar ward had improved and there was no longer only one member of staff working alone.
  • We found most observation records we checked met basic standards.
  • There was a reduction in over-reliance on as required medication (PRN), following an audit of PRN, and the hospital had started to introduce ways to reduce patient incidents via what it called Calm cards; these outlined behavioural coping strategies that were used before staff gave PRN.
  • The hospital had implemented Positive Behaviour Support (PBS) champions in order to improve the usage of the PBS interventions and reduce incidents. They were working with an external organisation to further develop staff understanding and implementation of PBS. PBS is a recognised method for helping some patients with a learning disability to develop less-challenging ways of interacting with others.
  • Managers were being supported to make improvements at the hospital. This included weekly calls from Huntercombe senior managers and input from external organisations, which were providing support to managers to reduce inappropriate placements and carrying out a project with staff to develop a shared vision for the future. Managers were actively focused on providing better care for patients who were inappropriately placed at the hospital.
  • The reasons for low morale amongst some staff due to safety had been recognised and the service was working with staff to respond to their concerns and make changes that would benefit them.
  • Managers had developed action plans for service improvements. The hospital had a plan in place to improve the environment and we saw new flooring being installed on some of the wards and some bedrooms and a dining room were being painted. There was a rolling programme of repairs.
  • During the inspection, we observed positive staff and patient interactions and good use of distraction and de-escalation techniques by staff.
  • There were now two emergency bags and two emergency response teams at the hospital and staff were better informed about the use of emergency medicines.

However

  • The ward environments on Folkestone, Folkestone ELS, Rochester and Maidstone wards were not clean. There was no regular cleaner for the wards employed by the organisation at the time of the inspection. Night staff had been asked to clean the wards but day staff told us they also had to clean the wards at the same time as working with patients and carrying out their caring duties. Contract cleaners were employed to do a deep clean on the wards monthly and the provider was advertising for housekeeping staff. In laundry rooms on two wards we saw chemicals were open and potentially accessible by patients, and there was loose tubing and items that were potential trip hazards. Bathrooms and toilets were not clean on Folkestone ward and the Enhanced Low Secure Service.
  • Between 22 July 2020 and 18 September 2020 there were 11 assaults on patients and 20 staff had taken time off work after incidents. Of the 830 incidents recorded, 11.8% resulted in minor or moderate injury to staff or patients. This meant we were not fully assured that the provider had assessed and mitigated the risks to patients and staff.
  • Despite the improvements in staffing levels and the work being done to ensure safe staffing levels, staff we spoke to had concerns about the confidence and competence of staff, as many were new or agency and did not know patients well.
  • Staff did not always develop holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff did not always store care records in one place. We found care plans on the electronic patient record system but also some were kept in a shared drive. Sometimes staff could not locate specific information they might need to guide their interventions with patients.

Physical health care plans were not always easy to locate in the electronic record system and some were kept in folders in a shared drive.

  • Wards did not always keep detailed enough handover notes to ensure staff on the next shift knew about the patient’s needs.
  • Two of the wards do not have a separate garden area from the shared hospital grounds, this meant that patients could not always access the grounds when the wards were busy and there were not enough staff on the ward. There were not always enough activities available to patients on wards
  • Ward staff told us that some multidisciplinary team members did not have a presence on the wards and therefore lacked a real understanding of patients risks and challenges presented on wards. Ward staff did not feel supported by some members of the multidisciplinary team.
  • Relatives and carers said they could not always visit their loved ones at the hospital and that the provider did not always respond to their concerns. Staff told us that restrictions due to Covid-19 had meant relatives and carers could not always visit their loved ones inside the hospital.

Although, there is still much work to do at Cedar House hospital there had been enough progress with improvements required as identified in the warning notice alongside plans in place to continue the improvements. We have therefore decided to lift the warning notice.

However, we will continue to monitor the hospital closely and will not hesitate to take action should the improvements not continue.

21, 23, 24, 27 July 2020

During an inspection looking at part of the service

Following this inspection, the Care Quality Commission issued a warning notice due to immediate concerns about the safety of patients using the service. We required the provider to make significant improvements to the safety of the service by 7 September 2020. The provider decided to suspend any new admissions at this time while they address concerns raised.

This inspection was a focused inspection; we did not provide a rating. The purpose of the inspection was to follow up on concerns that were found at the last inspection in February 2020 where the hospital was rated inadequate and placed in special measures. At the last inspection we found that the hospital was not always able to meet the complex needs of some of the patients. There was high use of restraint on patients and for long periods of time. Some patients had been in long term segregation for longer than was necessary. The environment was unclean and damaged in places. Ligature risk assessments were carried out but did not clearly state mitigation to reduce the risks. There was a lack of presence of senior and multi-disciplinary team members on the wards, and some staff did not always know patients well and what their needs were. We also had concerns raised about patients’ safety due to the high number of incidents at the hospital.

On 21 July 2020 we undertook an unannounced focussed inspection at Cedar House, the inspection continued remotely on 23, 24 and 27 July 2020. During the inspections we found:

  • Staff and patients told us there were not enough staff to meet the needs of the patients and that they did not always feel safe. The staffing attendance register confirmed there were not always enough staff on duty. One ward often had only one member of staff to support five patients on night shifts. Staff were often deployed to other wards to help out due to lack of staffing, this then left their ward and patients who required a certain level of staffing short. This meant there was an increased risk of harm to patients and staff.
  • There was a high number of incidents of aggression resulting in harm from patients to other patients or patients to staff. Subsequently, there were a high number of incidents of restraint used on patients. Staff were regularly off sick due to assaults on them which resulted in injury or stress. Following incidents there was a lack of learning or improvements made.
  • There was only one emergency equipment bag for the entire hospital. In this bag there were some emergency medicines used should a patient go into respiratory distress which can be a side effect of taking benzodiazepine medicines. Not all staff were aware that these medicines were at the hospital and there was mixed knowledge of this within the management team also. This placed patients at risk should they need this emergency medicine.
  • We reviewed medicines records on Folkstone and Folkstone enhanced low secure (ELS) wards. We found there was high use of PRN (as required) medicines used to manage patients’ behaviour and some staff told us this was used before other de-escalation techniques were used.
  • Care plans and positive behaviour plans used by staff providing day to day care for patients were conflicting and did not give clear direction of how staff should meet patients’ needs. These care plans were not person centred or written appropriately for patients with a learning disability.
  • There was no section at the front of the long files which gave brief summaries of patients’ needs and risks. This meant that should staff need to check information on a patient quickly, this was not easy to find.
  • Staff told us that ward managers, senior management and the clinical team did not spend much time on the wards. This meant that staff and patients did not get the support and input from other members of the team consistently.
  • We carried out observations and found that although staff managed patients’ behaviours well, there were little other interactions between staff and patients.
  • Patients physical health needs were not always monitored effectively or as regularly as required.
  • During our inspection we were given conflicting information from staff and the management team with regards to patients’ needs, staffing levels required and what emergency equipment was available.
  • Our findings from the other key questions demonstrated that governance processes did not operate effectively in identifying improvements needed, or where they did there was no clear plan that ensured these changes were made.
  • Staff morale was low due to lack of safe staffing levels and the high number of incidents in the hospital.

However:

  • The hospital was clean throughout.
  • Some improvements had been made since our last inspection in February 2020. The provider had begun works to improve the environment of the hospital.

19, 20, 25 February 2020

During a routine inspection

On the basis of this inspection, the Chief Inspector of Hospitals has recommended that the provider be placed into special measures.

We rated Cedar House inadequate because:

• The hospital was not always able to adequately meet the complex needs of some of the patients. These patients had behaviours that were very challenging for staff to manage but the measures in place to manage their needs and risks (such as long-term segregation and use of physical restraint) had impacted negatively on their quality of life.

• There were high levels of restraint at the hospital. Staff who were unfamiliar with patients did not always follow de-escalation techniques before restraint was used.

• All wards we visited looked tired and showed signs of damage which could present a safety risk for patients. Four of the six wards were visibly unclean. We raised this at the time of the inspection and undertook a further visit five days later and found that short term repairs to the environment had been made. All the wards at the service still looked bare.

• The hospital had insufficient systems and processes in place to ensure all environmental risks were identified and mitigated. The ligature risk assessment did not identify how some of the identified risks should be mitigated.

• Whilst there were always enough staff on each shift, there was an increasing vacancy rate and increasing use of agency staff, many of whom were often unfamiliar with the patients. Therefore, some permanent staff members felt there were not enough staff who knew patients well enough to provide good quality care and meet patient needs at all times.

• We found blanket restrictions on all the secure wards. Button batteries were not allowed on the wards. Patients had not had individual risk assessments to decide whether this restriction was necessary.

• A small number of patients had been receiving care and treatment at the hospital for too long. Senior managers were working with commissioners to identify alternative placements and support the transfer of patients.

• Senior managers were not visible in the service and nursing staff felt they did not understand the daily challenges on the wards. Some nursing staff felt that the psychology team were rarely present on the wards. Staff from different disciplines appeared to work in isolation and there was a disconnect between the nursing team and the wide multi-disciplinary team. Whilst ward managers were felt to be supportive, they were not based on the ward which affected their availability to lead and oversee care. Feedback from staff was that they did not always have enough time, training or support to provide person centred care for people.

• Support staff had a limited understanding of why some patients could have section 17 leave and others could not.

However:

• Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff recognised incidents and reported them appropriately. The senior management team had effective working relationships with stakeholders to review patient related incidents.

• The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medicines on each patient’s physical health. They knew about and worked towards achieving the aims of STOMP (stopping over-medication of people with a learning disability, autism or both).

• Staff provided a range of treatment and care for patients based on national guidance and best practice; this included access to psychological therapies. Patients had access to occupational therapies. Staff supported patients with their physical health and encouraged them to live healthier lives.

• Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They supported patients to understand and manage their care, treatment or condition. Staff actively sought patient feedback on the quality of care provided and enabled them to contribute to decisions about how the hospital operated. They ensured that patients had easy access to independent advocates. Staff informed and involved families and carers appropriately.

• Staff supported patients to access a range of therapeutic activities, opportunities for education and developing skills for employment within the hospital and local community.

22 May 2019

During an inspection looking at part of the service

We did not rate the service during this inspection as this was a focussed, unannounced inspection to follow up on concerns raised about the use of long-term segregation and overall management of incidents.

We found:

  • The ward maintained a secure environment appropriate for a low secure, enhanced care setting. The environment was safe, clean and well-maintained.
  • The ward operated with enough numbers of appropriately qualified staff. They were trained and supervised to be able to support people with learning disabilities or autism.
  • Ward staff managed patients’ risks on an individual basis. The ward contained a seclusion suite. Staff worked hard to ensure patients were not being cared for in an overly restrictive way and staff were trained in physical interventions which were used as a last resort if necessary.
  • Staff on the ward had been able to manage one patient who had previously been in long term segregation in the main ward environment. Similarly, they had supported patients to reduce the incidents of violence and aggression.
  • The ward had an effective system in place to summon police support to manage incidents when required.
  • Staff were aware how to report incidents, raise safeguarding concerns and manage complaints. All incidents were reviewed and investigated, and the ward used outcomes to learn lessons and improve practice.
  • Staff were appropriately trained to manage patient’s physical health needs and and access specialist physical health support when necessary. We saw examples of where patients with physical health issues had their needs identified and addressed.
  • The service supported patients with highly complex needs with care plans that covered all aspects of care and treatment. They used a positive behavioural support approach and prescribed medicine in line with national guidance.
  • Staff interacted with patients positively and with compassion. We observed lots of positive interactions between staff and patients including at times when patients were visibly agitated or distressed.
  • Medicines were stored safely and ward staff ensured medicines were in date and available for use when needed.

However,

  • Ward staff reported that in the three months prior to our inspection there had not been enough staff for them to safely manage patients on the ward which was highly unsettled at that time. They reported that staff were frequently being assaulted by patients and, at that time, they had not felt safe at work. However, we did not find these issues on the inspection.
  • Whilst staff supported patients to access a vast range of activities, these were patient led so sometimes lacked structure, which could prevent patients from developing effective therapeutic routines to support rehabilitation and recovery.
  • The provider did not always ensure that notifiable incidents were reported fully to the Care Quality Commission in a timely way.

22 - 24 January 2019

During a routine inspection

We rated the service as good because:

  • Overall, we observed lots of improvements since our last inspection. We noted that the culture had improved significantly and staff had worked hard to embed the behaviour support plans which staff told us had supported them to deliver person centred care.
  • The service maintained a secure environment appropriate for a low secure setting. Environments were safe, clean and well-maintained.
  • The service operated with sufficient numbers of appropriately qualified staff. They were trained and supervised to be able to support people with learning disabilities or autism.
  • The service managed patients’ risks on an individual basis. The service contained seclusion facilities and staff were trained in physical interventions. These were used as a last resort and patients were debriefed and supported following episodes.
  • Staff were aware how to report incidents, raise safeguarding concerns and manage complaints. All incidents were reviewed and investigated and the service used outcomes to learn lessons and improve practice.
  • The service had a team of staff who oversaw patients’ physical health needs. They were appropriate qualified and could recognise and access specialist physical health support when necessary. This team upskilled colleagues with a programme of training.
  • The service supported patients with care plans that covered all aspects of care and needs. They used a positive behavioural support approach and prescribed medicine in line with national guidance.
  • The psychology team offered a range of individual and group interventions that were relevant to the patients at the service. The occupational therapy team ran a course which focussed on patients’ individual recovery needs.
  • The service provided career progression opportunities. Support workers could gain nursing qualifications funded by the provider and nurses could attend leadership courses. All staff could access training in individual areas of interest, such as family work.
  • Staff interacted with patients positively and patiently. They followed details plans to help them deliver care to patients in a consistent way. Patients were supported to understand and be involved in their care plans.
  • The service had developed a family liaison nurse role to support communication between patients, their families and the service. They also had an onsite advocacy service that supported patients to give feedback and express their views.
  • The provider actively looked for solutions to meet the challenge of accommodating their patients after they left hospital. They were converting property, on another local site, into bespoke bungalows where patients could be accommodated.
  • The service provided an environment that promoted recovery and comfort, complete with information in an easy read format. Patients could personalise their rooms and choose their meals. Patients had access to the local community and this was encouraged to support their integration back into the community.
  • The provider had a vision, values and strategy that was patient-centred and installed in staff during induction and supervision. Their audit framework was based on regulations, national guidance and extracting learning opportunities.
  • Staff morale was high and the service had many initiatives to promote their well-being. The service participated in peer review schemes, contributed to research projects and used innovation to improve patient experience.

However,

  • The service was routinely using seat belt clips for two patients to stop patients undoing their seat belts whilst driving. They did not recognise this as a form of restriction and, therefore, had not assessed patients to ensure they were agreeable to them being used.
  • The service did not have care plans that fully promoted safe care and treatment for patients with symptoms and histories of epilepsy. However, the service acknowledged this and submitted an action plan to bring this area of care in line with national guidance.
  • The service completed seclusion records in line with national guidance. However, we found one instance where a female member of staff was observing a secluded male who was exhibiting sexually inappropriate behaviour. The was contrary to the provider’s seclusion policy.
  • We found some solution medicines had been opened without an opening date being recorded. This meant staff could not be assured they were safe to administer to patients.
  • Agency staff, on occasions, were entering notes on the electronic patient’s record system under substantive staff’s login details. This was due to them not using the agency login protocol. Furthermore, training in general data protection regulation was lower than the provider’s target.
  • We found that some forms, that documented patients’ consent to treatment, would have benefitted from being updated. Similarly, some financial capacity assessments would have benefitted from being reviewed.
  • Two out of seven carers we spoke with were unhappy about the service. They felt that their relatives had been their too long with little progress and felt the service had been unsupportive of their efforts to form an external carers’ group.

10 January 2018 and 30 January 2018 - 1 February 2018

During a routine inspection

We rated Cedar House as requires improvement because:

  • Staff followed poor infection control practice on Tonbridge ward. The ward was dirty and a patient had heavily soiled and dirty bed linen. We had concerns that staff and the senior management team had not picked up on the cleanliness issues on Tonbridge ward, particularly the dirty bathrooms and kitchen. In addition a patient had been expected to sleep in heavily soiled and unpleasant smelling bed linen. However, the provider rectified these concerns during our inspection.
  • Fixtures and fittings were not maintained to a satisfactory standard on all wards.
  • Not all paperwork associated with the use of seclusion was completed. In the Care Quality Commission review of seclusion in December 2017, two patients commented negatively about their experience of seclusion, however when we returned in January 2018 changes had been made to their care plans regarding seclusion.
  • 30% of the patients we spoke with made negative comments about the staff on the wards, for example that they did not care about them and that they did not have the time to spend quality time with them.
  • We found that staff accompanying patients to hospital did not take written information about patients’ physical health history to give to receiving healthcare professionals. The service relied on staff to verbally handover the patients’ history which could potentially lead to errors.

However:

  • Staff assessed patients’ needs and delivered care in line with the patients’ individual care plans. All patients received a physical health assessment. We carried out an unannounced visit to Cedar House on 10 January 2018 to look specifically at how the service monitored patients’ physical health. We reviewed six patients’ care records for the previous four weeks and found that, in the majority of cases, staff were responding to patients’ physical health needs appropriately. Care plans were personalised, holistic and recovery focused. Patients’ we spoke with told us that they were involved in the care planning process. Comprehensive risk assessments were in place for all patients on admission. All patients, where they had wanted to, and had consented to, had been involved in the risk assessment process.
  • We spoke with 28 patients, individually and in a focus group. We also received 15 comment cards from patients. The majority of patients we either spoke with or received comment cards from, 70%, made positive comments about their experience of care in Cedar House. Patients told us they got the help they needed to assist them with their recovery.
  • An excellent range of activities and groups were available to patients on all of the wards, facilitated by the activity co-ordinators, occupational therapy and ward staff. Patients had access to the education and therapy unit which was part of the recovery college, on site at Cedar House. The recovery college offered an extensive range of courses and groups.
  • The physical and procedural security at Cedar House was provided to a consistently good standard. Staff applied operational policies and procedures effectively which ensured the safety of patients, visitors and staff. Overall safe staffing levels were maintained. Cedar House staff had a 93% completion rate for mandatory training.
  • The provider’s vision, values and strategies for the service were evident and on display in all of the wards. Staff on the wards understood the vision and direction of the organisation. Staff we spoke with were able to discuss the philosophy of the hospital confidently.
  • All of the wards had access to governance systems which enabled them to monitor and manage the ward effectively and provide information to senior staff in the organisation and in a timely manner.

20-22 October 2015

During a routine inspection

We rated Cedar house as good because:

  • staff and patients kept the wards clean and well maintained and patients received specific training for this role
  • staff and patients told us that they felt safe
  • staff were suitably qualified and trained to provide care to a good standard
  • each patient had detailed risk assessments and risk plans that were thorough, up to date and person centred
  • staff followed guidance to report incidents and we saw staff learnt from them
  • staff assessed individual patient needs and planned their care thoroughly with a focus on recovery
  • staff assessed patients’ physical healthcare needs thoroughly and to a high standard
  • all staff we spoke to had a good understanding of the Mental Health Act 1983 (MHA), the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice
  • on all wards the multidisciplinary teams were consistently and proactively involved in patient care
  • multidisciplinary team members felt their contribution was equally valued
  • clinical meetings were effective and patient focused
  • staff told us the service offered good quality training and professional development opportunities and all staff took them up
  • staff interacted with patients in a respectful, patient, responsive and kind manner
  • all relatives and carers we spoke to commented on how caring and compassionate the staff were towards them and the patients
  • the service used innovative practices to engage and involve patients in their care and treatment
  • staff thoroughly understood relational security. This is how staff use their knowledge and understanding of their patients, to ensure they keep the ward calm and minimise any conflict
  • the service had effective bed management processes
  • the service had strong relationships with many commissioners
  • the service model encouraged patients’ recovery, comfort and dignity
  • there was a varied programme of recovery orientated therapeutic activities
  • the service listened to concerns or suggestions made by patients and their relatives to improve services, which they acknowledged and implemented when possible
  • staff told us their morale was good
  • there was a strong leadership team, made up of clinicians and managers, who engaged and supported staff
  • staff at every level felt part of the service and confidently discussed the philosophy of the hospital
  • the service looked to continually improve and innovate

However:

  • staff had not consistently checked the medicine fridge temperatures on four wards
  • when the alarm system was activated it sounded on all wards, which disrupted patients and staff each time it happened
  • most patients, who did not self- cater, complained about the food quality.

20 May 2014

During an inspection looking at part of the service

We carried out this inspection to follow up on non-compliance from previous inspections on 10 October 2013 and 22 November 2013. After the inspections the provider wrote to us to tell us what action they had taken to address this. At this inspection we looked at the non-compliance from previous inspections and confirmed that the provider had taken action, and was now compliant in these areas.

At a previous inspection we found that staff were not always aware of how care should be provided to people using the service, and there were inconsistencies in how care and incidents were recorded. At this inspection we found that the provider had addressed this, that care had been reviewed, and that key information about the care of people using the service was easily accessible. The service had implemented a new system for recording and monitoring incidents.

At a previous inspection we found the safeguarding processes to be non-compliant with a major impact on people using the service, and issued a warning notice which told the service they must take urgent action to address this. The service had not reported or responded appropriately to some of the safeguarding concerns that had been raised. At this inspection we confirmed that they had taken action to address the areas of non-compliance found at the previous inspection, and there were effective processes for reporting and responding to safeguarding concerns.

At a previous inspection we found that the seclusion room did not meet the expected environmental standards. At this inspection we found that this had been addressed.

At a previous inspection we found that the provider had not carried out all the necessary recruitment checks of all staff before they started work in the service. At this inspection we found that the provider had reviewed their processes to ensure that all new staff had the necessary recruitment checks completed before they worked unsupervised with people using the service; and had updated the recruitment records of existing staff where there were gaps.

22 November 2013

During an inspection in response to concerns

We undertook this responsive inspection as concerns had been raised about the patients nursed in segregation and patients nursed for periods in seclusion. Concerns had also been raised about how patients were protected from abuse at the hospital.

The inspection was undertaken with two Mental Health Act Commissioners.

At this inspection we went to four of the wards at the hospital. We looked at specific areas of care and support on these wards. We did not visit Poplar Ward or Tonbridge Ward.

The majority of patients who posed a risk to themselves or others had on-going multi - disciplinary assessments and plans of care in place. However, we found that the staff directly caring for one patient who was a high risk did not know the outcome of the MDT meetings and therefore did not have the guidance and support that they needed to care and support the patient in the best way.

Patients and staff told us that at times when incidents occurred on the ward they did not feel safe at the service.

The service had not taken the appropriate action to report some incidents of abuse. This meant that patients could not be sure were fully protected from all types of abuse or neglect.

Patients who use the service rights to privacy, dignity, choice, autonomy and safety were not protected by the environment in which they lived.

10 October 2013

During an inspection looking at part of the service

We inspected two wards at the service: Folkestone ward and Maidstone ward. We spent most of the time at this inspection on Folkestone as this was the part of the service where concerns were identified at the last inspection.

On Folkestone ward patients told us that on the whole they felt involved in their care planning and they told us about their goals and aims. They were able to tell us what was in their care plans and about their aims and goals. Patients were involved with their Care Programme Approach planning meeting (CPA ). This meant that patients had a say about how their care and support was planned and delivered.

The procedures for the recruitment were not always adhered to by the service. This meant that patients may be at risk of receiving care and support from staff who had not been suitably vetted.

More staff had received up to date training they needed to make sure they had the knowledge and skills to deliver care and treatment to the patients safely and to an appropriate standard. Staff told us and records showed that staff received regular supervision to make sure they had the support and direction to carry out their roles effectively and safely.

We did find that about 40% of care staff had not received and annual appraisal. This meant that some care staff had not received the support to help them develop and promote their skills and knowledge so that this could be used to benefit the patients and themselves.

29, 30 May 2013

During an inspection in response to concerns

We inspected three wards at the service: Folkestone ward, Maidstone ward and Rochester ward. We did not inspect: Rochester annex, Tonbridge ward and Poplar on this occasion.

We found that patients had different experiences depending on where in the hospital they were living.

We found that 'blanket rules' at the hospital were being addressed. Patients were being individually assessed to support them in managing their monies when they left the hospital and whether or not they could have access to their mobile phones when on leave.

On Maidstone and Rochester ward patients told us that on the whole they felt involved in their care planning and they told us about their goals and aims. On Folkestone Ward some patients told us they did not know what was in their care plans and were not involved with planning their care. Patient's views and experiences were not always captured. Patients were involved with their Care Programme Approach planning meeting (CPA ). Patients told us that they did not have a copy of their care plan.

There was enough staff available on the wards to make sure patients were supported to go out into the community and attend activities. The patients on Maidstone ward told us that things had improved. There was more staff available and they were supported to participate in activities inside and outside the hospital. They said that things on the ward had improved as staff had more time to spend with them.

13, 14, 20 December 2012

During an inspection in response to concerns

This report is based on a visits that were carried out as part of a co-ordinated responsive inspection. We inspected three wards at the service: Folkestone Ward, Maidstone Ward and Rochester Annex. We did not inspect: Rochester Ward, Tonbridge Ward and Poplar on this occasion.

Patients and their relatives told us that they were involved in planning their treatment and care at the hospital and that they understood the choices available to them. However, we found that patient's views and experiences were not always captured and therefore there was no way of knowing if they were involved in how their treatment care and support was delivered.

Some patients we spoke with accepted the fact that they could not carry their own money and could not have access to mobile phones in the community. They said that this was one of the rules. We found that patients had not been individually assessed to determine whether this was possible for them not.

We saw that patients were responsive in the company of staff. Staff listened to what they said, took their views seriously and answered their questions in a way that they could understand. The staff we spoke with had knowledge and understanding of people's needs and knew patients routines and how they liked to be supported.

Patients said that staff kept them safe. They said that sometimes when there were behavioural incidences it was frightening but staff acted quickly to make sure patients were protected.

4 January and 18 September 2012

During a themed inspection looking at Learning Disability Services

There were 25 patients at Cedar House when we visited. We met and introduced ourselves to 20 patients. We spoke to 13 patients in more depth to get their views of the service.

One patient told us 'I'm happy, I like Cedar House and the staff treat me okay.'

We spoke with two relatives. Overall, they were satisfied with the care and treatment offered to their relative. They told us that staff encouraged their relative to be more independent and supported them well.

We asked patients what activities they did. They told us they did a range of activities including IT, life skills, going to the gym, cooking, listening to music in their bedroom, riding their bike and playing football. Patients told us that when their doctor agreed they could have leave outside the hospital, they could go out shopping with staff, go to the park, swimming and to the cinema. A relative said that their relative was encouraged to be active and participate in social activities outside of Cedar House, so increasing their links with the community.

One patient said, 'I've got lots to do, it's like a hotel with a gym here.' Patients talked to us about running their social club every evening. They said they organised the music, chatted, played games and had drinks and snacks from the shop that was run by the patients. They had parties there for patient's birthdays and Christmas.

Relatives told us that their relatives' health needs were well met. They told us that patients' physical and mental health was monitored regularly. They said 'Healthy living is encouraged well.' 'My relative regularly exercises at the gym.' 'Staff give my relative nutritional advice.' 'My relative sees the GP and dentist when needed, they have blood tests done when needed and input from the psychologist.'

Patients said they had visitors or went to visit their relatives with support from staff if needed. They told us they could contact their relatives by phone if they wanted to. Patients told us that they could phone their solicitor when they wanted to and staff helped them to do this, so ensuring their rights were respected.

Patients told us that staff knew what to do to manage their behaviour, described as challenging. They said that staff tried to calm them down by going somewhere private and talking to them.

Relatives told us that staff treated their relative well. They said, 'Staff speak to my relative in a way that is firm but fair and respectfully, as I would want to be spoken to.'

Patients told us that they felt safe. They said if they had any concerns, they would talk to staff who would make sure something was done about it to ensure their safety and well being.