Pathfinder Ashness House

Ashness House is a 26-bed inpatient service for males with severe and enduring mental health illness, co-morbid physical health problems and complex needs. Tide Ward has 19 inpatient rehabilitation beds and Coast Ward 7 High dependency beds.

This service was last inspected in December 2022, and the service was rated good overall. At that inspection, we found that some legal requirements were not met. We had concerns that the service did not always explain the Mental Health Act to patients in a way they could understand, and the service must provide more ways to help patients understand their rights. This was a breach of Regulation 9(1)(3)(b).

At this assessment we rated the service as Good.

We spoke with 8 members of staff, 6 patients and 5 carers. We also reviewed the care and treatment records of 6 patients.

We identified several areas of good practice during this inspection. Staff had a good understanding of incident reporting processes, knowing what incidents to report and the process for doing so. Staff told us they avoided using restraint by using de-escalation techniques. Most staff were up to date with their yearly appraisals. Patients could access a range of interventions and activities in line with national guidance. Patients told us staff were kind and treated them well. All staff told us they felt respected, supported and valued by their colleagues and managers. Staff were using CAMS monitoring tool (Co-operations, Anti-social behaviour, Mood/Anger, sexually inappropriate behaviour), which has seen a decrease in incidents.

However, we did find areas for improvement.

We observed some gaps in employment records and mandatory training records.

The ward areas appeared mostly clean, however there was a malodour, some areas and the cleaning records were not up to date. Staff did not always follow best practice in infection and prevention and control in relation to ward signage.

The provider was unclear who was providing Independent Mental Health Act Advocacy (IMHA) services and information about accessing these services was not clear for patients or staff. Care plans did not always consistently reflect the views of the patient, in their own words.

The service had identified that additional meeting rooms were needed, to support the functioning of the ward.

At this assessment we identified breaches of regulations under 12 Safe Care and Treatment, 15 Premises and Equipment, 17 Good Governance, 18 Staffing. We found four breaches of regulation in relation to cleanliness and infection prevention and control, personal emergency evacuation plan documentation and employment documentation, and mandatory training records.

We have asked the provider for an action plan in response to the concerns found at this assessment.