Apple Hill

• The service did not always provide safe care. Environments were not always safe or well maintained. Staff did not always fully assess and manage risks to people using the service. The use of restrictive practices was not always managed safely or delivered by staff that had the required training. • Care plans for people receiving treatment through the mental health rehabilitation pathway were not always recovery-oriented or holistic. Records did not show how the service had assessed or met the entirety of people’s needs. Some aspects of the two care pathways were not delivered in line with national guidance and best practice. • People receiving care under the mental health rehabilitation care pathway had access to a range of specialists required to meet their needs. But there had been a vacancy for an occupational therapist within the service from August 2022 to February 2023 which meant there had been a period where the full range of specialists had not been available. • Staff did not always understand and fully discharge their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. • Aspects of care provided did not always uphold the privacy and dignity of people using the service. We observed concerns about some staff interactions, the language used within care records to describe people, and the use of observation peep-holes in some bedroom doors. Arrangements in areas such as facilitating visiting and meeting communication and sensory needs did not consistently promote person-centred care. • Care plans, risk assessments and behaviour support plans for some people did not evidence people, or those important to them, where appropriate, had been consistently involved in developing and reviewing their plan of care. Some opportunities for engagement were provided, such as regular family meetings and the service shared a regular newsletter. • Governance processes and systems were not effective and did not always ensure areas of improvement were identified and rectified in good time. However:

• The service had enough nursing staff. Staff managed medicines safely. Staff completed mandatory training in essential skills including basic life support. Staff felt supported in their roles. • People who were able to express their views told us they felt safe and we saw some examples where staff had used de-escalation techniques appropriately. • People using the service had access to good physical healthcare. Where possible staff would seek specialist advice and input. • Managers ensured permanent staff received supervision and appraisal. The ward staff worked well together and with external agencies involved in care delivery. • People told us staff were caring and compassionate.

Detailed findings:

Is the service safe?

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

2 Apple Hill Inspection report

Summary of findings We rated this key question as requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Systems and processes to safeguard people from the risk of abuse:

• Staff had training on how to recognise and report abuse, however we found this was not always applied in practice. For example, one person sustained unexplained injuries which were not consistently reported to the local safeguarding authority. • We observed a staff member use a form of physical restraint on a person where evidence did not demonstrate it was necessary, lawfully justified, in the person’s best interest and in a safe and proportionate way. We reported this to the registered manager who confirmed this was not how staff were expected or trained to support people. They acted immediately to report the incident to the Police and to the Local Safeguarding Authority. • We received feedback from two people’s representatives, who described two prior incidents where it was alleged people had experienced physical abuse. In response to our feedback, the registered manager informed us they had made safeguarding referrals and commenced internal investigations in response to concerns shared. • One person’s records implied the use of interventions which had not been agreed. Staff used phrases such as ‘make [person] sit on the sofa’ and ‘make [person] to lie down on the bed’. This had not been identified as a potential concern which meant the person could have been placed at risk of unnecessary or disproportionate restraint. • Another person’s records stated they were 'escorted' to their bedroom in response to being ‘aggressive’ without further explanation. Their behaviour plan stated to ‘redirect’ the person to their bedroom where there are safety concerns but did not provide guidance about how to do this or what staff should do if the person refused. A risk assessment said to ask the person to settle in their bedroom when ‘loud and disruptive’ to others and that ‘behaviour should be settled (minimum of one hour)’ before being allowed into the garden. There was no explanation about why this restriction was in place and meant there was an increased risk of the person being secluded in their bedroom without evidence it was necessary, lawfully justified or in the person’s best interest.

The service had failed to operate effective systems to identify allegations of abuse, including the risk people may experience unnecessary or disproportionate restraint. This was a breach of Regulation 13 (Safeguarding service users from abuse and improper treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

• Safeguarding and whistleblowing policies were in place. The safeguarding lead for the service had completed level 7 safeguarding training appropriate for their management responsibilities. • Staff told us they felt comfortable raising concerns with the service management. A staff member advised, “I do always report whatever I see to [the] manager or external safeguarding. [We] have a protocol and policy that we follow, also on notice board [and] also [at] staff meetings [the] manager discuss and remind [staff].” • Managers conducted enquiries when safeguarding concerns were raised and made changes based on outcomes. For example, a safeguarding enquiry highlighted the importance of staff keeping accurate financial records. This outcome was shared with staff via a ‘lessons learnt’ process, reminding staff to produce itemised receipts when helping people to make purchases.

Assessing risk, safety monitoring and management

• Risk assessments did not always identify risks to people or provide clear and up-to-date guidance about how to reduce risk. Where people’s records indicated they were at risk of harm to self or others which may require staff to use restrictive interventions these did not explain what interventions and techniques staff should use. One person’s

3 Apple Hill Inspection report

Summary of findings behaviour plan stated they may grab, push or punch staff without reference to what staff should do in response to this. Another person’s risk assessment failed to identify their history of grabbing, squeezing and twisting staff hands and did not refer to a breakaway technique staff recently used. Their behaviour plan instructed staff to ‘redirect’, ‘escort’ and stated the person ‘may need to be restrained’ without further explanation.