The Bethlem Royal Hospital

The majority of patients we spoke with said they were happy with the service and the staff were kind and caring. We observed caring and positive interactions between staff and patients on the ward.

We identified concerns across a number of areas that we looked at. Patients' care plans were not always reviewed on time and we did not see evidence of patients' involvement in their care planning. Patients' individual care plans did not include identified risks. Daily planning meetings and weekly community meetings did not regularly happen. Some risk assessments were not up to date.

Patients were not protected against the risk of abuse. Some of the staff were not aware of who the trust's safeguarding lead was or which local authority to report to. We found that some incidents had not been reported appropriately. Staff did not understand safeguarding procedures and referrals were not made to the appropriate authority immediately.

People were treated with dignity and received care and support through a multi-disciplinary approach to ensure their needs were met appropriately.

The staff demonstrated a clear understanding of their responsibilities in relation to safeguarding people from abuse and promoting people's welfare.

The provider had systems in place to regularly assess and monitor the quality of service that people received.

However, at the time of the inspection we found that the provider was not acting in accordance with legal requirements in relation to the Mental Capacity Act 2005. We also found that there were not sufficient numbers of staff on duty to support people with their needs. Ligature risks to people within the environment had not been properly addressed, despite having been identified for a number of years.

At this inspection we found that improvements had been made to the environment. The wards we visited were clean and provided a welcoming environment with pictures and noticeboards on the walls. We found the damaged furniture had been replaced. The wards provided a safe and secure environment for people using the service.

We spoke with 13 people using the service and two relatives. The majority of people we spoke with were happy with the care and treatment they had received. They felt they had good access to staff and the staff were responsive to their needs. The staff were aware of the high risks some of the people on the ward presented with and had processes in place to maintain the safety of people using the service. People's access to the community was dependent on the risk they presented and if the risk to the public or the person was judged to be high then the individual was escorted by a member of the staff team.

People had access to food and drink throughout the day. The food provided met people's individual needs and special dietary requirements were accommodated. However, there was a lack of choice for people on a special diet or who were vegetarian.

Medicines were stored and administered safely. People were aware of what medication they were on, why they were on it and what the possible side effects were.

There was an effective system in place for monitoring the quality of service provision. Staff undertook regular audits to look at service performance. Any areas for improvement were identified and the majority had been actioned.

There was a system in place for investigating and monitoring complaints and incidents. We saw an escalation process in place for serious incidents and high level complaints. This ensured appropriate individuals were involved in investigations.

Overall our inspection found the two wards we visited to be well led, effective, caring and responsive to people's needs, with the safety of people using the service being maintained as much as possible.

We received some positive comments from patients we spoke with about the staff in the wards we visited. On Norbury ward, one patient said of the staff, 'They're generally professional in their attitude, and treat you as an individual. They listen to me.' Another patient on Thames ward told us, 'They listen to me. The staff are cool with me. They respect me as a human being'.

We found that appropriate care planning arrangements were in place in the wards we inspected.

The Trust had an effective quality assessment and monitoring system in place, which sought the views of patients.

We found that care was not always provided in an environment that is suitably designed and adequately maintained. We found that on two of the four wards we visited, communal areas were not maintained in a good order.