Whilst we were there, up to four staff mainly worked on administrative tasks within their office, with one member of staff out on the unit.

Over the course of two days, we saw few social or therapeutic nursing interactions with people who stayed there. There appeared to be an impoverished environment with little therapeutic intervention or meaningful activities to do.

Staff could describe many types of abuse but did not mention neglect or institutional abuse.

There was one person on JSH [John Sharich House] who belonged to an ethnic minority. They were unable to access any specialist food via the in-house food preparation. Staff told us “It is easier to buy ready made meals”.

We noted the two downstairs bathrooms on STATT had missing shower curtains. The nurse in charge told us that the torn shower curtain had been removed at the end of August and new ones ordered. A different member of staff told us they had been removed for cleaning, but they were not in the unit laundry.

A relative told us their son, who was a voluntary patient, had frequently requested to leave. He had been told he many not do so unless he attended specific workshops at STATT which he did not wish to do so. This meant he was illegally deprived of his liberty and had his use of consent withdrawn.

None of the people we spoke with had a copy of their care plan. We asked why this was. Nursing staff told us the electronic care records did not neatly print into a useable document and was not available in an easy read format.

In a 35 minute period, we had not recorded a single interaction between a nurse and the person they were looking after. When the person left their room, the nurse followed behind with no eye contact, no physical contact and no therapeutic intervention.

They (patients) also said “There is a man here who just lies in his bed all day. All day, every day. Sometimes there are dvds to watch”.

We spoke with three nursing staff on STATT to try and understand how they assessed people, provided their care, and monitored progress towards a pre-determined goal. They were unable to describe how they assessed people’s individual needs within a structured framework.

There was also little evidence of imagination, planned purposeful activity or nursing support with a specific end point in sight. There was a lack of engagement and empathy with the people who used the service.

We asked the nursing staff what benefit they thought the STATT gave people who were being treated there. One person said that behaviour modification therapy was used. Another told us that medication regimes were started.  We discussed this further with staff and asked them to describe any appropriate social interactions or interventions, or productive  or appropriate activities for the people living there. They told us “If they don’t want to do something, we might just leave them as we do not want to challenge them.” We asked what would happen if someone chose to stay in bed all day. We did not get a reply.

We asked the nursing staff about their knowledge of physical illness. One person told us if a person had, for example, epilepsy, there was a regional nurse expert who helped them draw up their care plans. We looked at the care plan of a person with epilepsy but were unable to find any documentation relating specifically to the needs and requirements to effectively manage this disease.

We asked about bathing and observation routines of those who may have an epileptic fit on the unit. We heard from two nurses these had recently changed. The senior nurse in charge of the unit described that people with epilepsy were now “routinely observed discreetly” whilst bathing. This had been an organisational response put into place after a death on the unit this summer.

We discussed emergency life support training with nursing staff. They told us they had had  training in the last year. We viewed their training records and found that one third of them had not attended this basic training.

We noted that information regarding advocacy services was on the noticeboard, but was out of date and therefore not appropriate or accessible to those who may have required it.

During our inspection, we saw that this person was allowed to roam unchallenged through the female part of the house. We asked why the nurse did not prevent this from happening. The nurse told us the person may get very agitated, so they just followed him to ensure he was not physically aggressive. We observed no verbal interaction between this person and the nurse. This meant the person in the female part of the house was not kept safe from fear or harm.

A staff nurse told us that one person had not been able to have his family visit him because a more senior nurse had made the decision that it may not be “good” for that person. This senior nurse had told the other staff to always ask the person if they wanted visitors. The nurse said that the person was “given the choice” to say yes or no when relatives arrived, but the nurse could not confirm if the person had understood the implications of this choice as sometimes he had said no, then later asked where they were.This meant we could not be sure that people on the unit were not emotionally harmed by this type of ad hoc decision, as it potentially removed the comfort of a visit from their family and friends.

Whilst safeguarding processes were in place, there was a clear dis-connect between policy and practice. This meant that abuse and neglect was not prevented from taking place.

We found stuck to one medicines cupboard clinical guidelines published in 2005.

There were two fire points for extinguishers at the head of each staircase: this equipment and signage had been removed, and the only fire fighting equipment was locked behind a door at one end of the corridor at the opposite end of the corridor to the occupied bedroom.

The checks of the emergency equipment, such as the cardiac defibrillators and the fire extinguishers, were serially signed as being correct. Our inspection found that the battery was missing from the defibrillator on JSH, the oxygen was out of date on STATT unit.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the services, and others.

Staff described a culture of restrictive supervision practices and lack of support from one senior staff nurse who was “never on the ward, always at meetings somewhere.”

People were not protected from the risks of unsafe or inappropriate care because accurate and appropriate records were not consistently maintained or stored. This meant that people had been placed at risk of harm, because inaccurate or missing records gave false assurance to staff.