Chadwick Lodge

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service supported patients to be safe from abuse and neglect. Patient’s care records and risk management plans were person-centred, proportionate and staff reviewed these regularly, including after any incidents. The provider ensured there were sufficient numbers of staff to support patients. The provider used appropriate recruitment procedures to employ suitable staff. Staff completed induction and mandatory training was comprehensive and met the needs of patients and staff. However, staff did not always record observations in line with the providers policy. During our assessment, we found concerns around the timings of observations, which resulted in a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Some patients we spoke with said they felt safe on the wards. However, some patients fed back that there were high levels of incidents, and they did not feel safe due to high levels of agency staff. We spoke with 6 carers. All the carers we spoke with told us that they felt their loved one was safe at the hospital, and they knew how to raise concerns if they needed to, one family member said they had raised a concern which had been responded to. During the assessment, we saw community meetings for patients and staff were held on each ward on a regular basis, which included discussion about ward environment, relationships on the ward, planned events and activities, restrictive interventions, and blanket policies. Meetings included a check in with each patient attending and patients were asked if they wanted to make a complaint or raise any issues. The community meeting minutes showed what actions had been taken following previous meetings.

The provider’s processes promoted people living in safety, free from abuse, neglect, and avoidable harm. We saw evidence that there were effective systems, processes, and practices to make sure people were protected from abuse and neglect. The service had a comprehensive local safeguarding procedure which included good working relationships with other agencies, including the local authority, who also attended quarterly multi-agency safeguarding meetings. Staff received training on how to recognise and report abuse, appropriate for their role and kept up to date with their safeguarding training. Overall, the providers compliance with safeguarding training was 96%. As part of the assessment, we reviewed the hospital safeguarding log which was up to date and included details of the safeguarding incident, the incident date, and if the Local Authority had been made aware.

Staff knew how to make a safeguarding referral and who to speak with if they had concerns. At the time of the assessment, 96% of staff had completed mandatory safeguarding training. During the assessment we spoke with 17 staff members, including ward managers, nurses, healthcare assistants and members of the multi-disciplinary team. Staff were able to describe examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to recognise adults and children at risk of or suffering harm and worked with internal departments and external agencies to protect them.

During the assessment, we observed patients being supported by staff who understood how to protect people from harm. We saw posters displayed on wards giving details of the safeguarding lead for the hospital and information about how to contact the Independent Mental Health Advocate. We saw information about patients’ rights displayed on the hospital wards and care records we reviewed, showed that patients had been given information about their rights under the Mental Health Act upon admission to hospital and on a regular basis afterwards.

There were effective systems, processes, and practices to make sure people were protected from abuse and neglect. The management team regularly reviewed safeguarding concerns, these were discussed in daily staff meetings and monthly management meetings. The provider had good oversight of safeguarding concerns. As part of the assessment, we reviewed minutes from the last three months of clinical governance meetings, multi-agency meetings, and team meetings. Safety and risks were reviewed in detail at these meetings, including learning from incidents, reducing restrictive practice, and learning out of concerns. During the assessment we reviewed 13 care plans. Care plans were person centred and provided guidance to staff on how best to support patients in the way they wished to be supported. Risk assessments were completed on admission, regularly thereafter and after any incidents. Staff did not always record observations in line with the providers policy. All records reviewed were completed for a period of midnight to midnight. All records showed the general and intermittent observations were predictable and completed within 1-3 minutes of the hour or quarter hour. This meant patients could predict when their next observations would be.

Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident. Staff knew about any risks to each patient and acted to prevent or reduce risks, including responding to any changes in risks to, or posed by, patients. Staff followed procedures to minimise risks where they could not easily observe patients. Staff followed organisational policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. We spoke with 17 members of staff. Staff told us that a comprehensive risk assessment was completed for each patient on admission, which was regularly reviewed, including after incidents. Staff demonstrated a good understanding of the management of risk and reducing restrictive interventions. Staff told us that restraint was only ever used as a last resort and only when a patient was causing harm to themselves or others.

Patients we spoke with as part of the assessment, understood observations and why they may require an increased number of observations. One patient told us that staff fell asleep on observations. Patients care and risk management plans were person-centred, proportionate and staff reviewed these regularly, including after any incidents. Patients were informed about and involved in managing risks to themselves and in taking decisions about how to keep safe. Patients confirmed they were involved in Positive Behaviour Support plans. A Positive Behaviour Support plan is a person centred framework for providing long-term support for people who have, or may be at risk of developing behaviours that challenge.

Some wards were bland and uninspiring, in contrast to communal areas of the hospital, which had recently been updated. The provider told us there was a refurbishment plan in place for the wards. Clinic rooms on the wards were small and did not include a bed or couch. However, they were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly. The hospital had a central clinic room, which was spacious air conditioned and clean and had a couch and all necessary equipment to carry out physical health checks and ongoing health monitoring. The wards complied with guidance and there was no mixed sex accommodation. Staff had easy access to alarms and patients had easy access to nurse call systems. However, during the on-site assessment, we had to request alarms.

Staff completed and regularly updated thorough risk assessments of all wards areas and removed or reduced any risks they identified. Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Anti-ligature doors had been ordered and were going to be installed with the hospital refurbishment plan, the ligature risk assessment included the doors, and mitigation was in place to keep patients safe. The provider had a process in place in line with its enhanced observations policy to carry out patient observations. However, observations were happening at predictable intervals and staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk of harm to themselves or others. Eden ward had a high number of patient incidents in the months leading to inspection. We reviewed all incidents on Eden ward for the three-month period between December to February 2024, and discussed mitigation in place to reduce incidents. The provider had a clear focus to manage the level of patient needs on the ward and keep patient’s safe, including an awareness of the impact on ward staff of working in a stressful environment, and had reduced ward patient numbers and increased staffing levels. There was a full multi-disciplinary team and a model of care for assessing the needs of the patients and providing a therapeutic model of care.

We spoke with 23 patients and 6 carers. Carers we spoke with told us that people were cared for in a safe environment with facilities and equipment that were well-maintained. One patient told us that having CCTV made them feel safe, and protected staff and patients. Some patients we spoke with told us that wards needed to be updated.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.