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Inspection carried out on 24 and 25 and 31 October and 1 November 2017

During an inspection to make sure that the improvements required had been made

  • The monitoring of side effects following rapid tranquilisation (RT) was not always completed in line with the National Institute for Health and Care Excellence (NICE) guidance. Not all registered nurses knew where Flumazenil, (which is a medicine that is used to reverse the potentially harmful effects of benzodiazepine medication), was kept or what it was for. Although improving, there were various medication administration errors on Mendip ward, including missed staff signatures. Records to show that emergency medical equipment on Mendip ward was checked regularly was missing or incomplete.
  • Mendip ward was currently experiencing a high volume of patient on patient and patient on staff assaults. This was due to the current mix of patient’s. All five patients we spoke with shared concerns relating to staffs ability to safely diffuse situations. Although there was a comprehensive induction programme for all new starters at the hospital, this had failed to ensure that staff understood the differences between patients being nursed within a medium and low secure setting. Morale was varied at the hospital. Some staff that we spoke with prior, during and post the inspection visit described low morale, but did not feel able to raise this with senior managers for fear of recrimination. Not all staff said that their colleagues represented the values set by Elysium Healthcare, describing situations where communication could be better.
  • The rights of patients on Mendip, the low secure ward, were not being protected. Policies and procedures that should have been in place to protect the rights of patients not requiring medium security were either inadequate or missing. Care records were not in line with professional standards for record keeping. Daily records relating to patients general wellbeing, mental health and activity levels were either missing or poorly recorded. Care pans relating to specific health needs and or patient activities were poorly recorded and or absent. Records relating to the seclusion of patients were either completed incorrectly and / or incomplete. Dental care was available for patients who were able to leave the hospital but was not available for those that could not.


  • Ligature risks had been reduced by minimising ligature points within the building. Ligature assessments were up to date and available on each ward. There was a meeting each weekday morning to discuss incidents, staffing and other risk related issues.
  • Safeguarding events were recorded by staff and information sent to the safeguarding lead for further consideration and escalated to the local authority if necessary. The importance of relational security was covered in the staff induction. There was access to an advocate Monday to Friday.
  • The assessment of patient’s physical health was completed on admission and routinely and regularly thereafter. We observed staff interacting with patients in a patient and caring manner. Community meetings were held weekly on both wards. There was a patient council group within the hospital. A daily planning book was completed by patients in partnership with the lead occupational therapist (OT). All patients had their own bedrooms with ensuite facilities