Pinhoe View

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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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

Good: This meant people were safe and protected from avoidable harm.All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks for patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well. this means we saw evidence that people were protected from abuse and avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong, proactive and positive culture of safety, based on openness and complete honesty. They listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The service maintained an incident log called IRIS and incident dashboard. There were 38 serious incidents in the last 12 months. 4 of these incidents were classified as level 5 incidents resulting in severe harm and 34 were classified as serious incidents involving significant harm. Incidents rated severe or significant were 0.44 per cent and 3.74 per cent respectively of all incidents at the service during the past year. All incidents were documented in a way that captured date and time of day, incident type and incident severity to allow analysis of trends and peak times of concern. Nearly three quarters of all incidents in the last twelve months comprise violence and aggression between patients and security concerns.

Patients and staff received debriefs when incidents occurred. Ward staff told us they received feedback and outcomes from investigations, complaints and safeguarding referrals from inside and outside the organisation. Information was circulated via email, reflective practice sessions and during supervisions. Ward staff use this information to formulate patient protection plans where appropriate.

All staff told us they understood their duty of candour and were able to talk openly to patients, families and carers when things went wrong. Wards ran a ‘weekly ask’ program where named nurses ensure patients have received appropriate care. This information was recorded and audited by ward managers. Ward staff were committed to understanding the views of patients to improve service delivery. Patients were encouraged to record complaints in the ward complaints book. They were also encouraged to report to police when incidents occur and Clyst ward also had a patient suggestion box which was reviewed by the ward manager each week.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. The admissions process had been improved and standardised, though, at the time of assessment the provider did not have access to electronic records from Emergency Department and referring providers which led to delays in accessing vital information. The service operated well with Devon’s rehabilitation and intervention in psychosis teams and the home treatment team in Cornwall. Links with community mental health teams in both counties are less effective, sometimes causing delays in transition planning.

Both wards had been extended to include a patient library and 2 larger bedrooms separated from the main corridor of rooms, which were used for patients that were nearing the end of their treatment. Patients in these areas were given more autonomy to assist their transition to the community.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Eighty per cent of staff were trained in safeguarding. All ward staff were able to describe how they protect patients from abuse, neglect and harassment. Staff knew how to make a safeguarding alert and did that when appropriate. All staff at all levels were responsible for reporting concerns relating to abuse and safeguarding, and all staff we spoke to explained they do report concerns and were confident in doing so. The service monitored the use of ‘as needed’ medicines (PRN) by patients as part of safeguarding with the help of an external pharmacist PRN audit each quarter who met with each patient 1:1 weekly to capture individual patient concerns.

Staff supported patients to escalate any concerns they had. We were told by one ward manager that their mantra was ‘speak up and say it’. Staff followed safe procedures for children visiting the service. Restraint, restrictive practice, blanket restrictions were documented and audited every month.

Mental Capacity Act

Ninety-four per cent of staff had had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, particularly the five statutory principles. The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing behaviours that challenge. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We looked at six risk assessments and six risk management plans during the assessment. The quality of the assessment varied from one plan to another, ranging from excellent to adequate, depending on which member of staff had completed the assessment. The level of patient involvement in care planning and risk assessment also varied in accordance with the staff member completing the record, with two care plans evidencing involvement and four not evidencing involvement of patients.

Patients told us the level of involvement was as different as ‘night and day’ depending on the individual staff members involved. Patients told us some staff members communicated well and went the extra mile, but “most staff don’t bother talking to us”. The consensus view was that some staff tried to communicate “when they had the time”, “staff try, but I find them hard to understand”. In all cases, the physical health plans were good and all patients we spoke with said staff ensured they could access advocacy.

There had been 57 incidences of restraint in the last 3 months involving 18 patients. No incidents of restraint involved supine or prone restraint and there has been no use of rapid tranquilisation. The service followed the least restrictive principles using verbal redirects and minimal use of PRN.

Seclusion had been used 47 times in the last 12 months with 24 patients. 13 patients had experienced seclusion more than once, with the average time in seclusion being 48.91 hours. Within the seclusion suite, we identified seclusion recording folders which contained seclusion recording paperwork and packs available for use. For each seclusion episode, one seclusion folder is used to manage the associated documentation requirements. This created 1 pack per seclusion episode. Once the seclusion had ended, the folder was scanned and uploaded to the patient electronic record and sent down to a member of Senior Management, for a quality review and audit to be completed as per policy. We saw that patients had the opportunity to have a post incident debrief and provide feedback on the seclusion episode.

If the patient remained in seclusion after 72 hours, the MDT reviewed if the patient required a referral to Psychiatric Intensive Care Service in collaboration with the patient’s commissioner. Seclusion episodes were also reviewed in the Pinhoe View Reducing Restrictive Practice Group. Only 2 episodes of seclusion (4.26 per cent) lasted more than seven days. We found that episodes of seclusion were conducted in line with the service’s seclusion policy and Mental Health Act Code of Practice.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Wards were clean and tidy and allowed staff to observe most of the ward. Blind spots were mitigated by CCTV which was recorded. Staff did regular risk assessments of the care environment and ward layout allowed staff to observe all parts of ward. All ligature points were identified and mitigated adequately. Senior leaders were involved in creating ligature point maps of the ward and circulated these to staff. Ligature point map posters were visible on the back of doors throughout the ward.

Staff had easy access to alarms and patients had easy access to nurse call systems. All staff were provided with ward keys and alarms at the start of each shift.

Seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. We recommended inclusion of Intravenous access equipment in the resuscitation bag to align with the Resuscitation Council UK Mental Health Inpatient Care Equipment and Drug Lists for this acute setting.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

The service is fully staffed, and the service manager has adjusted staffing levels daily to take account of case mix, with establishment figures (Whole Time Equivalent) exceeded in every month for the past year in both nurses and health care support workers. There are no vacancies. Average turnover has remained relatively high at 19 per cent over the last 12 months. Sickness absence was low at 1.5 per cent. Agency use averaged 2.5 full time equivalent (FTE) over a 13-week period.

The service always operated under the safer staffing model with a qualified nurse present in communal areas of the ward. Each ward had 6 staff on duty per shift with a mix of registered mental health nurses and health care assistants. Both wards were fully staffed and rarely used bank or agency workers to cover shifts.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. Staffing levels were sufficient to allow patients to have regular one-to-one time with their named nurse, but 7 of the 10 patients we spoke with said this does not happen. Patients told us this was not an issue of not enough staff, rather they thought staff were constantly too busy, especially at weekends. Five patients told us they had experienced staff cancelling escorted leave or ward activities which they attributed to not enough staff.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. All ward areas were clean, had good furnishings, were well ventilated and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Staff adhered to infection control principles, including handwashing.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management, including storage, dispensing, administration, medicines reconciliation, recording, and disposal in line with national guidance. Staff reviewed the effects of medication on patients’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when the patient was prescribed a high dose of antipsychotic medication. The service worked with an external pharmacist to reviewed patient medication records and treatment plans and provided recommendations to improve patient care and treatment.