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Inspection carried out on To Be Confirmed

During a routine inspection

We rated St Matthews hospital as overall good because:

  • The provider had established the staffing levels required to meet the needs of the patients. The hospital manager had the autonomy to increase staffing levels if required. Staff training was all above 75% compliant. Staff received regular supervision and annual appraisal in line with the company policy. All wards complied with the Department of Health guidance on eliminating mixed sex accommodation. There was suitable medical cover and on call cover throughout the week.

  • We reviewed 11 care and treatment records and found evidence that patients received a comprehensive risk and physical health assessment on admission. Patients were involved in developing their care plans and were outcome focused. The hospital offered a range of psychological interventions recommended in the National Institute for Health and Care Excellence guidelines.

  • Patients knew the complaints process and had access to an independent mental health advocate if requested. Staff were aware of the provider’s whistle blowing policy and knew their responsibilities in relation to safeguarding. Staff told us they felt confident to raise concerns to senior managers without being victimised.

  • The manager had oversight of the hospital. Performance was monitored by completing regular audits and the outcomes were recorded on key performance indicator dashboards. This meant the manager could monitor performance over a period of time to ensure continuous improvement.


  • We found the provider had completed a ligature assessment and had taken steps to mitigate the risks. However, the provider did not have a formal action plan in place to remove ligature anchor points in line with NHS England’s standard contract for low secure services. This states that, Low secure services “will meet” the best practice guidance from the Royal College, and that in low secure service wards: furnishings minimise the potential for fixtures and fittings being used as weapons, barriers or ligature points.

  • There were blind spots throughout the ward areas which meant staff were not able to have clear lines of site. There was evidence of some convex mirrors used however not all blind spots were mitigated appropriately.
  • We found some maintenance issues that were not identified or reported. For example, Radiator covers throughout were damaged.

Inspection carried out on 11 and 21 December 2017

During a routine inspection

We rated St Matthews Hospital as requires improvement because:

  • The service had blind spots, which were not addressed by any mitigating actions.
  • Ligature assessments were not robust and did not cover all areas of the building.
  • The process for ensuring that staff received feedback from incidents and complaints was not robust. Staff did not understand what lessons had been learned from, or how they were shared.
  • Training compliance was below the providers’ target of 90% at 75% and there was a discrepancy over data. Compliance to the Mental Capacity Act training was low at 68%.
  • Blanket restrictions were in place for patients to have access fresh air.
  • Pat down searches were being conducted in the entrance to the service. This practice compromised patients dignity and privacy and was a blanket restriction.
  • Relevant checks that are required under the regulation of fit and proper person had not been undertaken.


  • The service was clean, presentable and well maintained.
  • Data supplied by the provider showed compliance with supervision of 87%.
  • Data supplied by the provider showed compliance with appraisal of 84%.
  • Staff were aware of the provider’s visions and values and demonstrated these in their behaviours.
  • We observed staff to be passionate and motivated to meets the patients’ care needs.
  • Staff demonstrated a good understanding of patients’ individual needs
  • All patients had received a timely risk assessment on admission. There was evidence that risks assessments are updated after incidents.
  • The Mental Health Act administrators had good oversight of the service, they provided support to the services and staff were aware of how to contact them.
  • Shift to shift handovers were taking place daily.
  • Senior managers had good oversight of the services and clinical governance.

Inspection carried out on 22 to 24 March 2016

During a routine inspection

We rated St. Mathews Hospital as good because:

  • The ward was safe, clean, well laid out and tidy. There was space for staff to carry out both individual and group activities. Patients had keys to their own ensuite bedrooms. There were sufficient staff to cover the ward and care needs of patients. There was access to medical cover when needed. Ninety six percent of staff had completed mandatory training. The patients’ care records included full and holistic risk assessments and all required Mental Health Act paperwork.
  • Medication management was good, and staff checked emergency drugs regularly. The pharmacist visited every two weeks to monitor prescribing and offered training as required. Patients had access to physical healthcare including weight management, blood checks and help with smoking cessation. There was a range of staff from different professional backgrounds, skills, and experience to deliver effective care to patients.
  • There was good multidisciplinary and multi-agency working to meet patient’s needs. Staff showed an understanding of the individual care and treatment needs of patients. Patients and carers' were involved in care planning and staff supported this when needed. There were clear arrangements in place for assessing new referrals. Staff planned for all new admissions, and there were robust arrangements in place for managing discharges. Patients had access to range of activities, to help meet their rehabilitation needs. This included healthy walking groups, creative therapy groups, skills training, talking therapy groups, and escorted leave where required to enable patient’s to use local services.

  • The provider had plans to build a new single storey extension that would provide the hospital with a larger meeting room, family visiting areas, and a workshop.

  • At a local level, the ward was well led. Managers were responsive to feedback from patients, staff, and external agencies. Staff had been involved in developing an electronic dependency and activity tool that would support shift pattern allocation and skill mix, depending upon the needs of each day.

  • There were robust systems for reporting incidents on the ward and feedback from incidents was shared with staff on the ward through handover meetings and team meetings. Between June 2015 and December 2015, St Mathew’s Hospital had no episodes of seclusion, segregation, or patients subject to deprivation of liberty safeguards. There were no outstanding serious incidents; staff knew what a serious incident was and how to report them. Patient’s records were complete and up to date.


  • Between 1 February 2016 and 18 March 2016, the medicine fridge temperature chart showed consistently high readings. Staff had not noted this or taken any action to rectify the situation, which posed a risk to medications stored in there. Though this issue was addressed by the ward manager once brought to her attention.
  • There was a restrictive practice regarding the frequency and timing of smoking breaks.
  • There was no formal medical on call rota, or medical cover in the absence of the providers own doctor.

  • At the time of the inspection, data showed only 54% of nursing staff and healthcare assistants had up to date supervision and 75% had in date appraisals. This was below the providers standard, staff explained they were not as good as they might be at recording their supervision.

Inspection carried out on 26 July 2013

During a routine inspection

We spoke to six out of 13 patients at St Matthews hospital. We also spoke to the registered manager and five staff who were supporting them and we observed how support was provided.

The patients told us that the staff were very kind and caring and that they were given support to be independent and learn new skills. One patient told us �The staff are good at their jobs� and �It�s the best clean hospital I've been in and the shops are very easy to get to from here". Another person said "I do cooking and buy my own food from the shops with support from staff�. They told us that they enjoyed this activity.

Patients also told us that they were generally satisfied and involved with the care, treatment and support they received from staff. They said that there were plenty of activities to do in the unit and in the community. One person told us �I am never bored here because there are lots of good activities to do� and �I help out by doing charity work�. Patients also told us that they knew how to make a complaint if they were not happy with the quality of service received. They told us that they were encouraged to express their views at their monthly �community� meetings and felt they were listened to by staff and the manager.

Inspection carried out on 1 November 2012

During a routine inspection

On the day of the visit there were 11 patients. We spoke with four patients and three staff on duty. All the patients in the hospital were able to communicate verbally.

We observed that there was good interaction between staff and the patients. The patients told us that the staff were �nice� and spoke to them in a dignified manner. They also told us that they were informed about their rights when they were admitted to the hospital and also afterwards at the ward meetings with professionals.

The patients told us that they did lots of activities in the hospital and out in the community. One patient told us that they liked St Mathews hospital because they helped with gardening, did voluntary work, went to the gym, and played football. All the patients we spoke with told us that they did their own laundry, kept their rooms tidy and cooked a meal with support from staff. Most of the patients told us that the food was good and that they had a choice of what to eat. Two people told us that they had to have special food and their needs were being met.

All the patients told us that they felt safe living at the hospital. They told us that if they had any concerns; they would talk to staff on duty or to the manager. They told us that all staff listened to them and took action when they had concerns and were not happy.