The Hamptons

On this page

• 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 remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service did not have a current ligature risk assessment in place at the time of the assessment. The previous ligature assessment had been due for review in November 2024. A review of the risks had taken place in February 2025 but had not been fully written up.

The maintenance system did not clearly document and allow for effective oversight of ongoing maintenance issues within the service.

Patient prescription charts had not been fully signed when all medications had been administered.

Mandatory training compliance was low for certain courses with 22 courses not meeting the provider’s 80% target.

However, there were mostly effective systems and processes to protect people from abuse and neglect. Staff understood how to protect patients from abuse. Staff completed risk assessments for patients. There was sufficient staff to support patients with multi-disciplinary team support available.

The service was in breach of regulations for people’s safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us that they generally felt safe on the ward.

The service had 2 serious incidents in February 2025. For the three months prior to that, there had been no serious incidents noted.

Staff were aware of what incidents to report and how to report them. Staff told us that learning from safety incidents was shared and they implemented this learning into their work practices. We saw evidence that learning from incidents was discussed in team meeting minutes and also within the clinical governance meeting minutes.

Managers noted that there had been a recent period of increased violence and aggression incidents within the service, which had impacted on staff morale. Managers were keen to make improvements to this and ensure that all staff were supported and felt safe at work.

Staff felt that whey were able to raise concerns about care and treatment if they had any.

Staff we spoke with knew what their responsibilities were under the duty of candour. They could provide examples of when they had provided apologies to patients when things had gone wrong. Managers reported that no incidents had formally met the threshold for the duty of candour in the 12 months prior to the assessment.

Complaints from family members and people who used the service were investigated and resolved with actions put in place where required.

Managers reflected that debriefs would be held after incidents, although noted it could be a challenge to get all the appropriate staff together for this to be facilitated.

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. The service undertook pre-admission assessments for patients entering the service.

Prior to the on-site assessment, a recent safeguarding concern had been raised and investigated in relation to the discharge of a patient from The Hamptons to another service. The concerns raised around this was that the patient had been discharged from the service without appropriate support and safety measures being put in place for the transfer of the patient to the other service.

The service had a discharge checklist which was expected to be used when any patient was being discharged from the service. The checklist prompted staff to escalate any items that were not completed on the checklist to the team leader prior to discharge.

The service had a placement monitoring form which they completed on a weekly basis. This recorded any patient whose placement may have been coming to an end for any reason. It recorded relevant information about referrals to places of discharge or transfer, along with an estimated discharge date. This enabled the service to have weekly oversight of where each patient was up to in their discharge.

From February 2024 to February 2025 the service had discharged 9 patients.

Staff were trained in safeguarding vulnerable adults and safeguarding vulnerable children. At the time of the assessment, the training compliance rates were 80% and 84% respectively.

In the 12 months prior to the assessment, the service had made 18 safeguarding referrals to the local authority.

The service had a safeguarding tracker to monitor the progress and outcomes of the referrals, although there were some gaps on the tracker which did not allow for full oversight of the ongoing and closed referrals.

The service had an identified safeguarding lead who had oversight of all ongoing safeguarding issues.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

We reviewed 6 risk assessments and risk management plans. Risk assessments were reviewed on a regular basis. Patient risk assessments and management plans were individualised and reflected approaches that staff could take to de-escalate and support patients. There was a section on the risk assessments for patient involvement and feedback, however, on the 6 records reviewed none of these sections had been filled in. Staff had recorded that patients refused to engage in the risk assessment on some of the records reviewed although this was not consistent across all records.

Between October 2024 and the day of the assessment, the service had 11 incidences of restraint including 1 prone restraint. The incident of prone restraint took place on the 08 February 2025 and had been under investigation by the service at the time of the assessment. We requested a copy of the finalised investigation report which identified areas of learning and actions to be taken to the service to improve practice going forward.

The service had received one complaint from a patient around the use of restraint during an incident which the complainant felt was unnecessary. The service had reviewed the incident and complaint and deemed that the use of restraint had been proportionate.

Managers reported that the use of restraint was generally low within the service, although noted that there had been an increase over January and February 2025. Managers noted that all staff were restraint trained as appropriate, and they were confident that staff could manage restraint safely.

We reviewed a sample of 4 patients observation records. Whilst there were no apparent gaps in recording, the records often contained limited descriptions and did not generally consider patient mood, mental state or presentation. The observation forms prompted staff to consider and document factors such as mood, mental state and presentation. It was not clear if the observation forms were checked or reviewed once completed, to assess if these met the standards expected of the service.

We attended 3 patient ward rounds. Patients attended these meetings and were given the opportunities by staff to contribute and have their voice heard. Staff discussed patient risks and risk assessments during the ward rounds.

Staff ensured that patients could access advocacy. Details about the advocacy services were present on a noticeboard for patients. Staff noted how they would support patients in accessing advocacy services as appropriate.

The service had not undertaken regular risk assessments of the care environment within their identified time scales. The service had undertaken a ligature risk assessment on 25 February 2025 which was still being written up and required sign off through the provider’s governance processes. The previous ligature risk assessment had been completed in November 2023 and indicated it was due for review in November 2024. The provider had added ligature as a risk on its service risk register which included some additional control measures pending the completion of the full ligature audit. The service had last reviewed this risk on the risk register on 04 February 2025. Following the on-site assessment, the provider confirmed that the new ligature risk assessment had been completed and sent a copy dated 11 March 2025. The audit listed several actions required to address issues identified in the audit, however, the column for “how actions will be taken forward” was blank for each of the actions. There was therefore no clear timeline as to when the actions should or would be completed, or how this would be monitored.

On the day of the assessment, the downstairs patient toilet was out of order and locked to prevent access pending repair. We reviewed the paper maintenance log and this was reported on the 25 January 2025. The service was also using an electronic maintenance system to report and have oversight of ongoing maintenance jobs. We requested a copy of this following the on-site assessment. The only entry for the “ground floor WC” was created on the 18 December 2024 which noted the toilet was “leaking”. This entry was in the “closed work orders”. It was not clear how long the toilet had been out of order or the timescale in which it would be repaired. There were 13 “current work orders” on the electronic maintenance log. The oldest was dated 26 September 2024. It was not clear that the systems in place for the monitoring of any ongoing maintenance issues within the service were always operating effectively or that allowed effective oversight by management.

Staff could observe patients in all parts of the wards.

The ward complied with guidance and there was no mixed sex accommodation.

Staff had access to alarms although the number of alarms was limited on the day of the assessment. The service could not provide individual alarms to all members of the assessment team. However, it was acknowledged that the unit had increased staffing due to enhanced observations along with there being 5 members of the assessment team, meaning the number of people on the unit was significantly higher than would be normal.

The service had recently had concerns raised about the alarm system not working as it should. Managers confirmed that the system had been reviewed, and a report produced with some recommended actions, including having more pinpoints installed in the building. Managers advised that they were still to review the full report but that any actions required would be implemented.

Patients had easy access to nurse call systems. All rooms had nurse call systems in place to summon assistance.

The service had a clinic room which was a small space with no examination couch, although patients all had their own bedrooms which could be utilized if required. There was a chair to take blood pressure, bloods or monitor other physical observations. The clinic room was generally clean, although was quite cluttered and had some boxes stored on the floor.

Emergency medicines were present in the emergency bag and all equipment was present and in date, along with the defibrillator and oxygen. A ligature knife was kept in this bag and it was sealed.

Staff were checking the temperature of the fridge in the clinic room and the temperatures were all within normal range. The clinic room cleaning records were up to date.

The nurse on duty, who was not a permanent member of staff, was able to easily locate all necessary equipment when asked, which reflected positively that staff had knowledge and could locate equipment when needed.

The service had low numbers of vacancies at the time of the assessment, which included the clinical lead and one registered nurse vacancies. The service had recruited into 1 registered nurse vacancy and had made an offer for a further registered nurse post. The service was fully recruited to support workers.

Managers monitored staffing levels and data using safe staffing reports. This enabled managers to have oversight of areas such as how many hours had been covered by managers on shifts along with bank and agency usage.

At the time of the assessment, the unit was running on increased staffing due to having 2 patients that were on 2:1 enhanced observations. The base numbers for day shifts was one nurse and four support workers whilst a night shift would be one nurse and two support workers.

The service was utilising bank and agency staff to cover shifts as necessary. In the 3 months prior to the assessment, 73 shifts were covered by agency registered nurses. For the same period, 290 shifts were covered by agency support workers and 60 shifts by bank support workers. The majority of the bank and agency shifts for support workers were to support enhanced observations and not due to vacancy rates within the service. Managers noted that the usage of bank and agency had increased in recent months due to the acuity of the service and a recent spike in incidents.

The service had low levels of sickness and turnover. The average sickness rate between October 2024 and February 2025 was 3%. The average staff sickness level for the 12 months prior to the assessment was 4.5%. The highest month of sickness in the 12 months prior to the assessment was May 2024 at 8%. The service had low numbers of staff leavers in the 12 months prior to the assessment.

Managers noted that staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

Managers described that there were enough staff to carry out physical interventions safely and staff had been trained to do so. Managers noted that they would ensure that there would be trained staff across The Hamptons and Brookhaven, the provider’s service next door, who would respond to incidents.

The service had moved to a different online training provider. We reviewed the service’s mandatory training data. The service had a target of 80% compliance for mandatory training.

We were provided with two separate sets of training data for February and March 2025 as the training matrix for March 2025 did not include the full list of online training compliance. The provider advised the February data was the most up-to-date as of the time of the assessment. For the 49 courses listed on the February data, 17 of these courses were below 75%, however, only 3 of these courses were below 60% which were in relation to legionnaire’s disease, riddor and supervision. 22 of the 49 courses listed did not meet the provider’s 80% target.

The service had a secure courtyard area that patients could access throughout the day. This area was significantly littered with cigarette ends and empty cigarette packets which made the area look unclean and unappealing.

The ward areas were generally clean and had good furnishings. We reviewed cleaning records and, although there were some minor gaps in the recording, these were generally complete and up-to-date.

We reviewed the provider’s most recent infection prevention control audit. The audit identified a compliance rate of 80%, which was below the required compliance identified on the audit itself of 85%. The audit recorded the identified issues and listed how these would be addressed in the future.

The service had undertaken a hand hygiene audit in December 2024 which identified no issues with staff understanding and compliance.

We reviewed 10 patient prescription charts. Out of the 10 reviewed, only 3 had all medicines signed. Some only had one or two missing but there were examples which had several missing including important medicines such as mood stabilisers and antipsychotics.

We reviewed an external audit of the clinic which had been undertaken in December 2024. This indicated an overall compliance of 78.9% but also raised issues around staff not signing when administering medication. The audit recorded actions which were to be taken by the provider to address this including an email being sent to all nursing staff and discussions to be held in supervision and the nurse meetings. As this was identified as an issue during the on-site assessment, we were not assured that the actions had appropriately and robustly addressed this issue.

The use of pro re nata (PRN) medication, which details certain medications given when required as opposed to regularly, was being used regularly for 5 of the 10 patients. Some were prescribed medicines such as Lorazepam, Haloperidol and Promethazine and were using all of them. We observed that, where the doses were variable, the lowest dose was not always tried first to see if that worked. PRN medication seemed to be used throughout the day but always at night. It was not always clear if the levels of PRN medication being used were being monitored or if it had been considered whether lower levels could have been used or encouraged to be used by patients.