St Andrew's Healthcare - Essex

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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. 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 to 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.

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

Staff knew what incidents to report and how to report them. Staff reported incidents clearly in line with the providers policy. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed by the ward manager. Staff understood duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong.

The service had up to date incident reporting processes The service understood its responsibility to submit statutory notifications. Governance processes showed leaders had oversight of incidents and took action to manage risks.

Staff were de-briefed and received support after an incident. Staff met to discuss learning from incidents which was shared in a variety of ways. Staff told us they received regular communication about learning from incidents. If an incident took place on the ward, it would be discussed at handover. Staff received feedback from the investigation of incidents. They met to discuss this feedback, review lessons learned and continually identified and embedded good practice.

Managers investigated incidents thoroughly and were able to give examples of learning from recent incidents. Managers reviewed incidents and identified any themes or trends. Information from these discussions were reported up to clinical governance meetings. Managers reviewed lessons learned, issues requiring support to resolve and areas of good practice in clinical governance meetings.

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 admitted patients who were safe and ready to work towards discharge, from other wards, such as low secure or acute services. Patients were also transferred to the ward from other rehabilitation services. Before, admission professionals’ meetings were held where risks and needs were discussed. The multi-disciplinary teams met to discuss new referrals to ensure they could meet the needs of the patient and maintain the safety of all patients on the ward. Ward teams liaised with the senior leadership team and were supported by them if a decision was made not to accept a referral.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Other agencies involved with patients’ care were invited to attend ward rounds and could attend virtually if that was preferred. Staff involved commissioners, care co-ordinators, social workers and the community mental health team.

Staff ensured that patients’ discharges from the service were managed safely. Discharge planning began at a patient’s first meeting following admission. Patients were either transferred to another placement closer to home when appropriate or discharged to their own accommodation. Staff liaised with the appropriate services to ensure robust discharge plans were in place. We looked at 5 patient care plans. Patients had a discharge care plan, which was discussed in meetings and was regularly updated.

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.

Staff received and kept up to date with safeguarding training appropriate for their role. Staff compliance with safeguarding adults’ level 3 training across the service was 100%. Safeguarding leads were identified within the service and there was an overall safeguarding lead for the hospital.

Staff knew who to inform if they had a safeguarding concern. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff gave us examples where they had raised safeguarding concerns.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them.

Children were not permitted to visit patients on the wards. Visits from children took place at other areas in the hospital.

There were clear procedures in place to promote patient’s safety. The safeguarding adults and children's policies provided guidance to ensure staff were aware of how to raise a safeguarding concern. Noticeboards in the ward offices also provided contact details for the local safeguarding authority, as well as who the safeguarding leads were.

Staff could recognise signs when patients experienced emotional distress and knew how to support them to minimise the need to restrict their freedom to keep them safe. Patients were restrained only where necessary and for the minimum period. Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the person safe. Staff understood the Mental Capacity Act definition of restraint and worked within 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 challenging behaviour. 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.

Staff made sure patients’ care plans were up to date. Staff involved patients in care planning. Some patients were offered and accepted a copy of their care plan. Patients were given the opportunity to participate in review meetings about their care. Care plans were personalised to the individual.

Staff completed a risk assessment of every patient on admission and updated these regularly, including after any incident. We reviewed 5 care records and saw staff used recognised risk assessment tools to assess patients on admission. Staff updated these regularly and following any incident.

Staff identified changing risk levels and amended observation levels and interaction with patients in response. Staff followed provider policy on the use of observation and searching, and staff discussed levels of observation with the multidisciplinary team.

Staff used restraint and seclusion only after attempts at de-escalation had failed. Compliance with safety intervention training was 94%, staff also completed relational security training (teaches staff to manage relationships safely to keep people and the environment secure) and self-harm and suicide training, compliance with these was 100%.

Tiptree ward recorded 3 incidents of restraint in the last 3 months, and 4 incidents of seclusion.

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.

The ward areas were clean and well equipped. Staff regularly reviewed the environment, identified and managed ligature risks, and mitigated risks quickly to keep patients safe. Managers ensured staff on the wards had easy access to information on environmental risks, this included a map of hotspot areas. The service completed ligature point and blind spot audit tools. These were comprehensive documents, covering all areas of the wards and external areas. Managers also carried out monthly ward environmental checks; findings were then taken to clinical governance meetings to be actioned. Staff we spoke with knew about any potential ligature anchor points and knew where ligature cutters were located. Staff could describe mitigations taken to reduce risks to patient’s safety.

The service complied with NHS guidance on delivering same-sex accommodation. Each person had their own bedroom, which they could personalise. Patients had a secure place to store personal possessions.

The ward had a range of rooms and equipment to support treatment and care. The ward had quiet areas patients could use. The service had a room where visitors could come and meet patients.

Seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock.

Staff could not observe patients in all parts of the ward. This risk was identified and recorded within the ligature risk assessment and mitigated using convex mirrors and staff observations.

Staff had easy access to alarms and patients had easy access to nurse call systems.

The service had policies to follow fire and safety practices on site. There was a fire escape plan and fire action notices on the ward which showed the assembly point.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

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.

The service had enough staff to keep patients safe. The service had low vacancy rates, the service identified 1 whole time equivalent (WTE) registered mental health nurse vacancy. There were 2.7 whole time equivalent vacancies for healthcare workers, however another ward had recently closed at St Andrews, and the staff members had been redeployed to Tiptree to fill the remainder of the outstanding establishment. Due to a change in the system to record staffing levels this had not yet been reflected in the establishment numbers. Turnover of staff for the last 3 months was 0%. Staff sickness for the last 3 months was 6.6% in July, 14.8% in August and 5.7% in September.

When necessary, managers deployed agency and bank staff to maintain safe staffing levels. When agency and bank staff were used, those staff received an induction and were familiar with the ward.

There were enough staff to carry out physical interventions, for example, observations, restraint and seclusion safely. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with appropriate mandatory training. Overall compliance with mandatory training was 98%. The mandatory training programme was comprehensive and met the needs of staff.

Leaders supported staff through regular constructive and comprehensive supervision of their work. Permanent staff were supported to develop through yearly, appraisals. Managers monitored compliance with supervision and appraisals. At the time of our inspection, supervision and appraisal rates were 100%.

Staff were given a comprehensive induction to the service to ensure they were prepared for the role. Managers monitored staff competencies on an annual basis to ensure staff were competent to carry out their duties.

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.

The ward areas were clean, tidy and had good furnishings. Housekeeping staff cleaned the wards daily. Staff maintained equipment well and kept it clean. The service followed their infection control policy, including hand washing.

The service conducted several infection prevention and control (IPC) audits as part of the hospital’s audit programme. The service carried out an annual infection prevention audit. Staff also completed monthly infection prevention audit tools, these included patient equipment, mattress inspection, sharps management, hand washing and waste management.

Staff completed Infection, Prevention and Control training. Staff compliance rate for infection prevention control training was 100%.

The service had a detailed Infection Prevention Control policy, which was reviewed regularly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff accurately recorded administration of medicines. Staff followed good practice in medicines management (which included, transport, storage, dispensing, prescribing, administration, medicines reconciliation, recording and disposal) and in line with national guidance. There were specific systems in place for the management of controlled drugs and medicines that were liable to be misused.

Medicines were stored appropriately. Medicine cupboards were locked when not in use. Medicines prescribed for individual patients were labelled and stored correctly. Staff kept up-to-date information about stock. Staff knew how to dispose of medicines and associated equipment safely. Staff kept accurate records of medicines. Sharps bins were available on the ward and were marked with the date of opening, as needed. Staff kept records of national medicines alerts and recorded what action they needed to take to improve practice.

The service ensured patient’s behaviour was not controlled by excessive and inappropriate use of medicines.

The service reviewed patient’s medicines regularly and provided advice to patients and carers about their medicines. Patient’s medicines were reviewed as part of their overall review of their progress at ward rounds. Where patients were self-administering medication, we saw evidence of regular discussion, however there was no risk assessment in place and no care plan to indicate the goal and action plan. One patient had remained on level 1, full nurse supervision (the service had 4 stages to self-administering of medication) for a long period of time with no plan to progress to the next stage.

The clinic room was clean, orderly and fully equipped. Cleaning records were available and completed. Staff recorded daily room and fridge temperatures to ensure the safe storage of medicines.