Bere Clinic

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

At our last inspection we rated this key question as good. This meant people were safe and protected from avoidable harm.

The ward was safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to young people and themselves well. Staff understood how to protect young people 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. There were care plans in place however not all young people had positive behavioural support plans which offered an additional level of service user involvement. Some meeting rooms that were very warm and there was not a dedicated area to de-escalate young people on the ward.

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 practices.

The service had a positive safety culture built on openness and honesty. Staff could raise concerns without fear. The freedom to speak up lead was well known, accessible and active on the ward.

Incidents were reported using the electronic system. Reporting rates were in line with what we expected. The ward manager reviewed all incidents within 24 hours. Serious incidents were escalated in line with policy and reported to the CQC and NHS England where required.

After significant incidents, staff and young people were debriefed. Root cause analysis was completed for all serious incidents and a sample of lower-grade ones. Learning was shared through safety briefings, team meetings and updated guidance.

Complaints were managed in line with policy. Responses were timely and personalised. The service analysed complaint themes quarterly and developed action plans when systemic issues were found. There were four complaints in the six months before the inspection. We could see they were being managed effectively by the hospital director.

The service reduced restrictive practice over the preceding 12 months. Physical intervention fell consistently. The service linked this to de-escalation training, relational security and positive behavioural approaches.

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 used clear, well-documented systems and pathways. The care pathway followed NHS England Tier 4 CAMHS guidance. There were structured processes at admission, transfer and discharge.

Admission processes were safe and consistent. A preadmission checklist gathered clinical, safeguarding and social information before offering a bed. On arrival, staff completed a physical health assessment promptly and documented a risk assessment within the required timeframe. Staff knew what information they needed from referrers and what to do if it was missing.

Risk assessments were completed on admission and reviewed regularly. They covered physical risk, self-harm, suicide risk and risks specific to eating disorders. Risk formulations were built into care plans.

Discharge planning started early. The service contacted community CAMHS and adult eating disorder services to confirm support before the young person left. A discharge summary went to the receiving team and GP before discharge.

When young people needed transfer to an acute hospital, the service followed a clear escalation protocol. Transfers were prompt and well documented. The acute team received a handover including medications, observations and reason for transfer.

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.

Safeguarding arrangements were strong. The policy was reviewed annually and reflected Working Together to Safeguard Children (2023) and local inter-agency procedures.

The named safeguarding lead was experienced, well known and accessible. They led case discussions and worked with other agencies. Staff knew the escalation pathway to the local authority or police and used it confidently.

All staff had completed safeguarding training at the right level. Level 3 compliance was 96%, above the provider’s 90% target. New starters completed induction training on time. Agency staff showed evidence of current training before starting shifts.

Safeguarding concerns were recorded clearly. The referrals we reviewed were timely, well documented and proportionate. The Bere Clinic communicated well and engaged constructively with multi-agency processes.

Staff applied the Mental Capacity Act 2005 and the Gillick competence framework correctly. They understood the Deprivation of Liberty Safeguards and the Mental Health Act provisions for this patient group.

Mental Capacity Act

The service had a clear, up-to-date approach to the Mental Capacity Act 2005. Policies were reviewed annually. Staff had easy access to them and to the Code of Practice.

Staff demonstrated a good understanding of the Act during our inspection. They could explain the five statutory principles correctly. They understood the difference between consent, assent and parental responsibility. They applied Gillick competence appropriately for young people under 16. Gillick competence is a way of deciding whether a child under 16 is mature enough to make their own decision about their medical care, without needing a parent to agree. Where young people were detained under the Mental Health Act 1983, staff applied Part IV consent provisions correctly and reviewed them at required intervals.

Capacity was not assumed to be absent because of a young person’s age or diagnosis. Staff told us they assessed capacity for each decision, at the time that decision needed to be made. Records we reviewed supported this. Where a young person lacked capacity for a specific decision, a best interests decision was made, documented, time-limited and reviewed regularly at MDT.

The MDT reviewed capacity and consent as a standing item. Where a young person’s capacity changed – for example, as their physical or psychological presentation improved or deteriorated – this was discussed and recorded. Staff from nursing, psychiatry and psychology all contributed to these discussions, reflecting a genuinely multidisciplinary approach.

Off-label prescribing was used for some patients, as is common in CAMHS. In every case we reviewed, the rationale was documented, consent was obtained and the MDT had agreed the decision. Families told us they received clear explanations about medicines, including why off-label use was proposed.

Independent Mental Health Advocacy was available to all eligible detained patients. Staff could show that patients had been told about this right at the point of detention and at subsequent reviews.

We found no concerns about the application of the Mental Capacity Act at this inspection.

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 young people 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.

During the assessment we reviewed six sets of care and treatment records.

The service involved young people and their families in risk assessment and management. Risk formulations were developed with the young person where possible. They were written in clear, accessible language. Staff used risk discussions as a therapeutic tool, not just a documentation task.

Risk assessments used a structured, validated tool covering physical and psychological risk. They were completed on admission and updated when presentation changed. Physical risk monitoring was thorough. Staff understood the risks specific to eating disorders, including cardiac compromise, electrolyte imbalance and nasogastric feeding.

The service used a paediatric early warning score for ongoing monitoring. There was a clear escalation pathway to the on-call doctor and to local acute paediatric services. Staff knew the thresholds and could describe the escalation steps. Records showed the tool was used consistently and escalation happened when needed.

We reviewed six care plans. All young people had basic care plans in place. However two contained detailed positive behavioural support (PBS) plans, developed with the young person. These plans named triggers, preferred coping strategies and agreed staff responses. They are examples of good practice. Four of the six care plans did not have a PBS plan. This means staff did not always have consistent, individualised guidance for managing distress.

Families were included in risk discussions in a way that was appropriate to the young person’s age and capacity. Parents and carers said they understood the risks and how the service was managing them.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The ward was clean, well maintained and suitable for this patient group. Ligature risks had been assessed and mitigated throughout the environment. Risk assessments were reviewed regularly and updated after incidents or changes to the building. Staff understood the ligature risk profile and how it affected observation practice.

The ward layout supported clear sightlines. Communal areas were well maintained. Bedrooms were an adequate size and personalised where young people had chosen to bring belongings.

Sharps, ligature items and other risk materials were stored safely. Searches were completed on admission and after leave, in line with policy. Records were consistent and included a rationale for each search.

However the Forest and Beach meeting rooms were very warm during our inspection. Staff and young people confirmed this was an ongoing problem, not a one-off. These rooms had no air conditioning at the time of the inspection. Other parts of the unit did. Young people with eating disorders are physically vulnerable. They may have cardiovascular problems, electrolyte imbalances and difficulty regulating body temperature. Sustained heat exposure adds to these risks. We were informed that air conditioning units had been added following the inspection.

The service does not have a dedicated de-escalation room. When a young person becomes distressed, staff use the patient’s bedroom, a communal area or the sensory room. Young people told us they could not relax in the sensory room after it had been used for de-escalation. This is not consistent with recognised standards for CAMHS inpatient settings which says that Tier 4 CAMHS inpatient units should have access to a low stimulus space for de-escalation that is separate from the young person’s bedroom. Without a dedicated space and without PBS plans for most young people, staff are managing crises with limited structure and limited environment to support a least-restrictive approach.

Three young people told us they were unable to access their bedrooms to use the toilet freely during the day. This was due to a blanket restriction, however when we asked staff if young people were able to access their rooms to use the toilet we were told they were but would need staff to open the door for them. There were also communal toilets available around the service for the young people to access during this time.

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.

Staffing levels were sufficient to meet patient needs safely. The service used a staffing model that reflected the complexity of eating disorder care. Qualified nurses worked alongside experienced healthcare support workers. Senior nursing oversight was consistent across all shifts.

There were no vacant posts at the time of inspection. Bank and agency use averaged 8% of nursing hours over the three months before the inspection. Temporary staff came from a consistent, familiar pool of workers. They completed a local induction before working unsupervised.

Of the mandatory training, 94% was completed on time. Basic life support, physical health monitoring, nasogastric tube management and de-escalation training were all current for clinical staff. Annual competency assessments for nasogastric tube insertion were in place.

Supervision was regular and documented. Registered nurses had monthly one-to-one supervision. All staff had access to reflective practice groups. Staff said these were particularly valuable for managing the emotional demands of this work. Appraisal completion was 100% for the preceding 12 months.

Staff felt confident and competent. The team culture was positive and supportive. Staff knew their lines of accountability and felt able to raise concerns through the ward manager, service manager or freedom to speak up process.

The inspection was triggered by concerns in relation to the safe use of nasogastric tube feeding and we could see from training records and observation of cctv that this was being done in a safe way and in line with national guidance.

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 unit was clean throughout our inspection. Cleaning schedules were in place and completed consistently. Domestic staff knew their responsibilities and had appropriate training.

The service had a current IPC policy and a named IPC lead. Audits were completed as required and shared with the team. Actions were recorded, assigned and completed promptly.

Hand hygiene was good. Alcohol gel was available at ward entry points and throughout the clinical environment. We observed staff using the five moments of hand hygiene correctly.

Clinical waste was segregated correctly. Sharps bins were assembled, stored and disposed of in line with national guidance. PPE was available in adequate quantities and used correctly.

Staff knew what to do in the event of a gastrointestinal or respiratory outbreak. The IPC lead could describe the escalation pathway to the local health protection team. There were no outbreaks in the 12 months before the inspection.

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.

Medicines management was safe and well governed. The policy was reviewed annually and reflected NICE guidance and relevant pharmacy standards. The pharmacist attended clinical governance meetings and advised on complex prescribing decisions.

All prescriptions were signed by qualified prescribers. Where off-label prescribing was used, the rationale was documented, consent was obtained and the MDT had agreed the decision. High-risk medicines were monitored in line with clinical guidelines.

The controlled drugs register was accurate. Dual-signature processes were consistently applied. Refrigerated medicines were stored within the required temperature range. Records showed no out-of-range temperatures in the three months before inspection. Medicines requiring special storage were correctly labelled and segregated.

Medicines reconciliation was completed at admission and discharge. Staff understood how malnutrition affects drug metabolism. The prescribing team and pharmacist worked together to monitor and adjust prescriptions as young people’ presentation changed.

The inspection was triggered by concerns in relation to the safe use of nasogastric tube feeding. During the assessment we found the service had a standardised nasogastric feed protocol developed with dietetics and pharmacy. All clinical staff were trained in its use. Records showed consistent application. There were no significant errors in nasogastric feed administration in the 12 months before inspection.

We observed several nasogastric tube feeds on CCTV. Staff carried out the procedure with care and compassion, maintaining the young person’s dignity throughout.