Pathfinder Ashness House

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 good. At this inspection, the rating has remained good.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew what incident to report and how to report them using the incident reporting system. All staff members had access to the incident reporting system.

Managers reviewed all reported incidents. Incidents were discussed in daily handover meetings and monthly team meetings.

In the last 3 months, there had been 91 incidents at the service. Managers told us several of the incidents were linked to two patients, but there had seen a decrease since the introduction of the CAMS monitoring tool (Co-operations, Anti-social behaviour, Mood/Anger, sexually inappropriate behaviour). We noted one serious incident within the last 12 months. The report, its findings and subsequent actions were all shared with staff.

Staff received feedback from investigations of incidents during daily multi-disciplinary team meetings. We also saw evidence of this in team meeting minutes and within clinical governance meeting minutes.

The service tracked incidents by trends and by patient, shared this information with staff and made changes where needed. Most staff we spoke with could tell us about recent incidents and the learning that came from those incidents. For example, a patient consumed hand sanitizer and was admitted to hospital. Following this incident managers ordered 0% alcohol hand sanitiser and removed all the old products and changed the dispensers to locked stations. Following a rise in incidents related to illicit substances being brought onto the unit, the service implemented more robust person and room searches.

Staff were debriefed and received support after a serious incident. Staff told us they also had reflective practice fortnightly where they were able to discuss incidents with a psychologist.

The service referral pathway ensured that the service received essential patient information to determine whether the patient’s needs could safely be met. The majority of referrals made come from integrated care boards. Once deemed appropriate for the service, a team from the service would meet with the patient to assess their needs. This assessment process also involved speaking with community teams and carers, where appropriate.

Managers told us they do not accept patients with a moderate to severe learning disability or those with a diagnosis of autism. Due to the environment and no lift facility, the service was limited to the number of patients they were able to admit with physical or high sensory needs. The patients risk level was also considered when assessing them for the service.

Staff coordinated necessary healthcare and social care services to ensure patients received continuous, safe care both within the service and after discharge. We observed evidence of care-coordinators being invited to ward round meetings.

Stakeholders gave generally positive feedback about the care received at the service but shared that there could be more timely discharge of patients.

Staff received training in level 1 and 2 safeguarding training for adults and children and demonstrated that they knew how to identify adults at risk of or suffering from harm and worked with other agencies to ensure their protection. Most staff were up to date with training, with a 95% compliance rate. The service should consider whether level 3 training should be delivered to the staff group, in line with national guidance on staff competencies in safeguarding.

The service had a named safeguarding lead, and all staff knew who this was.

Staff could give examples of safeguarding concerns, and we observed that the local authority was notified within an appropriate timeframe and staff worked with them to keep patients safe from harm.

The service did not have a safeguarding policy written in a format that was accessible to those using the service. This would have supported patient understanding of the safeguarding process and procedures in place to keep them safe.

We reviewed 6 patient care records at the service. Records showed that staff completed comprehensive risk assessments, reviewed these regularly, fortnightly at ward rounds or after an incident, and updated them with relevant risk information. Staff completed risk assessments looking at the patient’s potential risk factors. For example, risks to themselves, sexually inappropriate behaviour, abuse/exploitation from others and exploiting others. Each care record also contained a risk management plan.

At the daily multi-disciplinary meeting, staff discussed patient risk levels, including a review of recent incidents and concerns.

All staff received and completed training on prevention and management of violence and aggression.

Staff reported using de-escalation techniques, using physical restraint only when these methods were ineffective and necessary to ensure the safety of the patient and others. In the past 6 months, there were 3 situations where staff used holds as a restraint. None of these were prone (face down) restraints.

Staff held regular meetings with patients to review their risks and discuss their care and treatment plans.

We reviewed a sample of observation records, the records reviewed were thorough and there were no gaps. In addition to observations, the service used CAMS scores to monitor and respond to patient needs. Using CAMS, staff assigned a score to different behavioural areas every time the patient was observed, such as anger or sexual impropriety. This data could be used to see changes in behaviour over time and detect when a patient might need more support from staff.

The service carried out regular environmental risk assessments and a ligature risk assessment. This was to identify areas of risk and plans to manage risk. We identified one room, the visitor bathroom, that was accessible to patients, that was not included in the ligature assessment and had several risks present. We observed patients being able to access this room without staff observation. When we raised this concern to the provider, they informed patients not to access the room with a sign but did not lock the room to ensure this risk was managed more appropriately. During the inspection, the service ordered ligature free equipment to be installed into the bathroom.

The service had a number of blanket restrictions in place. Staff considered and reviewed blanket restrictions on a monthly basis to determine whether they remained proportionate to the level of risk they were designed to manage. Current restrictions were designed to support safety on the wards. Staff reviewed them at monthly clinical governance meetings to ensure they remained necessary and proportionate.

The service had policies and procedures in place to manage the sexual safety of patients on the ward. Although, one member of staff said they had tried to raise concerns about specific behaviours but could not find clear guidance and reporting thresholds to follow.

For one patient, staff had worked with them around the use of a personal camera in their bedroom. Although this was discussed in detail with the patient and some specific staff, not all staff could tell us clearly what the arrangements were for this, and the risk management around this, for both patients and staff. The impact of this on ongoing care, treatment and discharge were not stated clearly in the patient records.

Some staff reported challenges with limited room availability, making it hard to find suitable space for one-to-one sessions or group activities. The service had a games room and a multi-faith room. These were on the first floor and therefore not accessible to patients with mobility issues. Before a referral was accepted, staff would assess whether it could meet the needs of someone with mobility issues and would not admit a patient if they would not be able to access the first floor.

At the time of the inspection, personal emergency evacuation plans (PEEP) were being updated, and we could not see that all patients who required a PEEP had one in place. The PEEPs we reviewed at the time were not concise, each 2 pages long and not dated. Copies of these documents were kept in the reception office on the ground floor, which would not be easily accessible if needed by staff the first floor of the building.

The service was across 2 floors, with patient bedrooms on both floors, resulting in areas that couldn’t be fully observed. To manage these risks, the service utilised convex mirrors, CCTV, regular staff observations and patient risk plans. Managers and staff were aware of patient specific risk and the location of ligature cutters.

Wards had lounges which were spacious, with natural light. The lounge was equipped with tables, chairs, a sofa and a TV. There were some pictures on the wall. The Occupational Therapy (OT) Kitchen was accessible from the lounge. It was kept unlocked but staff supervised kettle use.

Both wards had access to a shared garden, which consisted of a large area of grass with some plant pots. There was an exercise bag available in the garden and some tables and chairs. There was a laundry outbuilding at the rear of the garden, where patients did their own laundry. There was a meeting room situated on the ground floor, which was used for various meetings, including annual health checks from the GP, tribunal meetings and visits.

Most patients told us they felt safe on the ward, although did report that on occasion there was scenarios involving violence and aggression.

The emergency resuscitation equipment was stored in the reception on the ground floor and in an office on the first floor and staff knew where this was.

The service was compliant with fire safety requirements and carried out regular fire drills.

The service calculated safe staffing levels based on patient need and acuity. The service had five support workers and two registered mental health nurses in the day and four support workers and two registered mental health nurses at night.

Managers adjusted staffing levels according to the needs of the service. For example, when a patient was being nursed on enhanced observations.

Most patients told us that they met with their named worker often, however one patient said they would like to meet with their worker more often.

Some staff told us that they feel more support workers on shift would be beneficial, as when acuity is high in the service or patients are on direct observations there doesn’t feel that there was enough staff to carry out all tasks.

There was adequate medical cover day and night.

There was one current nurse vacancy and one post with a recruited nurse starting soon.

Bank and agency use was low, and the service used staff who had either worked at the service previously or had acted in the role for a long time so know the patients well. Average fill rates for bank and for agency support workers was approximately 1.5%, and for nurses approximately 20%. There were no unfilled shifts in the last 6 months.

Staff were required to complete mandatory training. The training was appropriate for the patient group using the service. However, some staff members had not completed specific mandatory training for several years. All staff had completed basic life support or immediate life support training, depending on their role. New staff received a suitable induction, which all staff confirmed they had received. Staff were also offered refresher training where needed.

Staff received monthly clinical and managerial supervision, where they could discuss safeguarding, audits, required learning, issues within the team and discuss patients they supported. The staff’s wellbeing, sickness figures and annual leave allowance would also be discussed during their supervision. All staff files reviewed had monthly logged supervision. Supervision completion is at 97% and appraisal compliance was 89%.

Staff benefited from fortnightly reflective practice sessions held by the service’s psychologists, which they said was valuable. Managers ensured that staff had access to regular team meetings that staff could attend in person or remotely.

We observed gaps in employment records, including Disclosure and Barring Service (DBS) checks or expired DBS certificates, Curriculum Vitae and relevant qualification certificates. We raised this with managers during our inspection, and they have since confirmed this has been addressed.

The ward areas appeared mostly clean, however there was a malodour in some areas and some signage on the wards that was not following infection prevention and control principles. There was several unlaminated paper signs attached to walls with Sellotape. We observed a stained towel draped over a patient's bedroom door with a paper sign attached to the towel with some Sellotape. Staff said it had been present for several days and it also covered the observation panel. We queried with staff who were unable to give a clear explanation as to why it was there.

Cleaning records were not up to date and had not been completed for the week of our inspection.

We did see that staff kept logs of cleaning equipment within the clinic room. Staff carried out an infection control audit every 12 months.

The service followed national guidelines and legislation for medicine management, with established processes for the ordering, storage, administration, and disposal of medicines.

All relevant staff accessed medicines management training and completed a competency assessment as part of their induction. Management staff reviewed competencies if they identified a need. For example, a trend of someone making medicine errors.

Medicines were administered in accordance with Mental Health Act consent to treatment and the forms we reviewed were in line with this. The service ensured patients had a sufficient supply of medicines.

Nurses oversaw the monitoring of patients’ physical health, following established guidance. This included regular monitoring for patients prescribed high-risk medication. During our visit, the General Practitioner was on site completing the patients’ annual reviews.

The service received clinical support and auditing from an external pharmacy.

Medicines were not used to inappropriately control people’s behaviour. Instead, staff followed positive behaviour support plans.

The service assessed and supported some patients to self-administer their medication.

There were no controlled drugs being prescribed to any patients at the time of inspection. The key to the controlled drugs cabinet was not kept in a secured, designated place and could not be found on the day of inspection. This was escalated to the manager to rectify.