Grove Park

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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

We assessed five quality statements from this key question and we have combined the scores for these quality statements with the rating from the last inspection, which was requires improvement. Our rating for this key question has improved and is now good. We found that there were enough staff on duty with the right skills to keep people safe. Staff acted on people concerns and complaints. Staff could identify safeguarding concerns and knew how to report them. Staff recognised people’ risk and involved people in managing them.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service treated all concerns and complaints seriously and investigated them.

Staff completed an electronic form for all incidents, managers reviewed the forms at the multidisciplinary team handover every day. Managers told us that they sometimes needed to remind staff to complete the forms following incidents.

There is a weekly audit of incident forms, to ensure that staff had completed all forms to the correct standard. Senior leaders reviewed all at the incident forms at the monthly lessons learnt meeting, to identify any themes or trends. Qualified nurses shared any identified learning at handovers. Nurses updated risk assessments and care plans based on any relevant lessons learnt. Managers identified that staff were not regularly debriefing people following the use of physical interventions. Staff addressed this by using a debrief form, to confirm the person had a debrief. This ensured the person experience fed into the overall learning.

Managers introduced reflective practice sessions for the staff team to review and improve how they assisted distressed people. Managers identified that staff lacked confidence when addressing distressed people. Managers encouraged staff to work more proactively with people. This led to a reduction in incidents as staff felt more confident in engaging with people.

The hospital director reviewed previous incidents to ensure they could also influence improvements at the hospital.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

All staff had received training in safeguarding adults and children to an appropriate level. At the time of the inspection the provider only offered digital safeguarding training. However, senior managers told us that they were moving to a face-to-face training model.

There was a safeguarding lead and staff knew who they were. Ward staff could explain what they needed to report and what action they would take if they needed to make a safeguarding alert. Staff told us they could discuss safeguarding issues as a team and report issues via the qualified nurses or directly to the local safeguarding team. If they were unsure of what action to take, they could speak with the mental health units safeguarding lead.

People told us they felt safe at the hospital. They told us they could speak to staff if they felt unsafe and that staff had the skills needed to keep them safe.

People told us that staff always involved them in identifying and managing risk. People engaged in developing their care plans and risk management plans and staff gave them copies to keep.

The staff team reviewed risks regularly, staff discussed risks with people before they accessed section 17 leave, escorted or unescorted. The multidisciplinary team reviewed risks at ward rounds and staff encouraged people to give their views.

Staff understood people risks and knew how to help the person manage their risk. They could access up to date information about people’s risk and could update risk information when they needed to. The provider was operating a dual record system. Staff accessed printed off paper records, however, some records were only available via a computer. We found that not all relevant files were in the paper record. For example, one person had a risk identified and staff had taken action to address this but they had not recorded the management plan in their paper record. Not all staff where aware of what information was in each folder. The provider told us they were about to implement an electronic records system to address this and that would ensure all records were in a single place for ease of access.

Staff reviewed and removed any unnecessary restrictions placed on people. For example, the provider had installed hot drink making facilities on the wards so that people did not need to ask staff for a hot drink. However, drinking water was only available in the reception area and people had to ask staff for access to the water. People we spoke to told us that they never had to wait long for access to water.

Staff used a combination of CCTV in the garden areas and convex mirrors and staff observations in the ward areas, to observe people. We reviewed observation forms and saw that they were all completed correctly. However, staff completed the observation at regular intervals rather than at random times.

Facility staff, in conjunction with the ward staff, had completed a full ligature assessment of the mental health unit. This included a rating of the severity of each identified risk and actions to reduce the risk. Staff knew about any potential ligature anchor points and mitigated the risks to keep people safe. We saw that there were ligature heat maps in the ward offices which identified the ligature points and the risk level.

We saw that staff completed and updated thorough risk assessments of all ward areas and removed or reduced any risks they identified. Ward staff did this daily and entered their findings on the ward safety log.

The mental health wards comply with national guidance as there were no mixed sex accommodation.

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

Ward areas were clean and well maintained. Wards were well furnished, with modern purpose-built furniture. However, a bench in one ward courtyard required re painting and in both courtyards, there were cigarette ends and other litter that managers had not ensured had been cleaned up, which did not make for a pleasant environment .

Domestic staff where employed, and we reviewed cleaning schedules and saw that effective cleaning took place daily. Staff told us that if an area needed specific cleaning the domestic staff were able to prioritise that area to maintain cleanliness.

There were enough staff in post and deployed on the wards to keep people safe. At the time of our inspection the core staffing was one qualified nurse and two healthcare support workers, on all shifts, for up to nine people. If people needed additional support such as one to one observation or due to escorted leave, managers could deploy extra staff and staff confirmed this. The service also had a ward manager or charge nurse on duty during the day and a charge nurse on duty during night shifts.

In addition to the core nursing staff there were occupational therapy staff who ran groups across the week and could escort people in the community. The occupational therapy team could work with people individually when needed. The provider also employed a psychologist and psychology assistants who ran therapy groups and individual sessions with people.

The provider had reduced the number of vacancies since the last inspection and senior managers told us they no longer needed to use agency staff regularly. The provider still used agency staff to fill last minute gaps in the rota. When the provider used agency staff, they tried to use people familiar with the service.

The was enough doctors employed at the service. There was a consultant and junior doctor present during the day and an on-call system in place at night. Staff told us they could access a doctor when needed and we saw that doctors were present on the wards throughout our inspection.

Staff told us they felt supported by senior managers to do their job and that they could access the training they needed. Staff also told us that training had improved but the provider could improve training further by using more face-to-face training.

Staff received appropriate training. At the time of the inspection 97% of staff were up to date with their mandatory training. Staff had received training in the Mental Capacity Act and could explain when they needed to consider if a people had capacity to make a decision.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.