Grove Park

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

We reviewed all 8 quality statements in the safe key question. This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment in April 2024, we rated this key question Good. At this assessment the rating has remained as Good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff understood what type of incidents to report and were able to describe the process for reporting, reviewing and responding to incidents. Staff were able to give examples of identified learning and improvements that had been made following incident investigations. However, incident forms were not always reviewed and signed off by two managers, as per their own policy and process. Although this did not have any direct impact in responding to or learning from incidents, it was not in line with the providers own policy.

Staff were clear on their safeguarding responsibilities for patients. They were encouraged to raise concerns and were aware of the freedom to speak up and whistleblowing processes.

Patients we spoke with felt safe on the wards and were supported to understand and manage their risks.

Staff said they assessed referrals into the service following the correct protocols to ensure the correct care and support is available and suitable for people. Managers oversaw referral response times, admissions and bed management. There were clear processes to monitor and manage length of stay and patient flow and to ensure people did not stay in hospital for longer than was necessary.

Staff reported effective communication with internal and external colleagues, including GPs and dentists, enhancing patient care. Weekly ward rounds included the multi-disciplinary team, with external advocates invited if requested by the patient.

Staff ensured that patients’ discharge to their local mental health teams was managed safely. The service had a discharge checklist to ensure that all tasks relating to discharge were completed. Leaders highlighted some discharge challenges, noting delays often stemmed from coordinating with community mental health teams in diverse locations and identifying appropriate contacts. At the time of the inspection, all of the patients were out of area patients.

Patients we spoke with all said they felt safe, and supported by staff and would speak to staff if they had any concerns or felt unsafe. They said staff helped them to manage risks and when needed, would act to maintain their safety and offer support.

Staff identified and reported safeguarding concerns and demonstrated good knowledge of protecting people from harm. They identified different forms of abuse, and the signs associated with these. We saw the safeguarding concerns and awareness were discussed in shift-to-shift handovers, at the daily multidisciplinary meeting and as part of clinical governance.

There was a clear process when raising a safeguarding. Senior leaders had regular contact with the local authority safeguarding team to discuss progress on investigations.

We observed that staff approached and interacted with patients in a compassionate and caring manner. Relevant safeguarding information was displayed on the ward information boards.

Staff received annual training in safeguarding adults and children at risk. Staff had access to a safeguarding policy and the service had a safeguarding lead who staff could go to for support and guidance.

Appropriate systems and governance processes were in place to ensure people were safeguarded. There was a compliance tracker which logged all reported safeguarding incidents to enable oversight and effective management.

Patients we spoke with were aware of their personal risks, which staff supported with them on a daily basis and were discussed during ward rounds with the wider multidisciplinary team. Patients felt confident to raise any concerns they had with staff and were involved in their care and treatment.

We reviewed four patient records and all of them had an up-to-date risk assessment in place. Risk assessments covered key areas and captured relevant information to support the ongoing management of risk.

Staff had a good understanding of patients’ individual risk management and acted to prevent or reduce risks.They were able to describe how risk was assessed at referral, admission and as an ongoing process during treatment. Staff felt involved and able to contribute to the assessment of patient risk, including within multi-disciplinary reviews. Staff were knowledgeable about individual patient risks and were able to provide examples of effective risk management. Staff adhered to procedures and policies to minimise risks, conducting searches when necessary to maintain safety.
 

Observations were recorded as per the organisation’s policies, with records reviewed for accuracy. Staff kept clear records of patient leave and return, including descriptions and contact information. Patient logs and visual boards were consistently accurate, ensuring effective monitoring and safe care.

Staff completed thorough risk assessments of both the wards and removed or reduced any risks they identified. For example, the service had completed a ligature anchor point risk assessment. This included a form for recording risks and an associated action plan, covering all areas of the ward and external areas. However, the checklist used by staff to carry out and record their findings from the daily environmental checks they completed was not effective in guiding staff as to what they should specifically look for to ensure the environment and equipment was well maintained. During the inspection, we found an oxygen tank was not safely anchored to the wall and a set of weighing scales were not in working order. Neither of these were highlighted on the checklist.

Patients’ bedrooms and communal areas were fitted out to a high standard with anti-barricade doors and anti-ligature features.

Staff could observe patients in all parts of the wards. Closed circuit television (CCTV) was in place in communal areas on the ward. CCTV was not monitored constantly, but viewed retrospectively, for example, when investigating an incident. Bedroom doors had vision panels on them to enable staff to carry out observations from outside patient bedrooms, without the need to always open the door and disturb patients.

The service complied with NHS guidance Delivering same-sex accommodation, there was no mixed sex accommodation. The hospital had two wards; Sanderson ward was for males and Westbourne ward was for females.

Staff had easy access to alarms and patients had easy access to nurse call systems. Patients had call buttons near their beds and in their en-suite bathrooms.

We observed staff engaging with patients in a supportive manner and encouraging them to join in activities that were meaningful to them. Staff were familiar with patients and were able to tell us about individual patients’ background, risks, interests and dislikes. During the inspection and on review of staffing rotas, we saw there was sufficient staffing levels to meet the required level of observations and to respond to peoples’ individual needs.

We observed a daily morning meeting where leaders and managers discussed staffing across the hospital. They discussed the staffing levels for that day and night, and the next few days and they adjusted and made changes where necessary. They identified factors that impacted on staffing levels such as how busy the wards were, enhanced observations, patients having leave off the ward, and other activities.

Staff completed mandatory training. There was a policy and guidance documents to support the supervision process and promote individual development.

The service had enough daytime and night-time medical cover and a doctor available to go to the ward quickly in an emergency. The service operated an out-of-hours rota for consultants and specialty doctors and for management.

Staff told us they received training in infection prevention and control. They knew what their role was in preventing infection. This included hand washing prior to entering the ward, regular environmental checks and implementation of cleaning regimes.

The service had a dedicated housekeeping team. They ensured that general cleaning records were current and that the premises were kept clean.

Patients we spoke with told us they were involved in decisions about their medicines. They told us they understood what their medicines were for, and staff explained when they were giving them what they were and their dosages.

Registered nurses administered medicines in line with current professional guidance. Patients came to the clinic room to receive their medicines, and their medicines were recorded on their individual prescription chart.

We reviewed 4 patients’ medicine charts and found no concerns with prescribing, administering, recording and storing medicines. Staff reviewed the effects of each patient’s medicine on their physical health according to NICE (National Institute of Clinical Excellence) guidance including monitoring of blood tests and regular checking of their vital observations. They discussed in the daily morning meeting where there were risks to people’s physical health needs and if changes were needed to the medicines prescribed for them.

The provider had safe systems and processes in place to prescribe and administer medicines safely. All equipment to support treatment was well maintained, calibrated, and stored in a clinical bag and clinical room. Staff stored medicines and prescribing documents in line with the provider’s policy.