Avesbury House

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 assessment the rating was requires improvement. This meant improvements were needed to keep people safe and protected from avoidable harm.

There was a breach of regulation 12(1)(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found a number of safety issues during the inspection. These were addressed during or shortly after the inspection, but it was of concerns that the service’s own systems had not identified these issues independently. Issues we found included lack of recording of action taken if physical health scores were outside of the normal parameters; some patient records lacking clinical detail; storage of medication keys, out of date medicine stock items, and some environment security issues..

Staff completed comprehensive risk assessments using a structured judgment tool to assess the risks for each patient on admission and reviewed these regularly as needed. However, they did not always record what action was taken when patients’ physical health scores were outside of the normal parameters, and some patient records lacked clinical detail.

Staff reported incidents and were aware of the learning from recent incidents. Staff were trained in safeguarding and knew how to make safeguarding alerts. Appropriate safeguarding concerns were raised by staff relating to patients, with protection plans put in place when needed.

Staff completed targeted searches if there were specific risks identified. Staff applied blanket restrictions on patients’ freedom only when justified, such as items that they were not allowed to bring into the hospital. No physical restraints had been used on patients at the service within the last year.

There were systems in place for staff to follow before patients went out on unescorted leave. Staff recorded what patients were wearing and checked on how they were feeling and presenting before going out. However, the folder in use for patients who were absent without leave was not up to date. This was corrected shortly after the inspection visit.

Patients were positive about the environment within the unit. The hospital environments were visibly clean and well maintained. Staff were supported by CCTV to observe patients and ensure their safety. The hospital was for male patients only, and some patients shared bathroom facilities. All members of staff carried a personal alarm, and there were wall-based alarms throughout the hospital as well as in patient bedrooms. Work had been undertaken to reduce the risk of ligature anchor points in the unit by 35%. However, we found some security issues with the hospital environment including the car park gates, and the stable doors on the clinic and security rooms. These were addressed shortly after the inspection.

There were few vacant posts and little use of agency staff. Safe staffing levels (for registered and non-registered nurses) had been assessed. Extra staff were provided when enhanced observations were needed. When temporary nursing staff were used, those staff received an induction to familiarise them with the hospital and policies. Staff told us that there was adequate medical cover to meet the needs of patients. A duty doctor and an on-call consultant were available out of hours.

Most staff had received and were up to date with their mandatory and statutory training courses as at the time of the inspection. Overall compliance with mandatory training was 91%.

Relevant health and safety environmental checks were in place. Staff and patients said that the level of cleanliness on the was good.

The clinic room was clean and tidy. Prescribed medication stock was all in date and medication fridge/cupboards all tidy and in order. Medicines administration records were completed appropriately. Staff signed when they administered medicines or recorded why not, in accordance with provider policy. Staff understood how to use sedative medicines safely as a last resort. However, we found that storage of medication keys was not secure at the time of the inspection.

Medicines cupboards and drawers were cluttered, making items harder to find quickly. Five stock items were out of date, suggesting that monthly stock checks were not always completed or thorough. Several medication charts were missing patient photographs. The provider advised us that these issues were addressed after the inspection.