Fir Trees Independent Hospital

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

The ward was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients 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.

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.

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 practice.

There had been no serious incidents in the 12 months prior to inspection. All staff knew what incidents to report and how to report them. Staff reported all incidents that they should report.

They had an escalation policy in place if patients could not be safely managed on the ward, or their mental health was deteriorating.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. There had been no incidents requiring duty of candour reported. Staff received feedback from investigation of incidents, both internal and external to the service. The staff and managers had attended a development day to plan for the future and to develop the service.

Patients told us they felt able to raise any issues they had with staff and staff listened to them. Patients and staff were supported and encouraged to raise concerns about the service. The service had team meetings to discuss any concerns about safety, any safety events were investigated and reported. Staff met to discuss that feedback. Learning from any incidents was shared throughout the service; an example of this was where the Section 17 Mental Health Act leave policy had been reviewed and updated following a serious incident at another service.

Staff were debriefed and received support after a serious incident.

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’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The service had a good transition of care. Staff visited potential patients and completed an assessment, gathering all necessary risk assessments, care plans, and any other reports, for example any occupational therapy reports. The service met as a team to discuss any referrals into the service.

The staff team encouraged patients to visit before admission, to ensure they were aware of the service they were going to and to meet the staff and other patients.

Staff involved all the necessary healthcare and social care services as well as housing providers to ensure patients had continuity of safe care, both within the service and post-discharge. They made sure there was always continuity of care, including when people moved between different services.

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.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Between April 2025 and April 2026, Fir Trees had made 9 referrals to the local authority safeguarding team. The safeguard lead presented data monthly at a quality meeting, highlighting any themes and trends. There was an online portal direct to the local council which staff could access to report any concerns and safeguarding issues they had.

A ‘no abuse’ document had been co-produced with patients that was easy read and pictorial. This provided examples of what abuse is and provided local contact information and support contacts. It also contained information about human rights.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. People with a learning disability and autistic people were protected from abuse and had their individual needs taken into account.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Policies and procedures were in place to support this.

Staff followed safe procedures for children visiting the service and a site visiting policy was in place for any visitors to the premises.

There were some restricted and banned items within the hospital; however, this was risk assessed on an individual basis. Information about these were displayed in the welcome pack given to patients. There were no restrictive practices apart from keeping the outside doors to the unit locked. This was because of a recent break-in into the premises. However, there were signs to inform informal patients at the hospital that they could leave the hospital at any time, and this was also highlighted in the patient handbook.

Mental Capacity Act

100% of staff had had training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

There was no deprivation of liberty safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. We saw evidence that this had been completed in the care records we reviewed.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The service had arrangements to monitor adherence to the Mental Capacity Act.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients 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.

We looked at 5 risk assessments/risk management plans during the assessment.

There was only one instance of restraint in July 2025, this was not in the prone position.

There had been no rapid tranquilisation used in the 12 months prior to inspection, and no use of seclusion or long-term segregation. There was a therapeutic management of violence and aggression policy.

Staff involved patients in care planning and risk assessments, shown by evidence in care plans. Patients participated in their multidisciplinary team reviews and had access to a copy of their care plan. Risk assessments were all fully completed with review dates planned. Care plans were personalised and co-produced with the patient and included patients views and review dates. The care plans were recovery orientated and discharge plans were specific to each patient. This included taking into account the specific, person-centred needs of people with a learning disability and autistic people.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff enabled patients to give feedback on the service they received; for example, through surveys and community meetings as well as 1-1 meetings with their named nurse.

Staff enabled patients to make advance decisions and statements where needed to refuse treatment, sometimes called a living will when appropriate.

Staff ensured that patients had access to advocacy and details of advocacy support was displayed throughout the unit.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The unit was welcoming, clean, and well-staffed during the dates of the inspection. Staff did regular risk assessments of the care environment. Ward layout allowed staff to observe all parts of the ward with additional mirrors to mitigate any blind spots and the use of closed-circuit television (CCTV) in patient areas, apart from the bedroom areas.

Staff had mitigated the risks in relation to potential ligature anchor points adequately. There was a ligature risk assessment in place, and this was updated annually with the most recent being in December 2025. Ligature cutters were checked and available to staff. There was search training for all staff and ligature scenarios were part of the training.

Nurse call systems were available throughout the hospital as well as in patient bedrooms. Staff had easy access to alarms and patients had easy access to nurse call systems.

Fire risk assessments and environmental risk assessments were in place and regular fire drills were completed as well as weekly fire door checks.

The ward complied with same-sex accommodation guidance. All patients had their own room with en-suite showers and toilets in their room. Male and female bedrooms were on different corridors. Patients had access to their own bedrooms and had a key to their bedroom to safely store their possessions. Patients could personalise their bedrooms throughout their stay. They had a female only lounge.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Fire risk assessments were in place and up-to-date checks were completed. Evacuation drills were also completed.

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.

The service had a full-time manager, 1 senior nurse practitioner, 5 full-time nurses, and 3 part-time nurses. They had 1 full-time occupational therapist,1 full-time student nurse associate, 9 full-time support workers, and 2 part-time support workers. There were no vacancies at the service.

Managers had calculated the number and grade of nurses and healthcare assistants required. The number of nurses and healthcare assistants matched this number on all shifts. The ward manager could adjust staffing levels daily to take account of case mix.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. In the 12 months prior to our inspection agency staff worked 5% of the total shifts worked at the hospital. In the rare instances of staff shortages, the hospital managers had a daily meeting with registered managers of other sites to plan for shortages and could relocate staff from other services to help. The registered manager and senior nurse practitioner had been included in staffing levels to ensure no disruption to patient care when necessary.

The sickness rates over the 12 months prior to inspection were calculated monthly with the lowest being 0% and the highest being 5% due to long term sickness.

A qualified nurse was always present in communal areas of the ward. Staffing levels allowed patients to have regular one-to-one time with their named nurse, and this was recorded in patient progress notes. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There were enough staff to carry out physical interventions such as observations, restraint and seclusion, and staff had been trained to do these interventions.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. There was an on-call management rota also in place.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.

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.

Staff maintained equipment well and kept it clean. All ward areas were clean, had good furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Staff adhered to infection control principles, including handwashing. The furniture was in good condition and décor was well maintained. The courtyard garden had many cigarette ends on the floor, and this was brought to the attention of the registered manager who immediately arranged for them to be removed.

Staff had completed mandatory training in infection prevention as well as food safety. There was an infection control lead at the hospital and checks were completed by staff.

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.

Staff followed good practice in medicines management that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, and did it in line with national guidance. A medication audit was completed every 6 weeks. A medicines management report was also produced monthly. We saw that some medication errors which had been identified by an audit had not been actioned in a timely manner. This was brought to the attention of the manager and was rectified immediately. There was no impact on patients’ care and treatment.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when the patient was prescribed a high dose of antipsychotic medication. Staff had access to up-to-date medicines resources, including a British National Formulary (BNF) guide. Information was provided to the patients about any medication they were prescribed.

We checked 3 prescription charts on their electronic system, and all medications were administered on time. All medicines stored for individuals were individually labelled and there were no medicines out of date. When individuals self-managed their medication, this was risk assessed and patients had safes in their rooms to store the medication safely.

Daily cleaning of the clinic was audited and recorded daily. Clinic room temperatures were also recorded. All the necessary equipment required to carry out physical health checks was available in the clinic.

There were no controlled drugs stored in the clinic. However, if this was needed, they had appropriate storage and a policy in place.

The fridge was locked and temperatures were recorded and reset daily. Emergency medications and resuscitation equipment was checked daily, and sealed equipment was checked weekly.