Beverley 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

At our last inspection of the service, we rated this key question as Good. At this inspection the rating has remained the same. This meant people were safe and protected from avoidable harm. The service provided care and treatment in a way which made people feel safe, supported, and listened to. People felt safe within the environment and knew who to speak to if they needed any help or had any concerns. People were supported to make positive choices about their lives and encouraged to be involved in their care and treatment which helped balance the risk of harm. The environment was safe and clean. Staff had clear roles and responsibilities for managing and improving safety and were aware of policies and procedures to minimise restrictive practices and manage risk. Leaders ensured there were enough skilled people to deliver safe care that promotes choice, control and individual well-being.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Four relatives of patients told us they knew what to do if they had concerns about the service or their care. One relative told us, there were not a lot of agency staff and that patients had strong relationships with the staff. Staff built trust with patients and their relatives. One carer told us “I'm just really grateful my daughter is there.”

One patient told us they wanted to make a complaint about an incident of restraint. Staff talked it through with the patient and gave an option to raise as a concern. Once staff explained everything the patient understood and knew what to do. They felt listened to.
 

Staff told us they knew what to do if there was an incident. The provider put systems in place for staff to report and record incidents online. Staff learnt from incidents at staff meetings, clinical governance meetings, during informal conversations and by email. The ward manager told us staff were debriefed and received support after a serious incident. Staff and patients received debriefs and support from the psychologist following any incident. Managers ensured staff received clinical supervision.

Staff told us they understood the duty of candour. Staff were open and transparent and gave patients and families a full explanation if and when things went wrong. Managers provided feedback to staff from investigations of incidents, both internal and external to the service.

Staff had a strong, open and honest relationships with local safeguarding teams and were able to raise concerns and ask for advice when required.
 

Since April 2024 there were 9 incidents at the service. Five were safeguarding alerts and 1 was a ligature incident. The Registered Manager carried out a timely incident review which included care and risk assessment plans and an environmental audit with required actions that were highlighted and addressed immediately. The patient was safeguarded from any further risk. All staff involved felt that the response was quick and effective. They said both nurses had attended quickly and took immediate action. The 2 nurses felt well supported by the junior colleagues. They felt that the staff followed their instructions well and completed allocated tasks in a timely manner. Everyone felt that the team worked well together. Good practice was indicated by the alarm being raised, equipment at hand, and staff knowing what to do Managers completed Priory’s annual ligature audit to identify and address any risks or concerns.

People told us that the admission process was good and staff involved them with their transition into the service. One person told us staff encouraged other patients to help show them around the service. They said, “The allocated patient who showed me around on admission was friendly and genuine.

People told us staff listened and supported them when transitioning out of the service.
 

Staff said they assessed referrals into the service following protocols to ensure the correct care and support was available and suitable. Staff said people could speak to their named nurse or key worker. This would help build relationships with people and provided continuity of care and support. Staff said they regularly reviewed risk assessments and care plans and updated these to reflect people’s current risks and needs. The updates would be discussed with staff during daily meetings and handovers. Staff recorded these updates on the progress notes of peoples’ care notes.

During the morning meeting we observed staff discussions about care pathways including peoples’ transitions to other services and discharges. Staff discussions were patient focussed. Staff updated individual risk assessments. We observed staff noting carer concerns and changing plans accordingly. We observed handover discussions between staff which were risk focussed and patient specific including discussions about transition and discharge.
 

The service worked collaboratively with partners such as the local authority bodies, specialist clinicians, pharmacists and local GP practices to prioritise safety and continuity of care. Staff told us they could ask for advice if required.

The service referral and admission processes ensured all essential information about the person was received to ensure staff could determine whether the person’s needs could be met safely.

Leaders told us referrals to the service were reviewed and screened by the MDT (multidisciplinary team). The MDT comprised of the Hospital Director, The Responsible Clinician, Specialist Ward Doctor, Ward Manager, Director of Clinical Services, Staff Nurse, Health Care assistant, Psychologist, Assistant Psychologist, Occupational Therapist, and Occupational Therapist Assistant. This team decided if they should progress with carrying out an assessment based on suitability and ability to safely meet the persons care needs. Once a decision to assess the patient was made, a team was identified to complete the assessment. Leaders told us the assessing team provided feedback to the rest of the MDT making their recommendations and highlighting specific care and risk issues where relevant.
 

People told us they felt safe and were supported by staff. One person’s relative told us, they could confide in the staff and were happy to discuss any issues or concerns. People told us, sometimes there were patients admitted who were very unwell, and this could affect the safety of those already there. People told us staff supported them in these situations to ensure they were safe and encouraged them to raise any concerns. People told us staff did not use restraint often, and it would only be used if necessary. Staff ensured people understood why restraint was needed. Staff would talk to the people first about any safety concerns. Overall, people were very happy with the staff and safety of the service.

Staff and leaders told us they were trained in safeguarding, knew how to make a safeguarding alert, and took appropriate action. There were effective systems and processes in place to make sure people were protected from abuse and neglect. Staff recorded all information to review at staff meetings. Staff told us they would listen to people and advise appropriate action, for example raising the concerns in the form of a complaint or safeguarding alert. Staff told us they had strong and open relationships with the local authority safeguarding team and could ask for advice when required. There was a local policy in place if a child were to visit the service, even though this didn’t happen often. There was a room that could be used, outside of the patient areas for children visiting. Safeguarding concerns were discussed regularly with external agencies. There were no blanket restrictions at the time of the inspection. Staff had not recorded any use of restraint in the past 3 months.

We observed staff engaging with people and listening to their views. We observed a person speaking to a member of staff to raise a concern. Staff advised the person their concern would be raised as a safeguarding alert. Staff were going to have a conversation with both people involved. This showed that staff supported people in an appropriate way and took action to protect them from risk and harm. We noticed staff protecting people and ensuring this was recorded on notes and in their care plans.

Restraint was always used as a last resort and when de-escalation had been exhausted. All patients had specific care plans around the use of restraint. Staff developed these in collaboration with the person and set out what de-escalation methods to use such as offering PRN (pro re nata- meaning to be taken when required), using a soothing box and when it would be appropriate to use physical holds. Prone (face down) restraint was not used. Restrictive interventions were reviewed daily at MDT (multi-disciplinary team) meetings and debriefs were carried out with staff and people.

People told us staff involved them in developing their care plans and risk assessments. Relatives of people told us they felt the service was safe overall. One relative told us sometimes it would take a while before the person could go out, but they understood the person needed to carry out their ADLs (Activities of Daily Living) first.

One person’s relative told us they had concerns about other people there who were very unwell. They understood that there was only so much the staff could do, and they couldn’t avoid everything. They said the staff were helpful, supportive and protected people.

One person told us they hadn’t had unescorted leave and staff helped them to understand why. The person wanted to build this up slowly so that they could keep themself safe. The person said trauma therapy destabilized them, and staff were already aware of this.
 

Staff told us they involved people in their risk assessments and the team was responsive to risk. Staff said the daily handover meetings and weekly staff and multi-disciplinary teams helped reflection and discussion of lessons learned. Staff said they knew who to escalate issues to and were supported by psychology and leaders with advice and debriefs. Staff said they adapted peoples’ care plans with changes to meet the needs of the person and kept them informed. Staff told us they logged details in the care notes, key worker sessions and handovers. Staff said they encouraged people to use PRN and said there had been a positive change to reduce incidents.

Staff and leaders told us people had PBS (Positive Behavioural Support) plans in place and had a role in identifying their own state of well-being. Staff created individualised, patient specific PBS plans to support people with their recovery.
 

People were supported to understand and manage risk. Staff ensured risk assessments were clear and provided sufficient guidance to keep people safe. Staff updated people’s risk assessments during their meetings with the multidisciplinary team. Staff completed electronic and paper records of section 17 leave. Staff told us handovers were documented and saved, and peoples’ changes would be reflected. Staff followed processes to ensure leave was assessed before any person left the service and this was documented appropriately.

We observed that staff completed thorough risk assessments. The provider ensured there were clear processes in place for staff to follow. Staff used a recognised tool called the short-term assessment of risk and treatability. Staff completed this with a person on admission and reviewed quarterly. Staff also reviewed risk assessments following changes in risks or incidents. We saw staff updated risk assessments regularly in care records. We checked observation records and noticed 2 were not up to date. However, this was because the 2 people were involved in other activities. We also observed the blanket restriction log and there were no blanket restrictions in place.
 

People and their relatives were satisfied with the safety of the environment. People told us they kept their rooms clean and tidy.

Staff told us they carried out regular risk assessments of the care environment. Staff recorded any issues and informed maintenance. Managers carried out weekly audits and daily environmental checks. Managers allocated staff to a security lead role for each shift, although any staff member could edit the working book (a daily environmental risk audit. This was additional to the monthly environmental audit). The day security lead would handover to the night security lead to ensure checks were kept up to date. Staff told us this document was never ignored and was a working document. This was in addition to the monthly environmental monthly audits. The director reviewed this document at handover.

The Director of Clinical Services told us some ligature work had already been undertaken and addressed as part of their improvement plan.

We raised concerns regarding the pipes being exposed in the bathroom that could possibly pose a ligature risk. We escalated this concern to the registered manager who confirmed that the pipes were exposed as part of pipe repairs to the bathroom/shower area water supply pipes. The Registered Manager had since been logged with the site maintenance team who ordered the repair kits. The bathroom was temporarily out of use pending the repair work. The impact on people was minimal as most people had ensuite bedrooms and there was another bathroom available.
 

The layout of the ward/unit allowed staff to observe all parts. We identified ligature risks which were raised with the registered manager, such as the exposed pipes in the bathroom, hole in the bath tub, the ADL (Activities of Daily Living) kitchen door handle and the hand cleanser in the corridor. The manager confirmed that a ligature risk assessment was underway and immediate actions would be carried out to mitigate such risks. The registered manager confirmed, repair kits had been ordered with a delivery date of 9 August 2024 and we received confirmation of the maintenance order number. Follow up information received from the registered manager confirmed what was done to date including informing people during community meetings. People were informed in community meetings of 31.07.2024 and 7.08.2024 that the bath tub on the first floor could still be used. Progress of the repairs, were to be communicated in the follow up community meetings.

The unit only supported female patients, so the mixed-sex accommodation guidance did not apply here. Staff had easy access to alarms and visitors were given an alarm on entrance.

We observed that fridge temperatures were checked, and audit folders were available and completed. We saw weekly charts were completed by staff.
 

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Nurses completed clinic room checklists daily. Staff carried out daily checks and weekly environmental audits. The security lead in the day would handover a checklist to the night security lead. Staff recorded any environmental safety issues on the working document (a daily environmental risk audit. This was additional to the monthly environmental audit). Staff would address any immediate concerns instantly, such as loose cables.

Most people told us that they had strong relationships with the staff members and that there were not a lot of agency staff. People said they trusted the staff and felt safe. One relative told us that they were really grateful their loved one was at the service. One person had been to a number of other places but felt this service was the best. They were really happy to be there. One doctor was highly appreciated by the relatives and people, and they were sad they had left and hoped the person taking over would be just as good. People were happy overall with the staff and the way in which they cared.

Staff confirmed managers supported them with supervisions and unplanned one to one sessions. Psychology staff were very supportive and offered reflective practice. Staff felt they had a good rapport with each other and management and were able to respond to risk effectively. Staff were approachable and checked on each other which led to a positive team.

Staff told us they completed training throughout the year, both e-learning and face to face. Managers recorded staff training compliance on a training matrix that notified them of any out-of-date training and reminded staff to keep up to date. This included all mandatory training and clinical training.
 

We observed 2 Registered Nurses on duty and 4 Health Care Assistants during our visit. This was sufficient to meet the needs of people. We observed a staff handover meeting. Managers allocated additional staff on night duty to manage risk. We observed staff spending time with people throughout the day. Staff encouraged people to carry out activities. Staff were knowledgeable about their roles and responsibilities.

Staffing numbers were monitored and discussed within daily meetings. Staff checked for any appointments, meetings, visits and planned activities during the daily meeting. There was always a Nurse in Charge on each shift as well as 2 HCA’s and 1 additional staff for each one to one observation. Staff identified which staff were most suitable to facilitate different activities. Managers took action to address any staffing shortfalls. The provider had a safe recruitment process for new staff members which included completing required checks and references. Managers carried out checks for staff on professional registers such as the Nursing and Midwifery Council to ensure ongoing compliance and fitness to practice. Staff completed all mandatory training managers alerted staff to any training that needed updating. New staff undertook induction training to prepare them for their role and awareness of expected safety standards. Managers ensured staff received regular supervision to monitor their performance and discuss their learning and development needs.

People we spoke with said they were satisfied with how clean and tidy the service was. Relatives of people also said the service was clean when they attended the Carer’s event days.

Staff knew how to reduce the risk of infection because they received training and had knowledge of the provider’s policy and best practice guidance. Hand wash and sanitisers were available to use before entering the unit. Staff carried out regular environmental checks and kept cleaning records up to date.

We observed effective infection and prevention control procedures whilst onsite. Staff followed procedures including hand washing and ensured all areas were clean and tidy. This included the clinic room, which was observed to be very clean, tidy and hygienic.

The provider had an infection prevention and control policy for staff to follow. Staff received training about infection prevention and control. Staff checked daily and weekly cleaning schedules and monitored cleanliness and hygiene. Managers audited these checks to make sure staff adhered to policies and procedures. Staff carried out medicine’s storage fridge temperature checks in line with guidance.

People told us staff managed their medicines well. Staff gave people their prescribed medicines at the right time and in the right way. Staff /doctors invited People and relatives to meetings to discuss medicines and any changes. Relatives told us they felt involved in their family member’s care. One relative told us they understood why the medicines were prescribed given the complex mental health needs of the person. One relative told us their family member didn’t understand what medicines were given but felt staff were approachable and answered questions thoroughly.

Staff responsible for prescribing or administering medicines were knowledgeable about the safe use of medicines and about expected safety standards, policies and procedures. Staff followed safe checking and administration procedures when managing medicines. Only clinical staff, with appropriate skills and training, managed medicines. Staff prescribed and administered medicines in a safe way. The provider ensured systems were in place for reviewing and monitoring the effectiveness of prescribed medicines. Staff ensured medicines were checked and in date and this was recorded on checklists.

We observed the clinic room and saw that staff completed checklists. We did not identify any issues of concern. We observed staff stored and administered medicines appropriately and in line with national guidance. Staff reviewed the effects of medication on peoples’ physical health regularly and in line with NICE (National Institute for Health and Care Excellence) guidance. We spoke to a Physical Health (PH) Assistant who carried out assessments of people’s physical health on admission and completed regular monitoring and screening of peoples’ physical health. The PH Assistant was trained in phlebotomy and was able to take peoples’ blood in order to check they were safe to take a particular medicine, called clozapine. Staff supported people to attend external medical appointments and screening. The provider used an electronic prescribing system. We observed staff discussing medicine management with patients. For example, peoples’ preferences being discussed such as receiving their medicines via an injection, called a depot, instead of orally.

The pharmacy team carried out weekly audits on all medication related processes. Leaders followed processes to ensure people’s medicines were appropriately prescribed, supplied and administered. There were appropriate arrangements for the safe management and storage of medicines. Staff stored medicines correctly and safely in a clean and temperature-controlled environment. Staff kept accurate and up to date administration records for prescribed medicines. There were no controlled drugs at the service, however the provider had a process in place with separate storage facilities, if required.

The medicine cupboard was very tidy and all medicines were in date. Weekly reviews of stock checks were carried out by nurses. There was a Medicines Disposal Policy in place and this was adhered to. There were no controlled drugs on site however there was a key stored separately if there was a need for it.