Brainkind Neurological Centre York

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

This means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment of this service. This key question has been rated as Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Data showed that staff did not always receive supervision. The service used a safe staffing tool, and the wards were rarely short staffed. However, some people felt that there were not always enough staff during busy periods to ensure that people were cared for in a way that they preferred. The service aimed to promote a culture where staff and people were able to raise concerns, but some staff felt managers were not proactive and didn’t respond to issues raised in a timely manner. Nevertheless, safety was a priority for staff and leaders within the service, and they provided care in a way that made people feel safe. People were actively encouraged to be involved in their care and treatment. Staff were familiar with policies and procedures used to safeguard people and ensure the environment was kept safe.

The service was in breach of Regulation 12 safe care and treatment due to issues identified with medicines management. There were medicines management processes in place, however these were not always effective. We found issues relating to the storage, disposal and prescribing of medicines. This included issues with fridge temperatures, medicines checks and treatment certificates.

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.

People said they felt safe and knew how to raise concerns if they needed to. Staff ensured that any concerns were addressed. Most staff described a culture of learning where they felt able to raise concerns and gave examples of how they had been treated and supported in a proactive way. Staff told us that learning from safety incidents was shared and they implemented this learning into their work practices. A few staff told us they didn’t feel able to raise concerns with leaders and did not have confidence that these would be dealt with effectively. Staff received lessons learnt through team meetings and by email. Managers kept logs of lessons learned including identified themes.

All incidents and complaints were investigated thoroughly with outcomes and feedback given to all involved. There was regular patient safety, team and debrief meetings to discuss incidents, complaints and lessons learnt. We reviewed 7 de-brief notes and saw these gave staff the opportunity to discuss the incident, provide feedback to managers and to identify actions.

Staff and managers had good oversight of incidents within the service. We reviewed a sample of incidents and saw that staff knew what to report and how to report them. Staff received feedback from investigations of incidents. Whilst staff met regularly to discuss feedback, some staff told us that registered nurses could not always attend meetings. They said this occurred when there was only one registered nurse on shift.

Staff understood the duty of candour and could provide examples of when they had followed the duty of candour process. They were open and transparent and gave people and families a full explanation when things went wrong.

There was evidence that changes had been made because of feedback. Following a recent incident, managers and staff had met to discuss changes to practice through a ‘learning from’ session.

Complaints from family members and people who used the service were investigated and resolved with actions put in place where required.

The service’s referral and admission processes aimed to ensure that all essential information about people was received to determine if their needs could safely be met. There was a full multidisciplinary team approach to admission, with occupational therapy and psychology staff gathering key information about potential admissions to determine a person’s suitability for the service. One staff member fed back that the pre-admission assessment needed more nursing input. They felt that occasionally admission information was not accurate which meant they had to amend care and treatment plans at the point of admission.

Staff and leaders discussed potential admissions during regular referrals meetings, and they described a collaborative approach to decision making. Managers and leaders circulated emails to staff about admissions. All admissions were planned in advance. Managers gave staff prior notice of admissions and gave them sight of initial assessment reports.

Staff actively involved people using the service and their carers in care plans and multidisciplinary reviews. Staff documented people’s views in their care plans and reviews using their own words.

People said that they felt supported by staff and that they helped keep them safe. They said that they felt able to share any worries or concerns with staff.

Staff were knowledgeable about safeguarding and knew how to raise a concern when required. They were able to identify different forms of abuse, and the signs associated with these. Staff attended regular meetings where important information and lessons learned were shared. Staff were observed to have a caring and compassionate approach when engaging with people.

We reviewed four safeguarding alerts and saw there were effective systems, processes and practices in place to make sure that people were protected from abuse and neglect. The alerts we reviewed were detailed and submitted in a timely manner. Staff recorded what action they had taken to keep people safe. The Head of Nursing acted as the safeguarding lead and carried out monthly audits and checked staff understanding of safeguarding processes. There were dedicated safeguarding champions and managers told us they utilized the skills and experience of a social worker with safeguarding knowledge. Staff discussed safeguarding issues with senior nurses who took the lead on reporting the incident and completing referrals to the local authority if needed, ensuring relevant agencies were notified of any concerns.

Care records showed that staff understood mental capacity and best interest decisions. People were appropriately supported to know their rights and make decisions that were safe and in the best interests of the person.

People told us they felt safe, and that staff supported them to manage risks. Two people said they felt restrictions regarding access to food and section 17 leave were too restrictive.

Staff knew about any risks to each person and acted to prevent or reduce risks. Staff could easily access risk information via electronic tablets on the wards. Managers and staff held daily handovers where they discussed the previous 24 hours on the unit. This included staffing, patient updates, incidents and environmental concerns. Any concerns around risk were disseminated to the wider staff team with follow-up action acted on.

Staff discussed incidents regularly at a variety of meetings. These included information risk management groups, ward rounds, governance and performance meetings, multidisciplinary team meetings, and senior support workers meetings. Staff escalated concerns to managers when needed.

Staff were aware of guidance around restrictive practice and could provide examples of how they used the least restrictive option. This included making every attempt to avoid using restraint by using de-escalation techniques. Staff told us they restrained people only when these failed and when necessary to keep people safe.

Managers told us the new environment enabled them to care for people in the least restrictive way. People had fobs to access ward areas, and these were programmed to allow access to different areas based on individual risk. Any restrictions were clearly documented in each person’s care plan.

Staff completed risk assessments on admission and reviewed these regularly, including after any incident. Risk assessments were person centered and proportionate. Managers described a multidisciplinary approach to risk, with the team reviewing the risk matrix every 4 or 5 weeks. Staff could provide examples of positive risk taking, for example regarding community or unescorted leave.

The service recorded and monitored incidents and discussed these during regular meetings. Incidents were scored in terms of level of severity and reviewed by managers, with actions put in place where necessary. Themes and trends were identified and recorded on quarterly incidents reports.

We reviewed incident data for July to September 2024. The highest incident types were violence and aggression, accidents and medication related incidents. We saw that verbal aggression had increased by 33% between July and September 2024 in comparison with the previous three months. However, physical aggression had reduced by 31% during that time. This period also saw a reduction of 74% in the use of physical intervention.

People told us they felt safe on the ward, and the environment was safe, clean and well- maintained. Staff were aware of the importance of completing safety checks of the environment and equipment.

All ward areas were clean, well maintained, well-furnished and fit for purpose. Staff were observed completing observations in communal areas and corridors depending on the location and observation level of each person.

Wards had communal lounges, occupational therapy kitchens, and a second kitchen for people to make hot and cold drinks. Each ward had a dining room with a servery used to serve meals.

Each ward had a room with a tracking hoist to assist people with limited mobility, a room with anti-ligature fittings, and a room with an anti- barricade door. There was a dedicated visitors room off the ward and a suitable room for family visits.

All staff carried panic alarms. There were alert panels in every room and corridor including staff areas so that staff could identify where assistance was needed.

There were quiet areas on the wards where staff were observed having one to one time with people away from the busier communal environment. All doors and windows were secure with doors accessed with a key or fob. Cleaning and maintenance staff were visible during our inspection and were observed engaging with staff and people using the service. Managers kept logs of planned maintenance work to ensure that work took place in a timely manner.

We reviewed the environmental risk assessments and found that managers completed and regularly updated these. The assessments clearly highlighted areas of risk and appropriate mitigations that were in place to help reduce the risk level.

People said they did not always think there were enough staff, specifically for escorted leave and individual or group activities.

Staff told us that shifts were usually filled, but that cross- ward cover was frequent. They said they often felt short staffed due to the acuity of people or during busy periods. They said this impacted how much one to one time they could spend with people. Nevertheless, staff told us baseline numbers enabled them to keep people safe.

Managers said that the service was rarely short- staffed and shifts were filled according to core numbers. However, they recognised that some staff were used to working with higher staffing numbers at the previous service. They explained that staffing numbers had been reduced following the move to the new site because the environment enabled staff to observe people more easily. We did not observe any staffing issues whilst we were on site.

The provider used a safe staffing tool to produce a rota for clinical staff. The hospital manager and ward manager reviewed the staffing tool daily. We reviewed staffing data for the previous 3 months. Baseline numbers were met for all shifts and in most cases, there were additional staff on shift with one or two supernumerary staff members.

The provider used bank and agency staff to ensure safe staffing figures. We reviewed bank and agency data for the previous 3 months prior to our inspection. Bank usage was 7% for September, 5% for October and 8% for November. Agency usage was 30% for September, 19% for October and 11.5% for November. The service had low levels of sickness. Data showed an average of 3.19% sickness during the 3 months prior to inspection.

Staff had received and were up to date with appropriate mandatory training. Data showed that training compliance was 95% and above for all modules except for physical intervention training (93%) and moving and handling objects training (87%). Staff completed a range of training modules which were appropriate for the patient group.

Staff did not always receive regular supervision. The service aimed to complete supervisions quarterly. Feedback about supervision was mixed. Some staff told us they received regular supervision whereas other staff said that supervision did not always go ahead. Data provided by the service showed that 43% of staff had not received supervision between April and June 2024. This figure was 39% between July and September 2024 and had reduced to 18% for supervision due between October and December 2024.

Annual appraisals were due to be completed by the end of the first year of the service opening. Managers told us they were approaching the appraisal period and that they had begun scheduling these.

People said they did not always think there were enough staff, specifically for escorted leave and individual or group activities.

Staff told us that shifts were usually filled, but that cross- ward cover was frequent. They said they often felt short staffed due to the acuity of people or during busy periods. They said this impacted how much one to one time they could spend with people. Nevertheless, staff told us baseline numbers enabled them to keep people safe.

Managers said that the service was rarely short- staffed and shifts were filled according to core numbers. However, they recognised that some staff were used to working with higher staffing numbers at the previous service. They explained that staffing numbers had been reduced following the move to the new site because the environment enabled staff to observe people more easily. We did not observe any staffing issues whilst we were on site.

The provider used a safe staffing tool to produce a rota for clinical staff. The hospital manager and ward manager reviewed the staffing tool daily. We reviewed staffing data for the previous 3 months. Baseline numbers were met for all shifts and in most cases, there were additional staff on shift with one or two supernumerary staff members.

The provider used bank and agency staff to ensure safe staffing figures. We reviewed bank and agency data for the previous 3 months prior to our inspection. Bank usage was 7% for September, 5% for October and 8% for November. Agency usage was 30% for September, 19% for October and 11.5% for November. The service had low levels of sickness. Data showed an average of 3.19% sickness during the 3 months prior to inspection.

Staff had received and were up to date with appropriate mandatory training. Data showed that training compliance was 95% and above for all modules except for physical intervention training (93%) and moving and handling objects training (87%). Staff completed a range of training modules which were appropriate for the patient group.

Staff did not always receive regular supervision. The service aimed to complete supervisions quarterly. Feedback about supervision was mixed. Some staff told us they received regular supervision whereas other staff said that supervision did not always go ahead. Data provided by the service showed that 43% of staff had not received supervision between April and June 2024. This figure was 39% between July and September 2024 and had reduced to 18% for supervision due between October and December 2024.

Annual appraisals were due to be completed by the end of the first year of the service opening. Managers told us they were approaching the appraisal period and that they had begun scheduling these.

People were aware of their medicines and said staff discussed these with them. The service used a medicines management company who completed weekly medicines audits and produced pharmacy reports flagging outliers and errors. Managers reviewed these and identified any follow-up action. Medicines management was an agenda item at clinical governance meetings. Medicines reconciliation was completed regularly, and relevant observations were completed dependent on individual treatment plans.

Staff did not ensure that medicines were stored correctly and were in date. We viewed clinic rooms on all three wards. All clinic rooms and medicines fridges were clean, and staff had access to all appropriate equipment. However, we found issues with the storage and disposal of medicines. On Foss ward, the clinic room temperature was recorded as 26 degrees on 9 December 2024. The services’ medications storage and checks standard operating procedure directed staff to escalate temperatures above 25 degrees to a manager, however, staff had not documented they had done so on this occasion.

We also found out of date medicines on Foss ward. This included promethazine that had expired in November 2024, and Omeprazole which had expired on 10 December 2024. Furthermore, on 16 November 2024, staff recorded on their records that there was no staff member on Foss ward to oversee medication stock and check for out-of-date medicines. We raised this with staff during the inspection, but they were unable to provide written confirmation that staff had been checking medicines since 16 November 2024. Staff were also unable to provide us with evidence that they kept logs of out-of-date medicines.

Staff did not identify and correct prescribing errors. We reviewed 6 prescription charts and found prescribing errors in 3 records on Foss ward. In one record, a person was prescribed medicine that was recorded on the prescription chart but had not been authorised on the appropriate treatment certificate. In a second record, the treatment certificate stated that a person could be prescribed one of two medicines, however the prescription chart confirmed the person was prescribed both. In a third record, the treatment certificate specified medicine that was not present on the prescription chart. There was also a section 62 emergency treatment form on file which specified a medicine that was not present on the prescription chart. It appeared that staff had not removed the treatment form from the record. We raised the medicines management issues we identified with managers during the inspection, who took appropriate action to correct the issues and ensure the safety of people using the service.