Emerald Place Clinic

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 looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as Good. At this assessment, the rating has remained as Good. This meant people were safe and protected from avoidable harm. We did not identify any breaches during the inspection period,

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

Staff knew how to report incidents and recorded them on an electronic incident record. They were aware of the different types of reportable incident and reported all incidents that they should report.

Staff knew how to report incidents and recorded them on an electronic incident record. They were aware of the different types of reportable incident and reported all incidents that they should report. Staff received feedback from investigation of incidents in team meetings and kept a log of all the debriefs that occur following an incident.

The service had embedded a culture of learning. They developed a programme to “Keep Incident Lessons Learned Alive” and had the actions on display in the lounge area for the young people to read and comment on. The service had a monthly “Incident Analysis Report Meeting” which was attended by the MDT; the meeting identified themes and trends from incident reporting. Conclusions and action plans were created as a result of the analysis.

There was evidence that changes had been made as a result of feedback. For example, the service had implemented an “Evening wind down routine” for the young people as a result of feedback and incident learning analysis. The feedback received so far about the change has been positive overall.

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. Referrals were screened daily and feedback to referrers was given in a timely manner depending on the urgency of the referral. Admissions were mostly planned to ensure that they were completed in a timely manner and safe manner. Assessments for admission were generally completed online and relevant clinical information about the young person was received.

Staff involved all the necessary healthcare and social care services to ensure young people had continuity of safe care, both within the service and post-discharge.

The service operated an “internal care coordination” and all young people had a named person. This person was responsible for maintaining weekly contact with families and carers, supporting communication, and ensuring continuity to address any concerns. We saw evidence of external stakeholders attending clinical reviews and discharge planning meetings.

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.

Young people we spoke to stated that they felt safe on the wards.

Staff had training on how to recognise and report abuse, appropriate to their role. Staff were up to date with their safeguarding training for both children and adults. At the time of our inspection, 82.2% completed the combined safeguarding training for both adults and children. There was a plan in place for all remaining staff to complete their training by the first week of March 2026.

Staff understood how to protect young people from abuse and the service worked well with other agencies to do so.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff sent an email to the safeguarding team and included all relevant parties involved in the child’s care including safeguarding leads and social workers. Staff uploaded the information to the incident reporting systems within the service.

The evidence showed a good standard. 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.

All young people we spoke with confirmed they were involved in their risk assessments. Some young people told us they understood their observation levels and why their observation levels may increase or decrease, depending on their risk.

Staff told us that they had received training in restraint and restraint was only used as a last resort. Staff were able to discuss young people’ individual preferences and how to de-escalate young people to avoid the need for physical restraint.

We reviewed care records for 6 young people. Staff completed risk assessments for young people, these were updated frequently and mostly updated when risk changed, for example following an incident. Risk assessments were comprehensive and contained details on how to manage identified risks. Risk information relevant to each patient was clear and consistent which ensured staff were up to date. This included detailed discussions at handovers and multi-disciplinary meetings.

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

At the time of the last inspection the service was previously in breach of Regulation 15, Premises and Equipment. There was evidence of work being completed to address the issues identified in the previous report. The garden area now had anticlimbing fittings to prevent young people from being able to access the roof of the building.

The young people were generally happy with the environment. The hospital was in a good state of repair, and any maintenance issues were dealt with swiftly. Young people had personalised their bedrooms and they had also been allowed to personalise communal areas. For example, the walls had been painted with murals and young people who left the service were encouraged to add their designs to the wall. Young people attending the onsite school were also encouraged to put their handprint on the wall.

Staff ensured that all safety equipment was in good working order and that staff were complying with handover requirements including security checks. Staff also ensured the environment was clean and safe and any damage to items or the building were reported to the maintenance teams. Staff were also responsible for the ligature audit. Managers had oversight of the environment and could escalate issues as appropriate within the organisation. Managers and staff spoken to did not raise any issues regarding the environment.

During the assessment we reviewed both environmental and ligature risk assessments. These were well written. Staff knew about any potential ligature anchor points and mitigated the risks to keep the young people safe.

Staff had completed fire risk assessments for the building.

Staff had easy access to personal alarms and young people had easy access to nurse call systems. Staff always carried personal alarms on them.

The evidence showed a good standard. 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 enough nursing and medical staff, who knew the young people. Staff we spoke to stated that there was enough staff on a shift-by-shift basis. The service had a number of permanent qualified staff and used regular agency staff that were familiar with the ward and service users. There were 3 vacancies across different disciplines, and the service was over recruiting their unqualified staff.

Staff said that there was always at least 1 qualified nurse on duty but there were 2 on most shifts. Staff said that the skill mix of their teams was helpful because it meant that the needs of young people could be met to support their recovery. There were enough skilled staff to respond to incidents, and they attended quickly where needed. Managers told us that they step down to support on the ward at times when needed. However, 1 young person told us that their leave had been cancelled the previous week due to not having enough staff on shift. This was rearranged to take place the following day.

Staff within the multi-disciplinary team told us that they completed mandatory training which included, immediate life support, Mental Health Act and Mental Capacity Act. Staff had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation. Staff shared information with all parties involved within the young people’s care.

Managers made sure all bank staff had a full induction and understood the service before coming on the ward. We reviewed completed induction forms during the inspection.

During the inspection, we observed a ward round. The ward round had various members of the clinical team as well as staff from the school and representatives from the community joining online. All staff present were able to provide feedback to the meeting.

We reviewed evidence from daily MDT morning meetings where staffing levels were discussed each day. Staff told us that any shortfalls in staffing were discussed and arrangements were made to ensure that the staffing establishment was met.

The evidence showed a good standard. 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.

During the inspection, we observed the environment to be clean and well presented.

Young people that we spoke to did not raise any significant concerns in relation to the cleanliness of the hospital or about infection prevention and control measures.

Service leads had oversight of the environment and could escalate issues as appropriate. Managers and staff spoken to did not generally raise any issues regarding the environment.

We saw cleaning rotas were complete and observed the housekeeping staff attending to their duties during the inspection. Handwashing signs were correctly displayed around the ward.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Medicines including controlled drugs and medical gases were stored securely and were in date. Controlled drugs records and the registration of the location for the denaturing of controlled drugs were complete. Signs highlighted the storage of medical gas cylinders.

Records for fridge and room temperatures provided assurance that medicines were stored within their recommended temperature.

Prescribed medicines were reviewed by a pharmacist allocated to the service. Young people told us they were able to ask questions about medicines they were prescribed, or staff were considering prescribing to them.

Relevant Mental Health Act (MHA) documents were stored with the prescription charts. This allowed staff to review MHA documentation when prescribing, administering, and reviewing medicines.

Physical health information, for example, height, weight and allergies were recorded on the medicine’s charts. The prescribed dose and frequency of medicines had been reduced to reflect the young person’s' weights.

We identified that whilst 1 patient was prescribed 2 antipsychotic medicines resulting in a total daily dose above 100% of the BNF doses, the service had not risk assessed the prescribing as high dose antipsychotic treatment (HDAT). Whilst HDAT prescribing may be appropriate, it carries a higher risk of side effects. The impact of these side effects should be managed via the HDAT processes. We were concerned that 2 medicines were prescribed when required to help manage aspects of aggression and or anxiety. However, the prescribing lacked further details on when to administer which medicine in more detail.

We observed young people attending the medicines administration point (MAP) to receive their medicines. The MAP was a small room off a corridor providing access to the medicines room. This offered privacy for the patient when they received their medicines. Processes were in place to either order medicines described as TTOs (to take out) or secondary dispensing from stock or medicines dispensed for individual young people in advance for periods of leave, transfers, and discharges.

All equipment was in date and stored securely. Cupboards were locked to reduce risks when young people were in the treatment room.

A locally prepared equipment box was also available to support staff to fit naso-gastric tubes (to administer liquid food and medicines). However, the preparation of this box lacked governance and was not regularly audited resulting in a lack of assurance that the equipment would be consistently restocked following the use of the equipment box.

Emergency equipment and medicines, including oxygen, was available in tamper evident grab bags within the treatment room. The medicines included adrenaline for the treatment of anaphylaxis (allergic reaction). This adrenaline was available as an adrenaline auto-injector (AAIs), although a DH Supply Disruption Alert (SDA/2019/004) recommended that health care professionals should use ampoules and syringes and AAIs should be limited to direct patient use.