Sturdee Community 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

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

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained 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.

The service was in breach of a legal regulation in relation to, safe care and treatment (regulation 12).

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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

The provider had an incident reporting policy and process. Staff we spoke with understood their responsibility to report incidents. They told us there was usually a de-brief following an incident.

The provider carried out monthly incident analyses. Data provided showed a thorough analysis with incidents broken down by type, location, time, patterns and trends and individual patients. Lessons learned following incident analyses were considered, however this did not provide a clear action plan as to what action was taken, by whom or how the effectiveness of action would be reviewed. For example, the analyses identified a higher incidence of reporting occurring on Wednesday between 8 and 10 pm. There was no record of an exploration of the reasons for this peak time and day or any clear action plan to reduce the incidents occurring. However, all incidents were discussed at the daily patient safety meeting attended by managers and the multidisciplinary team (MDT).

The provider’s risk register did not capture all known risks. It did not include any reference to risk to patients and staff through verbal and physical aggression or self-harm incidents identified within the analyses. These risks were also raised as a concern by staff through anonymous complaints sent to CQC.

While staff were knowledgeable about patients’ individual risks, triggers and recover plans, we were not assured the provider had enough oversight of overall risk in the environment and day to day practices. Not enough action was taken to ensure learning from safety events was embedded into staff practice.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

There had been no serious incidents at the service in the last 12 months.

The service did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. Continuity of care was not always supported through effective communication with patients and staff.

Some patients required enhanced observations (higher levels of staff supervision to manage risk of harm to self or others) to keep them and others safe. Observation levels were decided by the responsible clinician and multidisciplinary team based on risk and decisions were evaluated daily at the patient safety meeting.

The provider had an ‘observation and engagement policy’ which set out observation levels and how staff should apply these interventions. Observations are known to be intrusive and should only be used in the least restrictive way and for the shortest amount of time. Ten patients were on continuous observations at the time of our visit with either 1, 2 or 3 staff members required to continuously be with the patient in order to keep them or others safe. The providers policy described the importance and therapeutic value of engagement being an essential part of observation. However, during our visit we saw staff sitting outside patients’ rooms and were not engaging with the patient for most of the time. The provider told us some patients may have been sleeping or had requested time alone.

The provider’s policy stated how observation tasks should be allocated to staff members and stated that only staff members with the required training should be allocated this task and staff should not undertake a continuous period of observation for longer than 2 hours. However, some staff we spoke with were concerned about ‘back-to-back’ enhanced observations and found this stressful when the number of incidents was high.

Daily patient safety meetings took place. These meetings were attended by the MDT such as ward managers, medical staff, other therapy staff and ward nurses. Each patient's observation levels were reviewed/clarified during the patient safety meeting. Recent incidents were also shared with the MDT by each ward manager.

The provider had identified some shortfalls regarding security and key holder management within the hospital and had taken action to manage this risk. Security was discussed at team meetings with staff reminded of actions to take to maintain safety.

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.

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

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.

Most patients we spoke with told us they knew what to do if they did not feel safe, they told us they would speak with their named nurse or social worker. The provider employed a social worker who also had the lead role for safeguarding.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. The provider had a safeguarding policy which staff understood.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of or experiencing, abuse or neglect. This included working in partnership with other agencies.

The provider kept a record of all safeguarding allegations and concerns. These were investigated and reported to other authorities such as the CQC, local authority safeguarding team and the police. Most recorded allegations were about staff assaulting patients, aggression between patients, self-harm and 2 were about staff sleeping when on enhanced observations. The provider carried out investigations including reviewing Closed Circuit Television (CCTV) footage where possible. All were found to be not upheld. Appropriate psychological support and medical attention was provided as required. Concerns raised were discussed with staff at team meetings so that learning could be shared.

The provider kept a record of ‘blanket restrictions’. There were few and mostly related to communal spaces where risks of harm could not be controlled, for example, patients could not have unsupervised access to the therapy kitchen. Patients were automatically assigned 1 to 1 observation when they were fist admitted so that risks could be assessed.

Staff had a good understanding of the Mental Capacity Act. 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. At the time of our inspection, there were no patients who were subject to deprivation of liberty authorisations to restrict their liberty.

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.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe.

Risk assessments included physical health risks, psychological and other risk behaviours. Each patient had a care plan for known risks including ‘crisis plans’ with known triggers, prevention strategies and action to take in response to risk escalating. However, these did not always provide enough detailed information about what actions staff should take to keep patients and others safe.

We reviewed 6 care records and risk assessments. Not enough detail was included in some risk assessments. Not all risks were considered or there was a lack of guidance for staff to follow about how to respond and manage known risks. However, most risk assessments did include known risks such as ‘self harm’, nutritional risk and infection control.

We reviewed 12 incident records. Records showed staff attempted verbal de-escalation techniques and only used restraint (approved physical holds) when necessary to keep the patient and others safe.

We reviewed CCTV footage of a restraint intervention staff used to keep a patient safe. We saw staff used correct techniques in line with the care plan and preserved the patient’s dignity throughout the process.

Staff were trained in the use of restraint to keep patients safe. This training was trauma focused and designed to reduce the use of restraint through person centered approaches. The use of restraint and ‘use of force’ act guidelines were discussed in staff meetings. Staff were reminded the use of ‘holds’ were a last resort and must only be used in accordance with the training provided. However, some agency staff had been trained with a different ‘restraint’ model so may not be working in line with the provider’s policy. The use of agency staff was reducing and was included in the provider’s risk register with action plans in place to manage and reduce this risk.

One patient we spoke with told us staff used restraint without warning, and this had left them feeling distressed. The provider had taken action to reduce this risk and had spoken with staff during staff team meetings.

Patient ‘safety officers’ were employed and attended all incidents to review the actions taken by staff with a focus on patient safety.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Ligature risk management required improvement. There was a ligature risk assessment in place. However, not all window blinds were ‘anti ligature’. The provider told us they were reviewing all window blinds and curtains in the hospital.

There were ligature anchor points in most areas of the premises including bedrooms and these were managed through risk assessment of individual patient along with risk management plans such as staff supervision and observation.

A TV bracket in the lounge on Foxton ward had sharp exposed edges. There were also exposed screws within some paneling in the corridor which the provider removed when we pointed this out. These risks had not been identified in the providers environmental risk assessment so we do not know how long they had been present.

Some flooring and furniture across the hospital site was in a poor state of repair and required replacing or repairing. This was identified in the provider’s improvement plan with action planned to make improvements with a target completion date.

The provider had a fire risk assessment completed by an external qualified fire risk assessor in 2024. An action plan was developed with all but 1 action completed. Further work was required to upgrade a ceiling to provide a minimum of 60-minute fire resistance. There was a missing fire extinguisher outside the laundry on Foxton ward and 2 fire extinguishers were found to have out of date safety checks. The provider replaced the missing fire extinguisher and told us further safety checks were booked in to be carried out. A fire door on Rutland ward required repair.

During our site visit not all staff could access firefighting equipment. The provider took immediate action and ensured all staff had appropriate access. We also found electrical sockets with Perspex lockable covers to prevent access were unlocked, cluttered outside areas, damaged flooring and a stained carpet.

We were concerned a courtyard gate was not secure as it was easy to climb due to its design. The provider took action shortly after our site visit and made the gate secure to prevent any climbing.

There was clutter in the courtyard such as old furniture and an engine oil container. There was a skip at the front entrance with some of its content on the floor beside it. Although patients did not access these areas unsupervised, these were avoidable risks and had not been included in the provider’s environmental risk assessment.

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

The service did not always make sure there were enough qualified, skilled and experienced staff.

Most patients we spoke told us there were enough staff on each shift.

There were not always enough staff on duty to manage the number of enhanced observations required in a safe way and this put staff under increased stress and pressure.

We received mixed responses from staff we spoke with. Some staff did not feel the wards were adequately staffed. They were concerned about doing back-to-back observations and managing incidents without a break. They described back-to-back observations as draining and unsafe. This was also against the providers policy which stated a maximum of 2 hours observation for each staff member. Some staff felt they required additional staff in order to receive an adequate break between incidents and restraints.

Staffing levels for each ward were shared at daily safety meetings.

At the time of our inspection there were 3 vacancies for registered nurses. All other grades of staff were fully recruited.

Managers had calculated the number and grade of nurses and healthcare assistants required. The use of agency nurses was between 26-38% for the 3 months before our inspection (May to July 2025) which was high. For health care assistants for the same period this was between 20-25%. The use of bank staff for registered nurses was between 2 %- 39% and was very low for healthcare assistants.

Although the provider had an action plan and these numbers were reducing, the use of agency nurses remained high. The provider told us their staffing establishment considered the ongoing need for enhanced support observations. However, the high agency usage and low staff vacancy numbers did not provide assurances that staffing establishment calculations were sufficient. The providers required number of nurses and healthcare assistants matched the required number on all shifts.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. All agency workers undertake an induction and could not book shifts until they have a profile and induction in place. The majority of agency staff used, were used regularly to increase consistency and familiarity with the service and patient’s needs.

Staff turnover (staff leaving) for the 3 months prior to our inspection was low. Staff sickness rates were at 3.2% or below for this 3-month period which was below the national average.

There were enough staff to accommodate escorted leave and ward activities. The provider told us that no leave had been cancelled due to staffing numbers. All leave was pre planned so that staffing numbers could be planned accordingly.

There was adequate medical cover day and night and a doctor on call to attend the wards in an emergency.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service and compliance with this training was above 95%.

The provider had a recruitment policy which included safe recruitment procedures such as carrying out all relevant checks so that as far as possible only staff with the right skills and experience were employed.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider had infection control policies and procedures which adhered to national best practice guidance. However, we found areas of the service which were not always visibly clean, and not all staff were following the ‘bare below elbow’ requirement to reduce the risks of spreading infection.

An infection prevention and control staff lead carried out checks and audits. However, these audits had not identified the concerns with cleanliness we found.

The provider took immediate action to improve cleanliness and carried out a deep clean of areas of concern we highlighted on day 1 of our site visit. Areas identified as not meeting safe infection control standards included the laundry room floor and skirting boards which were not visibly clean and the bin had no lid on Rutland ward. A chair in Foxton ward lounge was stained and dirty. A mattress in a vacant bedroom was in a poor state of repair and was not clean and the toilet seat was cracked.

Patients gave mixed feedback about the cleanliness of the environment. Some patients gave us examples of cleaning not being maintained to a high enough standard in the downstairs kitchen, such as bins overflowing and urine-soaked furniture.

In the kitchen we found the freezer required de-frosting and items in the fridge had no date of opening added. There was a wet and dirty bean bag and some litter including discarded cigarettes in the courtyard.

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.

Staff mostly followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication. A patient told us they were well informed about their prescribed medicines. They told us these were reviewed at least monthly at the ward round meeting.

The providers electronic system for managing patient’s medicines were effective and safety measures were in place to reduce the risk of errors.

Not all prescribed medicines were included in the patient’s authorisation of consent to receive prescribed medicine. This document is required for patients detained under the mental health act and have capacity to provide consent. The provider took immediate action to rectify this shortfall as well as strengthening procedures to ensure this error is not repeated.

We looked at the documentation required when rapid tranquilisation (the use of a medication to quickly calm a person down) is used and found not all of the required physical health checks and doctor reviews had been completed. The provider took immediate action to reduce the risk of this happening again.

The providers policy for medicines liable to misuse was not always followed because there were some missing signatures (2 staff were required to sign stock checks). However, stocks were checked and were accurate.

The provider carried a stock of a medicine used to reverse the effects of rapid tranquilisation medicine. Staff had limited knowledge of where this medicine was stored. The provider took immediate action to ensure this was stored in the emergency medicine bag and explained this medicine would be for use only by paramedics in and emergency situation.

A pharmacist visited the service weekly to ensure adequate stocks of medicines were available, stored correctly and in date.