Ellern Mede Ridgeway

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 good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

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 what incidents to report and how to report them. Staff we spoke with shared examples of learning from recent incidents, both internal and external to the service, and what changed as a result. For example, changes were made to searches and medication administration procedures following recent incidents. Staff had implemented a new door fob system based on learning from an incident at an NHS hospital.

No incidents classed as serious took place within the past year. In the 3 months prior to our inspection, the service recorded 497 incidents, most of which were classed as negligible or minor severity. The majority related to planned nasogastric feeding and deliberate self-harm. All nasogastric feeding activities were reported as incidents.

We reviewed a sample of 9 incident records across the wards. Most were thorough and demonstrated an appropriate level of detail and actions taken. Managers reviewed incidents in line with the provider’s policy. We saw evidence that staff and patients were offered post-incident debriefs. However, one incident report had been approved by a manager despite not being completed in full. In 4 records, staff recorded that there was no learning from the incidents.

The duty of candour is a statutory duty that requires registered providers to act in an open and transparent way with people receiving care or treatment and includes specific requirements for certain notifiable safety incidents. Staff completed mandatory training in duty of candour, with 100% compliance. However, in one incident record, duty of candour was not evidenced, and a post-incident review with staff had not been documented.

Most young people who had been restrained said staff had done so safely. One young person told us about receiving a debrief, and another was offered post-incident psychology support. Support was available to staff following incidents, including psychology and pastoral support. The service had a dedicated restrictive practice trainer who supported staff and patients before any anticipated incidents and with post-incident debrief and reflection.

Staff and managers discussed incidents and learning arising in a number of forums, including individual supervision, daily meetings, and clinical governance and the managers’ meetings. Monthly newsletters were shared and learning from incidents was part of mandatory e-learning.

The service had recently adopted the PSIRF (Patient Safety Incident Response Framework developed by the NHS). A dedicated patient safety lead oversaw incidents which met the PSIRF thresholds. We heard how this approach had contributed to creating a more open and learning-focused safety culture.

The service worked with patients 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 patients moved between different services.

The hospital received referrals from local NHS commissioners, as well as others across the UK and overseas. The service’s referral and admission processes ensured that all essential information about the patient was received to determine if their needs could be met safely. Staff discussed upcoming admissions and discharges in daily meetings and attended weekly patient flow meetings with the local system partners.

Decisions about the most appropriate ward were made by a multidisciplinary team. New patients were usually first admitted to Lask (high dependency unit) or Nunn (general ward). Patients aged 18 and over or those approaching discharge were accommodated at the Cottage (pre-discharge unit). Patients could also continue their treatment at the provider’s sister hospital for adult patients.

Staff involved relevant health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. These included the local acute hospital, GPs, schools and community teams. Staff worked closely with the NHS commissioners who provided input and support with the more complex care.

In the care and treatment records we reviewed, we saw evidence of effective discharge planning. Discharge plans were discussed in pre-admission meetings and throughout the treatment journey.

Due to the level of complexity involved and appropriate support required on discharge, lengths of stay at the hospital varied. Staff recorded provisional discharge dates, which they regularly reviewed with the young people, carers and professionals. One of the carers we spoke with said they found the discharge planning process clear and there was a Care Programme Approach (CPA) meeting planned.

At the time of our inspection, the hospital was in the process of reviewing its admission criteria. This was in response to changing demands and a recent decrease in appropriate referrals. The service was planning to expand the range of conditions it could treat alongside disordered eating, including co-occurring mental health presentations, autism and personality disorders.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared safeguarding concerns quickly and appropriately.

The service had established robust safeguarding systems. Over 97% of staff were trained in safeguarding adults and children in line with their role and PREVENT (training aimed at safeguarding people from the risk of radicalisation and extremism) and 100% in professional boundaries. Staff received monthly safeguarding supervision.

The service had a dedicated safeguarding lead who was embedded in the multidisciplinary team and easily accessible to staff and patients. The lead attended safeguarding, risk and handover meetings, and offered individual support sessions to staff. Learning from the outcomes of safeguarding cases was shared with staff via e-learning. The entries on the safeguarding log were comprehensive and up-to-date. Staff told us about plans to further improve safeguarding records by integrating them into the electronic care record system.

We reviewed a sample of safeguarding audits. They showed the number of safeguarding cases each month, identified themes, and monitored safeguarding supervision and training compliance.

Staff we spoke with knew how to recognise individuals at risk of or suffering harm and were aware of the risks specific to their patient group. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act 2010, for example autistic patients and those with learning disabilities. Staff escalated concerns appropriately to managers and when required, worked in partnership with the local authorities and police. This included working with relevant teams for young people who had already been discharged. The service had effective mechanisms to link with the relevant authorities when patients were admitted from out of area or overseas.

Stakeholders from partner agencies were positive about the safeguarding arrangements within the service. For example, one stakeholder described the safeguarding lead as very responsive to any concerns they raised.

The service maintained a blanket restriction register and reviewed it monthly. There were some restrictions in place, which were proportionate to maintain a healthy and safe environment. For example, staff supervised access to outdoor areas.

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 only after attempts at de-escalation had failed. Staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet patients’ needs that was safe, supportive and enabled them to do the things that mattered to them.

We spoke with 7 young people and 6 carers, who told us that they, or their relatives, felt safe at the hospital. The community meeting minutes we reviewed also showed that young people reported feeling safe on the wards. Although some young people found it hard being in hospital, most said that staff supported them to understand their own risks better. Staff we spoke with demonstrated a good understanding of each patient and their individual risks. The risks, and any changes to those, were discussed daily.

We reviewed 8 care and treatment records. Each contained a personalised risk assessment completed on admission and reviewed regularly thereafter, including after incidents. However, for a patient on Nunn Ward, although the risk assessment and care plan were updated following an incident, the changes and mitigations were not outlined in detail.

There was clear evidence of young people’s voice in the records we viewed. With input from psychologists, staff supported young people to complete their own PILRIMP (patient inclusion in least restrictive intervention management plan) and safety plan. Care plans were written in the first person and included clear instructions on what staff should do if they noticed certain behaviours and in the event of a crisis.

Staff we spoke with demonstrated commitment to reducing restrictive practices and using restraint only as the last resort. For example, staff introduced food exposure as soon as appropriate. Regular audits looked at incidents requiring restraint and staff restraint training. The service was planning to introduce eye movement desensitisation and reprocessing (EMDR) therapy for patients who had experienced nasogastric feeding and restraint, recognising the potential trauma associated with these interventions. A dedicated restrictive practice trainer supported staff and patients with de-escalation and identifying the least restrictive interventions to use. There was no use of chemical restraint, seclusion or long-term segregation.

The service had a leaflet for young people explaining the physical restraints in use. Most young people who had been restrained during nasogastric feeding told us they understood the reason for this and said that staff had done so safely and considerately. Some shared examples of staff reassuring and distracting them when they or someone else was distressed. However, one young person said staff had not explained the restraint process and were not gentle enough.

Young people and carers were involved in discussions about restrictions within the hospital. For example, they were recently involved in decisions about safe access to social media and smartphones.

Staff carried out different levels of observations and reviewed these based on individual need and risk. We reviewed a sample of observation records which contained comprehensive details of patients’ presentation at each observation point. However, we found some variation in how staff completed intermittent observations, with some randomised and some recorded at set intervals, meaning they were predictable. Three young people told us they were not always happy with how staff carried out observations. One young person did not like always having their bedroom door open, and another was disturbed during the night by staff talking loudly. Another young person said that some staff did not engage with them while completing observations.

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.

Staff completed regular risk assessments of the care environment. Staff completed relevant mandatory training, with 100% compliance in health & safety and fire safety training.

Staff had access to alarms and patient rooms had nurse call systems. Staff completed risk assessments for potential ligature anchor points and mitigated the risks adequately.

During our visit, building work was ongoing to add ensuites to patient bedrooms on Lask Ward. Staff told us they mitigated this by adding temporary soundproofing and offering ear defenders to young people. However, 2 young people we spoke with shared concerns about the noise, which they described as constant and stressful.

The hospital site was compact and quiet spaces were limited, with no sensory room in use. At the time of our visit, a sensory room for all wards was undergoing refurbishment. In the meantime, staff utilised other available rooms within the hospital to support the needs of neurodivergent patients. There was a large well-maintained garden with outdoor furniture and a den which young people used with staff supervision.

It was usual for 2 young people to share a room on Lask and Nunn wards, which could impact privacy. One carer we spoke with was concerned about their relative sharing a room with another patient, as they thought this was not appropriate for their needs and could impact their recovery. However, due to low occupancy at the time of our visit, young people had their own rooms. Lask Ward was undergoing renovations to provide single occupancy bedrooms, with 3 of 6 bedrooms completed shortly after our inspection. Rooms at the Cottage were single occupancy. Across all wards, single occupancy rooms could be requested based on individual need.

The bedroom doors were not anti-barricade and not equipped with vision panels for observations. As the hospital was planning to expand the range of mental health conditions it could treat alongside disordered eating, this was an area for future consideration to safely meet the needs of a different patient cohort.

Clinic rooms were equipped with appropriate equipment that was checked and calibrated regularly. However, on Lask Ward only an adult sized cuff was kept with the blood pressure monitor.

Staff followed procedures to keep patients safe from harm. However, in an incident record of deliberate self-harm on Nunn Ward there was limited learning recorded, although a post-incident debrief had been completed with the patient and staff. The young person told us that the item used to harm themselves was normally kept locked away by staff, but this was not the case on this occasion. This indicated that the procedures for managing risk items needed tightening. We were later told that learning about completing searches was shared with staff.

CCTV was in operation in communal and clinical areas. CCTV records were used to review incidents. Staff covered the CCTV cameras with curtains in the clinic room to maintain privacy and dignity during physical examinations.

Staff completed personal emergency evacuation plans (PEEP) for each young person which were kept in their folders.

Young people could raise maintenance issues in weekly community meetings. The minutes we reviewed showed that young people regularly raised queries and concerns and that staff followed these up.

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 patients’ individual needs.

Ellern Mede Ridgeway was fully staffed to safely meet the needs of young people. We saw staff always present in communal areas and engaging with patients. Due to recent low occupancy, there were no vacancies and some staff had been redeployed to other hospitals within the provider's group. However, some staff thought that staffing levels were not enough to support with activities when activities staff were absent.

Young people we spoke with did not report concerns about staff availability for escorted leave or ward activities. Managers reviewed staffing levels daily and adjusted those according to the changing needs, for example when patients were nursed on enhanced observations. The service used their own part-time bank staff who were familiar with the wards. There was no agency staff use. However, one young person reported that night staff talked loudly, disturbing their sleep. Another told us that staff sometimes woke them up or managed the lighting inconsistently during nighttime observations. One carer thought that night staff could be kinder in the way they spoke.

There was adequate medical cover day and night and a doctor could attend quickly in an emergency. Senior managers and doctors were part of the on-call rota out of hours. Staff received training in basic and immediate life support and first aid. There were regular, unannounced emergency simulation drills.

Staff participated in regular training, appraisal and supervision and managers monitored the completion rates. These were consistently high, with 98% overall compliance with mandatory training, over 96% with appraisal and 100% with clinical supervision. Training and induction were tailored to the needs of the patient group. All staff had completed the Oliver McGowan Tier 2 mandatory training on learning disability and autism.

There were enough staff to carry out any physical interventions safely. Staff had received accredited training to do so, with 100% compliance, and had support from a dedicated physical interventions trainer.

Managers ensured safe recruitment of staff. This included criminal record and right to work checks, and where relevant, evidence of continued professional registration.

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 adhered to infection control principles, with 100% up-to-date with hand hygiene and 95% with infection control training.

Wards were visibly clean and had appropriate furnishings which were well-maintained. Staff maintained clinical equipment well and kept it clean.

Cleaning records were kept up to date by the provider’s housekeeping team and demonstrated that all ward areas were cleaned regularly. Carers we spoke with described the hospital environment as clean.

Staff, patients and carers told us about a recent bedbug infestation in the hospital. Staff arranged fumigation promptly to manage this.

The service made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. They involved patients in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely. Staff regularly reviewed the effects of medicines on each patient's mental and physical health. Staff told us that the pharmacist visited the unit every two weeks, and we saw evidence that pharmacists checked the legality of prescriptions and informed prescribers if there were any issues.

We saw evidence that Mental Health Act consent to treatment forms were in place and verified by the pharmacist.

Staff were aware of STOMP (Stopping over medication in patients with Learning Disabilities and Autism) and followed the principles. Medicines care plans were electronically documented and were patient centred. Staff recorded the reason for the use of ‘when required’ (PRN) medicines.

Medicines were stored safely and securely within the locked treatment room. Staff had access to controlled drugs storage facilities that met legal requirements. Temperature readings for medicines storage areas were appropriately monitored and within the recommended range. Emergency medicines and equipment were in place and checked regularly.

We saw evidence of competency assessments for staff responsible for administering medicines, including the management of percutaneous endoscopic gastrostomy (PEG) tubes.

The provider had a system in place to ensure staff knew about safety alerts. Staff told us that medicines related incidents were reported and investigated. The pharmacist attended the monthly governance committee meeting and produced a medicines report summary on themes and trends in incidents.