The Langford Centre

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 found a breach of Regulation 12, Safe Care and Treatment.

Physical health monitoring for patients after taking clozapine needed improvement. Care plans did not contain information for managing high risk medicines such as clozapine.

The ward environment was not safe and had several blind spots due to its layout which meant that staff could not easily observe all areas of the ward to ensure patients were safe. The service did not manage risks well. We found blind spots in corridors and found ligature risks in the windows which did not have safety guards in place. This was urgently raised with the management team during our feedback session on the day of the inspection. A ligature is anything which could be used to attach a cord, rope or other material for the purpose of self-strangulation. The provider had committed to replacing all sash windows by end of the year 2022 but these works had still not been completed, posing a potential risk of harm to patients. For example, we found sash style windows on the ward which were still potential ligature fixed points.

We found trailing wires and cables in the television room, with consoles which were accessible to patients. This was not a known risk to staff and there were no plans in place to minimise or manage this risk. Risk assessments and care plans were not always updated to reflect current risk needs. The provider did not always maintain facilities and equipment to be able to deliver safe care. For example, we saw a weak kitchen door frame and torn sofas in the communal lounge. Staff were not always completing the required quality assurance checks for blood glucose monitoring machines.

Some patients did not always feel safe on the ward. Some patients said they felt restricted and did not feel staff encouraged them to take risks with their daily living skills. Personal emergency and evacuation plans were in place but were not easily accessible to staff. This posed a risk that staff would not have access to the emergency plans during a fire emergency. A patient who had repeated falls did not have record of falls monitoring chart in place which meant that staff would not be able to monitor their falls appropriately.

The systems, processes, and practices were not always effective to ensure patients were protected from abuse and neglect.

Formal training for one staff on Pevensey ward around how to safely and effectively administer medicines had not been completed. This put patients at potential risk of medicines errors which could lead to health complications.

However, staff reported, and managers investigated incidents and complaints. Managers used lessons learned information to improve the care in the service. Patients said they were supported to understand safeguarding and raise any safety concerns they had. Patients told us they were involved in debrief sessions following an incident. We evidenced good multidisciplinary collaborative working and patient views.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients felt staff were interested in their care but did not routinely explain what their care plans meant to them. Patients told us staff usually avoided using restraint by using de-escalation techniques and restrained patients only when de-escalation failed and when it was necessary to keep the patient or others safe. The ward participated in the provider’s restrictive interventions reduction programme which meant that the least restrictive approach was taken, avoiding interventions like restraint and seclusion where possible, when managing patients who were distressed.

Patients told us they knew how to complain, felt supported to raise concerns and staff treated them with compassion and understanding. Patients told us they were involved in debrief sessions following an incident. Patients said staff gave them complaints form to complete when they needed to complain.

The service managed incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients and families honest information and suitable support.

Staff told us they received feedback from the manager who updated staff about what action had been taken following an incident. Staff told us they received updates about incidents during handover sessions and discussed incidents with the manager. Staff felt incidents were properly investigated and managed when they happened and felt the debrief sessions were reassuring for staff.

Staff told us they respected the privacy and dignity of the patients and knocked on their doors to seek permission before entering patients’ rooms.

The manager systematically reviewed and shared incidents and complaints with all staff and demonstrated how learning from incidents and complaints had led to improvement.

We saw a list which had all the names of patients who were risk assessed to access the kitchen posted on the kitchen wall.

Staff reviewed closed circuit television (CCTV) and gave feedback to patients when managers investigated incidents.

The manager told us they encouraged staff to read the professional boundaries policy and discussed the policy with staff during supervision. The psychology team trained staff on how to use Antecedence, Behaviour and Consequences (ABC) analysis chart which is a tool used by clinicians to assess the function of behaviour so they could support patients to prevent incidents. Staff also worked with patients to develop Positive Behavioural Support (PBS) plans which provided information about how to best support patients who were distressed to avoid incidents.

The hospital director shared learning after incidents with staff using a newsletter.

The patients we spoke with understood their discharge plan or the barriers to their discharge. Patients told us staff informed them when they were being moved from one service to the other and staff involved their families during their admission process. One patient told us they felt staff prioritised their discharge planning.

Staff supported patients when they were referred or transferred between services and explained how patients were supported through this process.

Staff collected detailed information about patients during the referral process before the patient was admitted onto the ward to make sure their needs could be met. The nurse in charge completed the admissions process and the doctors assessed the patients during admission. Patients did not stay in hospital when they were well enough to leave. Managers and staff worked to ensure they did not discharge patients before patients were ready to be discharged. Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason. The service had low numbers of delayed discharges. There was evidence of conversations and considerations in relation to discharge in the patient care records and notes that we reviewed. Staff supported patients when they were referred or transferred between services and staff explained how patients were supported during this process. Staff told us they had positive working relationships with community mental health teams which helped ensure patients had the right support when they were discharged from hospital.

One patient had a delayed discharge since 31 January 2024. This was raised with the ward manager who said the delayed discharge was because the body funding their placement had not managed to identify suitable accommodation for the patient to be discharged to. The average length of stay on the ward was 12 months and some patients had stayed for two years.

When a patient was ready for discharge, the discharge was planned in stages. For example, patients were supported to go on placement leave.

The service was part of a provider collaborative (partnership between two or more NHS trusts that work together to improve care for their local population by sharing resources and sharing patient outcomes) and received patient referrals through different organisations. The service had a patients flow manager who managed referrals. Some patients came from outside the local area and staff kept in touch with the patient’s home team.

The multidisciplinary team discussed patient discharges during ward round meetings.

The wards had access to admissions and discharge coordinators. When referrals came in, the nurse and psychology manager assessed the patients and coordinators ensured paperwork work completed.

We reviewed nine care records which evidenced multidisciplinary collaborative working and patient views. Risk assessments and care plans were updated.

Four out of the five patients we spoke with said they generally felt safe on the wards, although one patient said they sometimes felt bullied by some patients and when it happened, they shut themselves in their room to protect themselves. Patients felt staff were not very responsive to incidents like this. This was raised with the manager who said they would meet to discuss this with the patient. Carers we spoke to said they believed their relatives felt safe at the service, and that staff knew their needs. We reviewed weekly community meeting minutes and identified that discussions took place around whether patients felt safe on the ward.

A patient had a statement written in their care plan that their father could not visit them due to covid restrictions on the ward. This was addressed with the manager who confirmed they would rectify the record because it was out of date.

During the inspection, we spoke with staff including managers, doctors, nurses, support workers, members of the multidisciplinary team and housekeeping staff. All the staff we spoke with showed commitment to taking immediate action to keeping patients safe from abuse and neglect and felt comfortable and safe to do so.

Staff understood how to protect patients from abuse and the service worked well with other agencies to keep people safe. Staff knew how to make a safeguarding referral and who to inform if they had concern. For example, staff told us they reported safeguarding incidents to the nurse in charge, manager and the safeguarding lead who raised safeguarding referral with the local authority.

The ward had a safeguarding vulnerable adult’s protocol in place and all staff knew how to make safeguarding referral and who to inform if they had concerns.

Staff gave clear examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff followed procedures to keep children visiting the ward safe. There was an allocated visitor’s room away from the ward which had suitable room for children to visit, available to be booked dependent on the individual risks of the patients.

During the site visit we observed that the ward felt safe, and staff were visible and engaging with patients. We saw information posters displayed on the ward giving details of the safeguarding lead for the hospital. We saw positive staff interactions with patients and staff were generally warm towards patients.

The provider followed processes which ensured patients lived in safety, free from abuse, neglect, and avoidable harm. We saw evidence that there were effective systems, processes, and practices to ensure patients were protected from abuse and neglect. Managers ensured the service had a comprehensive local safeguarding procedure which included good working relationships with other agencies, including the local authority. Managers held morning meetings where safeguarding incidents were shared, discussed, and managed with onward referrals to the local authority and protection plans put in place. As part of the inspection, we reviewed the ward’s safeguarding log which was up to date and included details of the safeguarding incident, the incident date, and if concerns were reported to the local authority or being investigated by them with a record of the outcome.

Staff understood the duty of candour process and apologised to patients when things went wrong. Staff understood the whistle blowing process, had access to the safeguarding and whistle blowing policy and had read and understood the policies.

We saw evidence that patients were actively involved in assessments and interventions that addressed areas of concerns and needs identified. All patients had occupational and psychological interventions in place as well as capacity assessments to treatment and specific decisions. For example, we saw evidence of capacity assessment that had been completed for patients’ finances and these documents were regularly updated.

We saw evidence that patients were involved in managing their risks. The provider had improved on their risk management plans and care plans and involved carers in care planning. We saw evidence that patients and their families were involved in producing their care plans, and risk management plans and had copies of these, whereas some patients said they had not been involved in producing or seen a copy of their care and risk management plans. Eight out of nine patients record we reviewed had positive behavioural support plans that included patients’ views on how they preferred to be cared for and how to manage their risks. One patient told us even though they had access to their positive behavioural plan, they could not read or understand the contents but said staff read their plan to them when they requested staff to do so. Two patients told us staff sometimes made them sign documents without explaining the contents to them. Similarly, a patient who could not read told us staff gave them documents to sign without explaining the contents to them. We informed the ward manager about this finding.

A patient said they were not allowed to independently cook in the kitchen even though they had been risk assessed to cook on their previous ward.

One patient said even though they were a wheelchair user, they did not have access to all the aids to help them to effectively transfer themselves out from their wheelchair. The patient said staff deprived them of the necessary assistive aids to help them move around the ward, while using their bathroom, to access their bed and when out on section 17 leave. This was urgently raised with the manager during our inspection who confirmed the patient had an occupational therapy assessment already planned and would discuss this concern with the occupational therapist during the assessment process.

Staff completed risk assessments for patients on admission to the wards and following a change in risk. Staff used recognised tools to assess patients’ risks, manage risks to themselves and followed best practice in anticipating, de-escalating, and managing challenging behaviour. Staff involved patients in risk assessments to determine their suitability to access section 17 leave. Staff used restraint only after attempts at de-escalation had failed.

Risk management plans were in place to help staff support patients with their physical health needs.

At the time of inspection, 86% of staff had completed their Prevention and Management of Violence and Aggressiontraining, received yearly refresher training.

Staff told us they had received training and competency assessment in relation to therapeutic observations to ensure patients with heightened risks were kept safe from harm and 96% of the staff had completed this training.

The provider had made some improvements on reducing restrictive practices on the ward.

Managers completed monthly restrictive practice meetings with staff and audits to know what blanket restrictions were on the ward and shared the details with staff teams to make them aware of why the restrictions were in place. Staff had access to a restrictive intervention policy which included guidance and procedures for managing restrictive practice and blanket restrictions. During this inspection managers and staff told us that restrictive practice had reduced, and all patients were individually risk assessed before they were restricted from anything.

All patients’ files contained completed risk assessments which were in date and updated regularly. Needs were identified and assessment tools included Systemic, Therapeutic, Assessment, Resources and Treatment (START); The World Health Organization Disability Assessment Schedule (WHODAS), Historical Clinical Risk Management (HCR-20); A set of 12 scales measuring mental health-related problems in the domains of behaviour, symptoms, impairment, and social functioning (HONO)S, assessment for use of electricals and COVID risk assessment.

A patient who was at risk of falling did not have falls risk assessment as well as falls monitoring chart in place. This finding was raised with the manager who confirmed they would put a falls monitoring chart in place for any patient who required one.

One patient who had sensory processing difficulties told us the environment was not autism friendly and therefore impacted negatively on them. Similarly, one carer fed back that the ward environment was not conducive for patients with sensory processing difficulties and was therefore not meeting the sensory needs of their relative. The carer believed the environment had contributed to the deterioration of the patient’s mental health instead of helping them to recover. Another patient told us they engaged in self-harm because they did not like the ward environment.

One patient gave feedback back that when they reported maintenance concerns to the staff, their requests were not dealt with on time.

However, most of the patients we spoke with told us the ward environment was clean, maintained and had facilities and equipment to meet their needs. Some patients told us that they felt safe in the hospital.

Patients who were risk assessed to have access to their mobile phones had access to their phones. Patients told us they had access to the garden. Patients reported generally experiencing a good word environment.

Managers informed us patients who were risk assessed to be able to have their keys were allocated keys to access their bedrooms.

Staff told us they were aware of where the ligatures risks are on the ward as well as the ligature heat map which identified the potential areas where ligatures could be found on the ward. Staff briefed agency staff about the heat map when they were deployed to work on the wards. Staff told us the patients’ rooms were safe from ligature risks.

Staff told us there had been a reduction in incidents where illicit substances were smuggled onto the wards. Staff completed weekly drugs searches and urine drugs screening which had helped to reduce patients bringing dugs onto the ward.

The manager told us the service had made improvement on searching patients. For example, two staff conducted searches in the de-escalation room to help maintain the dignity and privacy of the patients. Staff always explained the reason for the drug tests to patients. Staff told us they briefed patients about contraband items during admission process.

The ward environment was not always safe and had lots of blind spots due to its layout. The staff team mitigated this risk by using parabolic mirrors to allow them to see into the blind spot areas. For example, we found blind spots in corridors and ligature risks in windows which did not have safety guards in place. This was raised with the management team during feedback session. We also found trailing wires and cables in the TV room, with consoles which were accessible by patients. This was raised with the management team during our feedback session who assured us this would be addressed.

Staff were visible around the ward. We observed staff who carried out environmental checks twice during our visit. We also observed that a staff member was allocated to carry out general observations.

Each bedroom had a nurse call bell system that worked. However, during the inspection we triggered the call bell to review the staff response to the call and found that the staff did not respond to the call even though staff had pagers on them and the call sounded in the office This was raised with the managers during our feedback session.

The ward was generally well maintained even though the environment looked a bit tired and needed some re-decoration. However, we raised issues with the ward manager about chipped kitchen door frame and some torn sofa. The manager escalated these concerns to the estates team during the inspection.

The ward had en-suite bathrooms, quiet rooms, de-escalation room as well as a television lounge. The ward also had a visitor’s room outside the ward where patients received their visitors. Patients had access to outdoor space which they could access independently based on their level of risk. We raised some concerns about potential ligature risks in the outdoor environment during our inspection and were given assurance that this area was not accessed by patients without staff supervision.

Managers told us they had processes in place for checking and ensuring the environment was safe for the patients. Environmental risk assessment was completed for the ward, including ligature risk assessments. These had been reviewed regularly and were in date at the time of this inspection. We reviewed these in line with the environmental risks and found risks had been identified and appropriate mitigations were in place. A ligature risk assessment of every part of the ward was in date and staff were aware of this policy. We saw that maintenance issues were discussed as a standing item on the agenda during the morning flash meetings and a maintenance log was in place to record any issues. Most maintenance issues were addressed in a timely manner, however, at the time of our inspection we identified an issue with the the kitchen door and staff had not recorded it on the maintenance log.

The ward had processes in place to manage restricted items on the wards. For example, staff briefed patients about restricted items during admission. The provider had a search policy in place which staff followed to search patients who went out and returned to the ward.

Although patients had personal emergency evacuation plans (PEEP) in place, the plans were not easily accessible to staff. The manager informed us that the completed personal evacuation plans documentation was available in the administrative office but could not be easily found in the event of an emergency. At the time of our inspection, we found that the plans were not located in a designated folder which could be easily found in an emergency. One patient did not have a personal evacuation plan in place. We raised our concerns with the manager at the time of this inspection and manager confirmed they would put one in place.

Patients told us the ward was usually short staffed, and managers did not always use the daily expected allocated staff to manage the ward. Two patients said staff sometimes cancelled escorted leave for patients due to staff shortages. Patients did report that there could be delays in accessing escorted leave and using the shared garden area which required staff to accompany them. Two carers told us the ward was usually short staffed. For example, one carer told us about how worried they were about the low staffing levels on the ward which could affect the quality of care given to their relative. These concerns were raised with the manager who assured us that the ward was usually safely staffed, and patients received the appropriate care.

Staff reported the service generally had enough nursing and support staff to keep patients safe. Staff said sometimes it was difficult to support patients out on escorted leave due to low staffing numbers. Staff said sometimes they worked under pressure due to staff shortages. Staff said sometimes due to patients’ activities, such as cooking and escort to the garden, the ward was sometimes left with two nurses and two health care assistants and therefore nurses could not complete their nursing duties.

Staff reported that they did not always work with an experienced team as there were times when agency members of staff were required. Staff said it was difficult to take their breaks sometimes due to low staffing numbers.

Staff reported having enough daytime and night time medical cover and a doctor available to go to the ward quickly in an emergency including out of hours. Managers reported staff worked with a minimum of two nurses and four support workers, during the day but this number increased with every patient that was put on enhanced observation. Four staff were deployed on the ward during the night which included one nurse and three health care assistants. Staff participated in reflective practice, regular supervision, and appraisals. Managers reported staff supervision rates at 87% and appraisal rates at 93%.

At the time of this inspection, we observed the service had enough staff on each shift to carry out any physical interventions safely.

The manager told us they monitored staffing levels and ensured that shifts were filled. The minimum number of staff expected on duty was six staff during the day and four staff on nights. These numbers included two registered nurses for every shift. The manager accurately calculated and reviewed the number and grade of nurses and health care assistants required for each shift. The manager could adjust staffing levels according to the needs of the patients.

Staff completed their mandatory and specialist training to enable them to have the knowledge and skills to meet patients' needs and to keep patients safe on the ward. We found that most training compliance rates were above 75%. For example, break away was 85%,Prevention and Management of Violence and Aggressionwas 86%, internal ligature awareness was 99%, safeguarding vulnerable adults was 98%, observations and engagement was 96% and basic life support was 94%. Ninety eight percent of the staff had received training in caring for autistic people and people with a learning disability.

Staff received an induction when they commenced employment at the service.

Managers ensured all bank and agency staff had a full induction and understood the service before starting their shift.

Patients told us the ward was generally clean.

Staff and leaders told us the provider supplied staff with appropriate Personal Protective Equipment (PPE) to ensure staff and patient safety. Staff supported patients to clean their rooms. The manager undertook regular audits to ensure staff adhered to wearing PPE appropriately. All staff we spoke to told us they had completed their infection prevention and control and food and hygiene training and receive yearly refresher course.

We observed that the ward environment including the bedrooms was generally clean and saw the housekeeper who was cleaning the ward areas.

The kitchen was clean, and the staff used the appropriate personal protective equipment when handling food.

We saw a copy of an up-to-date cleaning record document of the ward environment and bedrooms. Staff followed the provider’s infection control policy, including handwashing, and completed enhanced infection control checklists every morning, afternoon, and night. Infection, prevention, and control processes were managed well, and protective equipment was available to staff. Manager completed handwashing audits.

Patients did not always receive their medicines safely or in a way that met their needs. One patient who was prescribed medicines to manage their diabetes was not always receiving their insulin in line with their prescription and care plan. This put the patient at risk of physical health deterioration if their blood sugar levels were not managed as needed. We escalated this concern to the senior management team during our feedback session. Where patients were prescribed medicines with side effects that needed to be carefully monitored, plans for how to monitor and manage these were not always documented. However, the ward consultant completed regular health monitoring for patients taking High Dose Antipsychotics [HDAT].

Patients had information in place to support them with de-escalation techniques rather than resorting to medicines when they felt agitated or distressed. There were PRN protocols in place to support staff with de-escalation techniques.

Staff told us they discussed the purpose and side effects of medicines with patients during ward round and dealt with concerns raised by patients. Staff discussed the side-effects of medicines and doctors prescribed medicines to help manage these side-effects when necessary.

The clinic room door was reinforced to protect the safety of the dispensing staff. The door had a second lock at the bottom to ensure it was secured.

At the time of our inspection, we observed the office to be cluttered with paper and files.

Medicines were not always managed safely. Where patients were prescribed high risk medicines, the provider did not always ensure patients had care plans in place detailing the risks and how these should be monitored or managed. Staff were not always completing the required quality assurance checks for blood glucose monitoring machines. Audits had not identified all the issues we found on the inspection. Not all staff had received medicines training. For example, one staff member we spoke with said they had not received medicines training when they started their role but received guidance from other staff. Following our inspection, the provider informed us that the member of staff had completed their medicines competency assessment but had not yet completed the providers own medicine training module.

There were records in place for bowel monitoring and physical health monitoring which staff completed daily.

Staff completed regular monitoring of the temperature of the clinic room and fridges where medicines were stored. Staff completed daily audits to ensure all medicines had been administered and signed for.

Consent to treatment forms were in place and completed correctly in line with legal requirements. Staff had access to these when they administered the medicines. Doctors used the Glasgow Antipsychotic medicines (GAS) to assess the side effects of medicines. Staff told us they did not covertly give medicines to patients. The provider had a policy on the use of rapid tranquilisation. The doctor informed us the provider had as and when needed medicines (PRN) protocol in place which all doctors had to adhere to.