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

Safe - This means we looked for evidence that patients were protected from abuse and avoidable harm. At our last inspection we rated this key question as requires improvement.

At this assessment, the rating for this key question remains requires improvement. We reviewed seven quality statements.

Nursing care plans, although in place, showed little evidence of any patient involvement.

Patients told us that they were not always able to freely access fresh air without requiring staff support which was not always available. Due to the ward being on the second floor of the hospital, staff were required to accompany patients to the garden.

Most staff had completed safeguarding vulnerable adults training since they had started working at the Langford Centre.The completion rate for safeguarding vulnerable adults was 98% and for safeguarding vulnerable children it was 97%.

Of the three staff available on the ward, none of them were unable to unlock the fire safety equipment on the ward.

However, there were sufficient staff deployed on the ward, some patients told us more staff would be appreciated to support their access to the community.

There were processes in place to ensure patients were receiving their medicines safely and as prescribed.

All patients had Positive Behavioural Care Plans in place to support staff to manage escalations in behaviour.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with two patients on the day of the inspection. The patients we spoke with expressed that they were unhappy with their day to day care. Our assessment found their care plans were generic and showed little evidence of patient involvement. Patients reported that they had community meetings and were aware of how to make a complaint but preferred not to as they felt they would not be listened to. They felt they were not fully informed of their care and did not know how they would be able to progress from the ward back into the community.

Patients told us that staff avoided using restraint by using de-escalation techniques and rarely restrained patients. They said that restraint was used only when de-escalation failed and when necessary to keep the patient or others safe.

The ward participated in the provider’s restrictive interventions reduction programme, which met best practice standards. This meant that the patients did not feel they were exposed to unnecessary restrictions.

Staff understood the Mental Capacity Act definition of restraint and worked within it. Staff followed nationally recognised guidance when using rapid tranquilisation.

All patients had care plans that followed the “My Shared Pathway” model of care planning. However, most care plans we reviewed were generic and not written by or from the perspective of the patient. Care plans around physical health care issues were more detailed? and clearly had medical input but were orientated from the medical perspective. Those that were written from the patient perspective used terminology that was clearly clinical and not patient led, for example, one patient’s care plan stated, “I want to void normally” referring to using the toilet.

However, there were psychologically informed, positive behaviour support plans in place to support staff around how best to support patients with behaviours that challenge services. This was also in accordance with guidance on how to support people with a learning disability and autistic people.

The manager encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a priority.

Although the ward had a board that identified who was on shift, patients were not aware who to go to on a daily basis to express their thoughts and concerns which meant that sometimes they felt unsupported.

When we asked patients about their care plans, they told us “I have never seen it and have never had any involvement”. Another patient said, “I don’t have a copy”.

Staff told us that they knew patients well and understood their needs. Staff told us they felt that patients were involved in their care and made choices about their support.

We reviewed 5 sets of care plans and although there were care plans in place, there was little evidence to confirm patients were involved in the care planning process.

One patient had a comprehensive care plan around his physical health care needs with input from external medical team but within the section where it was stated “patients’ perception of need” it was written from the perspective of the staff member.

There was no recognised rehabilitation model in place on the ward and the ward did not have any written document that identified the philosophy of the ward. At the time of the inspection we were told by the ward manager that the hospital director was in the process of developing one.

Staff and the registered manager had not identified through their audits that patients were not involved in their care planning. When we reviewed the case file audit it was not recorded if the patients and families had been involved in the care planning so it was not being measured.

However, the governance systems on the wards had improved since our last inspection and we could see that restrictive practice audits and ligature management was happening on the ward.

There was a ward specific environmental risk register, which covered high risk areas and described mitigations to manage the risks.

Patients told us they felt safe on the ward and that staff were present although they did not know who was allocated to support them on a daily basis. Patients were not subject to blanket restrictions and restrictive practices were reviewed regularly and in line with the organisation’s policy. Levels of incidents were low on the ward and patients felt that they would know how to complain if they needed to. However, they said they didn’t want to as they felt it might impact negatively on their care.

The staff we met with, including the ward manager, were clear on their safeguarding responsibilities and demonstrated knowledge about the safeguarding process and how and when to escalate incidents.

The staff worked with partners in a collaborative way to share concerns about the risks to the patients on the ward. The ward manager told us they knew how to report incidents of abuse to the local authority. Staff were aware of the impact of reporting incidents on the patients and the staff and ensured they offered a debrief after any such incident occurred.

We observed positive and respectful interactions between staff and patients throughout the assessment. We saw there was safeguarding information available to staff in the office and to patients on the ward identifying a flowchart of responsibility if a safeguarding referral was required. There was information available to patients on the noticeboard informing how to report concerns to the CQC or the Local Authority.

We observed sufficient numbers of staff across the ward.

We found that systems to identify and report safeguarding concerns to the local authority safeguarding team and CQC were in place. The systems, processes and practices were effective which meant that patients' human rights were upheld and they were protected from discrimination.

Staff received up to date mandatory safeguarding training. Mandatory online training for safeguarding vulnerable adults was 98% and safeguarding vulnerable children was 97%.

Patients felt safe on the ward but told us that they did not feel connected to their care.

Staff knew about any risks to each patient and acted to prevent or reduce risks. Staff spoken with were aware of patients' individual risks and how to manage these.

Staff used a recognised risk assessment tool which was regularly reviewed and identified any changes in risks to, or posed by, patients. All five records we looked at had a risk assessments in date which helped staff to be aware of procedures to minimise each patient’s risk. Staff assessed risks of each patient and increased observations where needed to reduce risks. Staff followed the provider's policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm.

Levels of restrictive interventions were low. Levels of restraint used were proportionate to the risk posed by the patient and each restraint incident was investigated. The management team reviewed incident data at their monthly clinical governance meeting.

However, although patient’s risk assessments and risk management plans were in place, they but showed little evidence of patient involvement. There were historic clinical risk documents in use and a dynamic risk assessment which showed that risk was being managed but patients did not feel they were a part of that process.

Ward areas were clean; however furniture and fixtures were tired and needed an update.Patients said that the ward was regularly cleaned and their bedrooms were cleaned daily apart from at weekends.

Patient community meeting minutes showed that maintenance issues were discussed at each meeting. A log was kept of action taken and any outstanding issues were discussed at the meeting the following week

Patients told us that they were unable to freely access fresh air. The rehabilitation ward was on the second floor and the patients were unable to leave the ward without staff support. This meant that staff had to be available to support and often patients had to wait until they were free.

We found that when assessing the fire safety of the ward, the fire extinguishers had been locked with padlocks and the three staff we asked were not all able to identify or access the correct keys to open the padlocks. This meant that in the event of a fire the staff were not confident to be able to access the correct equipment.

The hospital gave reassurance that this would be dealt with immediately and reviewed all sets of keys to ensure there was consistency and staff training.

Staff completed and regularly updated risk assessments of all ward areas and removed or reduced any risks they identified.

The clinic room was fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, we were concerned that when open, the medication cupboard could be easily accessed from the corridor.The provider informed us that after the inspection immediate action was taken to address our concern.

The ward had a system in place for the management of ligatures. There was a weekly audit by the ward manager that was sent to the hospital director for review against the annual ligature audit.

There were weekly audits in place for the management of environmental risks and the manager was aware of the processes for reporting and recording any maintenance issues that required attention.

Patients felt that there were suitable numbers of staff on the ward and they were treated positively with dignity and respect. However they felt that staff were not available to support their access to fresh air, which for some people meant they were not able to access the outside space for the designated 6 times a day. This was mostly due to the ward location being on the second floor and the distance to the garden which required staff to leave the ward environment repeatedly throughout the day.

Patients felt they were able to contact their doctor at ward round and also in between ward rounds if they felt they needed to.

The ward had enough nursing and support staff to keep patients safe. Staff worked 12 hour shifts and the number of staff was calculated using a staffing ladder which factored in the needs of the patients. The ward manager told us that sometimes, staffing numbers were affected due to staff sickness, injury or bank staff cancelling shifts. They told us that they would get cover from overtime or bank staff and the ward would always be supported by the ward manager and members of the multidisciplinary team working on other wards when needed.

The ward had enough staff on each shift to carry out any physical interventions safely. In addition, the ward had an allocated response member of staff who remained on the ward and was identified as a responder in the event of an emergency on another ward.

We observed sufficient numbers of staff on duty across the ward.

Patients were being spoken with in a dignified manner and it was clear that the staff knew the patients’ needs well.

The provider had a comprehensive mandatory training programme. Recent clinical governance meeting minutes had indicated that training levels were acceptable.

Data provided by the hospital identified that the ward had enough nursing and support staff to keep patients safe.

There were arrangements for medical cover for each ward, current vacancies and arrangements in place to cover any vacancies.

Patients were supported to receive their medicines in a way which met their individual needs. Care and treatment was regularly discussed with a multidisciplinary team. Patients were supported to self-administer their medicines to support their path to discharge. However, patients prescribed medicines which may have additional effects on their physical health did not always have risk assessments in place. These assessments helped staff to know how to keep patients safe from avoidable harm when they were taking these medicines. We raised this at the time of the inspection and asked for the assessments to be updated.

Patient’s responses to medicines were monitored regularly, and any adverse effects were reported and managed. Regular audits were conducted to monitor medicines management practices, and findings were reported to the senior management team. However, these audits had not identified the need to complete physical health monitoring for patients prescribed medication which may impact their physical health.

We observed medicines being administered in a safe way by qualified practitioners. There were clear protocols for the administration of medicines. Staff followed appropriate procedures for checking patient identities and obtaining consent before administering medicines. Although we had concerns that the medication cupboard could be reached from the corridor, medicines were stored in accordance with legal requirements, and controlled drugs were managed in line with national guidelines. There were procedures in place for the disposal of unused or expired medicines.Following our inspection, the provider informed us that action had been taken to address the distance between the door and the medicines cupboard.

There were processes in place to ensure patients were receiving their medicines safely and as prescribed. When a medicine was administered to sedate a person as rapid tranquilisation, the process to ensure a person’s physical health was monitored for their safety was being followed and learning from these incidents shared with both the person affected and staff. In the clinic room, access to some medicines was not entirely secure due to the close distance of the medicine cupboard to the door of the room.. There was a clear medicines policy that was reviewed and updated in line with national guidance.Following our inspection the provider informed us that they had addressed the concern relating to the location of the medicine cupboard.

Most staff responsible for administering medicines had completed 'the safe management of medicines' training. Training data showed that 95% of staff were up to date.