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

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.

We rated This key question requires improvement because:

• A cupboard containing a fuse box and waterpipes was left unlocked in a ward communal bathroom. Patients could potentially access this area and cause harm to themselves.
• Staff had not recognised fixed point ligatures when completing their daily environmental checks. This meant the risk that patients might use these ligature points to harm themselves wasn’t being effectively managed.
• Damaged mattresses had not been replaced in a patient’s bedroom, which posed an infection risk.
• Staff did not always follow processes to manage medicines safely.

However:

• All staff were trained in safeguarding adults and they made appropriate referrals to the local safeguarding team when needed.
• The wards were fully staffed and staff were up to date with their training.

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.

We scored the service as 3. The evidence showed a good standard. 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.

In the 12 months prior to our inspection there had been 2 serious incidents across the two wards, both involving patients falling. The service reported both incidents to the local safeguarding team.

Staff we spoke to understood what actions to take when there was an incident and how to report incidents following the providers reporting systems. They completed a paper incident form which was then copied onto the electronic patient record. Staff understood the need to explain when things had gone wrong to patients and their families. Staff and patients had debriefs following incidents.

The service has monthly patient safety meetings where staff could discuss any lessons learnt following incidents. Managers circulated minutes of the meetings to staff following the meeting and the service completed a monthly lesson learnt newsletter to keep staff informed. We reviewed 6 months’ worth of minutes and saw that lessons learnt was a standard agenda item at the patient safety meeting. However, the meeting did not document any progress against any of the previous lessons learnt, which meant that staff were not kept informed of the hospitals against any of the previous lessons learnt.

We scored the service as 3. The evidence showed a good standard. 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.

Staff assessed all patients prior to admission to ensure they could meet the needs of the patient. Staff discussed the patient with the referrer and, when appropriate, with the family. Staff created care plans for each new patient admitted that covered all their identified needs.

The ward managers told us that they could decline an admission if they felt the patient’s needs could not safely be met by the service. There were clear exclusion criteria in place that supported staff to identify if a patient was not suitable for admission.

The staff told us they received copies of relevant care plans and risk assessments prior to admission. The care team review all care plans and risk assessments shortly after admission to ensure they are all relevant to the patient and that staff are meeting all known needs.

We scored the service as 3. The evidence showed a good standard. 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.

At the time of the inspection 100% of staff had completed their online safeguarding adults and safeguarding children’s training. Staff also completed a face-to-face safeguarding training following the online training and 97% of staff had completed this training. Staff we spoke with knew how to raise a safeguarding concern and when they should do this. The ward managers kept a log of the safeguarding concerns that they had raised on the wards. They would track the concerns and take any identified action needed to keep patients safe.

Staff told us that they understood what incidents needed to be referred to the local safeguarding team. The service had made 21 safeguarding referrals in the 6 months prior to the inspection.

There were policies in place for visiting the ward including when children visited and there are visiting rooms and outside space that can be used if needed.

Staff received training in restrictive practice and 100% of staff had received this training at the time of the inspection. Staff do a quarterly audit of restrictive practices in place on their ward, which fed into the hospital governance process.

Mental Capacity Act

At the time of our inspection 100% of staff had received training in the Mental Capacity Act (MCA). Staff understood the five statutory principals of the act. At the time of our visit the provider had not admitted any patients under deprivation of liberty safeguards (DoLS). The provider had a Mental Capacity Act policy in place for staff to follow.

Staff could get support and advice around the MCA from the Mental Health Act administrators based at the hospital. Staff worked with patients to make decisions for themselves. If patients lacked capacity staff would make decisions in the patient’s best interest and involve families when appropriate. Staff made best interest decisions on an individual decision specific basis.

We scored the service as 3. 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 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.

We reviewed 3 risk assessments across the two wards. We found that staff had involved the patient and other family members in 2 of the risk assessments. We saw that staff regularly reviewed risk assessments and updated them when needed. We saw that there were plans in place to manage the identified risks, but staff had not developed dedicated crisis management plans. Crisis management plans would have advised staff of what actions they could take if a patient had a mental health crisis.

There were 40 physical interventions across the two wards in the 6 months prior to our inspection, 38 were on Fairlight and 2 were on Cooden. There were 3 prone restraints on Fairlight ward and none on Cooden.

In the three months prior to our inspection, staff used rapid tranquilisation on 6 occasions all on Fairlight ward. Ward managers did a monthly audit of all rapid tranquilisation to ensure staff had followed best practice and identified any actions that staff need to take.

Staff worked with patients to ensure they understood their treatment. Staff wrote care plans in plain English and staff could access translators if English was not the patient’s first language. Staff encouraged patients to attend ward rounds and multi-disciplinary meetings to ensure they were fully involved in discussions around risk.
 

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Staff completing the daily environmental check list did not always identify maintenance issues and potential ligature risks, therefore staff were not managing the risks they posed. We found that staff had left a door to an electrical cupboard open and that repairs made to bedrooms could have been used as ligature points. There was no privacy screening curtain in Fairlight communal bathroom which meant people could see into the bathroom if the door was open when in use. There was also no privacy screening on the Fairlight bedroom windows that looked onto the ward garden. We found a safety mat used in the de-escalation room for physical interventions, on Fairlight ward, was dirty and appeared to have been like this for several days, which posed a potential risk of infection to patients. Staff cleaned this before we left the ward.

Since our last inspection the provider had introduced a daily environmental check of the wards which staff completed to identify any issues, so the maintenance team could fix them. The ward managers completed a monthly audit of this checklist to ensure that staff had completed them correctly. We reviewed the checklist and identified that staff were not finding all the maintenance issues on the wards. The new ligature points had not been identified by staff completing the environmental checklist. Staff also completed a comprehensive ligature assessment for each ward that identified any ligature risk and how they should be mitigated. Managers had not updated this with new ligature risks or removed risks that had been addressed.

The provider had made improvements to the ward environments since our last inspection to make the environment safer for patients admitted to the wards. Since our last inspection they had replaced the windows with anti-ligature windows or made the existing window safe prior to a new window being fitted. There was emergency equipment on the ward that staff checked daily.

We scored the service as 3. 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.

At the time of this inspection both Cooden and Fairlight wards were fully staffed for Registered Nurses and Health Care Support Workers. The average sickness rate at the hospital was 2% which is lower than the NHS average of 5%. The Turnover rate of staff leaving the service was 2% which was lower than the average rate in the NHS of 5%.

We reviewed the staffing numbers for the past 6 months and saw only 3 occasions on Cooden ward when they did not make their core staffing figures. Senior managers reviewed staffing levels and ward managers told us they could increase their staffing as needed. There was very low bank or agency use in the 6 months prior to our inspection of the service.

Managers had calculated the number of staff needed on the wards and had recruited to this number. Staff we spoke to told us that there were enough staff on the wards and that they very rarely cancelled activities or leave due to staff shortages.

We scored the service as 3. 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.

The wards were clean and well maintained. There was general wear and tear across the unit and staff told us that the maintenance team were quick to respond to any issues raised with them. The wards were cleaned every day and we saw housekeeping staff working on the wards during our inspection. Housekeeping staff record what cleaning they had completed on a daily basis and ward managers audit this to ensure cleaning was completed to the necessary standard. We saw that there were hand sanitiser units at the entrance to clinical areas. The service completes an infection control audit and a hand hygiene audit quarterly.

We scored the service as 1. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff did not always follow processes to manage medicines safely. Medicines governance arrangements were not always effective. While audits and pharmacy support were in place, these did not always identify or address risks, including gaps in documentation and out of stock medicines. Audits from the pharmacy provider showed extensive interventions recorded including prescribing and administration errors. However, the provider had only recorded 1 medicines incident in 2025. We could not be assured the provider had a robust system in place for escalating errors or learning lessons.

We found concerns with the oversight of rapid tranquilisation (RT). Audits completed by the wards did not reflect the actual number of RT episodes when compared with pharmacy data. During the inspection, staff could not always tell us if any patients had been administered RT. This meant the service could not demonstrate there was robust oversight of the use of RT on the wards to ensure staff were following national guidelines on least restrictive practice. Medicines were not always prescribed safely. One patient had been prescribed 2 medicines containing paracetamol, another patient had been prescribed 2 hypnotic medicines to help with sleep, this could place patients at risk of harm. One patient was prescribed a medicated transdermal patch. There was no clear record of the application site or monitoring to ensure the patch was being applied in line with the manufacturer’s instructions. Where medicines had special administration instructions, staff were not following these which meant medicines may not work as expected. Antibiotic medicines were not always available in a suitable time frame.

The management of ‘when required’ (PRN) medicines was inconsistent. Protocols did not always match current prescriptions, and staff did not always record the reason for use or the outcome when administering medicines used to support patients experiencing distress or anxiety. This meant the service could not effectively monitor whether these medicines were used appropriately or effectively, or if a non-medicines approach had been tried first.

Where people were prescribed high risk medicines such as clozapine, these were reviewed and monitored in line with national guidelines. Mental Health Act documents were in place and met legal requirements. Patients were supported by a multidisciplinary team with regular medical reviews and access to pharmacy advice.