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

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 changed to Good. This meant people were safe and protected from avoidable harm.

The ward was clean and fit for purpose. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service was fully staffed and staff were up to date with their training.

However, 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 was not being effectively managed. We also found issues with medicines governance and oversight.

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 for Pevensey ward. The service reported both incidents to the local safeguarding team. One incident had been investigated and closed with no further actions, and for the second one the investigation was in progress.

Staff we spoke to understood what actions to take when there was an incident and how to report incidents following the provider’s reporting systems. They completed a paper incident form which was then copied onto the electronic patient record. The service was working towards implementing an electronic only incidents reporting system. Staff understood the need to explain when things had gone wrong to patients and their families. Staff and patients had debriefs following incidents. We reviewed 8 sets of morning huddle minutes for Pevensey ward and found that incidents, risk management and debrief planning following incidents was standard agenda items.

Learning was embedded through structured processes. Staff told us that incidents were discussed every morning in multi-disciplinary meetings and during supervision meetings. Staff had developed a lessons learnt log which was updated during the daily multidisciplinary meetings. The service also had 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 lessons learnt newsletter to keep staff informed. We reviewed six months’ worth of patient safety meeting minutes and saw that lessons learnt was a standard agenda item at the patient safety meeting. There was a lessons learned champion for the ward. Lessons learnt were also discussed during staff meetings where staff had the opportunity to discuss areas that required attention and agreed on necessary actions. For example, following an incident with a patient, additional radios were provided to staff to ensure that they always carried one with them when escorting patients out in the community.

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.

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 be safely met. We reviewed 6 patient records and found that staff had completed appropriate assessments, such as physical health assessments for patients on admission. New referrals were discussed during daily multi-disciplinary meetings as a standard meeting agenda item. Staff discussed the patient with the referrer and, when appropriate, with the family.

We reviewed 7 patient records and found that staff created care plans for each new patient admitted and involved all the necessary healthcare and social care services to ensure patients had continuity of safe care. Staff told us that they were working closely with various teams to ensure that patients were moved on appropriately. We reviewed patient records and found evidence of this. For example, community mental health services had been invited to attend a multi-disciplinary meeting for a patient to discuss handover of care.

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.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Data submitted by the provider showed that all staff had completed safeguarding training appropriate to their role. At the time of the inspection 100% of Pevensey ward 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 all Pevensey ward staff had completed this training.

Staff we spoke with knew how to raise a safeguarding concern and when they should do this. They were clear about their responsibilities and described the process for escalating issues and knew how and when to contact safeguarding leads or the police. Staff reported all safeguarding concerns internally and would refer to the local authority safeguarding team, when needed. Managers were able to explain their safeguarding processes and how they ensured oversight.

Staff discussed safeguarding concerns in daily multi-disciplinary meetings and monitored safeguarding trends through clinical governance meetings. There was also a safeguarding champions meeting.

There were policies in place for visiting the ward including when children visit and there were 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 our visit the inspection. Staff were completing quarterly audits of restrictive practices in place which fed into the hospital governance processes.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. At the time of our inspection 100% of staff had received training in 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.

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. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

Staff could get support and advice around the Mental Capacity Act from the Mental Health Act administrators based at the hospital.

We scored the service as 3. The evidence showed a good standard. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour, and used restraint only after attempts at de-escalation had failed. They provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them.

Staff involved patients in care planning and risk assessment. We reviewed 7 patient records and found that staff completed risk assessments on admission and patients were involved in creating the risk assessment. Staff regularly reviewed risk assessments and updated them when needed. There were care plans in place to manage the identified risks. For example, we saw that staff had developed specific care plans to support a patient with physical health needs such as hypothyroidism and constipation.

We observed multidisciplinary team meetings where discussions were patient focused with emphasis in managing risks.

The provider reported 6 incidents on Pevensey ward where restraint was used in the 6 months prior to our inspection. No prone restraints had occurred during this period.

The provider reported that there were no incidents in the 3 months prior to our inspection where rapid tranquilisation had been used on Pevensey ward. Managers completed a monthly audit of all rapid tranquilisation to ensure staff had followed best practice and identified any actions that staff needed to take.

Staff worked with patients to ensure they understood their treatment. Staff encouraged patients to attend ward rounds and multi-disciplinary meetings to ensure they were fully involved in discussions around risk. We saw information on notice boards about patient accessing interpreters when needed.

Staff ensured that patients could access advocacy and relevant information was displayed on notice boards.

We scored the service as 2. The evidence showed some shortfalls. 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.

Maintenance issues and potential ligature risks were not always identified by staff and the risks they posed were not being managed effectively. Staff completed daily environmental checklists of the ward to identify any issues, and the ward managers completed a monthly audit of these checklist to ensure they had been completed correctly. We reviewed the daily environmental checklists that staff had completed for the 4 days prior to our visit and found that changes to the environment that placed patients at risk of harm had not always been identified. For example, repairs carried out on bedroom wardrobes which could have been used as fixed anchor points for ligatures. The provider gave us assurances that the potential anchor points we identified on Pevensey ward were immediately eliminated.

Managers had completed a ligature assessment for the ward that identified ligature risks and how they should be mitigated. However, not all potential ligature risks had been identified and were not included on the assessment.

During our previous inspection we had identified that the ward had several environmental risks including blind spots and some of the windows on the wards posed a risk to patient safety because of their ligature anchor points. During this inspection we found that the provider had taken action to improve the environment. The premises where patients received care were well equipped, well furnished, and fit for purpose. The ward was clean and tidy and in a good state of repair.

The design and layout of the wards meant that there were areas accessible to patients that were out of sight of the nurse station. Staff mitigated this by using convex mirrors positioned in corridors to reduce blind spots, through patient observations levels, and CCTV in communal areas.

Staff had easy access to alarms and patients had easy access to nurse call systems in bedrooms.

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 to provide safe care that met people’s individual needs.

At the time of this inspection, Pevensey ward was fully staffed for registered nurses and health care assistants. The hospital was advertising for a forensic psychologist and a part time receptionist. A locum forensic psychologist was providing cover until a permanent member of staff was recruited.

The average sickness rate at the hospital was 2%. The Turnover rate of staff leaving the service was 2%.

Managers had calculated the number and grade of nurses and healthcare assistants required. They increased or decreased the minimum number of staff allocated to each shift depending on the number of patients on the wards. We reviewed the staffing numbers for the 6 months prior to our assessment and saw that the number of nurses and healthcare assistants matched the number needed on all shifts. Staff told us that managers were ensuring that staffing needs were appropriately covered. There was low bank or agency use. For example, in February 2026 no nursing or healthcare assistant shifts needed to be covered by agency or bank staff. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

Staff told us that they completed effective inductions. We reviewed a sample of five completed induction checklists and saw that staff were completing inductions appropriate to their roles. Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. There was a consultant forensic psychiatrist who was visiting the ward one day per week and the consultants from the other wards were providing cover. The consultant was also available remotely when needed. The service also employed a full time associate specialist doctor who could contact consultant when needed. There were arrangements in place to access doctors out of hours during the week and weekends.

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 ward was clean, had good furnishings and were well-maintained. The ward was cleaned every day and we saw housekeeping staff working on the ward during our inspection. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. The housekeeping team had cleaning schedules and rotas in place, and staff carried out audits to ensure that the cleaning was thorough. The service was completing quarterly infection control audits.

Staff maintained equipment well and kept it clean. For example, staff were completing weekly clinic room and emergency equipment audits.

Staff adhered to infection control principles, including handwashing. Staff were completing quarterly handwashing audits.

There was a nominated infection prevention and control lead for the service.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

During our visit we spoke with staff and the pharmacy provider. We looked at medicines records including the electronic prescribing system, care plans and monitoring records for three patients. Additionally, we reviewed audits and polices to support our judgement.

We found some issues with medicines governance and oversight. When required (PRN) protocols were not always accurate or up to date, and there were discrepancies between protocols and current prescribed medicines. There was limited governance to ensure PRN protocols were reviewed after prescribing changes. 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 one medicines incident in 2025. Therefore, we could not be assured the provider had a robust system in place for escalating errors or learning lessons.

However, controlled drugs were managed safely, with appropriate storage, accurate registers and regular stock balance checks. Medicines were stored securely, and staff completed daily clinic room checks. Staff recorded the administration of PRN medicines with the reason for use, which supported monitoring of effectiveness. Long-acting antipsychotic medicines were prescribed and given with appropriate monitoring. Physical health monitoring was carried out, including the management of diabetes and anticoagulation, with clear escalation pathways in place. Mental Health Act documentation, including T2 consent to treatment forms, was present and matched prescribed medicines. Use of rapid tranquilisation was low, which showed practice was in line with least restrictive principles.