St Neots Neurological 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 as Requires Improvement. At this assessment the rating has changed to 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 evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service used an electronic incident reporting system and followed the Patient Safety incident reporting framework (PSIRF) to investigate incidents. All incidents were reviewed by the senior management team, discussed at clinical governance meetings and any lessons learned were shared with staff via email, discussion in daily staff meetings and posters displayed in staff areas.

Staff we spoke with were able to give examples of changes made as a result of lessons learned including nurses wearing red tabards when administering medicines to let other staff know not to disturb them in order to reduce medicines errors.

Staff were debriefed and received support after a serious incident, and psychology staff offered additional reflective practice following an incident if required.

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 had operational procedures in place to support safe systems and transitions. Staff worked within multidisciplinary teams including nursing staff, healthcare assistants, medical staff, occupational therapists, psychologists and social worker, and worked well together to deliver 5 pathways within the neurological service.

Following a new referral to the service, a multi-disciplinary team would visit the patient at their current service to complete an in-depth assessment of their needs. The assessment was then reviewed by the full multi-disciplinary team to ensure that the patient’s needs could be met by the service and whether any additional equipment or technology was required.

The service had a clear pathway from admission through to discharge and worked closely with relevant healthcare and social care partners to ensure patients had continuity of safe care.

The service worked with people to understand what being safe meant to them as well as with partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect and they made sure to share concerns quickly and appropriately.

The service’s processes promoted people living free from abuse, neglect, and avoidable harm. We saw evidence there were systems, policies, and practices in place to make sure people were protected from abuse and neglect. The service had a comprehensive safeguarding policy in place.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff knew how to identify adults and children at risk of, or suffering from significant harm.

We reviewed the safeguarding log for the 3 months before inspection which included 7 referrals to the local authority safeguarding team. The service had a good working relationship with their designated link practitioner from the local authority multi-agency safeguarding hub and met with them quarterly to review referrals and examine themes and trends. Themes were identified as self-neglect, dysphagia and bruising/cuts.

Staff were aware of closed cultures and the risks that were posed to patients if a closed culture developed. A closed culture is a poor organizational environment characterized by a lack of transparency, weak leadership, and minimal external scrutiny, which increases risks of abuse, neglect, and human rights breaches. Staff received training in closed cultures and senior staff conducted quality checks of the wards, including night visits, to ensure staff were treating patients with dignity and respect.

The service worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them.

During the inspection we reviewed 6 risk assessments and saw that patients had a risk assessment in place on admission, and these were thorough and regularly updated. Staff completed additional risk assessments according to patients’ individual needs including Waterlow pressure sore assessments, mobility and falls assessments, and dysphagia assessments. Risk management and care plans were in place for all patients with identified risks. Psychology staff completed positive behaviour support plans for patients with an identified risk of violence or aggression.

The service had a reducing restrictive practice policy in place. Its aim was to support the reduction of restrictive practices to ensure that least restrictive principles and practices were supported. The service held monthly reducing restrictive interventions meetings where staff reviewed any restrictions and discussed reducing restrictive interventions audit outcomes, behaviour support and least restrictive practice.

We reviewed the service incident data - in the 6 months prior to assessment there had been 23 incidences of restraint on 12 individual patients. None of these incidents were in the prone position. Two of these incidents resulted in the use of rapid tranquilisation.

The service detected and controlled potential risks in the care environment and made sure that the equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular risk assessments of the environment. They completed and routinely updated ligature risk assessments for all internal and external areas. Identified risks were removed or reduced. For example, mirrors had been installed to mitigate blind spots where staff could not easily observe patients.

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

The wards were all single sex accommodation and had sufficient shared shower and bathroom facilities. The wards were all clean, tidy and well furnished.

The clinic rooms were small but tidy and all essential equipment was present, calibrated and in good working order. We found one blood glucose monitor that had not been calibrated. This was raised with the service at the time and was rectified immediately.

Managers made sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that met people’s individual needs.

Managers calculated the number and grade of nurses and healthcare assistants required for each shift. At the time of inspection, the service did not have any vacancies for registered nurses or healthcare support workers. The service had one medical vacancy which was covered by a locum doctor until the newly recruited doctor was in post.

The service used bank and agency healthcare support workers to ensure safe staffing levels and to cover additional observations. Managers booked regular agency staff to support continuity of care and ensure familiarity with patients’ individual needs.

Staff received appropriate training for their role with overall compliance of 97% for mandatory training courses.

Managers provided new staff with induction, and all staff had regular supervision and annual appraisals. At the time of the inspection 91% of staff were up to date with supervision and 79% had received an annual appraisal, with the remaining 21% booked to take place in February 2026.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean.

The service had a programme of infection, prevention and control audits. These included quarterly infection control and hand hygiene audits, monthly mattress audits and weekly cleanliness audits.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened where people had capacity to do so.

Systems and processes were in place to ensure the safe prescription, storage, and administration of medicines.

During the inspection we reviewed 11 prescription charts. Staff followed good practice in medicines management in line with national guidance. Where patients lacked the capacity to consent staff followed the correct procedures for detained patients and patients with Deprivation of Liberty Safeguards (DoLS) including best interest decision meetings with patients’ families.

Staff reviewed the effects of medication on patients’ physical health regularly, including high doses of anti psychotics. However, we saw on one occasion that a patient who had received rapid tranquilisation had not had their vital signs monitored every 15 minutes in line with guidance.

The service followed the STOMP (Stopping the Over-Medication of People with a learning disability, autism, or both) guidelines of care to ensure that patients with a brain injury were not given medication that would hinder their recovery.

Medicines including controlled drugs and emergency medicines were stored appropriately and managers conducted clinic room audits weekly.

Nursing staff responsible for the administration of medicines were appropriately trained with 100% of staff having completed up to date medicines management training.