Archived: The Chimneys Clinic

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 rated Safe as Good

Staff knew how to report incidents and lessons learnt were shared and embedded within the service. Staff knew how to protect people from abuse and neglect. Staff completed and updated individual risk assessments. There were thorough environmental risk assessments in place and the use of restrictive interventions were a last resort. There were enough suitably qualified and trained staff to keep patients safe and patients told us they felt safe.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to. Safety incidents were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

There were systems in place for the recording and reporting of incidents. The service followed the Patient Safety Incident Review Framework (PSIRF) for investigation of serious incidents. They kept a local PSIRF register which was submitted to the Patient Safety meeting every quarter.

Lessons learnt were well embedded in the service. Managers told us that staff were invited to come to after action reviews and staff confirmed that incidents and lessons learnt were discussed in team meetings, supervision, debriefs, handover and circulated via email. We reviewed handover meeting notes and saw that individual risks and incidents were shared with staff. We saw actions taken following incidents were clearly documented. We saw that risk management and lessons learnt, and incident analysis were standing agenda items at governance meetings staff governance meetings.

Staff received feedback from investigation of incidents, both internal, from other sites across the wider organisation and from the NHS. We saw examples of key patient safety messages that were shared with staff. Staff told us they were debriefed and received support after serious incidents.

We reviewed incident data from 1 April 2025 to 3 September 2025. This showed that incidents were recorded against different categories and PSIRF response type, including whether the incident was referred to the patient safety meeting and learning response. During this time 11 incidents had been referred to the patient safety meeting of which 9 had resulted in an improvement response and 2 had required a learning response, such as an After-Action Review (AAR) report.

Staff had access to an electronic reporting incident system. Staff we spoke with knew what incidents to report and how to report them.

Staff reported every incident of self-harm by ligature or self-strangulation and self-inflicted injury, including head banging, through their incident reporting system. We saw in the incident data we reviewed for the period 1 April 2025 to 3 September 2025, that a high number of incidents had been reported in these categories. Managers told us they accepted patients with high levels of risk, and we were assured that the service worked with patients after each incident to manage, mitigate and work to reduce the likelihood of the incident recurring. The learning and mitigation from each incident were reviewed at morning meetings and an email of the discussion was sent to the clinical team. A further afternoon meeting was held to review all daily actions following incidents and we saw examples of daily ligature and head banging audits took place.

Staff received mandatory training on the Patient Safety Incident Response Framework (PSIRF). At the time of inspection, the training compliance rate for Level 1 was 97% and for Level 2, 96%.

At the time of inspection, 100% of staff had received duty of candour training. Duty of candour mandates health and social care providers to be open and honest with people about their care and promotes a culture of learning.

The service worked with people and their system partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The service ensured continuity of care, including when people move between different services.

The service had operational procedures in place to support safe systems, transitions and pathways for rehabilitation and recovery. Staff worked within a multidisciplinary team including, a registered clinician, a consultant psychiatrist, registered nurses (mental health, physical health, learning disability nurses), Health care assistants, psychologist, assistant psychologist, occupational therapist and activity co-ordinators, and Occupational Therapy assistant who worked together to look at the patient pathway and deliver the service.

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. There was a clear care pathway in place from admission through to discharge, including for self-discharge.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care. Staff work across the system to ensure patients’ needs were met within pathways.

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 that there were systems, policies, and practices in place to make sure people were protected from abuse and neglect. The service followed the provider’s Safeguarding policy and the local Multi Agency Safeguarding Hub (MASH) team. 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, significant harm. The service had Safeguarding leads and staff knew who these were. Staff completed Provider level safeguarding assurance audits.

Staff were kept up to date with mandatory training for safeguarding adults and children. At the time of inspection, the training compliance rate was 92%. Staff were kept up to date with both training on the Mental Capacity Act (98%) Mental Health Act (100%) and the Oliver McGowan Mandatory Training on Learning Disability and Autism (96%).

We reviewed the service safeguarding log for the period 2 March 2025 to 15 August 2025 which included the total number of safeguarding concerns raised, immediate action taken and outcomes. We saw this included working in partnership with other agencies.

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. There were management plans in place for identified risks and needs of individuals, including crisis management plans.

The service had a reducing restrictive interventions policy in place. Its aim was to ensure restrictive interventions should only be used as a necessary, justified and proportionate in measure and were regularly reviewed.

There was evidence of appropriate restrictions to manage individual risks that had been care planned. Where there were restrictions in place these were well planned and documented.

We saw the use of restrictive interventions and the use of any blanket restrictions on the ward were regularly reviewed by the reducing restrictive practice group. We saw from the minutes of this group and governance meetings that the service’s reducing restrictive interventions register was a standing agenda item for discussion and review at these meetings, including themes and trends and lessons to be learnt. The lead for reducing restrictive practice was the forensic psychologist, they ran a group where patients were invited to attend and contribute to the local reducing restrictive practice group meetings. Staff completed Provider level reducing restrictive practice audits.

We reviewed the service incident data for the 6 months prior to inspection. There had been 308 incidences of restraint on 19 individual patients. None of these incidents were in the prone position. Fifty of these incidences resulted in the use of rapid tranquilisation. Staff completed and reviewed a rapid tranquilisation audit during handover meetings. Staff reported all incidences of restraint, including “friendly come-alongs” a lower-level physical hold used by staff to safely guide a person.

Staff we spoke with described the de-escalation techniques they used and told us that restraint was used only as a last resort.

Staff received mandatory training on the safe and therapeutic management of violence and aggression. At the time of the inspection the training compliance rate was 90%

There were clear procedures for supportive observations and engagement and security checks, staff we spoke with knew these. During the inspection we observed positive interactive observations taking place.

We reviewed handover notes and saw that staff discussed each patient and clearly documented any presenting risks or concerns on each shift. Staff, including agency were required to complete enhanced observation and therapeutic observation and engagement competencies.

Staff enabled patients to give feedback on the service they received. We reviewed examples of community meeting minutes and patient survey results. These showed that patients were given opportunities to be involved in care and treatment decisions.

We reviewed 6 patient records, and we saw evidence of patient involvement in the formulation of risk assessments and care planning in all except 1 record. Whilst we found limited evidence of family input recorded in patient notes, the service ran fortnightly therapy sessions for family and carers, and a monthly parent forum for all parents to come together with staff. Carers were invited to attend monthly care review meetings where patients consented. Carers also confirmed they had opportunities to be involved in care planning.

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 did regular risk assessments of the environment. They completed and regularly updated ligature risk assessments for all internal and external areas. We saw examples of these. Identified risks were removed or reduced. For example, mirrors were installed to mitigate blind spots where staff could not easily observe patients and patients were escorted by staff, subject to individual risk assessment, when accessing the front garden.

Staff assessed risks to patients and took action to reduce risks where possible. Staff reviewed and completed a ligature risk audit tool during handover meetings and after each incident. Management plans were developed with the multi-disciplinary team and the patient to reduce the incidence of ligature attempts. We saw from clinical governance meeting minutes that harm reduction and incident analysis was a standing agenda item.

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

All bedrooms were single occupancy, lockable rooms with en-suite facilities. The service had a list of high-risk items. Patients were informed before admission of these items. The service had search policies and procedures in place to keep patients safe.

We observed both wards to be clean, tidy, safe and well furnished.

We observed the clinic room to be secure, clean and tidy, with suitable equipment and space.

Keys to access the room were held appropriately by a qualified member of staff. Patients’ physical health was assessed in a dedicated physical health room.

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, there were 2 vacancies for registered nurses and 6 vacancies for healthcare assistants. When necessary, managers deployed bank and agency staff to maintain safe staffing levels. Managers tried to book regular bank and agency staff, when required. For the 3 months prior to the inspection there were 9 unfilled shifts. During these shifts safe staffing levels were maintained by staff supporting from another ward, a reduction in staff breaks (paid time) and nursing staff supporting with observations.

During the onsite inspection, we observed staff to patient numbers were suitable to meet the patients’ needs.

The service had a low turnover rate of 4.4% during the 3 months prior to inspection. The yearly turnover target rate was to achieve lower than 15%.

Staff had received and were up to date with all mandatory training courses. The training was appropriate for the patient group using the service. There were enough staff to carry out physical interventions such as observations, restraint and seclusion if needed, safely. Staff received the necessary training and induction to do this effectively. For example, at the time of inspection 97% of staff were up to date with mandatory Breakaway training and 90% had received mandatory training on the safe and therapeutic management of violence and aggression. The compliance rate for observation and engagement competency was at 100%.

The service had a lead nurse with responsibility for physical health to meet patients’ physical health needs. There was adequate medical cover day and night and at weekends. A doctor could attend the ward quickly in an emergency.

Staffing levels allowed patients to have regular 1:1 time and participate in activities on and off the ward. However, patients told us, and staff confirmed that on some occasions leave outside of the hospital had been cancelled due to a lack of drivers and/or vehicles. The service had access to 15 drivers and 3 vehicles and they had recently also introduced a shuttle bus service.

The service assessed and managed the risk of infection, prevented 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 documented clinic room and fridge temperatures daily and these were regularly audited.

We reviewed cleaning records and these were fully completed, audited daily and we saw evidence that any actions arising from cleaning audits were taken.

We observed all ward areas were clean, tidy and kept well-maintained.

The service had an infection, prevention and control audit which alternated between being led externally and internally. The service also conducted a bi-monthly hand wash audit.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Systems and processes were in place to ensure the safe prescription, storage, and administration of medicines. This included secure storage of medicines, particularly controlled drugs, which require additional safeguards due to their potential for misuse.

We saw evidence of regular review of medication. An external pharmacy supported the service and visited every week to review medicines optimisation in the hospital. The service conducted regular medication and stock audits. Medications were in date and equipment had been calibrated.

The service did not stock flumazenil. This is a drug that can be used in overdose emergencies. However, we were assured because the service had a rapid tranquilisation policy in place that clearly set out the rationale and the emergency procedures to be followed.

Staff reviewed the effects of medication on patient’s physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance. Access to appropriate, up to date medicines resources were available both in hard copy and online.

We reviewed 14 medication charts and their associated MHA consent to treatment authorisations. We saw people detained under the Mental Health Act (MHA), had been prescribed and administered medicines in line with MHA consent to treatment authorisations.

We saw evidence that patients on medicines such as lithium and clozapine received regular health checks and monitoring.

Nursing staff responsible for the administration of medicines were appropriately trained. The training compliance rate for Safe Administration of Medicines Level 1 was 96% and for Safe Administration of Medicines Level 2, the compliance rate was 91%.