All Saints Hospital

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 good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

The ward was generally safe and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

However, there was furniture on the ward that had ripped or torn armrests which meant that the furniture would not be able to be cleaned effectively. This was an infection prevention and control risk. The clinic room was cluttered and contained some items and kits which were out of date or had missing items. Ligature audit documentation was not consistent and clear to ensure staff would be appropriately informed of any risks.

This service scored 66 (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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service provided hospital-wide incident data for the 6 months prior to the assessment. There were 401 incidents recorded during that period with 63% of the incidents being recorded as level 1, no harm, 29.68% of incidents were reported as level 2 and 6.73% as level 3. One incident within the service was recorded as level 4 which related to an incident of violence and aggression. The highest proportion of incidents during the 6-month period related to aggression and violence at 42% of the 401 recorded incidents.

All staff knew what incidents to report and how to report them. Staff could describe what incidents they would report and how they would do this. Staff reported all incidents that they should report.

Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong. There had been no incidents within the 12 months prior to the assessment that had met the threshold for the duty of candour.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff met to discuss feedback. There was evidence within team meeting minutes that staff and managers discussed incidents and learning on a regular basis. Staff were debriefed and received support after a serious incident.

The service sent a quarterly lesson’s learned newsletter to staff which highlighted issues identified during the quarter and the specific learning and actions that staff should be taking to address these issues.

The organisation also sent regular patient safety bulletins to staff which highlighted key learning and practice on a national basis.

There was evidence that changes had been made because of feedback. An example of this was that the number of security incidents had reduced significantly following the service’s Lead Nurse designing and implementing a security action plan in May 2025. This had involved the implementation of new security books and a revision of the processes on Appleton Ward where the service had identified an increase in security related incidents. The service also provided staff with the opportunity to attend a local sister hospital to undertake experiential learning of security processes in a medium secure environment to refresh their knowledge on the importance of security processes when working within a secure environment.

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 safely be met. A representative from the service would complete a full assessment for any potential new admission and would request all relevant information. The potential referral would be discussed within the senior management team handover and a decision made if the patient could be managed safely within the service.

The Registered Manager had identified a need to review the service’s model of care upon joining the service and this review had been completed to map out what was being offered by the hospital. Managers involved patients in this process. Managers reported that they now had a clear model as to which interventions would be used for each discipline, for both the low secure and the rehabilitation ward.

There had been no admissions on Appleton ward in the 12 months prior to the assessment. One patient had been discharged from the ward in this period.

The average length of stay as of 02 October 2025, was 2,205.5 days.

Managers described that improvements had been made to discharge planning and working with external agencies and teams to prepare patients for discharge. Managers noted that previously it had felt that patients were stuck in the system. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

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. The compliance rate for safeguarding training was 93% at the time of the assessment.

On Appleton ward, 15 safeguarding referrals had been made to the local authority in the 12 months prior to the assessment. One of these was in progress whilst the others had been closed with no further action identified.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

The hospital had a safeguarding lead and a regional safeguarding lead. The safeguarding lead would attend relevant meetings and provide feedback to managers and staff. Managers had oversight of any safeguarding issues as part of a morning handover. Safeguarding was a standing agenda item within the service’s clinical governance meetings.

Managers were aware of recent themes and gave examples of actions taken to address these issues. An example was in relation to concerns that staff were sleeping on night shifts. Managers undertook night visits to observe practice and had conversations with staff about their understanding of their roles and responsibilities. Managers had raised relevant safeguarding referrals in relation to this. Managers had reduced the night visits to once a month at the time of the assessment.

Staff followed safe procedures for children visiting the service. The service had a child visiting policy and a localised protocol.

The ward had a restrictive practice register which had last been completed in August 2025. The service discussed reducing restrictive practices in the patient forum to enable patients to raise any concerns they may have had in relation to this.

Mental Capacity Act

89.7% of staff had completed their mandatory training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

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. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions

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. Managers gave examples of how capacity was considered and the processes that were followed within the service.

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

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 2 patient records during the assessment. Staff involved patients in care planning and risk assessments. Care plans were individualised to patients and reflected their identified needs. Patients felt involved in decisions about the care and treatment.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Patients were supported by staff in understanding their care and treatment. This included helping them with understanding aspects of their care plan and supporting them in line with their communication needs.

Staff enabled patients to give feedback on the service they received including patient surveys, community meetings and a patient forum. Staff ensured that patients could access advocacy.

There were 7 incidents of restraint on Appleton ward in the 6 months prior to the assessment. These 7 incidents were in relation to 2 patients. Managers noted that, due to the low levels of restraint used within the hospital, they had identified some issues with staff knowledge and experience when using restraint in February and March 2025. Managers had implemented 6 drop-in sessions for staff following this to provide support and refresher training.

There had been no use of rapid tranquilisation on Appleton ward in the 6 months prior to the assessment.

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.

Staff had undertaken risk assessments of the care environment, but these had not always been completed effectively. We reviewed a copy of the ligature audit for Appleton ward. The rooms listed on the audit were not all identifiable or it was not clear as to which rooms were being referring to. Managers could not provide clarity when asked which rooms these were. The ward also had a ligature map although this also did not specify the rooms and there was no date recorded as to when the ligature map had last been reviewed or updated. The activity room and the de-stimulation room were both recorded on the map as the “lounge”.

The ligature audits referred to monthly ligature point audits. The monthly ligature point audits for August 2025 included updated ligature audits that did specify the rooms on Appleton ward. It was a concern that the different versions were not consistent and could cause confusion for staff as to which rooms had specific ligature points to be aware of. In particular, that the ligature map had not been updated and there was no evidence as to when it was last reviewed.

Appleton ward was a low secure service that provided accommodation for up to six male patients. There were six bedrooms with ensuite facilities.

The ward complied with guidance on eliminating mixed-sex accommodation as the ward was for male patients only.

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

The wards had some larger pending maintenance projects to improve and update the general ward environments, although these did not specifically impact on patient safety or wellbeing.

The clinic room on Appleton was generally clean but was cluttered with some boxes being stored on the floor. There was a cupboard which had a broken lock that contained a food and drink thickening agent for patients with dysphagia or swallowing difficulties, along with laxatives. The staff member present was aware of this issue. There was no evidence that this issue had been reported to maintenance. This was escalated to the service. The service provided the maintenance log following the on-site assessment that the cupboard lock had been logged on 25 September 2025 and fixed on 26 September 2025.

During our review of the Appleton clinic room, we identified that there were different kits which were out of date or had items missing. This included an emergency eye wash station which was an empty box, biohazard kits which had missing items in each one and were out of date since 2017, a first aid kit which was broken and open, although most of the equipment was present, and a burns kit which was empty, although there was a second kit elsewhere in the clinic room.

There was evidence that staff were checking clinic room and fridge temperatures and there was a protocol to escalate where temperatures were outside the appropriate range.

At the time of the on-site assessment, there was no evidence to confirm when medical equipment, such as weighing scales and blood pressure monitor, had last been checked, calibrated and when it was due for review. The service provided evidence to confirm that this had been requested in August 2025, along with certificates to confirm that this had been completed on the 26 September 2025.

The ward had accessible resuscitation equipment and emergency drugs that staff checked regularly.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

At the time of the assessment, the hospital had 8 healthcare support worker vacancies. The hospital was fully staffed aside from this, with a psychologist having been recently recruited to and due to start in October 2025.

The hospital had an average sickness rate of 5.7% for the 12 months prior to the assessment. The month with the highest sickness rate was February 2025 at 9.9%. The service was able to provide commentary as to why the sickness levels had increased during certain months, mostly due to multiple staff being on long term sickness.

Staff turnover rates for the 12 months prior to the assessment were similar to that of the previous 12 months. The staff turnover percentage as of September 2025 was 28% which equated to 16 staff leavers in the 12 months prior to the assessment. The average length of service for staff in post as of September 2025 was 5 years and 4 months.

For the 3 months prior to the assessment on Appleton ward, an average of 41.07% of shifts were filled by bank staff, 10.44% of shifts were filled by agency staff and 4.72% were filled by locum staff.

When agency and bank nursing staff were used, the service did not always have appropriate assurance that staff received an induction and were familiar with the ward. The service had implemented a “new staff” induction checklist, but we were not assured that these were being completed with staff as required. We reviewed the completed checklists for any agency staff that had worked the week of 15 September 2025. For the 20 agency staff listed as having worked in that week, only one had a completed “new staff” induction checklist. Managers noted that it was expected that reception staff would complete these checklists with the new starters, alongside the key induction. We found that not all agency staff above had completed key inductions within the folder in which they should have been stored. The service confirmed that observation competencies for agency staff were not carried out by the service. We were therefore not assured that agency staff were being appropriately inducted and familiar with the wards in which they were working.

On Appleton ward, both the day and night shifts were staffed by 1 nurse and 6 healthcare support workers.

Managers could adjust staffing levels daily to take account of case mix and had oversight of this. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Managers reported that they had an extensive bank of staff and that agency staff would be used as a last resort.

Patients raised concerns about not having enough staff that were able to sign on the ward, in particular at night. They described feeling ignored by a lot of staff. Patients noted that the wards had enough staff but that they were often in the office and did not engage with patients.

Managers stated that the minimum standard of BSL training for non-clinical staff was Level 1 and for clinical staff it was Level 2, over their first 2 years of being employed by the service. Managers considered the staffing on each shift to ensure that a competent signer was allocated to the ward, with managers aiming to have at least 2 competent signers as a minimum. Managers were considering how staff were recruited into the service and the levels of experience required. The service was in the process of recruiting 2 BSL interpreters to be employed directly by the service. At the time of the assessment, one of the interpreter posts had been recruited to but not yet started in post, whilst interviews were on-going for the second post. However, the service did not use agency staff that were specifically trained or that required these staff to be trained in BSL, meaning agency staff could work in the hospital without having any signing abilities.

There were enough staff to carry out physical interventions safely and staff had been trained to do so.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with appropriate mandatory training. The overall service compliance rate for mandatory training was 96.7%. The mandatory training course with the lowest compliance rate was basic life support at 81.5%. Managers explained that multiple staff had been booked on basic life support training the week prior to the assessment however, this had to be cancelled due to the trainer being off sick. The training was being re-arranged. The mandatory training was appropriate for the patient group using the service.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

On Appleton ward, there was furniture on the ward which had damaged, or was worn. Some furniture also had torn arm rests. This was a concern as it meant that staff would not be able to effectively clean this furniture and was therefore an infection prevention and control risk. We escalated this to managers during the assessment who told us they would take action to address this.

Appleton ward had an infection prevention audit which had a start date of 25 March 2025. The overall compliance rate from this audit was 87%. This audit had identified issues with furniture in the clinical environment, and we were concerned that this remained an issue at the time of the assessment.

The ward area itself was generally clean and tidy.

On the day of the assessment, the only cleaning records for the clinic room on Appleton ward available were for the last 2 days. Copies of the clinic room cleaning records were requested whilst on-site but were not provided. The service was able to provide these records as part of information requests following the on-site assessment.

Cleaning records were mostly up to date and demonstrated that the ward areas were generally cleaned regularly.

Staff received training in infection prevention and control. Support staff received level 1 infection control training, and the compliance rate was 100% at the time of the assessment. Clinical staff received training in infection control level 1 and level 2 with compliance rates being 93.1% and 100% respectively at the time of the assessment. Staff adhered to infection control principles, including handwashing.

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.

Staff followed good practice in medicines management and did it in line with national guidance. The service had protocols and processes in place to manage and monitor medications. The hospital had oversight from an external pharmacy provider.

Medicines records were complete and recorded correctly with no gaps or missing signatures. All relevant paperwork was present as required.

Staff reviewed the effects of medicines on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medicine. Staff monitored and reviewed medicine at each ward round. There was evidence that staff were undertaking regular physical health observations of patients.

The hospital had an agreement with a local GP practice to provide additional support in relation to physical healthcare.