St Mary's 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

We reviewed all 8 quality statements in the safe key question and found it to be good. The service had not been previously inspected.

The service had enough staff to meet need and deliver safe care. There were effective systems and processes to protect people from abuse and neglect. Staff understood how to protect patients from abuse. Staff completed risk assessments for patients.

Environments were clean, well-maintained and fit for purpose. Ligature risk assessments were up to date and staff managed environmental risks effectively.

The service had appropriate systems for the safe storage, handling and administration of medicines.

Patients we spoke with told us they felt safe on the ward.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients we spoke with felt safe on the wards and were supported to understand and manage their risks. Some of the patients we spoke with told us that staff had supported them after incidents. This included staff spending time with the patient to offer reassurance. None of the patients we spoke with had been involved in a serious incident or an incident that had required further investigation.

Staff understood what type of incidents to report and were able to describe the process for reporting, reviewing and responding to incidents. Staff were able to give examples of identified learning and improvements that had been made following incident investigations. Staff understood the processes for managing and investigating complaints and supported patients, relatives and carers to raise concerns. Staff told us there was an open and honest culture in the service. They were encouraged to raise concerns and were aware of the freedom to speak up and whistleblowing processes.

Appropriate systems and governance processes were in place to support the effective management of incidents and complaints and to promote learning and improvement. The service, as part of the wider hospital had been a pilot site for the new Patient Safety Incident Response Framework (PSIRF) and had implemented the required structure and processes. Incidents and complaints were regularly reviewed at hospital and provider level to help identify themes and trends. Staff had been trained in appropriate incident investigation techniques. Identified learning was shared across wards and the wider hospital and provider. Staff had access to a range of policies and procedures for additional guidance. There was a clear structure around whistle blowing and access to a Freedom to Speak Up guardian. Staff completed annual suggestions, ideas and complaints training. Compliance at the time of our assessment was 98%.

Patients we spoke with told us they had felt supported during referral and admission to the service. They had received information about the service, facilities and care and treatment as part of the process. Some patients we spoke with had begun discussions about transfer or discharge out of the service and knew what plans were in place. Patients told us they understood their care and treatment and the purpose of their admission.

Staff worked collaboratively with each other and external stakeholders to promote joined-up care and ensure transitions between services were managed well. They demonstrated a good understanding of the processes and policies relating to referral, admission, transfer and discharge. They felt able to support patients along these pathways and were able to give examples of when they had done so. Staff were aware of the risks to people across their care journey and worked to ensure sufficient and appropriate information was shared during referral, admission and discharge processes. For example, staff described changes to the referral and discharge forms to better capture physical health risks.

We contacted stakeholders for comment, but they did not raise any issues.

Appropriate systems and governance processes were in place to support safe admissions, discharges and transfers of care. There was a corporate team that oversaw admissions and bed management and processes to monitor and manage length of stay and patient flow. Staff had access to policies and procedures to support transitions and pathways into and out of the service.

Patients we spoke with told us they felt safe on the ward and that they could raise a concern with staff without fear of reprisal. They were aware of how to raise a complaint and of services such as Independent mental health advocacy services. Patients we spoke with had not experienced restraint or seclusion. None of the patients we spoke with were currently involved in a safeguarding concern or investigation.

Staff demonstrated a good understanding of safeguarding, the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff were able to describe types of abuse and what constituted a safeguarding concern. They had a good knowledge of safeguarding processes and reported positive relationships with local safeguarding bodies. Staff knew how to get advice and support and worked with the hospital’s safeguarding lead where required. They were able to describe examples of actions taken to help safeguard individuals. Staff showed a good understanding of the Mental Health Act and Mental Capacity Act, and this was integrated into their everyday practice. Staff supported patients to understand their rights under the Acts and supported access to Independent Mental Health Advocates.

We observed management of safeguarding concerns in care records we reviewed. Safeguarding had been considered on referral and assessment. Where appropriate there was evidence of ongoing safeguarding management and liaison with relevant authorities. We observed multi-disciplinary patient review meetings where safeguarding was considered.

Appropriate systems and governance processes were in place to ensure people were safeguarded. Safeguarding incidents were identified and referred as needed. There was a database of safeguarding incidents and referrals to enable oversight and effective management. Staff received annual training in adult and children safeguarding. At the time of our assessment compliance was 86%. Staff had access to a safeguarding policy and hospital safeguarding lead for support and guidance.

Appropriate systems and governance processes were in place to provide assurance and oversight on the use of the Mental Capacity Act. The service completed regular audits around consent to treatment and had been part of a wider review of Mental Capacity Act assessments. Staff completed Mental Health Act and Mental Capacity Act training. Compliance at the time of our assessment was 95%.

Patients we spoke with felt safe on the ward and felt supported to manage their risks. They told us they would speak to staff if they had any concerns. They were able to access relevant information when they needed it. Patients told us they were generally involved in their risk assessments.

Staff had a good understanding of risk and risk management. They were able to describe how risk was assessed at referral, admission and as an ongoing process during treatment. Staff felt involved and able to contribute to the assessment of patient risk, including within multi-disciplinary reviews. Staff were knowledgeable about individual patient risks and were able to provide examples of effective risk management.

Staff reported low usage of physical restraint and restrictive practices. They were able to describe a least restrictive approach and told us they only used restraint as a last resort. Staff were able to describe de-escalation and diversionary techniques for patients. Staff reported low usage of rapid tranquilisation but were able to describe when it may be used, for example to facilitate a depot injection. They were able to describe the required post administration actions, including appropriate physical health monitoring and review.

Staff maintained a register of blanket restrictions which was reviewed regularly.

Appropriate systems and governance processes were in place to promote and ensure good risk management.

The service monitored and reviewed the use of rapid tranquilisation, restraint and seclusion. Use of restrictive practices was low and reducing. There was a least restrictive culture and a reducing restrictive interventions policy to guide staff The service maintained a restrictive practice register which was subject to regular review.

Staff competed a range of training to help them manage risk. These included behavioural support (95% compliance at the time of our assessment), breakaway training (98% compliance at the time of our assessment), conflict resolution (98% compliance at the time of our assessment) and the safe and therapeutic management of violence and aggression (100% compliance at the time of our assessment).

We reviewed nine records and found that each had a full and up to date risk assessment in place. Risk assessments covered key areas and captured relevant information to support the ongoing management of risk.

Patients we spoke with did not raise any concerns regarding the environment. They told us they had access to their bedrooms and the facilities on the ward were clean and well maintained.

Managers had oversight of the environments and could escalate issues as appropriate within the hospital and provider organisation. They were able to explain the programme of regular checks and audits that ensured that the facilities, equipment and technology on the wards were well-maintained and safe.

Staff we spoke with displayed a good understanding of environmental risks. They were aware of ligature risk assessment that had been completed and were able to describe how they used individual risk assessments, care planning and observations to manage environmental risk.

Staff were aware of fire evacuation procedures and reported regular drills and alarm tests.

Managers and staff we spoke with did not raise any concerns regarding the environments.

We reviewed the environment on both wards. Environments were clean, well-maintained and appropriate for use. Environmental and ligature risks had been identified and were managed and mitigated by staff.

The service had access to a seclusion room on Leo ward. The seclusion room allowed for clear observation and included a two-way intercom. Patients in seclusion had access to toilet and showering facilities. A clock was in place to allow orientation to time and day.

Staff accessed fire safety and health and safety training as part of the mandatory training programme. At the time of our assessment, compliance in both courses was 100%.

The service completed environmental and ligature risk assessments. We reviewed these during the assessment and found them to be appropriate and comprehensive. The service completed an annual fire risk assessment. We reviewed this during our assessment and found it to be appropriate and comprehensive. The wards had fire evacuation plans in place and where appropriate patients had personal emergency evacuation plans (PEEPS).

Patients we spoke with told us there was enough staff. They told us that staff were a visible presence and that there was normally a staff member available when they needed one. They told us they were able to have regular 1:1 sessions when required.

Patients told us they felt safe on the ward and that staffing levels meant they were able to take their escorted leave as planned. They reported that planned activities were rarely cancelled.

We spoke with patients who had engaged with staff within the wider multidisciplinary team including occupational therapy and psychology. They were positive about their involvement and felt they supported their care and treatment.

Staff we spoke with reported positive staffing levels and happy and supportive teams. The service had recently converted a number of agency staff into permanent staff. This meant there was a more stable and consistent staffing group. Staff told us that the change in the wards purpose from a learning disability and autism wards to acute adult mental health wards had meant there was less acuity and more time to engage with patients and complete work. Staff reported that the wards were rarely short staffed and were able to describe how the staffing groups supported each other. Workloads were manageable and staff were able to seek support when needed. There was access to medics including out of hours.

Staff completed appropriate mandatory training and received regular supervision and appraisal. Staff we spoke with also described additional specialist training they had completed including training around substance misuse that had been introduced following an increase in patients with substance misuse problems. Staff we spoke with told us they felt supported and were able to access advice and guidance when required.

We observed sufficient numbers of staff on the wards to facilitate the delivery of safe care and treatment. Staff were a visible presence in communal areas. Staffing data we reviewed showed that the service met the identified staffing levels on all shifts.

We observed staff engaging with patients and encouraging them to join in activities. Staff were familiar with patients and were able to describe individual patients’ background, interests and dislikes. We observed therapeutic engagement between staff and patients. There was sufficient staffing levels to meet the required level of observations and to respond to individual need.

The hospital had undertaken a recruitment drive in 2023 which included open days and employing agency staff on a permanent basis. The hospital also ran a Healthcare support worker sponsorship programme. At the time of our assessment there were no vacancies on either ward. Any staffing issues were discussed in a daily hospital-wide meeting.

Staff worked a two-shift pattern. Establishments for the day shift on Leo ward was 2 qualified nurses and 6 healthcare support workers. On Leo ward the shift establishment was 1 qualified nurse with 3 healthcare support workers, one of whom worked 9am to 5pm. Establishments for the night shift on Leo ward was 2 qualified nurses with an additional nurse working a 5pm to 12pm twilight shift. There were 3 healthcare support workers. On Leo ward the shift establishment was 1 qualified nurse and 2 healthcare support workers. Where required staff supported across both wards. Staffing data we reviewed showed that the service met the identified staffing levels on all shifts.

In the 12 months prior to our assessment the service had a sickness rate (across both qualified nurses and healthcare support workers of 6.15%). Staff had access to support services including human resources and occupational health.

Staff completed mandatory training. At the time of our assessment compliance across all services was 96.7%. No course was below 85% compliance. Staff received regular supervision. There was a policy and guidance documents to support the supervision process and promote development. At the time of our assessment supervision compliance for qualified nurses was 100%. Supervision compliance for health care support workers was 86%.

Patients we spoke with did not raise any concerns in relation to infection prevention and control. They told us the ward and equipment was clean and well maintained.

Staff we spoke with told us the wards were cleaned regularly and they had no concerns regarding infection prevention and control. Staff were able to tell us how they could access personal protective equipment and further information and guidance on infection prevention and control.

We reviewed the environment on both wards. Wards were clean and well-maintained. Staff had access to infection prevention and control resources including personal protective equipment, hand gel and cleaning materials. We observed staff following infection control principles including using handwash. Staff made sure cleaning records were up-to-date, and that clinical equipment was appropriately cleaned and maintained.

The service completed infection prevention and control checks and audits to ensure required standards were met. Staff had access to an infection prevention and control policy and support at provider level. Staff completed infection prevention and control training as part of the mandatory training programme. Compliance at the time of our assessment was 98%.

People were supported to have access to healthcare professionals to maintain their physical and mental health. People had access to a pharmacist to ask questions about their medicines. There was no evidence that people’s behaviour was controlled by excessive and inappropriate use of medicines. People had access to medicines to support self-limiting conditions. For one person we found that their care plan did not contain any alerts or information for staff to inform them they were prescribed a blood-thinning medication. After the assessment we were told this had been rectified.

A Pharmacist attended the wards weekly to review charts and conduct audits. Staff explained how the pharmacist could be contacted outside of this visit if they needed support with medicines. Doctors were available to review and prescribe medicines. People had access to the doctors on a weekly ward round.

Staff were trained to manage and administer medicines. Lessons learnt including those relating to medicines were shared with staff.

Medicines and related paperwork were stored securely. Staff recorded temperature of areas where medicines were stored. Controlled drugs were stored according to legislation and policy. People’s medicines records contained information staff needed to administer medicines safely such as allergies.

Medicines prescribed to be given when required (PRN) had clear indications and maximum doses recorded. Staff recorded the times that these medicines were given to ensure that the safe gap between doses was maintained. Medicines were administered safely.

For one person we found the stock held by the service did not match the recorded stock. We found for one person that monitoring of their high dose antipsychotics was not recorded.

Medicines alerts were reviewed and actioned by staff. Medicines records were mostly completed accurately. For one person we found two gaps in the chart, so it was not clear if this person had received these medications at that time. Medicines and equipment used in emergency were stored and checked daily by staff. Where items were found to be out of date it was evidenced that this was escalated, however items were not always replaced promptly. Staff followed national policy practice to check patients had the correct medicines when they were admitted to or moved between wards. People’s physical health monitoring was not always completed as required; we saw one person who had gaps in their bowel monitoring chart.