255 Lichfield Road

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

Safe

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.

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

Good: All wards were safe, clean well equipped, well furnished, well maintained 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, during our inspection although we saw appropriate staffing levels according to a safe staffing tool, patients and staff told us the hospital often felt short staffed. Managers told us that there were processes in place to escalate a request for additional staff support but it was not clear that staff knew what these processes were and when it was appropriate. The provider had also not ensured regular supervision was taking place for all staff.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Staff knew what incidents to report and how to report them. The hospital followed the provider’s policy on incident reporting. We reviewed incident reports that showed staff had taken appropriate action in each instance and records were completed fully and accurately.

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.

Managers investigated incidents thoroughly and supported staff following incidents through debriefs and reflective practice. Staff told us that debriefs did not always take place after every incident but that leaders were supportive.

Staff gave us examples of recent learning and changes made to the service following investigation and lessons learnt. This included a new alarm system being implemented.

Staff met to discuss the feedback and look at improvements to patient care. Staff discussed individual incidents at handover and in the morning multi-disciplinary meeting.

Managers shared learning from other services, ensuring that information was cascaded across the team.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

The service had clear acceptance processes for admission and managers told us that they would only accept referrals if the service could clearly meet their needs and that they felt supported by senior leadership when making these judgements. Managers told us that the multi disciplinary team worked in collaboration to process referrals and members of the team would always visit potential patients before admission.

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.

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. External partners such as local mental health teams and other representatives within the patients care team were involved within the care plan and invited to multi-disciplinary meetings.

We spoke with two commissioners who worked with the provider. They spoke positively about the referral and admission process and told us that staff worked collaboratively using a person centred approach to ensure successful continuity of care.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Most patients we spoke with told us that they felt safe. Two patients told us of occasions where they did not always feel safe due to the acuity of other patients. They told us that staff had responded quickly and appropriately to concerns.

Staff we spoke with had good knowledge about safeguarding and any potential safeguarding concerns were discussed in morning risk meetings, handovers, clinical governance and multidisciplinary meetings.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff were 100% compliant in Safeguarding Level 2 and 96% compliant in Safeguarding Level 3.

All staff that we spoke to knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns.

Staff told us that they had good relationships with local safeguarding structures and had regular engagement with the local authority safeguarding teams.

Staff followed clear procedures to keep children visiting the ward safe. Patients told us that there had been some recent changes to how children were permitted to visit the hospital. Children were previously allowed to visit patients in their living areas and communal garden. Visits, where children were in attendance were expected to take place in a meeting room in a secure area within the main building as there was no dedicated visitors room at the hospital. The hospital explained that this was to ensure safeguarding protocol of children was in place. Patients told us that they were not happy with this arrangement as it meant all visits were scheduled and were dependent on staff being available as they were required to gain access to the meeting room. Carers told us the recent change had made an impact on how visits took place with family members. Two carers told us that they were not clear why the change had taken place and that staff had not communicated the reasons why.

Staff explained the safeguarding procedures to patients on admission and patients had access to relevant information.

The hospital monitored the use of restraint and restrictive interventions and worked closely with staff to ensure they were appropriately trained and up to date with relevant practice and policy.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We reviewed 5 electronic care records. Staff completed risk assessments on admission, reviewed them during monthly ward rounds and updated them after incidents. Staff discussed incidents during handovers and the morning meeting.

Most patients we spoke with said they felt supported to understand their risks and keep themselves safe. We observed patients living areas to be personalised and kept in a manner that they preferred. Patients gave examples where they were working towards being independent in daily living skills but if they were finding this difficult staff would support. For example, patients were encouraged to clean their own living areas but would need varying levels of support.

Staff told us that they were committed to reducing restrictive practices. In the 6 months prior to our assessment there was 1 restraint and 0 incidences of rapid tranquilisation

Staff told us they made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.

Incidents and restraints were reviewed by managers and discussed within clinical governance. Leaders discussed themes and regular occurring issues.

Staff enabled patients to give feedback on the service through community meetings and patient and carer feedback surveys. The provider had also implemented “You Said, We Did” boards to ensure that patients were aware of actions that had been taken following feedback.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Staff completed and regularly updated thorough risk assessments of all wards areas and removed or reduced any risks they identified. Staff completed daily checks of the environment including health and safety checks, maintenance needs and perimeter checks.

The hospital consisted of two four bedded enhanced recovery and rehabilitation units which were located in the main building and twenty self contained bungalows located within the hospital grounds. Due to the nature of this layout staff were therefore not able to observe all parts of the hospital. There were blind spots and ligature points throughout the hospital. These were managed through convex mirrors, staff observations and individual risk assessments of patients.

Staff had easy access to alarms and following lessons learnt managers had issued staff with additional pagers and were awaiting radios to ensure staff upstairs could be contacted promptly in the event of an emergency.

All clinic rooms were clean and staff had access to all appropriate equipment. Physical health checks took place regularly however there was not a examination couch in the clinic room and physical health checks took place in patients’ rooms or bungalows. Staff checked, maintained, and cleaned equipment that they used regularly. Clinical equipment was clean, well maintained and in date however two blood pressure devices had not been calibrated. When informed this was rectified by staff.

We make sure there are enough qualified, skilled and experienced people. We do not always ensure staff receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We looked at the staffing figures for the service. At the time of the inspection the service employed 46 staff. The vacancy rate was low. There were 2 vacancies for a registered nurse. The multi-disciplinary team was fully staffed.

Managers had calculated the number and grade of nurses and healthcare assistants required. Agreed staffing levels varied dependent on the volume of care required. Some staff told us there had been changes to staffing levels when there had been a change in leadership and they felt there were not always enough staff. Staff told us that they had been told they could request additional support but were not clear on the appropriate communication channels to do this.

Leaders told us that changes did occur at the time of new leadership however staff levels were decreased due to a reduction in occupancy and that changes had been made in accordance with the staffing ladder. Managers told us that staffing levels could be adjusted to take account of levels of acuity or when needs of arose but would need a clear rationale as to why additional support would be required.

We reviewed the most recent staff survey. 20 out of 43 staff responded to the survey. 60% of staff who responded said that their wellbeing was impacted by workload. Recommendations from the survey stated initiatives were needed to improve wellbeing need to focus on efficacy and workload. Managers told us they were working with staff to ensure more effective shift planning and promoting the correct channels of escalation when more staff were required.

Staff said shortages rarely resulted in staff cancelling escorted leave or activities but they would be rescheduled to account for staffing figures. There were enough staff to carry out physical interventions safely such as observations and restraint and staff had been trained to do so. Patients told us there were enough staff to support them to participate in activities and to access leave but they would need to ensure leave requests were made in advance and sometimes times could be rearranged. Patients told us staff were available when they needed them.

When necessary, managers deployed agency and bank staff to maintain safe staffing levels and they received an induction and were familiar with the hospital. In the 6 months prior to our inspection the rates of agency use for Health Care Assistants was 3% and 6% for nurses. This was due to annual leave cover, sickness and support for escorted leave.

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. At the time of our inspection overall mandatory training compliance was 90%. The training was appropriate for the patient group using the service and managers told us of specialist training that had been implemented to meet the needs of patients such as courses in autism, dementia and trauma informed care.

Managers provided new staff with an appropriate induction and ensured that shadowing opportunities took place.

In the 6 months prior to inspection supervision of staff had been inconsistent. The average percentage of staff who had received clinical supervision from January 2025 to June 2025 was 60% and the average percentage for managerial supervision from January 2025 to June 2025 was 78%. Some rates of supervision during this time period were low. In March 2025, the clinical supervision was 44% and in April 2025, it was 48%. In May 2025, the managerial supervision rate was 39% and in June 2025 it was 30%.

Managers told us that supervision rates were low due to staff compliance and a lack of understanding around the purpose of supervision and it being a supportive process as opposed to a punitive meeting. We saw that leaders discussed supervision rates regularly in clinical governance meetings and had implemented an action plan to increase compliance. The hospital had recently recruited a Director of Clinical Services who had taken the lead on this work. We saw that supervisions had been scheduled at the time of our inspection.

Managers dealt with poor staff performance promptly and effectively. Ward managers investigated concerns around practice and appropriate actions were taken including disciplinaries and support for learning and development.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Staff told us that they received specialist training which met the needs of patients and were confident that if they asked for additional training managers would support them with this. Managers ensured that staff had access to regular team meetings to provide feedback and discuss items related to the safe functioning of the ward.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

All ward areas were clean, had good furnishings and were well-maintained.

Staff ensured that cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff 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 from infection prevention and control leads within the hospital and wider provider. Staff completed infection prevention and control training as part of the mandatory training programme.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Staff followed good practice in medicines management. They followed systems and processes and safely stored, prescribed, dispensed, administered and recorded medicines in line with national guidance.

We saw staff administer medicines safely to patients and complete relevant documentation. Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines.

Staff completed medicines records accurately and kept them up to date. We reviewed 6 patients’ medication and physical health records. Staff completed them fully and accurately.

Staff followed national practice to check patients had the correct medicines when they were admitted, or they moved between services.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance.

Staff learned from safety alerts and incidents to improve practice. We saw that medication errors were discussed in daily meetings, within clinical governance and lessons learned cascaded.