St Martha's

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 looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. This meant we looked for evidence that people were protected from abuse and avoidable harm. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed. The rating is Good: This meant people were safe and protected from avoidable harm.

The service was in breach of the legal regulations in relation to safe care and treatment.

At this assessment we found that: the service did not always ensure environment risks were mitigated to ensure patient safety. There were fixed ligature anchor and high-risk ligature points across the Mental Health wards without sufficient mitigations in place to manage the risks.

However:

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. Managers made sure staff received training and regular appraisals to maintain high-quality care. The facilities and equipment met the needs of people and they were clean. Staff managed medicines well and involved people in planning any changes.

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.

Overall, patients were positive about staff training and learning.

Staff and leaders felt there was good training on how to report and respond to incidents and learning. We reviewed care plans which indicated changes had been made in response to incidents on the wards. St Martha’s was a member of the Quality Network for Older Adults Mental Health Service (QNOAMHS) under the Royal College of Psychiatry.

We observed a multi-disciplinary team (MDT) meeting where risks were discussed and incidents reviewed by a full range of professionals including occupational therapists, psychologists and social workers.

The service treated all concerns and complaints seriously and investigated them. We saw that staff reported and reviewed incidents regularly and escalated any concerns appropriately. Clinical effectiveness meetings were held on both wards which senior leaders and staff attended.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

There were good pathways in place for the admission and discharge of patients. The ward had an admissions criteria. Staff assessed risk prior to admission and could refuse to admit patients that did not meet the admission criteria.

We received positive feedback from carers and patients. They were confident that staff and leaders could keep their relatives safe and well cared for. Carers described being involved in the discharge process and being consulted about their future plans.

In five patient files we saw discharge plans that evidenced staff involved the patient in decisions.

Staff were trained to the appropriate level for their role. There was a safeguarding lead at the service. Staff knew how to raise a safeguarding alert. The lead kept a record of all safeguarding raised which included details of lessons learned. Safeguarding concerns are also documented on the services incident reporting system.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Overall, staff managed risk well. They worked closely with patients to help develop their risk management plans so they could find practical ways for them to manage their identified risks. For example, the organisation had purchased a number of vehicles to enable staff to support patients in accessing the community, after identifying some patients were triggered by being in larger groups. This meant more patients could access the community safely.

Staff offered all patients copies of their risk management plans and spent time explaining the plans to them.

Staff regularly invited all patients to review risk management plans with them.

Staff completed risk assessments for each patient on admission using a recognised tool, and reviewed this regularly, including after any incident.

The staff were mindful of restrictive practices and regularly reviewed any blanket restrictions. At the last assessment in 2020, we found patients could not access water in the communal areas without asking staff. Patients could now access water without first asking staff. We found no concerns about restrictive practices for patients.

We saw staff working closely with patients to reduce risk. For example, in relation to patients safely having hot drinks on the ward.

Staff only used restraint after attempts at de-escalation had failed. Staff members were trained in NAPPI (Non abusive Psychological and Physical Intervention) This focuses on the management of challenging behaviours in a way that ensures the safety and the wellbeing of patients.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

Patients did not always have access to a safe environment. For example, in Shamrock and Rose wards there were fixed ligature anchor and high-risk ligature points across the ward without sufficient mitigations in place to manage the risks. In both Rose and Shamrock wards there were multiple ligature points including bedroom door hinges, cupboard doors and windows. Bedroom doors, door furniture, windows and wardrobes were rated high risk on the ligature risk assessment.

The wardrobes did not have curved doors. This meant they could be closed on a ligature. The bedroom windows were open and able to be shut closed presenting a ligature risk especially to patients assessed by the staff to be a high risk of self-harm. Staff said that this risk was mitigated by being able to lock the wardrobe doors and windows. They said that anyone who was at high risk of ligaturing had their own separate care plan.

However, we reviewed five care plans for patients, two with high risk of harm to self and both were noted as spending a lot of time in their own bedrooms. Staff had not locked the wardrobe doors and windows in these patients' rooms to ensure patient safety. They had not completed separate care plans for patients to mitigate individual risk. This meant there was not an individualised plan in place for staff to follow to ensure their safety

The risks in the environment did not always have sufficient mitigation to ensure patient safety. For example, staff could not view all the ward from the nurses' office. CCTV, which was streamed in the nurses' office, covered most of the ward corridors. However, there were three identified blind spots on the ward. Staff said they mitigated these risks by being present in those areas when patients were. From observing these areas, we saw that this did not happen at all times during the day. This meant at these times patients were at risk.

There was an environmental risk assessment for Rose and Shamrock Wards but the mitigation was generic and copied and pasted across all areas of risk. All staff could access the risk assessment on their shared electronic database. The ward manager was working on a more bespoke assessment but at the time of the assessment this was not completed. This meant staff did not have a bespoke plan to follow consistently to ensure patient safety.

There were individual patient risk assessments and evidence of daily security checks which were identified by staff to be additional mitigation towards risk oversight. However, upon review the additional controls were identified as the same for each risk and there was no variation for high-risk items.

The ward manager said they were not planning on changing the ligature points; staff would increase observations to 1:1 if a patient was assessed as potentially suicidal. These were reviewed at MDT meetings.

The service did not follow their own policy in relation to the use of vapes. The vaping policy states that only two types of vapes were permitted and following individual risk assessments these were only to be used in bedrooms. In Rose ward we observed patients were openly vaping in the communal areas. Staff and patients said it helped some patients relax and they could also access the garden area to vape. There were no complaints from patients and staff about patients vaping.

The glass on the lounge door leading to the garden on Rose ward was broken and had been for some time.

A qualified nurse was present in communal areas of the ward at all times. Staffing levels allowed patients to have regular one-to-one time with their named nurse. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. Staffing on each unit was one qualified nurse, a Senior Support worker plus 3 support workers. Ward staff were supported by Occupational Therapists, Activities staff, Social Workers, Therapists and Medics.

On Iris ward 4 of 4 rooms were in use, there were two staff on this ward but if they took a break this left 1. There was no communal area, but patients could go to other communal areas in the hospital if they wished.

The service did not have a dependency tool in use, however if a 1:1 was required this was taken from the staffing team. If further 1:1s were required there was a staff member duty system.

There were two dedicated drivers for trips out/appointments, and they worked flexibly over the 7 days when required. They were both working during out visit.

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

The service had an infection prevention and control policy in place that followed national guidance. Staff used the policy in conjunction with specific policies that covered areas including for example hand hygiene. Staff told us they were aware of their roles and responsibilities and had received appropriate training. The service carried out regular audits to ensure policies were followed and to measure how effective they were. The service has an Infection Prevention and Control (IPC) team that audited the service annually. They identified areas for improvement. For example, 8 months ago, they identified staff were using the wrong mop heads and this was immediately changed. The service monitored any infection outbreaks, took appropriate action to prevent further spread and recorded the outcome so they could learn from the incident. Ward areas were clean, had good furnishings and were well maintained.

The service 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.

The service involved patients in decisions about their medication. Staff ensured medicines were stored and administered safely. Staff told us that medication was discussed with patients as part of their MDT meeting. There were no concerns from patients about medicines.

We reviewed four medication records. We saw staff reconciled patients' medicines on admission. There were monitoring processes in place for high dose anti-psychotic medication and staff understood their responsibilities to ensure they monitored physical health in line with the service policies.

Medication was checked and balanced by staff and seen to be accurate. They reviewed as required medication (sometimes called PRN) regularly to ensure it was being used appropriately. The treatment room was clean, tidy and well maintained.

Staff completed regular checks to make sure medication was stored safely. For example, room and fridge temperatures were recorded and action taken if they were too high or low.

Medical devices were clean and maintained appropriately.