Becton Centre for Children and Young People

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.

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.

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 scored the service as 3. The evidence showed a good standard. 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.

Staff we spoke with knew what incidents to report and how to report them. At the time of assessment there were 200 open incidents, with 35 that were over the Trust target of 28 day KPI. Following the onsite assessment the service submitted updated evidence to show that there were 185 open incidents with 15 over the Trust target of 28 days. This has reduced significantly since our last assessment.

Lessons learnt from incidents were shared with staff in handovers, reflective practice sessions, supervision and via email. Lessons learnt were shared across each of the lodges to ensure site wide learning.

Each morning hospital managers had a risk meeting, which reviewed incidents from the previous 24 hours and identified actions.

Staff understood duty of candour, the trust had a policy that staff knew how to access.

Following a death at the service, the hospital had made changes to the building, including replacing all bedroom doors to ones with integrated door top alarms.

We scored the service as 3. The evidence showed a good standard. 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.

All patients are reviewed for their suitability for admission to the service, this review includes all professionals on the lodges and takes into account the patients presentation, the current admissions and staff available. These reviews were able to take place online or in person, the service was able to travel to meet the potential patient face to face.

We reviewed 8 care records and found each patient had a physical health assessment on admission and a risk assessment. We found patients, relatives and social workers were involved in discharge planning for the patients.

We scored the service as 3. The evidence showed a good standard. 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 we spoke with had a clear understanding of safeguarding and knew how to report safeguarding concerns.

The hospital had specialist safeguarding nurses available to staff for advice and guidance around safeguarding concerns. The hospital had introduced safeguarding supervision with individual staff members, there was a low take up for this at the time of our assessment, the service actively encouraging staff to attend.

Staff received safeguarding training for adults and children and training compliance across all lodges inspected was 100%. Staff also received prevent radicalisation training, compliance for this training was at 96%.

The service had 11 safeguarding incidents reported to the local authority designated officer.

Mental Capacity Act

All staff received Mental Capacity Act training as part of their mandatory training, at the time of our assessment the compliance rate for this was 99%. Staff we spoke with had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

We scored the service as 3. The evidence showed a good standard. 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. The lodge 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 8 risk assessments during the assessment; all records were up to date. There was evidence that the risk assessments were updated after incidents. Patients and their carers, where appropriate, were involved in care planning. We observed the service actively engaging patients and carers as part of the multidisciplinary team meeting.

Staff we spoke to had restraint and conflict resolution training.

The service had 381 incidences of restraint from September 2025 to December 2025. 195 of these restraints were planned restraint; a planned restraint is a restraint that is required to help patients with nasogastric feeding (nasogastric feeding is providing nutrition, hydration and medication through a temporary tube passed through the nose into the stomach). The majority of the restraints occurred on Sapphire lodge with a total of 357 incidents, compared to 21 instances on Emerald Lodge and 1 at Ruby lodge.

The hospital was engaging in a programme of work to reduce restrictive practice across the lodges. Staff informed us that this programme of work was central to care planning, risk reviews and multidisciplinary meetings.

Staff communicated with patients in the way they could understand. Staff provided many examples of ways they adapted communication; they used language line for patients whose first language was not English, staff were trained in Makaton, they utilised the speech and language therapy team and utilised communication cards. The hospital could adapt communication to however the patients could or wished to communicate.

We observed information about advocacy services on each lodge, with a contact number and an image of the advocate. The advocate visited the lodges on a weekly basis.

The hospital gathered feedback on care from patients through community meetings on each lodge. The outcomes from these meetings were shared on ‘You said, we did’ boards on each ward. Emerald Lodge also had a feedback tree where patients and carers could write feedback on the wall. The hospital also gathered patient and carer feedback through a questionnaire when they were discharged from the service.

During the assessment we spoke with 1 patient and 6 carers and they spoke highly of the staff and the care given. Carers felt that they were kept up to date on their relatives care and involved in key meetings.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did make sure equipment, facilities and technology supported the delivery of safe care.

A variety of environmental risk assessments were undertaken on a daily, weekly and monthly basis. These included infection prevention and control, moving and handling, slips trips and falls, and use of medical equipment. These risk assessments were collated and audited by senior leaders. However, we did find a backlog of these assessments on Sapphire lodge that had not been submitted. We raised this with the deputy chief nurse, who was aware of the backlog on Sapphire and were taking steps to improve this.

We did find inconsistencies across each lodge with ligature risk assessments. Each lodge had a different type of ligature risk assessment. We raised this with the deputy chief nurse, they informed us that following a inquest they had changed the ligature risk assessment policy and were rolling it out across the lodges, starting with Emerald.

Not all parts of the lodges could be observed by staff from a singular point. This was mitigated with the used of mirrors at key intersections of the lodges and 1 to 1 observation.

The lodges were compliant with regulations in relation to mixed sex accommodation. Each patient had their own en-suite room and a female lounge was available for female patients.

Staff had access to individual alarms on the lodges and patients had access to nurse call systems in key areas of the lodges.

At the time of our assessment, we were informed that the seclusion room had been decommissioned.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had recently undertaken a staffing review using the Mental Health Optimal Staffing Tool (MHOST). However, this was conducted using the number of patients on the lodges at the time. At the time of our assessment Ruby Lodge had 1 patient but had capacity for 7, Sapphire Lodge had 6 patients but capacity for 10 and Emerald Lodge had 5 patients but capacity for 9. The service informed us that Emerald lodge was only commissioned for 5 beds.

At the time of our assessment the site had low vacancies for the service. Across the site there were 2.22 WTE nursing vacancies and 2.03 WTE vacancies for health care assistants. The service had a long term vacancy for a consultant on Sapphire Lodge, this had been filled using locums, the service was going back out to advert for the role at the time of our assessment.

The hospital had a daily staffing meeting to ensure there were safe staffing levels across the lodges. For the 12 months prior to our assessment the service had utilised bank nurses for 152 shifts and agency nurses for 258 shifts. 399 support worker shifts were filled by bank staff.

The service provided an induction for all bank staff and regular bank staff were used wherever possible to ensure continuity of care.

At the time of our assessment one of the ward managers for the lodges had recently moved on, this had resulted in the movement of staff from other lodges to cover.

Each staff member received mandatory training including mental capacity, resuscitation, risk management, medicines management, equality, diversity and human rights, infection prevention and control, prevent, safeguarding and Oliver McGowan training on learning disability and autism. Overall compliance for mandatory training at the time of our assessment was 96%, with no modules with less than 75% compliance.

Appraisals for staff were at 100% for all lodges except Emerald Lodge at 96% and the multidisciplinary team at 94%. Clinical supervision for the service was 78% for Sapphire Lodge, 64% for Ruby Lodge, 93% for Emerald Lodge and 85% for the multidisciplinary team. Management supervision compliance for the service was low with 35% for Sapphire Lodge, 39% for Ruby Lodge, 43% for Emerald Lodge and 25% for the multidisciplinary team. The Associate Director of Nursing was aware of this and had reviewed the policy that was awaiting approval by the safety quality risk and learning committee. The senior leaders for the site had put in a number of new leadership roles to support the staff and on the lodges, however these roles were temporary. Staff we spoke to were aware of this and felt that the lack of a permanent structure was impacting staff wellbeing.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All lodge areas were clean, had good furnishings and were well maintained. Staff we spoke with were aware of infection prevention and control requirements and policies.

All staff received infection prevention and control training as part of their mandatory training, the compliance level at the time of our assessment was 98%.

Each lodge had an infection prevention and control risk assessment, each of these assessments had been updated before our assessment.

We scored the service as 3. The evidence showed a good standard. 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.

We reviewed 11 medication records for patients across the 3 lodges. We found good practice in medicines management in line with national guidance.

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

The service worked towards achieving the aims of STOMP (stopping overmedication of people with a learning disability and autistic people).

We had concerns regarding covert medication at our last assessment. We were assured at this assessment that these issues had been addressed by the service.