St Bernard'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

At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The service was in breach of regulation for people’s safe care and treatment in the ways that people’s medicines were managed safely and oversight of medicines.

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.

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 had 8 serious incidents in the last 12 months. 6 of these were on Meridian ward, 1 on The Limes and 1 on Jubilee ward.

At our previous inspection we found one breach of regulation in relation to the identification and recording of restraint incidents. The trust had made improvements. All restraint incidents were recorded appropriately and reviewed at the clinical improvement group meetings.

The service had effective processes, policies and procedures to monitor and learn from incidents and near misses, and this learning was shared with staff. The trust followed the NHS England Patient Safety Incident Response Framework (PSIRF) which set out the service’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety.

All staff knew what incidents to report and how to report them on the trust electronic incident reporting system. Staff were aware of adverse events that were specific to their patient group, such as falls and pressure ulcers. When incidents, such as episodes of aggression or falls occurred, staff responded promptly, documented incidents accurately, and updated care plans and risk assessments. Incidents were discussed daily at the patient safety huddle to ensure that any immediate support, learning and or actions were addressed and implemented. We reviewed three after-action reviews following incidents and found that each incident had been subject to a comprehensive investigation, with immediate learning identified and actions taken to support ongoing improvement and reduce the risk of recurrence.

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. For example, on Jubilee ward staff, had apologised to a patient following a medicine error.

The service continually identified lessons learnt and embedded good practice. Managers and leaders discussed incidents during team meetings, safety huddles, supervision and through the trust patient safety newsletters and patient safety learning vignettes. Following a choking incident in another service staff, had undertaken refresher dysphagia training.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff confirmed they received a debrief and were supported by managers after deaths in the service and serious incidents. Staff told us that there was a positive and inclusive learning culture within the service.

There was evidence that changes had been made because of learning or feedback. Staff we spoke with were able to tell us about recent incidents and the learning that came from those incidents. For example, staff on The Limes told us following a falls incident, all admission assessments were now reviewed for falls risks when patients transferred from the other two wards.

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 relating to patients was obtained to assess whether their needs could be safely met. Continuity of care was maintained through effective patient handovers, ensuring that individual needs and risks were communicated appropriately.

Staff worked with other health and social care services to ensure continuity of safe care, both within the service and when patients moved between services or were discharged.

The service had good working links with the local emergency department at Ealing and Charing Cross Hospitals so physical health issues could be addressed promptly for older patients. The service had good working links with palliative care services for older patients.

Staff at all levels attended regular safety huddles throughout their shifts, providing opportunities to share important safety information, discuss risks, and coordinate care effectively.

The service also held daily bed flow meetings to monitor and manage patient movement across the wards. Since the previous inspection, the function of The Limes had been changed to a step-down unit. Patients from Meridian and Jubilee wards were referred there once their conditions had stabilised. Leaders reported that this change had improved patient flow across the two admission wards, supporting more timely admissions and discharges while maintaining safe and effective care.

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.

The provider’s processes promoted people being cared for in safety, free from abuse, neglect, and avoidable harm. We saw evidence that there were effective systems, processes, and practices to make sure people were protected from abuse and neglect. Managers ensured the service had a comprehensive local safeguarding procedure in place, supported by effective partnership working with external agencies, including the local authority. For example, the safeguarding lead for Hammersmith and Fulham participated in a joint audit alongside the local authority safeguarding team and other partner organisations, demonstrating a collaborative approach to safeguarding and continuous service improvement.

The staff we spoke with knew how to make a safeguarding referral and who to inform if they had concerns.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff completed training in safeguarding adults, safeguarding children and PREVENT radicalisation training. Compliance figures were over 88% for these training modules. On Jubilee ward compliance rates were 71% for safeguarding level 3 training. The manager showed us that staff had been booked to undertake this face-to-face training.

Staff we spoke with could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Each ward had a designated safeguarding lead with oversight of safeguarding activity across all three wards. Safeguarding leads maintained comprehensive safeguarding trackers for both adults and children, ensuring effective monitoring and follow-up of all concerns. The service had robust governance arrangements in place to oversee safeguarding activity, including regular review through the monthly Safeguarding Clinical Improvement Group and Clinical Governance Meetings. Learning from safeguarding incidents and best practice was actively shared across the service through a range of initiatives, including seven-minute learning briefings, safeguarding webinars, and a dedicated safeguarding drop-in clinic. These processes supported a strong safeguarding culture and promoted continuous learning and improvement.

Mental Capacity Act

Over 94% of staff had had 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 took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, we saw that staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

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

All children's visits to the ward were risk assessed by the multidisciplinary team prior to them taking place. There were appropriate spaces on and off wards for visits to take place.

Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing needs and 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 10 risk assessments and risk management plans during the assessment. Staff completed risk assessments for patients on admission using recognised tools and reviewed these regularly, including following incidents. Risk assessments included patients’ risk history, physical health risks and dysphagia. Tools used included malnutrition universal screening tool (MUST), skin and pressure ulcer and multi factorial falls risk assessments. Patients received timely access to specialist assessments for nutrition, hydration, or swallowing difficulties.

Staff responded promptly to signs of deterioration in patient’s health. They used nationally recognised tools to identify deteriorating patients and escalated concerns appropriately. These included the national early warning score tool (NEWS2) to assess and manage physical deterioration. Staff referred promptly to external professionals or contacted emergency services when appropriate. Shift handovers and team meetings included all relevant information to keep people safe. A carer we spoke with told us the staff at The Limes were very responsive in contacting the emergency services when their family member was unwell.

Some patients using the service had Positive Behaviour Support (PBS) plans in place that reflected their preferences for care and provided guidance on managing any identified risks. For example, on Jubilee Ward, staff had effectively implemented a PBS plan to support a patient with behaviours that challenged, helping to promote their safety and wellbeing while reducing the risk of incidents.

Staff we spoke with showed a good understanding of the management of risk and reducing restrictive interventions. Staff spoke about using restraint and seclusion as a last resort and examples of interventions they would use to manage and de-escalate situations. Each of the wards used a tailored risk management approach so that they could provide person-centred care. All staff across the service completed bespoke Prevention and Management of Violence and Aggression (PMVA) training. The training excluded the use of floor restraints and enforced treatments. The training focused on least restrictive approaches and interventions, helping to reduce the risk of harm to patients while promoting their dignity, safety, and wellbeing.

The trust reported 32 restraints via the incident reporting system in the 6 months leading up to inspection, none of these were in the prone position. Twelve of the episodes of restraint resulted in rapid tranquilisation being used. The service had robust oversight of restraint incidents. These were reviewed at ward clinical improvement meetings and at the service restrictive interventions group.

Staff carried out different levels of observations, determined by assessed need. The trust had identified an area of improvement in whether staff carried out intermittent observations at predictable time intervals, or unpredictable, which was trust policy. We saw this reflected in different practice across the wards. We found intermittent observations being carried out at regular intervals on Meridian ward for two patients. On The Limes we saw that they were being completed intermittently within the hour and not at a predictable time. The trust had plans in place to ensure staff understood the reasons for carrying these out at unpredictable time scales and consistently adhered to trust policy around this.

Staff involved patients in care planning and risk assessment processes, care records detailed discussions with patients and where appropriate, their families. Patients were encouraged to attend weekly multidisciplinary team (MDT) review meetings and were actively involved in their Care Programme Approach (CPA) meetings.

Patients had access to an Independent Mental Health Advocates (IMHA). Information about how to access the advocate was displayed on each ward and given to patients and their families as part of the admission process.

There were processes in places for patients and family members to give feedback on the service they received. This included directly to staff, surveys and feedback forms.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff completed regular risk assessments of the care environment to ensure it remained safe for patients, staff and visitors. This included areas of risk related to the patient group, such as trip hazards and accessibility. Staff and leaders described how facilities and equipment were maintained to ensure the delivery of safe care. Staff on each ward told us they carried out daily environmental and security checks to identify and address any potential risks.

Staff on each of the wards took part in monthly emergency simulation exercises, such as responding to a collapsed patient or managing a ligature incident, to ensure staff were confident and prepared for real-life scenarios. Records we reviewed showed that any shortfalls identified during these exercises were followed up promptly, ensuring that learning was embedded and staff developed the skills and knowledge required to respond effectively in practice.

Managers ensured risk assessments for fire safety, water monitoring, and calibration of equipment were up to date. All staff had undertaken fire safety training and desktop fire drills.

All of the wards met national guidance on same-sex accommodation. Wards had separate bedroom areas,bathrooms and lounges for male and female patients.

Jubilee Ward presented with the most environmental limitations, such as numerous corridors, blind spots, narrow bedroom doors, lack of bariatric capacity and toilet doors that opened outwards onto the corridor. We also found that some toilets lacked adequate grab rails to support patients with mobility needs. Several toilet doors did not have vision panels, limiting staff's ability to check on patients' safety without opening the door and potentially compromising their privacy and dignity while the facilities were in use. The senior leadership team had developed and implemented a comprehensive environmental improvement plan to address identified concerns while working within the financial constraints and budgets set by the trust. This demonstrated a proactive approach to improving the care environment and maintaining patient safety and experience despite resource limitations.

Each ward had a ligature risk assessment and where there were blind spots a blind spot audit had been undertaken. Staff knew the locations of ligature cutters and had been trained in their correct use. Blind spot risks were mitigated using regular staff observations and convex mirrors. The Limes and Meridian wards had closed-circuit television in place. Plans were in place to install CCTV on Jubilee ward. Staff were aware of potential psychological, physical, or sexual harm and used the environment to manage this such as by caring for people in different parts of the service.

Managers spoke about the use of closed-circuit television to review any incidents of harm so that this could be learned from and prevented.

Staff had easy access to personal alarms, and patients had access to nurse call systems. However, on Jubilee ward call bells in some bedrooms and bathrooms were poorly positioned, making them potentially inaccessible to patients when needed. The service had identified these concerns through their environmental review and sought to mitigate it by ensuring portable call alarms were available and accessible to those patients. Meridian and The Limes had accessible nurse call systems.

Fire safety arrangements were in place. Of eligible staff, 100% were up to date with fire safety training. Fire escapes were clearly signposted throughout the wards. Fire equipment was regularly checked to ensure it was fit for purpose. For patients with mobility difficulties fire evacuation chairs were available. Where required, staff completed personal emergency evacuation plan (PEEP) for patients who had mobility difficulties. The service conducted regular desk top fire drills and there were enough staff on each shift with fire safety training.

Clinic rooms were fully equipped with accessible resuscitation equipment.

Dining areas were appropriate to enable older patients to eat in comfort and to encourage social interaction. We observed staff engaging and supporting patients at mealtimes, for example at The Limes staff where possible enabled patients to eat independently.

Staff had access to all appropriate equipment, for example, moving and handling equipment, sensor mats, and hoists with different size slings.

Staff had access to pressure-relieving equipment including appropriate beds and pressure-relieving mattresses.

Clear, dementia-friendly signage with both words and pictorial cues were used throughout the wards to help patients navigate key areas such as bedrooms, toilets, bathrooms, and communal spaces. On The Limes we saw that contrasting colours were used on doors, handrails, and important features to assist patients with visual perception.

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.

Patients and carers we spoke with said there were always staff visible on the wards. We observed sufficient numbers of staff with the appropriate skill mix to meet people's needs. We observed staff present in communal areas of the wards at all times.

Managers had calculated the number and grade of nurses and healthcare assistants required on the wards. Staffing fills rates were at 100% on Meridian and Jubilee wards for the previous six months. The Limes had 8 unfilled shifts during the same six-month period.

Jubilee Ward had a vacancy for an activity co-ordinator and clinical psychologist at the time of inspection. To maintain the provision of therapeutic activities, the ward was being supported by the activity co-ordinator from The Limes while recruitment was underway. The matron was also providing leadership support by acting as the ward manager during this period. A locum psychologist was in post and supported both Jubilee ward and The Limes.Meridian ward had a vacancy for a discharge co-ordinator (who supports with social needs) and Jubilee ward had a vacancy for an activity co-ordinator. The occupational therapist was supporting staff to undertake activities. All vacancies had been advertised and were being recruited into. The physiotherapist, dietician and speech and language therapist worked across all three wards.

The ward managers could adjust staffing levels daily to take account of patient needs, for example if patients required one to one observations or additional physical health complexity. On Jubilee ward additional staff were on duty to support a patient with complex physical and mental health needs.

The service leads met monthly with the Chief Nurse to look at safer staffing across the service.

When necessary, managers deployed bank nursing staff to maintain safe staffing levels. When bank nursing staff were used, those staff received an induction and were familiar with the ward. The service very rarely used agency staff.

The service had low turnover rates. The average staff turnover rate for the service was 6.1%.

Staffing levels allowed patients to have regular one-to-one time with their named nurse. This was confirmed with the patients we spoke with.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There were enough staff to carry out physical interventions such as observations and restraint safely and staff had been trained to do so. Staff shared key information to keep patients safe when handing over their care to others. Handover meetings took place between shifts. Site and ward safety huddles were held daily. Staff told us they used these meetings to discuss any incidents that had occurred and update patient risk information.

There was adequate medical cover day and night and a doctor could attend the wards quickly in an emergency. Jubilee ward had a vacancy for a staff grade doctor. This role was being covered by a locum doctor. A GP visited each of the wards weekly to support with the management of physical health conditions.

There was adequate medical cover day and night. On Meridian and Jubilee wards medical cover was provided by the duty doctor for each site. At The Limes, staff were required to contact emergency services and out of hours GP services. All staff were aware of these processes.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service. Meridian ward overall compliance rate was 93%, Jubilee ward 94% and The Limes 96%. Mandatory training covered areas including safeguarding, medicines administration, basic life support, therapeutic engagement and observations, clinical risk training and moving and handling. Staff also received and were up to date with training in learning disability and autism.

Over 92% of staff were up to date with supervision and 100% with appraisal. Staff had access to additional supervision formats, such as clinical supervision and reflective practice sessions.

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.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

All ward areas were clean, had good furnishings and were well-maintained. Each ward had an infection prevention and control board which detailed results of hand hygiene audits.

Cleaning records were up to date and demonstrated that the wards were cleaned regularly.

Staff followed infection control principles including the use of personal protective equipment (PPE) such as gloves, masks and aprons. Staff had received training in infection control and disposed of clinical waste safely. The service carried out infection prevention and control audits, which included checks on personal, protective equipment (PPE), handwashing, equipment, cleanliness and mattresses. Staff could access advice and guidance from the service infection, prevention and control lead.

Staff completed infection, prevention and control training. Compliance at the time of our inspection for Infection, Prevention and Control was 100% on all three wards.

The evidence showed some shortfalls.

We found several areas of good practice. Patients usually received their medicines safely and as prescribed. Medicines, including controlled drugs (medicines that require additional legal controls relating to their storage, prescribing, administration and record keeping) and prescription stationary, were stored securely, and met legal requirements.

We saw appropriate and well-documented arrangements for giving medicines covertly where this had been agreed.

Medicines used to manage behaviours that challenge were prescribed infrequently and were rarely needed.

We also identified several areas where improvements were needed.

The service used an electronic system to monitor medicine storage temperatures, but oversight was not always effective. Staff were not always clear about who was responsible for checking temperatures. On Meridian Ward, temperatures were not recorded for 3 days by the electronic system, but staff did not appear aware of this and there was no evidence of manual checks being completed in line with local policy. Although medicines were reviewed when this was raised during the inspection, we could not be assured that temperature monitoring processes were consistently followed or that medicines had been stored within recommended temperature ranges.

Whilst medicines audits were undertaken, they did not consistently identify concerns or provide assurance that identified actions were followed up and completed. For example, on Meridian Ward a weekly crash trolley audit identified that an adrenaline syringe was missing. Staff had ordered a replacement but had not responded to a follow-up email regarding the order. Although the item was replaced during the inspection, records showed it had been unavailable for approximately 10 days.This meant there was a risk that emergency medicines may not have been immediately available via the crash trolley when needed. The service did inform us that staff had access to alternative emergency medicine arrangements by way of the grab bag.We also found on The Limes that audits of an emergency grab bag were not completed daily as per the providers policy. This meant we could not be assured that emergency equipment was consistently available and fit for use. In addition, on The Limes expired and obsolete prescription stationery stored within a medicine’s cupboard had not been identified during the annual pharmacy audit.

Pharmacy staff attended the ward at least once a week between Monday to Friday. The pharmacist told us they were providing advice to support medicines optimisation and prescribing decisions. However, clinical interventions, including those relating to physical health conditions, were not always actioned promptly or consistently by the clinical team. We were told that reviews of physical health medicines were occasionally deferred to GPs following discharge. This may result in people remaining on medicines for longer than necessary and delays in optimising treatment.

Clinical records did not always contain enough information to support safe medicines management. For example, antimicrobial prescriptions did not consistently include documented review dates. This may result in antimicrobial treatment continuing for longer than necessary. Risk assessments for Venous Thromboembolism (VTE, clots in the blood that can occur due to reduced mobility during hospital stays) prevention were not always completed for patients, increasing the risk of possible clots. Trust data showed compliance of 80% VTE recorded during the admission and 70% within the first 24 hours. Oversight of VTE was held through the local clinical governance meetings and the Borough Community Health Quality Governance Meetings. The trust reported that further work would be undertaken through induction for junior doctors and primary nursing supervision.

Monitoring of medicines used for both physical and mental health conditions was not always completed or recorded. For example, a patient newly started on lithium treatment did not have their lithium levels monitored within the required timeframe in line with local and national guidelines. This could have delayed the identification of low or toxic lithium levels. We also saw a type 2 diabetic patient prescribed rapid-acting insulin without written guidance for staff on when to administer it. During their admission their blood sugar levels were reading high. This increased the risk of inconsistent management of people with physical health conditions and delays in recognising deterioration. We saw 1 example where a clozapine level had been undertaken but the result had not been clearly documented in the clinical record. As a result, we could not be assured that levels were acknowledged and acted upon as needed.

The service did not record where skin patches, such as rivastigmine patches, had been applied. This meant we could not be assured that patches were being rotated correctly to reduce the risk of skin irritation in line with manufactures instructions.

Across all 3 wards, we found excess stock medicines stored in cupboards. Patient-own medicines were not always kept separate from ward stock, and on one occasion a patient-own medicine was being used as ward stock. This increased the risk of medicines errors.