Silverwood

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. This is the first inspection for this newly registered service, however the rating for this key question remains the same as when we last inspected the locations that sit within this assessment service group in January 2020. This key question has been rated good. This meant people were safe and protected from avoidable harm. There was a positive learning safety culture where events were investigated, and learning was embedded to promote good practice.

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.

All staff knew what incidents to report and how to report them. Staff reported all incidents that they should report.

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 encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a priority.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff met in regular ward meetings to discuss that feedback. There was evidence that changes had been made as a result of feedback. The Hospital had a regular quality assurance review process which was being managed effectively to review operational and environmental issues. This quality assurance meeting provided information about improvements in safety specific to this service.

We found examples of how learning was shared following investigations into safety events. The provider also shared learning across the wider organisation, and we saw examples where staff received safety and learning bulletins from other areas within the organisation.

Staff were debriefed and received support after a serious incident.

The wards participated in the trust’s restrictive interventions reduction programme, which met best practice standards.

The hospital’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.

Although most clinical notes were stored electronically, the wards used a combination of electronic and paper records to record daily observations, community access forms and physical healthcare monitoring. This worked effectively and staff were aware of where information was held.

The hospital monitored people who were admitted to their wards from out of area and there was a policy and pathway for people to return home.

Partners told us that ward rounds, care review meetings and discharge meetings were routinely held for patients. The provider invited external partners to these meetings and worked in partnership with external organisations in order to support and facilitate safe transitions to and from the service.

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.

Of the 17 patients we spoke with, 13 patients said that they felt safe on the ward and 16 patients said that staff spoke to them with kindness dignity and respect. However, from reviewing ward meeting minutes we could see that the patients had on occasion presented concerns around being treated in hospital alongside more challenging patients. We could see this was being addressed by the individual ward teams who were alleviating patients’ anxiety and the minutes reported that patients felt this was helping to improve the therapeutic atmosphere of the ward. This meant that the hospital protected people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff routinely identified and raised safeguarding issues. Staff knew the patients, were aware of their protected characteristics and cared for them in line with this. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Due to their training staff knew how to identify adults and children at risk of, or suffering, significant harm. This included knowing how to raise safeguarding referrals or welfare checks when required. Staff followed safe procedures for children visiting the service.

The freedom to speak up guardians routinely visited the wards which ensured that staff were able to speak out about any concerning practice they identified.

Levels of restrictive interventions were reported by patients to be low. Data supplied by the trust showed that the average use of physical restraint was under constant review and was reducing month by month and the use of rapid tranquilisation to manage severe behaviour was low. Rapid tranquillisation is the use of medication, usually by injection to quickly calm a person who is extremely distressed and at risk of harm, when other methods haven't worked.Patients told us that staff avoided using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. Patients felt that when physical restraint was used it was appropriate and proportionate to manage risk.

We reviewed 24 sets of individual patient risk assessments / risk management plans during the assessment. Staff described how the risks relating to each patient's care were assessed on admission to the service using a nationally recognised assessment tool and regularly reviewed, including following any relevant incident. Staff and patients told us that there were low levels of physical intervention on the wards and was rarely used. Rapid tranquillisation is the use of medication, usually by injection, to quickly calm a person who is extremely distressed and at risk of harm, when other methods have not worked.

Staff used restraint as a last resort and only after all efforts at verbal de-escalation had failed. The provider had a reducing restrictive practice program that patients were involved in. This meant that people who used services were directly involved in oversight of patient safety issues.

Community meetings took place regularly and improvements were made because of patient feedback. We could see the issues we were finding during the assessment were being shared by the patient groups across all wards in relation to lack of activity and low staffing numbers. When speaking with people using the service, 13 out of 17 patients we spoke with told us that they felt safe on the wards.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients who had communication difficulties. Staff enabled patients to give feedback on the service they received for example, via patient surveys and community meetings.

We observed staff interactions with patients on each ward and saw that the majority were positive. Therapeutic observation of patients was used appropriately as a method of managing risk.

Trust uses the risk formulation approach in line with current NICE Guidance to manage risk. Risk assessments were completed on admission and reviewed regularly and after each incident.

Staff ensured that patients could access advocacy, and we saw information posters on every ward and in patient information leaflets that detailed how to access advocacy services.

The hospital had recently been built and was co-designed and built with the support of service users, their families and clinical staff.

All bedrooms were en-suite and had advanced safety systems built into the rooms and doors to maintain safety and minimise the impact of observations on patient dignity. All patients we spoke with said their wards were always clean. Patients said the modern nature of the building meant that it was easy to keep clean and there were always enough domestic staff. There were excellent transitional spaces on the wards which meant patients felt they were not “locked in” and high ceilings and lots of natural light and fresh air improved the patient experience. Patients were also happy with the visitor’s areas and the communal canteen area in the hospital which was used for family visits which patients told us felt “safe” and “normal”.

Staff did regular risk assessments of the care environment, and the wards layout allowed staff to observe all parts of ward. Patients had the opportunity to consent to a system of monitoring bedrooms which meant that their vital signs were able to be reviewed without staff having to continuously enter their bedroom or shine lights through their doors at night.

There were few potential ligature anchor points and staff had mitigated the risks appropriately and the senior leadership team were aware of all issues with ligature risks as soon as they were flagged.

All wards complied with guidance on eliminating mixed-sex accommodation.

Staff had easy access to alarms and door entry fobs when they arrived on shift and patients had easy access to fobs to enter and exit their single sex bedroom corridors and nurse call systems. There was an allocated support worker dedicated to ward security on each ward every shift.

Staff told us that the observation policy was always followed. Staff rotated patient nursing observations within the staff team hourly, and they were able to take a break between one to one observations with patients. Staff had received competency-based training in the therapeutic observation of patients and there were enough staff on the wards to safely manage this.

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

Patients gave positive views about the staff that were caring for them. All patients we spoke with spoke positively about the staff on the wards, saying that staff treated them with kindness and were caring and respectful. However, 10 patients expressed concern about the number of temporary staff that were being used. Overall, patients felt the wards were safe but found it difficult on occasion explaining their issues to different staff each day. During the inspection staff were observed to be helpful with patients responding to their changing needs in a caring manner. We saw that staff responded promptly to assistance alarms when required.

When we reviewed the staffing rotas, we could see that staffing numbers were being met however it was clear from the rotas and from speaking to the ward managers that all wards were using large numbers of temporary staff. This was an issue the hospital was aware of and had elevated this risk to the trust risk register and recruitment plans were extensive and ongoing to recruit to the vacant posts.

A qualified nurse was present in communal areas of the ward at all times.

Each ward was supported by a multidisciplinary team which included a psychiatrist, occupational therapist, psychologist and the patient’s named nurse. Each ward had a leadership team consisting of a ward manager, duty manager and matron. Staff used a proforma during the daily safety huddle to consider safe staffing numbers and ensure that inductions for temporary staff took place. We saw that each ward manager held a copy of induction checklists for all temporary staff that were working on the ward and staff were not permitted to work until this had been signed off as completed.

The number of nurses and healthcare assistants matched this number on all shifts. The ward manager could adjust staffing levels daily to take account of case mix. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels.

The mandatory training courses in place for staff were appropriate and thorough. Staff were compliant in most courses and the overall mandatory and statutory training compliance average was 88%.

Patients told us that they did not always feel there was a lot of structured occupational therapy activity on the wards and when this was discussed with the therapy team, we could see that there were vacancies in the staffing structure that were in the process of being recruited to, this included psychologist who was due to start in July. In addition we saw that there were 5 diversional activity co-ordinators who had not all finished their training at the time of the inspection but were due to start on the wards in the weeks following the inspection. Speech and language and dietician vacancies were being recruited to but were being covered by the team at the other acute hospital, Farnham Road, to ensure that there was a level of consistent cover.

Managers had calculated the number and grade of nurses and healthcare assistants required and this was reviewed in a safety huddle every day.

There were enough staff to carry out physical interventions for example, observations, restraint and seclusion safely and staff had been trained to do so.

There was appropriate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Patients told us that the wards were clean, tidy and well maintained. They expressed how cleanliness was always a priority and the night staff had duties during the night to support the domestic staff.

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.

Staff and leaders told us that there we an infection prevention and control policy in place which covered all areas including hand hygiene, personal protective equipment, safe management of equipment and safe disposal of waste. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

The provider had a dress code for staff uniform which included being bare below the elbow and with the absence of jewellery or false nails. On all the wards we visited we observed compliance with the Trust ‘bare below the elbows’ dress policy.

There were a number of processes in place to prevent the spread of infection. This included cleaning schedules and audits. Hand hygiene facilities were readily available including hand sanitizers and wash stations, and staff demonstrated good hand hygiene practices. Staff were up to date with infection control training with an average of 88% of staff had completed infection prevention and control training in the month of the inspection.

People were appropriately involved in decisions about their medicines. Patients were provided with information about their medicines in a format they could understand, and their preferences and concerns were taken into account. Almost half of the 17 patients we spoke with said they were given enough information about their medicines. Wards demonstrated a commitment to safe and effective medicines optimisation.

The wards had robust systems in place to ensure that medicines were prescribed, administered, and managed in line with best practice guidelines and legal requirements.

The wards had a designated medicines management lead who oversaw medicines optimisation and ensured compliance with relevant policies and guidelines. There was a clear medicines policy that was reviewed and updated in line with national guidance.

Medicines were prescribed by qualified and competent practitioners, and prescriptions were reviewed regularly by the multidisciplinary team. There were clear protocols for the administration of medicines, including high-risk medications such as high dose antipsychotics and controlled drugs. Medication cards showed regular oversight by pharmacist staff who were responding directly to prescribers and nursing staff.

Staff followed appropriate procedures for checking patient identities and obtaining consent before administering medicines. Medicines were stored securely in accordance with legal requirements, and controlled drugs were managed in line with national guidelines. There were clear procedures for the disposal of unused or expired medicines.

Medication times were supported by nurses allocated to that task and there were rooms adjacent to the medication room that had been designed specifically to allow patients to have safe and private conversations with dispensing nurses away from the busy ward area.