NAViGO Health and Social Care CIC

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• 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. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

All wards were safe, very clean, exceptionally equipped and designed to meet the complex needs of patients. The wards were well furnished and maintained and staff assessed and managed risks to patients and themselves very well. Staff had a high level understanding of how to recognise and protect patients from abuse and the service had strong links and relationships with external agencies and partners. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents exceptionally well, with strong evidence of a learning culture from post incident reviews and learning.

This service scored 84 (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 4. The evidence showed an exceptional standard. The service had a strong proactive and positive culture of safety, based on openness and complete honesty, with clear learning from incidents and effective outcomes. They actively listened to concerns about safety and thoroughly and extensively investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

There were no serious incidents recorded within the last 12 months. There was strong evidence of senior level oversight of incidents and information sharing to ensure lessons were learned, including incidents being managed under the Patient Safety Incident Response Framework(PSIRF). Incidentswere discussed in weekly incident meetings. This includes the Chief Operating Officer, Deputy Chief Executive, Deputy Chief Operating Officer, the Assistant Director for Estates, Facilities, along with the Head of Patient Safety, Head of Operational Qualityand Governanceand the Incidents Officer.

There were clear policies and guidelines for staff to identify and report incidents and staff we spoke with were confident in doing so. Incidents were reported onto an online system. 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.

The Patient Safety Team sent a monthly report to the Quality andClinicalGovernance Committee which included an overview ofthe top 4 categories of incidents,along with any other incident areas for learning and discussion. This provided feedback to staff and partners in care, and identified additional learning opportunities. There were clear debrief procedures in place and staff also received regular feedback during supervision.

We saw evidence of improvements in safety for patients through thorough reviews of incidents such as falls, where staff were able to identify that increased furniture on wards were contributing to falls. Through reviews and discussion, environmental changes resulted in action plans being implemented to aid reduction in the number of falls incidents.

We scored the service as 3. The evidence showed a good standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

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 and which environment was most appropriate. Senior staff completed pre-admission assessments and considered the holistic needs of patients and their carers, with a strong vision to help patients remain close to home and their community. The wards maintained excellent links with external teams such as social workers, care co-ordinators, specialist teams (such as the Huntington’s Team) which ensured ongoing continuity of care and seamless transitions during transfers to other wards and discharges. Feedback from stakeholders reflected this. Stakeholders told us “Navigo demonstrate an open, positive,proactiveand transparent approach to working with the Integrated Care Board (ICB), inviting us tointernal meetings.Navigodemonstrate apositive and proactive approach to working with system partners,they are an active member in the ICB-wide all-age mental health collaborative andactivelycollaborate with system partners”.

We scored the service as 4. 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 were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Across the three wards, safeguarding training completion was above 95% for both safeguarding adults and children. Staff we spoke to could give examples of how to protect patients from harassment, abuse and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify signs of suffering and significant harm. This included working in partnership with other agencies such as local authority safeguarding. We reviewed 3 months of internal safeguarding advice requests, which showed 20 requests had been made. This evidenced staff knew when to seek advice and support regarding referrals. We also reviewed a 3 month period where 4 safeguarding referrals were sent into the Local Authority Safeguarding Adults Team from Navigo Practitioners and the Navigo Safeguarding Team. All of these were in relation to the Konar Suite. Navigo are implementing external safeguarding audits to ensure strong oversight and governance.

The service also had a Safer Recruiting and Disclosure and Barring Service Policy in place to ensure staff pre-employment checks were carried out. Staff followed safe procedures for children visiting the service and there were designated visiting area’s where children could visit relatives across all three wards. The service had policies in place for safeguarding adults and children, staff experiencing domestic violence, sexual safety and safeguarding supervision.

The service ensured all staff were trained in de-escalation, 100% of staff had completed training which is provided inhouse by Navigo. The service looked at use of force reports which were produced twice a year and quaterly restraint reports were presented to the Quality and Clinical Governance team. The service completed audits and analysis of incidents requiring any level of restraint and fed this back in multi-disciplinary team reviews. The service is starting a new forum to discuss restraint reduction. Restrictive Interview forms were completed with patients who had witnessed any restraint. Clinical Governance minutes included any figures of restraint. The service did not use any face down (prone) restraint.

Mental Capacity Act

98.78% of staff across the three wards had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. The service had a Mental Capacity Act and Deprivation of Liberty policy in place.

The service had funded staff across older peoples inpatient services to train as Best Interests Assessors, and had multiple staff within the service who hold the level seven post graduate qualification including the Associate Director and Senior Operational Managers. They were also in the process of rolling this training out to Band 7 Team Leads of wards, with one team lead already attaining the qualification. This role had been developed to ensure best interest decision making was consistently recognized, examples included supporting capacity assessments and providing expertise to inform legal literacy when exploring best interest decision making around discharge plans or care on the units for example use of falls sensors.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards and took all practical steps to enable patients to make their own decisions. There were MCA champions on each unit and and organisational lead who staff could seek advice from. Staff assessed and recorded capacity to consent appropriately and this was evidenced in care records we reviewed. They did this on a decision-specific basis with regard to significant decisions, including medication.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies. The service had arrangements to monitor adherence to the Mental Capacity Act through audits and this helped identify issues in documentation, which was addressed quickly and effectively.

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. Staff used restraint and seclusion 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 13 care records across Konar, Janine Smith Suite and the Jane Lewington Suite. We also reviewed 3 months of care record audits from each ward. Care plans evidenced needs had been assessed and there was some clear evidence to suggest patients’ preferences had been addressed.

Care planning meetings showed that both patients and their family were engaged and supported throughout admission. This included a detailed summary which involved family providing history, details around the admission, what carers’ needs are and explaining how the ward worked. In turn, these formulated risk assessments and care plans, identifying where patients had a higher level of needs. Care planning and risk assessments followed the services restraint policy between primary, secondary and tertiary strategies to support patients’ needs. There was an advocate available for patients.

We reviewed 12 months of data for use of rapid tranquilisation. There were 0 incidents on Jane Lewington Suite, 9 incidents on Konar suite and 5 incidents on Janine Smith Suite. These numbers were in keeping with the level of complexity of patients between the wards. There was minimal levels of restraint across the three wards and no use of prone restraint. There is no seclusion or segregation unit within the older persons services.

Carers and advocates were able to provide feedback to staff regarding their involvement through a range of methods including satisfaction surveys. We spoke with 6 carers who reported high satisfaction with all aspects of the service. Communication, involvement, and responsiveness beingparticular strengths.

We scored the service as 4. The evidence showed an exceptional standard. The service was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

We toured the environment of all three wards. The wards were purpose built, consisting of large en-suite bedrooms that also had lounge areas within the ensuite bedrooms. Staff explained that this allowed for carers to stay with the patient if appropriate to do so, as the lounge sofa’s pulled into beds. Staff told gave us examples of family members who had stayed overnight where their relative had been unwell or comforted by their loved ones presence. There were specific sensory bathrooms with specialist equipment to provide a therapeutic experience during personal care interventions. The décor of the units encompassed local landmarks, familiar wall art and was well received by both patients and carers.

The environments were maintained daily by a team of domestic staff and in house maintenance and facilities team. Environmental risk assessment audit’s were carried out on a 6 monthly basis with oversight from the Health, Safety Estates Committeewho oversaw the completion of all risk assessments and any actionsrequired. Corporate Governancereceived all minutes from the Health, Safety Estates committee, supplemented by a bi-annual assurance report.

Risk assessments of the environment included identified risks, workplace regulations, provision and use of work equipment, control of substances and hazardous to health materials (COSHH), fire safety, security and lone working, first aid, electrical safety, ligature risks and ensuring a safe and clean environment. Staff completed daily walk arounds to identify any new or emerging risks. The wards could not be observed from a single point however, this was mitigated by staff corridor observations, general observations and 1:1 patient observations where risk was identified. There was CCTV in place in communal areas.

The risk assessments included a ligature risk assessment, and risks were minimised where identified. Any individual ligature risks were documented in patients care records. The three wards were mixed sex, however risks were mitigated through staff observation, corridor observation and individual risk assessments. There were no shared bedrooms, and a sexual safety policy was in place.

All staff and visitors had access to personal safety alarms, as well as all bedrooms, bathrooms and communal areas having call alarms to enable patients to seek assistance from staff where needed. We reviewed clinic rooms and found these were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. There was access to ligature cutters within both the clinic and ward office.

We scored the service as 4. The evidence showed an exceptional standard. The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

The service had a complete and comprehensive multi-disciplinary team employed at the time of our inspection. There were no current vacancies; however, they were awaiting the start date of an occupational therapist, who had been recruited. All wards had access to pharmacists, safeguardingpractitionersand dieticians within the wider Navigo teams.The service employed a peer support worker who led community meetings,gathered essential feedbackwithin the units and activity coordinators who supported therapeutic use of time and meaningful engagement in the facilities available both within the units and into the local community.

There was evidence of close working with adult social care colleagues from the Local Authority who provided social workers to lead on Care Act Assessments to address social and emotional concerns,assistwith accessing community resources, accommodation, benefits, and linked in with families and carers.There was always access to a consultant psychiatrist.

Ona monthly basis, Quality and Learning Network meetings were held across operational service areas. The network meeting reviewed reports to inform decisions and actions to ensure effective service delivery. This included details of staff turnover for the service area.The olderpeople’sservices management team, in partnership with the workforce team, determined if actionswererequiredto support staff across the service area.We reviewed 3 of these reports,during the period April – September 2025, which showed no staff from the Older People’s Services left Navigo employment, however,two staff did move to another team within theorganisationto pursue development opportunities.

Nurse and health care/support worker establishment levels were fully met. There was a vacancy only due to a part time role. The wards did not use any agency staff in the 12 months prior, and any deficits in numbers were filled by older persons’ own bank staff. Staffing was above expected numbers to meet the needs of patients on 1:1 observations. Staff we spoke with told us that staffing levels always felt safe, and activities were never cancelled due to staffing levels. There was always a registered nurse on shift and staff knew how to escalate if it was felt more staff were required.

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.

Each inpatient site hada dedicatedsoft facilitiesmanagementteam consisting ofcaretakers,housekeepersand domestics whoareresponsible fortheday-to-day environmental upkeep.All staff were able to log environmental, health and safety and infection prevention control (IPC) concerns via the estate’s helpdesk, enabling prompt resolution by local teams. Housekeepers acted as a link between services and the corporate estates team, conducting regular environmentalchecksandworking with the widersoftfacilitiesmanagementteam in the undertaking and reporting of audits.

The domestic service performed monthly environmental sweeps, complementingthe timetable ofinfection control audits carried out bythe IPC teamas part of their service quality checks.We reviewed the IPC briefing report which covered April to October 2025, which showed that the majority of standards audited were embedded into practice and operating effectively. All key standards demonstrated compliance between 75% to 95% with no major weaknesses or unmanaged risks identified or changes to patients’ care needed. The service used audits to identify areas of concern and these were acted on quickly. This included the replacement of mattresses. A continuing issue for most inpatient sites, which was reported in the 2024 audit report relates to prescribed medication/dressings not being dated and/or signed when opened. The service increased auditing to quarterly timescales for regular auditing to address this, including ensuring all auditors are aware of the process.

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 throughout the three wards. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Staff adhered to infection control principles, including handwashing. Staff compliance for IPC training at level 1 was 100% and 91.36% at level 2.

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.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. Staff reviewed the effects of medication on patients’ physical health regularly and in line with National Institute for Health and Care (NICE) guidance, especially when the patient was prescribed a high dose of antipsychotic medication.

Regular audits were completed by the pharmacy team, who completed a quarterly medication safety report which senior leaders had oversight of. The report highlighted T2/T3 issues are consistently not meeting the target of ‘0’ issues. A T2form is a certificate of consent to treatment, used when a patient has the capacity to consent and has provided it.A T3form is a certificate for a second opinion, which is used to authorise treatment if the patient is incapable of consenting or is refusing treatment.The report also highlighted the percentage of inpatients having a medications process completed within 24 hours of admission showed as an improvement but it is still not achieving the set target, and the number of times a patient with dementia has been prescribed antipsychotic medication has been above national average since October 2024.

We reviewed 18 patients’ medication records from across the three wards. Care records were well written and clear. We observed that staff were competent in dispensing and administering medication and followed policy and procedure. We identified that one covert medication plan required amending and the service completed this efficiently and also ensured learning was circulated to the wider staff team.