Dorset Healthcare University NHS Foundation Trust

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 good. This meant the service was safe.

At this assessment the rating remains good.
The service’s referral and admission processes ensured that staff had access to essential information to determine whether patients’ needs could be safely met. Staff described how risks were assessed on admission using a nationally recognised risk assessment tool and how these were regularly reviewed, including after any incident. Patients were protected from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and staff demonstrated a clear understanding of their safeguarding responsibilities.
However, we found that patients did not always receive safe care and treatment in relation to the environment, infection prevention and control, and the safe management of medicines. Patients’ privacy and dignity could not be consistently maintained. Some bedrooms lacked privacy screens, and patients shared bathrooms, with some patients observed walking across the ward to access the shower facilities.
 

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with seven patients who told us they felt safe on the ward, understood how to make a complaint and saw improvements made through regular community meetings. Patients reported low levels of restrictive interventions and said staff used de escalation effectively, with restraint used only when necessary.
Staff described a calm and safe ward environment with low incident and seclusion rates. Team away days, reflective practice sessions and psychologist led focus groups had strengthened team culture and improved patient safety. Safeguarding training had increased following concerns from an external stakeholder about low levels of safeguarding referrals and incident reporting, and staff told us they continued to build on learning opportunities and noted their improved practise.
Staff received feedback from incident investigations, were debriefed after serious incidents and discussed learning in team meetings, with safety and learning bulletins shared across the organisation.
 

The service’s referral and admission processes ensured that staff had access to essential information about the patient to determine if the patient’s needs could safely be met. The preadmission information in all 3 patient files we reviewed was recorded clearly.
Staff made sure clinical notes were up-to-date and complete. They used a combination of electronic and paper records to record daily observations, community access forms and physical healthcare monitoring.
Multidisciplinary team (MDT) meetings and clinical governance meetings took place regularly at senior management and ward level to review the quality of the service, risks in the service and the service’s transformation and improvement plans. Staff members expressed concern about communication between the MDT and wider team and its role in oversight of the service in relation to an online piece of work which had taken place with a patient. The team was working closely with an external stakeholder to further develop and improve these areas.
The provider ensured they had a record of people who were admitted to their services out of area and there was a policy and pathway for people to return to provision in their area or home.
The provider invited external partners like the provider collaborative, commissioners, other providers if appropriate to care review meetings and discharge meetings to ensure patients had continuity of safe care, both within the service and post-discharge. They worked in partnership with external organisations to support and facilitate safe transitions to and from the service.

Staff demonstrated awareness of safeguarding processes and had received bimonthly safeguarding training led by the trust’s safeguarding lead. Training compliance had improved, and staff were confident in identifying and escalating safeguarding concerns. Following additional staff training and input from an external stakeholder staff increased safeguarding referrals from infrequent reports to several per month. Staff understood the local safeguarding referral processes and key priorities for action, and daily multidisciplinary team and nursing handovers included discussions of any safeguarding concerns. The service worked closely with external agencies, including the local authority safeguarding team, to ensure incidents were managed appropriately and lessons learned were shared with staff through team meetings and reflective practice sessions. Advocates attended the ward weekly and had confidential spaces to support patients. Safeguarding incidents were reviewed and monitored by senior leaders and the provider collaborative, demonstrating oversight and accountability. These processes contributed to a culture where staff knew how to act to protect patients, and where concerns were taken seriously and acted upon promptly.

Staff members understood and managed risks by thinking holistically so that care met the needs of patients in a way that was safe and supportive.
Staff were able to describe how risks relating to each patient were assessed on admission using a nationally recognised risk assessment tool, and that these were reviewed regularly, including after any incident. Risk assessments were updated when risks changed; for example, following an incident where a patient was absent without leave, staff completed an incident report and updated the patient’s risk assessment to reflect the increased level of risk. Staff told us there were low levels of physical intervention on the ward, and restraint was used only as a last resort after all attempts at verbal de escalation had been exhausted. Two patients had been restrained and subsequently secluded in the past year, with prone restraint used briefly on two occasions in November 2024. Records reviewed showed appropriate assessment, monitoring and post incident review, and patients told us staff explained their care plans clearly and treated them with compassion. The ward was working with an external stakeholder to ensure all incidents were accurately recorded. Therapeutic observations were used appropriately as part of managing risk. We observed positive interactions between staff and patients and saw examples of patient centred care plans that included patient and carer involvement.
However, in one patient file a risk assessment and care plan had not been completed on admission, although these were in place for all other patients. Blanket restrictions were in place on the ward, some of which related to environmental limitations rather than individual risk. For example, the courtyard was closed at midnight for all patients. Staff told us there was no clear log of these restrictions, and patients did not always understand why they were applied. This meant the rationale for restrictions was not consistently recorded or reviewed, and some restrictions had become routine practice rather than being linked to individual risk assessments.
 

The service did not always detect and control potential risks in the care environment to support the delivery of safe care
Most patients told us the ward was generally clean. However, some patients shared bathrooms, and we observed patients walking to the showers wearing towels, with no suitable place to store their clothes once inside. Three patients told us they often cleaned the bathrooms before using them. They said the bathrooms were not always clean after other patients had used them. Space and storage on the ward was limited. The ward had a range of facilities available including activity rooms and quiet lounges. Some patient bedrooms overlooked the garden and car park or shared spaces. These bedrooms lacked privacy screens which means people outside could look into their rooms.
Occupational therapy cupboards were not lockable, which meant patients could access potentially dangerous items like scissors.
The outside space was not accessible from the seclusion room, so patients had to walk through the ward to go outside.The Estates Leadership Team was working with the ward’s Clinical Leadership team to review issues, including the condition and layout of the seclusion room. The seclusion shower had visible watermarks, and patients were provided with a thin mattress. Thicker alternatives had been trialed but had been determined unsafe by the leadership team as they could impede PMVA ( prevention and management of violence and aggression)techniques or be used to obstruct viewing panels. This issue remained under discussion with an external stakeholder.
‘You Said, We Did’ boards were visible on all wards, and patients confirmed these were used in community meetings. Staff were able to describe security procedures, including checks of hazardous items and environmental checks, although these systems did not always ensure patient safety, particularly during a recent three week bathroom issue.The manager told us here were repeated delays in the completion of the refurbishment of the bathroom. This meant that during this time patients could not use all bathrooms. The workmen brought and left items that could be used by patients to harm themselves. Ligature audits were in place, and staff told us the observation policy was followed.
Wards were not fully accessible for patients with mobility needs. The manager told us that a ramp for steps to facilitate wheelchair users access was available on request; however, at the time of inspection there were no adaptations in the bathrooms to support patients with reduced mobility. Leaders told us that following our inspection handrails had been added to all bathrooms.

The service made sure there were enough qualified skilled and experienced staff to deliver safe care and treatment. There were currently two support staff vacancies and a vacancy for a full-time occupational therapist. Patients told us there were always sufficient staff on duty to assist.
Patients spoke positively about the staff that were caring for them. All 8 patients we spoke with said the staff treated them with kindness and were caring and respectful. Patients said that staffing levels on the wards were good.
The provider had processes in place to ensure safe staffing. There was a daily meeting across all the inpatient wards at St Ann’s hospital to discuss staffing levels. Leaders from Tywnham ward attended to present staffing levels for their ward and request support from other wards should additional staff be required.
Staff sickness levels were between 3 and 4% annually and there were no current staff on long term sickness leave.
There was a nurse present in communal areas of the ward at all times to ensure patients safety.
All staff completed an induction that covered policies and procedures within the ward.
The mandatory training courses for staff were appropriate and thorough. The current and statutory training compliance was 90%. The manager had a system in place to ensure staff were compliant with mandatory training and had a list on his wall of his own training needs. Staff members received regular supervision and appraisal to ensure they were working consistently.
 

Patients told us that the ward was mostly clean; however, they raised concerns about the cleanliness of the shared bathrooms

On the day of inspection, we found that bathroom bins were full and had not been changed. There were no cleaning schedules so we could not be assured they would be emptied regularly. The ward environment had limited space and appeared cluttered, which increased the risk of ineffective cleaning and infection control.
Staff could not demonstrate how regularly ward areas were cleaned. There were no cleaning schedule and no records for the cleaning of the seclusion room, including the wiping down of mattresses or the cleaning of bathroom areas. The mattress cleaning audit had not been completed since May 2025, meaning staff could not be assured that mattresses were clean. Paper debris was also seen on the clinic room floor.
We found additional concerns relating to infection control practice. Staff were sharing an anti ligature blanket with another ward, despite additional stock being available elsewhere in the hospital, and they could not be assured that it had been cleaned between uses. We also observed mugs being stored in the sluice room, which posed an infection control risk; these were removed during the inspection, following a prompt by the inspection team. However, we could not be assured that this would have happened should it not have been raised. There were no checks in place to assure that housekeeping tasks had been completed.
Despite these issues, hand hygiene facilities were readily available, including hand sanitiser dispensers and wash stations, and staff demonstrated good hand hygiene practices. Compliance with infection prevention and control training was high, with approximately 90% of staff having completed the required training.
 

Staff mostly followed good practice in medicines management in line with national guidance; however, we identified several areas where practice did not meet required standards.
The clinic had many bits of paper on the floor. The clinic couch was overdue for servicing, with the last service due on 24 November 2024 with no date for the next service. Blood glucose test strips and calibration solutions were not dated when opened. This meant that staff could not be assured they were still valid for use.
There were gaps in medicines related checks and documentation. One controlled medicine, codeine phosphate, had not been checked since 3 November 2025, despite daily checks being required at the beginning and end of each shift to ensure all tablets are accounted for. Codeine phosphate is an opioid painkiller used to treat mild-to-moderate pain, dry coughs, and, in some cases, diarrhea. It is a controlled drug because it is an opioid that carries a high risk of addiction, dependence, and fatal overdose, particularly when used long-term or mixed with alcohol.The medication should have been returned to the pharmacy once it was no longer in use.

Medication fridges had gaps in temperature monitoring, including in the last 3 months several one day gaps and a four day period with no recorded temperatures. This meant staff could not be assured that medicines requiring refrigeration had been stored safely and may present a risk to patients.
However, staff understood concerns regarding the use of high dose PRN (as required) medicines associated with falls and low blood pressure. Staff responded appropriately by increasing blood pressure monitoring to twice daily to ensure patient safety.

People were appropriately involved in decisions about their medicines. Patients told us they received information in a format they could understand, and their preferences and concerns were taken into account during medicines reviews.