West London NHS 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

We looked for evidence on how the service provided safe care and treatment. During an inspection in March 2022, we rated this key question as requires improvement. At that inspection, the service was in breach of regulation 12 (safe care and treatment) and regulation 18 (staffing).

At this inspection, the rating has changed to good. This meant people were safe and protected from avoidable harm and the service had arrangements in place to support people to receive safe care and treatment.

Ligature risks identified at the previous inspection have been addressed. Staff we spoke with were confident about how they managed ligatures, assessments and keeping patients safe.

We found significant improvements to staffing levels since the last inspection. We received positive feedback in relation to this from both staff and patients. The improvements in staffing had resulted in an increase in additional night staff, a reduction in the use of nighttime confinement on the rehabilitation wards and improvements in patient accessing activities off the wards. Staff morale had improved.

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 strong proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons learnt were always identified in order to continually recognise and embed good practice and address areas of improvement. Staff knew what incidents to report and how to report them, in line with the trust’s policy.

The service had a good track record on safety.

Between January and July 2025, the service reported 2232 incidents of a range of types. All incidents were graded with a harm rating.

The service had had 8 serious incidents between January 2025 and July 2025.

All staff knew what incidents to report and how to report them using the electronic incident reporting system. Staff told us that they would report any incident of harm, potential harm, near miss and/or risks to safety in line with trust policy.

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 Sandown Ward we saw that the ward manager met with a patient and sent a letter of apology following an information governance breach.

Managers investigated incidents thoroughly. Patients and their families were involved in these investigations. We reviewed a patient safety incident investigation (PSII) and saw that the service had actively involved the family of a patient following a serious incident.

Since our last inspection, staff involved in incidents were able to review CCTV footage to reflect on their actions during the incident and to consider if alternative actions/approach could have been taken. This allowed for staff to continuously learn and improve patient care.

Staff received feedback from investigation of incidents, both internal and external to the hospital. Staff and patients met to discuss the feedback and staff looked at improvements to patient care in handovers, clinical multi-disciplinary meetings, team meetings, clinical governance meetings and weekly reflective practice meetings.

Staff confirmed that they received daily communication through emails, Patient Safety Bulletins, security intelligence bulletins, learning vignettes and the Trust wide alerts. These included information about patient safety incidents and any associated learning. The service held a weekly patient safety incident clinic where all incidents were reviewed. Where required, rapid reviews were carried out and any immediate learning actions shared with the ward staff. Managers reviewed and analysed incidents at clinical governance meetings to understand themes and trends, how to reduce these and implementing action plans to put things right.

The service had a strong and positive learning culture where staff reported that they felt able to speak up without fear. Staff consistently described a ‘no blame’ culture and a focus on learning so that incidents could be prevented and patient and staff safety enhanced. They told us there was honesty, openness and transparency when things went wrong.

When a serious incident had taken place there was evidence of learning. For example, in response to multiple occurrences of damaged fittings within seclusion rooms, a comprehensive review was undertaken across all patient bedrooms and seclusion areas. The findings from this review were being used in the design and refurbishment of the Paddock Centre to ensure that any fittings were more robust and enhanced environmental safety.

There was evidence that changes had been made as a result of learning from incidents. For example, the policy for working with the Police had been updated following a patient death at the hospital in 2024.

Arrangements were in place for de-brief sessions to take place for both staff and patients following a serious incident. This was to ensure that staff and patients were provided with appropriate support. Staff we spoke with said that they were very well supported. The service had introduced a staff support and liaison team who supported staff on the wards following an incident. Psychology staff undertook Critical Incident Stress Debriefing and reflective practice sessions for the wards following an incident.

All staff were committed to continually learning and improving services. The hospital was trialling a new programme of supporting staff wellbeing following incidents called Trauma Risk Management (TRiM) a trauma-focused peer support system designed to help staff who have experienced a traumatic, or potentially traumatic, event.

Patients confirmed they were also supported to debrief following an incident and provided with support.

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, monitored and assured. They made sure there was continuity of care, including when people moved between different services.

Patients confirmed they were involved in transfer and discharge planning. They told us they were active participants in planning when they wished to be.

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. The service had a weekly admissions panel which considered all new referrals from external referrers. The panel reviewed all assessments undertaken before deciding whether the patient met the criteria for admission.

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. Systems to transfer patients to other wards were well established and ensured that patients received continuity of care. The service held a weekly hospital-wide transfers meeting where ward managers and consultants met with the clinical director to discuss each patient who was ready for transfer to another ward or be discharged from the hospital. The service worked closely with the prison service to ensure that prison transfers were managed safely.

Staff referred patients to external agencies when required, including accident and emergency departments and hospitals to ensure patients had continuity of safe care.

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. Staff identified, and shared and recorded safeguarding concerns with necessary staff and external agencies quickly and appropriately.

The wards had a calm and welcoming environment. All patients told us they felt very safe on the wards.

Patients were involved in decisions about their safety to the maximum possible extent and their wishes are respected.

Staff understood how to protect people from abuse and the service worked well with other agencies to do so. Staff worked with the local authority safeguarding team at Bracknell Forest. We observed that staff had developed positive and trusting relationships with patients that helped to keep patients safe, for example on Euston ward safeguarding records detailed the actions taken to support a patient at risk of financial exploitation.

The service had a safeguarding policy and clear processes in place for staff to follow when they had identified a concern. All staff said they had training appropriate for their role on how to recognise and report abuse, and they knew how to apply it. Staff told us they were confident that if they did raise concerns they would be listened to and action taken.

The head of social work was the safeguarding lead for the service. They had oversight of all safeguarding concerns within the hospital and kept a detailed tracker of the progress of each referral and the actions taken.

Staff received training in safeguarding adults and children. Compliance with the training was high, with 100% of staff up to date with their levels 1 and 2 safeguarding adults and children training and 95% of staff up to date with level 3.

There were strict protocols around visits to patients by children. They had to be assessed as being in the child’s best interests with careful assessment and liaison with the host Local Authority and Bracknell Forest Council. When permission was granted a well-equipped child visitor suite with toys, games and an outside courtyard was available.

We scored the service as 2. The evidence showed some shortfalls. The service did not consistently ensure accurate completion of records related to therapeutic engagement supportive observations (TESO) and NEWS2. However, 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 looked at 16 records relating to the identification and management of risks, including risk assessments, risk management plans and care plans.

Staff completed comprehensive risk assessments of every patient on admission. Risk assessments were reviewed and updated regularly, including after any incident with the multi-disciplinary team, reflecting a structured and collaborative approach to risk formulation and management. Staff used a recognised risk assessment tool, the HCR-20 (Historical Clinical Risk Management) risk assessment tool, to ensure that all aspects of patient risk were covered.

Patients told us they were involved in managing risk and contributed to their risk management and care plans. They told us there was a focus on co-production and they were full partners in their care. Staff empowered patients to have a voice. Care plans and risk assessments demonstrated a strong patient voice in a simple and clear manner. We saw and heard that patients’ individual preferences and needs were always reflected in how care was delivered.

Each patient had an individualised ‘My safety plan’ in place which identified individual risks. On Richmond Ward we saw that a dysphagia assessment had been carried out for a patient with support from the Speech and Language Therapist (SALT). Additionally, the occupational therapist had conducted a falls risk assessment and installed appropriate equipment, with a corresponding care plan documented.

Staff used National Early Warning Score (NEWS2) track and trigger system. NEWS2 is a tool used to score a patient’s vital signs to identify those at risk of physical deterioration. We found staff on the wards were using both paper and electronic records to undertake NEWS2 scoring. This resulted in the paper-based records not being consistently transferred to the individual electronic NEWS2 system. We raised this at the time of our assessment and the service took immediate action to address the confusion of using both systems. We did not find any impact on patient care with these inconsistencies during our inspection.

Person-centred risk management processes were in place to anticipate, manage and reduce the risks of patients experiencing harm. Staff knew about any risks to or from each patient and acted to prevent or reduce risks. Staff shared key information to keep patients safe when handing over their care to others. Handovers were comprehensive and included effective communication of all important information such as risk and updates related to individual patients to staff coming onto the shift.

Staff in multi-disciplinary team meetings comprehensively discussed individual patients’ needs and demonstrated an in-depth understanding of each patient. Risk screening and a comprehensive physical health assessment were completed at admission and documented appropriately. Physical health care plans were in place for all patients, addressing individual needs. Monitoring included blood tests, weight checks, ECGs, and GP reviews. Staff who were redirected to other wards could access ‘Patient at a Glance’ documentation which summarised the risks that each patient presented with and how the risks were managed.

Staff had a strong understanding of relational security. Relational security is the knowledge and understanding staff have of a patient, including their background, relationships with staff and peers, risks and how these impact on daily life within the hospital. This is further strengthened by both environmental security and procedural security. Staff were able to use this knowledge and understanding to build safe and effective relationships with patients. This helped staff develop appropriate responses, care and support for each individual. All staff completed mandatory boundaries training. Staff told us they discussed and reported any boundary issues within the ward teams and reported any boundary breaches as incidents.

Patients confirmed they were involved in their care and risk management plans. Staff had open conversations with patients concerning their risks and produced a collaborative care plan and risk management plan. This was updated if there was a change in current risks. Staff identified and responded to any changes in risks to, or posed by, patients. Staff used their knowledge of patients to understand and predict patient risk behaviour and triggers and intervened with suitable support such as reassurance, increased observations, medicine review and the use of seclusion.

Staff routinely reviewed patient dynamics and interpersonal compatibility both within individual teams and across wards. This proactive approach ensured that patients with known negative relationships were appropriately managed to avoid unnecessary contact, for example, during transitions such as movement from the ward to the central therapeutic hub.

The service had a contactless patient monitoring system which could be used, when appropriate, to monitor patients’ vital signs when patients were in their bedrooms or in seclusion and after rapid tranquilisation. Patients were made aware of the monitoring system and its use when they were admitted to the hospital and through information available on the wards. Staff had received training in its use and there were policies and procedures in place to safeguard the safety, privacy and dignity of patients when this system was used. We saw that the technology was used in a way that balanced people’s privacy with any safeguarding and risk management needs. Patients we spoke with who had experienced the use of this technology described their dignity and privacy being consistently upheld.

Staff followed trust policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. All patients were subject to searches which took place in accordance with the High Security Psychiatric Services (Safety and Security) Directions 2019.

Staff observed patients in line with the trust’s policies and procedures. Wards were designed to allow observation of all areas. The hospital had installed CCTV in communal and seclusion areas.

All patients were subject to various levels of therapeutic engagement supportive observations (TESO) to manage risks around self-harm, physical health or risk to others. Decisions about the level of observation were made by the multi-disciplinary team. The team reviewed the level of observations regularly to ensure they were appropriate to risk levels and were not being imposed for unnecessary lengths of time. These observations ranged from constant eyesight, arm’s length observations to intermittent general 15- and 30-minute observations.

Eyesight and arm’s length observation records were completed in full. However, we found that the quality of recording varied on the wards for intermittent general observations. Across wards, there was variation in whether intermittent observations were carried out at predictable time intervals or not, and the level of detail about patient presentation recorded. On Richmond Ward, there were occasional gaps where the staff had not completed an entry, and the patient presentation was not always clear. On Euston Ward, patient presentation was recorded but not the actual time the patient was seen, which it should have been. We did not find any impact on patient care with these inconsistencies during our inspection.

Service audits of TESO had already identified the recording issues and these were being addressed through supervision, updates at team meetings and reflective practice. CCTV was checked as part of the audit process to ensure that observations had been carried out. We raised our findings with the Trust at the time of the inspection. The Trust took immediate actions by issuing a hospital wide communications regarding the TESO policy and reviewing patients on intermittent observations to ensure that the levels of observations were appropriate.

Staff we spoke with confirmed they had undertaken the TESO Knowledge Skills Assessment Framework training. This was a competency-based assessment for all clinical staff who are required to undertake TESOs. All inpatient staff were required to complete mandatory e-learning on therapeutic observations. At the time of our assessment compliance with this training was 100%. The service had plans to introduce e-observations in the near future as part of a Trust wide programme. The service was actively collaborating with the other two high secure hospitals to enhance the approach to therapeutic observations, with a focus on consistency, effectiveness, and sharing best practice.

Between January 2025 and June 2025, the Trust reported 269 restraint incidents. 87 of these were on Stratford (Intensive Care Unit) Ward and 49 on Euston Ward. There was 1 episode of prone (face down) restraint only. Within the same period the Trust reported 7 incidents of rapid tranquilisation.

Between January 2025 and June 2025, there were 354 episodes of short-term seclusion involving 171 patients.

A Mental Health Act (MHA) monitoring focused review of long-term segregation (LTS) and short-term seclusion (STS) was carried out at the same time as this assessment. At the time of the review there were 30 patients in LTS. Overall findings indicated safe and appropriate use of restraint with robust governance arrangements in place. A separate visit report has been issued to the service.

Levels of restrictive interventions were proportionate to the level of risk presented by the patients. When patients were subject to any restrictive interventions these were person-centred. Staff participated in the hospital’s restrictive interventions reduction programme, which met best practice standards. The service had a fully embedded Reducing Restrictive Practice (RRP) team on the wards. They supported wards where restrictive practice, such as STS or LTS occurred. They actively assisted staff to bring patients out of STS or LTS and to facilitate association and engagement with activities on and off the ward. The team also supported clinical teams where planned interventions such as blood tests were required.

The Reducing Restrictive Practice (RRP) team collaborated with the other two high secure hospitals to co-develop and strengthen their RRP programme. This helped in promoting consistency, shared learning, and evidence-based approaches across the three hospitals. The RRP team also supported carers by attendance at the carers forum by providing clear explanations of short-term segregation (STS), long-term segregation (LTS), and the distinctions between restraint, seclusion, and segregation. This helped carers to have a more accurate understanding of restrictive practice and overcome incorrect views circulated by television or social media.

Minimisation of the use of restrictive interventions was embedded within the hospital as business as usual. When restraint did take place, each episode was discussed, reviewed and analysed within the multi-disciplinary team to understand how the patient could be better supported to avoid a repetition. Reducing restrictive practice over time involved reviewing information about incidents, identifying lessons learned and measuring and monitoring data relating to incidents.

There were robust governance arrangements in place to ensure that there was good oversight, challenge and review when a patient was assessed to require more restrictive interventions. For example, if a patient required the use of a waist restraint belt this could only be agreed by the trust’s executive team. The use of nasogastric clozapine had to be authorised by the clinical director for the service.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Interpreters were booked where English was not the first language of the patient.

Staff enabled patients to give feedback on the service they received. Patients had fortnightly community meetings on the ward. All wards had a patient representative who attended the monthly patient forum. Patients’ representatives were provided with updates on service development at the forum which they then shared with the patients on each ward. All ward community meetings fed into this forum, so issues raised on individual wards received a wider hearing.

Patients said staff helped them access independent mental health advocates (IMHAs) and they said they were able to voice their views and were listened to. Patients had access to information about independent mental health advocacy. Advocacy contact details were clearly displayed on the wards. At the time of the assessment there were 3 advocates. Another 2 had been recruited and were undergoing an onboarding process. The IMHAs were actively involved in meetings such as independent multidisciplinary STS reviews, care programme approach (CPA) meetings and 3-monthly external LTS reviews.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment very well. People were cared for in environments that were especially designed to meet their needs. Facilities, equipment and technology were well designed, well maintained and consistently supported staff to deliver safe and effective care.

The hospital and wards had been carefully and considerately designed to support staff to deliver safe care and manage and reduce risks. The design and layout of the ward, facilities available for staff and patients, spaces on the wards and the way staff used the space, meant staff could deliver care for patients in a light, comfortable and well-equipped environment. The service had a full range of appropriate environmental procedures and well-trained, skilled teams to ensure safety and security was maintained.

The hospital had an integrated security team, most of whom have a clinical background, who had oversight of physical security within the hospital. A security liaison team of nurses provided a link between the ward teams and the security teams. Security staff could access out-of-hours support from the on-call security manager.

Ward areas were clean, well maintained, well-furnished and fit for purpose. The service had a comprehensive renovation plan for the Paddock Centre. Each ward was to be fully refurbished including windows and doors so that ward environments met the needs of patients better.

Staff did regular risk assessments of the care environment. Staff told us that they regularly completed daily security and environmental checks to ensure the environment was safe for patients. Daily security checklists were completed by staff on a tablet 3 times per day. If the tablet failed there was a paper version which could be used as a backup. Staff were required to check items in non-patient areas such as the nursing station and staff room to count items in and out to ensure none were misplaced or lost. If items were not accounted for staff knew to complete an incident form.

The results of the security checks were uploaded onto the main hospital system and could be audited. If a check was missed this would flag on the system and the ward would be contacted by the main security team to understand why the security check had been missed. Other security checks included level 1 searches when patients left and returned to the wards. Level 2 body searches were carried out only under the authorisation of the Responsible Clinician. Bedroom and central building therapy room searches were carried out in line with the hospital policy to ensure that any contraband items were not being stored by patients.

Ward layouts allowed staff to observe all parts of ward. All communal areas, corridors, seclusion rooms and laundry rooms were covered by closed circuit television (CCTV). CCTV is monitored by security staff. Ward staff had access to body worn cameras, these were always on charge and in standby mode in case of an incident. Identified staff on each shift routinely wear Body Worn Cameras and they were always used for any planned intervention.

Staff completed ligature risk assessments for each ward. At our previous inspection we identified ligature anchor points in the ward gardens in the new hospital and with bathroom drain covers at the Paddock Centre. At this inspection we found improvements. Ligature points in the ward gardens and bathroom drain covers had been addressed. The service was no longer in breach of regulation. Staff had a good understanding of ligature management. Staff confirmed that they knew where the ligature risk assessment, heat maps and ligature cutters were located.

Staff had easy access to alarms and patients had easy access to nurse call systems. The Ascom alarm system was now fully operational following a cybersecurity incident. The incident had impacted the functionality of the alarm system. The service had been proactive in keeping patients safe by increasing staffing levels, using radios and portable alarms to ensure continuity of care and summoning a rapid response if required.

Seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff received training in resuscitation and first aid at different levels depending on their role and compliance was high. The service ensured there were enough staff on each shift, including night time, with appropriate training to respond to patients' physical health needs.

The hospital is required to undertake an annual security audit to ensure its compliance with The High Security Psychiatric Services (Arrangements for Safety and Security) Directions 2019 issued by the Department of Health and Social Care. Physical, procedural and relational security is covered. The last audit was carried out in October 2024 by members of staff from the security teams at the other high secure hospitals in England. Broadmoor Hospital received a ‘substantial’, compliance rating.

Fire safety arrangements were in place. Compliance rates were 88% and above for fire safety training. Desk top fire drills were carried out every three months. Staff completed a personal emergency evacuation plan (PEEP) for all patients.

The service has made significant progress in supporting patients who had fallen to the floor. To enhance safety the service had introduced Hover Jack lifting equipment which was designed specifically for individuals who were unable to assist in their own lift or whose weight or size presents a manual handling risk to staff.

A remote system to monitor people’s vital signs had been installed in every bedroom and seclusion room throughout the hospital. This provided a contact-free, vision-based monitoring and management system. Each ward had an electronic tablet used by staff to monitor vital signs without entering the patient’s bedroom or seclusion room. This helped to keep both staff and patients safe when patients were distressed and it meant staff could check on them whilst they slept without disturbing them.

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 now had enough nursing staff to meet patient’s needs in a timely and safe manner. The majority of patients told us there were enough staff on the wards to keep them safe and to meet their needs.

At our last inspection we found that there were not enough staff to meet the needs of patients. At this inspection, this had been addressed, there were enough staff and the service was no longer in breach of regulation. At the time of our inspection there were 10.6% registered nurse vacancies. On going recruitment was taking place and 6 posts were ring fenced for nurse apprentices who were due to qualify at the service in September 2025. The improvements had been made by the introduction of a robust recruitment and retention programme for qualified nursing staff. This included a comprehensive education and development plan for newly qualified nurses, staff accommodation and improved staff support. The improvements in staffing had resulted in an increase in nighttime staffing establishment, a reduction in the use of nighttime confinement on the rehabilitation wards and improvements in patient accessing activities off the wards. All staff that we spoke with confirmed that there was an improvement in staffing and this had increased staff morale.

The hospital had a full range of specialists to meet the needs of the patients on the wards. This included doctors, registered nurses, clinical and forensic psychologists, psychological wellbeing practitioners, occupational therapists, speech and language therapists, social workers, pharmacists, physical health leads and sports therapists.

The staff turnover rate for the 12 months to June 2025 was 12%. Over the same period, the service staff sickness rate was 6%.

Between 1 April and 31 June 2025, the service reported that 50 shifts had not been filled to the required planned staffing requirement.

Managers had calculated the number and grade of registered and healthcare assistants required to keep patients safe. To maintain safe staffing numbers staff, when necessary, were redirected to other wards. Redirections were always authorised by the site manager.

The ward managers prioritised the safety of the patients and staff and booked additional staff as needed. Managers reviewed staffing every morning and when necessary. Managers deployed bank staff to maintain safe staffing levels, support high levels of acuity and patient leave of absence from the hospital. The ward used regular bank staff who were familiar with the patients. Between 1 January 2025 and 31 June 2025, 129904 staff hours were covered by bank staff. The highest use was on Euston Ward where 19841 staff hours were covered by bank staff. This was to support a patient who was on long term leave of absence.

When bank nursing staff were used, those staff received an induction and were familiar with the ward. The service did not use agency staff. Since our last inspection all bank staff were offered regular supervision.

Staff presence was consistently visible across communal areas, promoting both patient safety and accessibility.

Patients confirmed they had regular one -to-one meeting with their named nurse. Staffing levels allowed patients to have regular one-to-one time with their named nurse.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities, however two patients on Euston Ward reported that planned activities did not always take place when there were not enough staff on duty.

There were enough staff to carry out observations and physical interventions, and these staff had been trained to do so safely.

The hospital had enough daytime and nighttime medical cover and a doctor available to go to the wards quickly in an emergency. There was always a consultant psychiatrist who was on-call 7 days of the week.

Staff had received and were up to date with appropriate mandatory training. At the time of our assessment the service was showing a compliance rate of 96%. The training was appropriate for the patient group using the service. New starters received a role-specific induction, and managers used a checklist to ensure they had completed it prior to starting work.

Managers assessed staff competencies and identified training needs by conducting quarterly emergency simulation exercises. These included unannounced emergency scenarios to evaluate staff responses in real-time. This proactive approach helped reduce the risk of errors during actual emergencies. A recent simulation identified the need for clearer communication with the control room to ensure accurate identification of incident locations.

The continuing development of staff skills, competence and knowledge was recognised as an essential component for providing high quality care and treatment. Staff were fully supported by the service’s practice development team. The service had a comprehensive preceptorship programme for newly qualified registered and international nurses, tailored to develop the skills and knowledge required to work in a high secure forensic environment.

Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge, including accessing specialist training. Staff confirmed there were ample opportunities for learning and development, for example the psychological service had carried out a focused programme of trauma awareness training within high secure environments for both patients and staff. All team psychologists and assistants were trained in the Feeling Safe Programme which was a cognitive approach to working with persecutory/paranoid delusions.

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.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Patients told us that ward areas were clean and well maintained.

All ward areas were clean, had good furnishings and were mostly well-maintained. The service demonstrated awareness of environmental issues, including concerns about the windows in the Paddock Centre. These windows were scheduled for replacement as part of the ongoing refurbishment programme and had been appropriately recorded on the ward’s risk register. During our site visit, no patients raised any concerns regarding the windows.

Staff made sure cleaning records were up-to-date, and the premises were clean. Housekeeping staff were seen cleaning high touch areas throughout the day.

Staff followed infection control principles including appropriate handwashing techniques, use of personal protective equipment (PPE) including aprons, masks, gloves, and hand sanitiser was readily available. Infection control audits were undertaken on each ward including regular hand washing audits. Audit findings and actions were discussed in handover and staff meetings if any issues were identified.

Wards followed infection prevention and control protocols when two or more patients were diagnosed with influenza or COVID-19. During such instances, all off-ward patient activities were suspended to minimise the risk of transmission.

Staff accessed infection control training. All wards had training compliance of 85% and above.

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. Treatments with medicines were supported by robust guidance and a drive to reduce the use of restrictive practices where possible.

The service had systems and processes in place to support the safe and effective use of medicines. Staff followed clear protocols for prescribing, storing and administering medicines, and made good use of the electronic prescribing and medicines administration (EPMA) system to accurately prescribe and record medicines administered.

Medicines were stored securely, and emergency equipment was routinely checked and maintained. Staff were knowledgeable about the medicines they administered and described person-centred approaches to managing distress and/or agitation. This included the use of non-pharmacological interventions, and oral medicines before considering rapid tranquilisation (RT). RT refers to the urgent use of injectable medicines to calm someone who is severely agitated or distressed. Staff told us this was only used as a last resort when other strategies had failed. Medicines with known risks, such as clozapine (an antipsychotic used for treatment-resistant schizophrenia) and lithium (used to treat mood disorders), were monitored in line with national guidance.

The service had clear policies and protocols around the use of high dose antipsychotic therapy. This is where patients may be administered doses of medicines above the British National Formulary (BNF) recommendation. Staff understood their duties and responsibilities around this and we saw they carried these out.

Staff completed regular physical health checks and described clear escalation pathways where concerns were identified. Patients were involved in decisions about their treatment, and staff described efforts to support adherence.

As a high secure service, there were occasions when staff discussed the use of nasogastric (NG) administration with patients as an alternative to other methods of administration and for very specific medicines. Nasogastric administration is where medicines are given via a tube passed through the nose into the stomach. This method was considered where oral treatment was refused and all other options had been exhausted. We looked at records of its use to ensure that all necessary decision making was recorded fully and procedures were carried out appropriately. We saw that this would only be used as a last resort, was kept under strict review, and was for as short a time as possible. Staff described clear protocols for authorising this method, outlined that it was always to support adherence to medicines and for a limited period of time. Protocols included staff wearing body worn cameras during the administration. This method had been used 13 times between January and July 2025.

Staff received regular training in medicines management and spoke positively about the support provided by the pharmacy team. There was a culture of learning from medicines-related incidents, and staff were confident to report concerns and reflect on practice. However, there were some minor gaps in records relating to medicines use. Occasionally records did not always include a clear rationale for the administration of PRN (when required) medicines.

We found that Venous Thrombolytic Embolism (VTE) wasn’t consistently risk assessed or recorded when people entered the service or if their risks changed. These issues were discussed with the provider during the inspection and were being addressed at the time of our visit.