Hampshire and Isle of Wight Healthcare 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 inspection we rated this key question Requires Improvement. The service had made improvements and is no longer in breach of regulations. However, it is noted that there are staffing issues on Austen House, which is currently supporting Bluebird House with staff, this had an impact on their staffing numbers.

All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We spoke with 15 patients and 5 carers and relatives. Patients and carers said they knew how to raise concerns about the service. Patients said they felt confident to do this and that staff would listen to them if they felt unsafe on the ward.

We spoke with 19 staff members. Staff learned lessons to continually identify and embed good practices. Staff were able to tell us about recent incidents and the learning from them. Staff said they reported things such as inappropriate behaviour between patients, incidents of short staffing, verbal or physical aggression and medication errors. Staff said learning from incidents was done well and when the staff teams met to review the incidents action was taken to improve safety. There was evidence that changes had been made because of feedback. After a serious incident occurred on Bluebird House where a patient had managed to damage property, senior nursing staff completed an action plan to identify areas of improvement. Actions included improvements to handover and communication with patients to encourage them to share information with staff.

The service had a good incident reporting culture. Debrief was happening after incidents occurred and we saw this in action at Bluebird House during the assessment.

Staff understood the duty of candour. This was regularly reviewed at clinical effectiveness meetings. The service was open and transparent and gave patients and families a full explanation if and when things went wrong.

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

Patients said they knew about their discharge plans. However, we could not always find these easily in the patient record. Patients described feeling frustrated because their discharge from the service was delayed due to challenges in finding an appropriate onward placement. Patients said they had access to an advocate and knew what to do if they would like to speak with them.

Staff teams worked proactively with staff at services where patients planned to be discharged to, to ensure safe discharge planning and minimal delay. This was also supported by the Specialist Forensic Community Team (SFCT). Staff made referrals to other health professionals when needed and supported patients to attend specialist healthcare appointments.

Senior leaders attended referrals and allocations meetings with the locality provider collaborative to ensure a smooth transition pathway for patients.

Senior staff from all services met every day to discuss incidents, discharges, and long-term segregation. There are senior meetings to discuss security and safety on a Monday, Wednesday and Friday and in addition each unit has daily huddles. Patient care records showed discussions about patients discharge plans.

Clinical effectiveness meetings were carried out at local level and fed into the divisional quality oversight and risk meeting. These meetings reviewed the model of care and themes including patient discharge pathways when relevant to the patient group.

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. The service shared concerns quickly and appropriately.

We spoke with 15 patients and 5 carers during the assessment. Patients mostly said they felt safe on the ward, including from sexual harassment. Three patients said they did not feel safe on the wards from other patients and felt that when they had raised this with staff, staff had done something to help them. In Bluebird House, ongoing safeguarding disclosures were managed with social worker involvement. For example, a young person disclosed historical abuse during therapy; safeguarding procedures were followed, and multi-agency meetings were convened to support the young person. All services made safeguarding referrals and had fortnightly meetings to review how the referrals were progressed.The social workers also support the Multi-Agency Public Protection Arrangements (MAPPA).

Carers reported feeling their loved ones were kept safe whilst on the ward. Two carers were very complimentary about their loved ones support within secure services. One carer told us that communication was sometimes a problem but had no concerns about the safeguarding of their loved one. We observed staff ensuring patient safety and protecting people from abuse.There are also Carer Lead roles across Adult Secure Services.

Staff worked with the local authority to ensure that patients were protected from abuse. Staff were aware of the referral process and shared concerns quickly and appropriately. Staff met with patients where there was a safeguarding concern. Staff also discussed the outcome from investigations with patients. The service had multiple dedicated social workers who supported staff to report safeguarding concerns and liaised with the local authority.

Staff kept a local safeguarding action log to ensure safeguarding concerns were reported and monitored. In the last 3 months 23 safeguarding concerns were reported across the wards. These included safeguarding concerns such as violence and aggression between patients, financial abuse between patients and incidents of self-harm.

Restraint, restrictive practice and blanket restrictions were all discussed on a monthly basis in clinical effectiveness meetings.Reducing restrictive practice were also discussed with patients. Patients at Ravenswood were invited to a number of workshops to discuss their thoughts on blanket restrictions and invite them to provide feedback on their experiences. Patient meetings also took place, and Ravenswood had a Patient Council forum that was held monthly (this is in addition to the ward community meetings).

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.

During the assessment we reviewed 21 sets of care records across the wards. Staff recorded risk management plans to help reduce the risks to patients. Staff used a daily risk assessment tool for things such as section 17 leave and restrictions so that risks can be assessed at the time. Seclusion records were completed and then reviewed by the multidisciplinary team (MDT) during a patients' episode of seclusion. A second independent MDT review of the seclusion care plan and process was also completed.The services worked closely with MAPPA (multi agency public protection). We use the HCR-20 tool (used to assess risk based on historic risks of violence), which is a KPI and reported on to the Provider Collaborative. The services are 100% compliant.

On most wards staff communicated with patients so that they understood their care and treatment, this including finding effective ways to communicate with patients with communication difficulties. However, this was not always the case on Bluebird House where we reviewed five sets of care plans and found two where there was little evidence of young people’s voice being actively involved in the care planning process. In addition, feedback from “Have Your Say” meetings on Bluebird House indicated that young people wanted more input into leave planning and activity scheduling.

Staff monitored patients’ physical health. For all patients staff used the national early warning score (NEWS2) system to record patients’ physical health observations. We looked at patients’ NEWS2 records. They showed that staff completed these observations weekly and escalated any high scores to clinicians. This reduced the risk of patients’ physical health deteriorating rapidly unnoticed. An electronic system was used to gather and record NEWS2 scores which fed directly into the patients care record which made it easier for staff to record and evaluate scores quickly to help to support a deteriorating patient.

Staff followed the Trust’s policy and procedures when carrying out patient observations. Patients were on different observation levels according to risk. Patients were searched when they came back from leave and random searches took place.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The ward areas and the clinic rooms were secure. Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly. Equipment included an emergency grab bag, oxygen cylinders, an automated defibrillator and a breathalyser. Staff carried out daily safety checks for the clinic room equipment and emergency medicines. Staff monitored the temperature of the medicine fridges.Each unit had a physical health clinic room

There was space on the wards to safely manage the number of patients and if restraint needed to be carried out there was sufficient space for this to take place. The wards were clean and tidy, and the décor well maintained.Staff made sure cleaning records were up-to-date and the premises were clean. We observed cleaning staff maintaining the cleanliness of the ward. Staff also supported and maintained the cleanliness of the ward after patient contact. Staff followed infection control policy, including handwashing.

The ward layouts at Ravenswood House did not allow staff to easily observe all parts of the wards. To mitigate the risk, cameras and convex mirrors had been installed to enable staff to observe blind spots. Environmental risks were also mitigated by patient engagement, risk assessment, staff awareness of potential ligature risks, staff presence in communal areas and the observation of patients. The ward complied with guidance and there was no mixed sex accommodation. At Southfield the ward areas were graded red, amber and green to indicate patient access and there was an allocated security nurse on every shift.

The services had closed circuit CCTV in place in the corridors and communal areas which records any activity taking place. CCTV helps the trust understand and learn from an incident.

Staff had access to personal alarms and patients have access to nursing call alarms. In addition, each ward had a radio and the Duty Senior Nurse carries one on their person. The allocated Security Nurse also carries a radio on their person. The radios can be used to escalate a situation and call for staff support.

Radios and personal alarms were checked daily.

Each ward allocates a Response Person to attend in an emergency across the unit. This is allocated to the shift planner.

At Tatchbury Mount site, the radios are used across the secure services to provide a site response, using the same wave frequency.

Patients can lock their bedroom doors to stop other patients entering.

There were potential ligature anchor points in the services. At Ravenswood this was largely due to the age of the building, and the facilities staff had limited capability to make changes to the fabric of the building. However, Staff knew about any potential ligature anchor points, which were recorded on heat maps of the wards and staff mitigated the risks to keep patients safe. In addition, the building was on the corporate risk register for the trust as a concern, which meant that the trust were aware the buildings needed additional resource to keep safe and they were addressing this in the development of a potential new build. Staff completed daily security checks and ligature risk assessments to identify and mitigate environmental risks. Allocated security leads for the wards were responsible for the security checks which we observed being completed each day during the inspection.

On Bluebird House ligature risks had been identified regarding doors and spiral notebooks. The estates team replaced the high-risk door handles and removed spiral-bound notebooks after these audit findings. We also saw that windows that did not open and broken equipment were logged for urgent repair.

Staff had easy access to alarms and patients had easy access to nurse call systems, we could see there were audits in place for maintaining the safety of the nurse call systems.

The seclusion rooms allowed clear observation and two-way communication. They had a toilet, shower, sink and a clock. The trust had an up-to-date seclusion policy which provided guidance for staff to follow. During the assessment the seclusion room in Ashurst was in use and a care management plan was on display in the nurses’ office.

We scored the service as 3. The evidence showed a good standard. Whenever possible 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.

Data provided by the trust for June and July told us that the trust had identified staffing hotspots on Malcolm Faulkner ward and Austen House In June. This had improved due to staffing recruitment and in July there was an identified hotspot only in Austen house. This was because Austen house had significantly higher sickness levels and had increased it's bank and agency usage from 25% to 30% for unregistered staff. This was under continuous review by the senior leadership team and the wards were using consistent agency staff who had been inducted onto the wards to minimise the impact.

Managers used a professional judgement framework to help them calculate the number and grade of nurses and healthcare assistants required. The guide is based on evidence relating to the use of the Safer Nursing Care Tool on acute general hospital wards and has been developed with those settings in mind, although the principles apply in other settings. This framework gave the managers a structure to support decision making around safe staffing levels.Adult Secure also have a daily SitRep (site report) where staffing is reviewed and safer staffing is discussed in the unit's daily huddles.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

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

Staff had received and were up to date with appropriate mandatory training and all training was above the trust guideline of 80%. The training was appropriate for the patient group using the service.

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.

Staff described the trust policy on handwashing. Staff knew about the importance of infection control to stop infection spreading. Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

The wards were visibly clean, had good furnishings and were well-maintained. Staff ensured cleaning records were up-to-date. Staff disposed of sharps waste appropriately.

Staff followed infection control policy. Senior nursing staff on the wards carried out monthly audits of the ward environments to minimise the risks of infection. The IPC lead for the division also attend the wards and provide feedback. The service had employed full time domestic staff to clean the premises. Domestic staff kept cleaning records up to date and these demonstrated that staff cleaned the ward daily.

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.

Patients’ medicines were reviewed regularly at ward rounds, with patients involvement. Staff provided specific advice to patients and carers about their medicines. Pharmacy staff provided specific counselling to patients when they were discharged with new medicines to ensure that they understood how to take them. Staff reviewed the effects of medicines on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication.

Staff ensured the appropriate treatment authorisation certificates were in place, in line with the requirements of the Mental Health Act 1983. Staff ensured that when rapid tranquilisation was used, the appropriate physical health monitoring was carried out in line with national guidance, to ensure patients remained safe.

Medicines including controlled drugs were stored securely and safely. We observed that medicines were given to patients in a person-centred and caring way. Patients’ medication was given in private to maintain privacy and dignity. 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.in the Adult services we support patients with medicines management by helping them understanding why they have been prescribed medication, and work towards holding their own medication in a suitable locked cabinet in their room and onto self administration.

Patients were supported to manage meds by understanding why they have been prescribed medication, and work towards holding their own medication in a suitable locked cabinet in their room and self administration.

Control drugs were audited weekly by the wards.

The units also have pharmacy technicians and the pharmacist complete monthly medicines management audits.