Berkshire 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 as good. This meant people were safe and protected from avoidable harm. At this assessment it remains as good.

The wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks patients and themselves well. Staff understood how to protect people from abuse. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well with reviews and governance in place to make improvements if required and learn from incidents.
 

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.
The service demonstrated a positive safety culture built on openness and honesty. Staff told us that the ward is part of the trust wide culture of no blame. This means that the trust works to remove blame and fear of reporting incidents. We observed daily meetings where concerns were escalated as required and it was clear from listening to staff at the meetings there was an honesty and openness evident in interactions and asking for support required for their team as a strength not a weakness.

Staff reported incidents using the trust electronic reporting system. Significant incidents were escalated in line with policy and reported to the CQC and NHS England where required. Incidents were investigated in line with the trust Patient Safety Incident Response Plan with oversight from the trust’s Patient Safety Team. Staff and patients received a debrief following incidents. Relatives told us they were updated about incidents on the ward involving their relative. Staff completed proportionate responses to incidents in line with the trust Patient Safety Incident Response Framework (PSIRF) policy and plan. Learning was shared through safety briefings, and updates at team meetings. Staff wellbeing data, gathered quarterly, had reported an increase in wellbeing, feeling integrated in the team, listened to and supported by managers.
There was a trust-wide learning and review group which enabled staff across the directorate to review patient safety incidents and share learning more widely. Recent learning and quality improvements on the wards had focused on improving discharge times and supporting people through transitions between different stages of care pathways. However, it was acknowledged that this will be ongoing.

Quality Statement Score: 3
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.
 

The service had clear, well-documented systems and pathways. There were structured processes at admission, transfer and discharge. Staff told us that referrals were initially screened through ward management and nursing processes. In addition, for patients coming from the community, the admitting team sought to understand why the admission was required, the target symptoms and what needed to change for the patient to return to their previous environment.
Admission processes were safe and consistent. An admission checklist gathered clinical, life history, safeguarding, social information and communication preferences. Staff told us that they had particular focus on of types of delirium because it can be missed as it fluctuates rapidly or is mistaken for cognitive symptoms. On admission, staff completed a physical health assessment promptly, to include blood tests, physical examination and observations such as blood pressure and a documented a risk assessment. Staff knew what information they needed from referrers.
Risk assessments were completed on admission and reviewed regularly. Risk formulations were built into care plans in addition areas of specific concern were identified. For example, for a post fall review. Reviews involved the multi disciplinary team and considered what happened, the triggers and circumstances. This included potentially modifiable factors and what could be done differently.
When preparing for discharge staff told us that the aim was not necessarily complete resolution of every symptom but achieving a level of stability at which the patient can be safely and appropriately managed in their care setting. Many relatives spoke positively about discharge planning and said that they were consulted about long term plans: that they were involved in discharge planning meetings and described staff working hard to identify appropriate future placements.
Staff were involved in a quality improvement project around reducing length of stay. However, prolonged admissions could occur because of lack of appropriate social care provision, difficulty finding suitable care homes, failed placement attempts, complexity of behavioural needs and particular challenges associated with younger/early-onset dementia. The team attempted to identify placements early through initial care-planning discussions and by involving social services at an early stage. Staff told us this work was ongoing and acknowledged that a number of factors for transition to other services were out of the ward and trust’s control.
 

Quality Statement Score: 3
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 concentrate 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.

Safeguarding concerns were recorded clearly. The referrals we reviewed were timely, well documented and proportionate. Staff highlighted that they had a particular awareness of potential financial, sexual or relational exploitation because of the dementia diagnosis and cognition of some patients, which can potentially make them vulnerable. This is because they may not be able to retain information and use it to process information and danger. Staff told us they observed interactions with relatives and visitors and escalate concerns when relationships appear to increase distress or create risk. Staff were observed adapting their communication and interactions depending on the individual. Some patients benefited from being offered choices, while others became more confused and needed simpler, more direct support.
The wards used positive behavioural support plans and team formulations for patients with more complex or challenging behaviour. Team formulation involved staff collectively identifying why the behaviour may be occurring and individual triggers. Formulations were incorporated into care plans and shared with prospective care homes to support continuity after discharge.
Staff had completed safeguarding training at the right level for their role. Level 3 compliance was at 100% across both wards, level 2 was 90% on Orchid and 97% on Rowan.

Mental Capacity Act

Staff had easy access to the Mental Capacity Act (MCA) policy via the trust website and to the Code of Practice. The wards had a clear, up-to-date approach to the Mental Capacity Act 2005. Capacity was not assumed because of a person’s age, diagnosis or presentation. Staff told us they assessed capacity for each decision, at the time that decision needed to be made. Records we reviewed supported this. Where a person lacked capacity for a specific decision, a best interest’s decision was made and documented.
The Multi-Disciplinary Team (MDT) also reviewed capacity and consent. Where a person’s capacity changed – for example, as their physical or psychological presentation improved or deteriorated – this was discussed and recorded. Staff all contributed to these discussions, reflecting a genuinely multidisciplinary approach. Staff applied the Mental Capacity Act 2005 framework correctly. They understood the Deprivation of Liberty Safeguards and the Mental Health Act provisions for this patient group.
However, on Rowan ward we found a patient being given covert medication. Although we could find mention of a best interest meeting, we could not find a record of the meeting or decision documented. We could not find a care plan for the covert medication nor evidence of discussion with the family. We were assured that the trust immediately took mitigating actions for this risk.
Independent Mental Health Advocacy was available to all eligible detained patients. Staff could show that patients had been told about this right at the point of detention and at subsequent reviews. Information in written form was on display in the wards. In addition, reminders and data was held to support and notify staff to undertake actions required for the mental health act.
 

Quality Statement Score: 3
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 people and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. 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 5 sets of care and treatment records.
The service involved patients and their families in risk assessment and management. Risk formulations were developed with the person where possible. They were written in clear, accessible language.
Risk assessments covered physical and psychological risk. They were completed on admission and updated when presentation changed and weekly at multi-disciplinary meetings. Physical risk monitoring was thorough and supported by technology with physical observation charts held on computers allowing better clarity of information and assessment. Staff understood the risks specific to older person’s care and the risks around restraint of older persons. There had been no prone restraints recorded for either ward in the last 6 months. This is where a person is restrained face down and may cause difficulty breathing. There were appropriate risk assessments for ligature risks across both wards. It was noted that where building work was being completed and risks heightened appropriate care was taken to protect the patients and keep the environment safe.
The staff and ward were person-centred, with a proactive model of dementia care. Staff knew patients well and intervened early when distress began to escalate. Over the last 6 months on Orchid Ward there had been a decrease in restraint interventions in the number of restraints with none recorded in the last 2 months. There were 7 instances of rapid tranquilisation. (This is where fast acting medication is given). On Rowan Ward the number of incidents had reduced for restraint, although rapid tranquilisation was higher at 15 occasions in the same period. Restraint was handled in line with trust processes.
The percentage of staff trained in these interventions was lower than the required trust compliance level, with Rowan ward at 81% and Orchid ward at 76%. Senior leaders told us training was booked for staff. Restrictive intervention was also subject of review by a restrictive intervention oversight group.
There was a clear escalation pathway to the on-call doctor. Staff knew the thresholds and could describe the escalation steps.
Families told us they were included in risk discussions in a way that was appropriate to patients age and capacity.
 

Quality Statement 3
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 wards were clean, well maintained and suitable for this patient group. Ligature risks had been assessed and mitigated throughout the environment. Risk assessments were reviewed regularly and updated after incidents or changes to the building. The ward layout did not always support clear sightlines however mirrors were used to supplement this.
Communal areas were well maintained with wide clear corridors. Staff told us that there was some environmental disruption from ward remedial works and this had an effect on the patients. The noise, increased activity on the ward, and reduced space for patients to move freely around had an impact, as ward areas were closed off for the works and resulted in temporary changes to a familiar environment.
The principal risks and challenges where the environment may contribute were falls, vulnerability through illness or complex behavioural presentations.
Overall sharps, ligature items and other risk materials were stored safely and following an incident the ward had reviewed systems and processes in response to this. This included improvements to search procedures about items being brought onto wards.
The wards did not have a dedicated seclusion area although they could access facilities on site if required. When a person became distressed, staff used the patient’s bedroom, a communal area or a de-escalation area, combined with the use of safe wards initiatives, to support them. Staff told us this approach was person centred and they prioritised the early recognition of distress enabling early, less restrictive interventions and de-escalation approaches.
 

Quality Statement Score:3
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.
Staffing levels were sufficient to meet patient needs with agency and bank staff used to provide safe staffing levels where required. However, both wards were carrying support worker vacancies and recruitment was underway to fill these positions. The service used a staffing model that provided a mix of registered mental health nurses, registered general nurses and health care assistants. Leaders described how this skill mix enabled the service to respond effectively to both physical and mental health needs.
Temporary staff came from a consistent pool of bank and agency staff familiar with the wards and patients. From observations we had no concerns over the staffing levels on the days we visited.
All nursing staff completed a local induction before working unsupervised. Staff told us that they felt confident and competent. Staff told us that they undertake mandatory training and are given time to complete face to face training and e-learning.
The team culture was positive and supportive, and morale was described as good. Staff told us that they knew their lines of accountability and felt able to raise concerns through the ward manager, service manager or freedom to speak up process. We reviewed staff meeting minutes which supported these observations.
Staff told us that the absence of an activity coordinator on Rowan ward was impacting on the provision of activities, although other staff were providing support. Recruitment was underway for the current vacancy. While most patients and staff were satisfied with the activities available, some patients and relatives expressed the view that there was insufficient stimulation for patients at times.

Quality Statement Score: 3

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.

Both wards were observed to be clean throughout our inspection and relatives told us they found the wards consistently clean. Cleaning schedules were in place and completed in line with identified frequencies.

The service had a current infection prevention control (IPC) policy and a named lead. Audits were completed as required and shared with the team at meetings. Actions were recorded, assigned and completed promptly.

Hand hygiene was good. Alcohol gel was available at ward entry points and throughout the clinical environment.

Clinical waste was segregated correctly. For example, sharps bins for needles were assembled, stored and disposed of in line with national guidance. Personal Protective Equipment (PPE) was available in adequate quantities and used correctly.

Staff knew what to do in the event of a gastrointestinal or respiratory outbreak. IPC compliance check lists on both wards were well within range with compliance for Rowan at 99% and Orchid 100% for June 2026. Infection prevention training for all staff was recorded as 100% for both wards.

Quality Statement Score: 3
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.
Medicines management was safe and well governed.
We completed a medications audit on both wards. There were no concerns around prescribing, administration, or information being shared with patients or carers and family.
We completed clinic room audits for both wards. They were spacious and organised, and there was good collaboration with Pharmacy. Systems were in place to monitor room and fridge temperatures electronically through a central system.
High-risk medicines were monitored in line with clinical guidelines.
There was a controlled drugs register in place which contained accurate information. Dual-signature processes were applied. Refrigerated medicines were stored within the required temperature range. Medicines requiring special storage were correctly labelled and segregated. However, the medication fridge on Orchid Ward was locked using a code, and had the code displayed on the front of the fridge, enabling all staff to access this.
Medicines reconciliation was completed at admission and discharge and relatives commented on how well they thought medication supported their relatives with improvements seen since admission.
On Rowan ward we found that a patient was being given covert medication, which means a patient may not be aware of taking medication as it may be in food or in a drink. Although we found mention of a best interest meeting, we could not find a record of the meeting or decision documented to ensure agreement for covert medication to be given. We could not find a care plan for the covert medication nor evidence of discussion with the family. We were assured that the trust had already taken mitigating actions for this risk and reviewed all covert medication care and we were provided assurances that this was now being addressed.