St Andrew's Healthcare - Birmingham Also known as 1-121538294

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

It was not clear to some staff how learning from incidents was shared with staff to make changes that improved care for others.

On most wards staff had information about a person before they were admitted ensuring safety and continuity of care. However, staff on Moor Green ward told us this was not always provided.

Some staff had a limited understanding of safeguarding and how to take appropriate action to report abuse. However, people told us they felt safe and the provider trained staff in safeguarding.

People gave mixed feedback about involvement in their risk assessments. Risk assessments were not always reviewed and updated. People were not cared for in a well-maintained environment. Equipment and technology did not consistently support staff to deliver safe and effective care.

People were not always protected from the risk of infection and the approach to resolving the risk of infection was not always effective.

The electronic system to record the administration of medicines was slow at times which meant recording was not always accurate. However, people’s medicines were appropriately prescribed and supplied.

Restraint was only ever used as a last resort and restrictions were proportionate.

Staff were supported and received training to respond to people in an emergency.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

It was not clear whether staff understood how learning from incidents resulted in changes that would improve care for others. Staff told us that incidents were reported appropriately on the electronic reporting system. However, although staff were aware of how to report incidents, they were unaware of how learning was fed back or shared. Staff were unable to tell us if incidents and complaints were appropriately investigated.

Staff said that agency staff did not have access to the incident reporting system so permanent staff had to complete these on behalf of agency staff. However, the provider evidenced that all staff could log incidents through the incident reporting system.

Staff told us that following an incident they were involved in they had a debrief and this was discussed in supervision with their manager. They said lessons were identified during these but were unable to give us examples of this.

Staff told us there was a ‘learning newsletter’ and ‘patient safety learning notices’ that they had to sign to say they had read. However, some staff were unable to recall examples of these.

The provider evidenced debriefs for people who used the service and staff and monitored incident learning through their action and improvement plans.

Staff told us how information was shared before a person was admitted to the ward and they were encouraged to read this. However, some staff on Moor Green ward told us they were not given information about a person when they were admitted. This meant the person’s risks were not identified or assessed so that staff on the ward could safely manage these.

Before a person was admitted information about their needs and risks was emailed by the referrer to the ward. Staff printed this out to share this with all staff on the ward and in handovers between shifts. The multidisciplinary team or doctor visited the person before admission to complete an assessment of their needs and risks.

People told us they felt safe. They knew which staff to speak with that they could trust if they felt unsafe or had difficulties in their relationships with other people who used the service.

Some staff had a limited understanding of safeguarding and how to take appropriate action to keep people safe. Several staff described themselves as being involved in “a safeguarding” when a person using the service had been verbally or physically aggressive towards them. They were offered the option of a ward move, which they appreciated. However, staff were unclear on safeguarding process and when it would be appropriate to raise a safeguarding concern. Staff told us they complete an incident form if they were involved in an incident and if safeguarding referrals were needed the social work team did this. This meant that staff may not always be aware of when a person may be at risk of abuse or harm. However, staff were trained in safeguarding to appropriate levels for their roles.

The provider trained staff in Safeguarding levels 1 and 2 for children, young people and adults. Those staff eligible for Safeguarding level 3 training had been trained in this. Whilst the provider had processes in place for staff to complete safeguarding refresher training, some staff were unable to articulate when questioned.

The social work team told us that there was a weekly safeguarding meeting for the hospital where they reviewed all the incidents for the previous week to ensure appropriate referrals had been done and action taken where needed. They worked with the safeguarding team from the local authority to ensure systems ensured that people were protected from abuse and neglect.

People had mixed feedback about involvement in their risk assessments. Four people were not aware of their risk assessment and had not been involved in it. However, evidence from the provider showed people were involved in their risk assessments and were regularly asked for their input.

People told us that restraint was hardly ever used at the hospital and if it was used only as a last resort and for the shortest amount of time needed to keep people safe.

People in medium secure and first floor wards told us about restrictions on using the garden as they always needed staff to support so they could not access it except at set times.

Staff, including bank and agency staff told us they had handovers at the beginning of every shift which gave the information they needed about each person’s risks. Staff told us about the tool used to assess people’s risks and understood this.

Restraint was only ever used as a last resort. Staff told us that restraint was rarely used, and they used de-escalation techniques to good effect. All staff were trained in techniques to manage people’s aggression and how to de-escalate situations to reduce the need for restraint. Staff had a limited understanding of relational security, what it meant and how it was used in practice. Most staff told us they completed an online training session; however, they could not explain how the team worked together regarding relational security or how it was applied and implemented on the ward.

Staff told us about blanket restrictions and identified the ward 'vape break' policy as such. Managers completed a risk assessment for each blanket restriction. They discussed these in the ward community meeting and a plan was agreed with the people using the service.

Staff were aware of the therapeutic observation policy. They completed an online training module on this. Staff told us they entered people’s bedrooms at night when completing their observations to check the person was breathing and ensure their safety. However, staff told us that sometimes they experienced difficulties of connectivity when using the electronic therapeutic observations system. At the time of our visit the system had been unavailable for 2 hours. Staff immediately reported this as an incident and temporarily transferred to a paper-based system to continue to record patient observations.

Risk assessments were not always updated when a person’s risk changed. For a person who was in seclusion, staff had not updated to reflect change in risk following an incident. Staff did not always understand people’s risks. However, we found people’s risks documented in positive behaviour support plans were clear in recording the person’s risks and their coping mechanisms. Those reviewed were updated when people’s risks and needs changed.

The multidisciplinary team used the ‘relational security wheel’ to complete a formulation of people's risks. However, most nursing staff were unaware of this.

Staff did not always record people’s therapeutic observations in line with the person’s assessed levels of observation. On Lifford ward we found 36 gaps in recording of 2 people’s enhanced observations (1 person 2:1 and another 1:1) between 3/11/24 to 11am on 13/11/24. Some showed as backdated corrections. On Northfield ward we found 14 late observations recorded between 03/11/24 to 13/11/24. On Moor Green ward we found 5 people’s observations were recorded as late as between 86 to 95 minutes. On Hurst ward we found for 3 people there were 9 late recording of observations which ranged from between 30 – 60 minutes late.

The environment was not safe and well maintained to meet people’s needs. People told us that when things get broken repairs take a long time, sometimes months to repair their showers which they found frustrating. One person on Northfield ward told us they had no running water in their sink and their toilet did not flush, they were however offered to use an alternative bathroom and toilet within close proximity to their bedroom.

People on Northfield ward told us that one bedroom corridor had no heating for some months, and they had to wear coats and hats in bed to keep warm in the colder weather. Staff confirmed this as correct. However, the provider took actions to implement temporary heating systems and provided people with thicker duvets.

Staff reported repairs took a long time. They said Estates staff did what they could but getting parts was slow. Staff gave us examples of delays to repairs: Hawkesley ward 1 person’s toilet had not flushed since September and was repaired at the time of our visit; Lifford shower was out of use for over a year, however ensuite showers were available for all patients. Staff hoped it would be changed to a bathroom to benefit people but no decision was made by managers about this; Hawkesley ward a toilet in ensuite was blocked for 3 months, so the person had to use the extra care suite in the seclusion area as their ensuite; communal toilets on Hawkesley ward out of order sign on door for several months; Speedwell ward the staff toilet needed a new part but was out of action for 3 weeks.

Staff said some seclusion rooms were out of use due to a broken door on Hurst ward & Speedwell seclusion room was being renovated. The intercom on Hazelwell seclusion room needed repair; contractor had been appointed, day and date on the clock was not working. Lifford ward staff were unsure if the seclusion room was in use as it was previously decommissioned. Staff also said some people were brought from the medium secure wards to use these seclusion rooms due to several seclusion rooms across the site having been decommissioned. The provider told us that due to limited use of Lifford seclusion room this was repurposed as additional storage space to meet the significant need for storing & charging people’s specific adaptive equipment. They said if people from other wards needed to use this, it could be quickly repurposed to meet required seclusion standards.

Staff were aware of where ligature cutters were kept so they could find them in an emergency. However, some staff were not aware of the ligature risk assessment, & these were not available on all wards.

The environment was not well maintained. We observed numerous issues and outstanding repairs including blocked toilets, lack of running hot or cold water, paintwork on bedroom walls ‘bubbling’ from the ensuite shower, torn and worn carpets and equipment such as tumble dryers broken for several months. However, the provider was awaiting contractors to complete the repair and we saw evidence that this had been identified by the provider.

Technology used did not consistently support staff to deliver safe and effective care. We observed several issues with IT which impacted on the electronic patient records, the observations tablets and the electronic medicines system. This meant that staff were not always able to immediately record observations and medicines administration directly into these systems.

We saw there were blind spots on all wards. Staff told us these were reduced by walking around these areas and observation, and we observed staff doing this on some wards. However, on Edgbaston ward we observed that staff were not always observing a person in accordance with their prescribed therapeutic observation levels.

On Hawkesley ward staff showed us a store cupboard which was very cluttered and disorganised. It included bags of a person’s personal belongings that were not labelled and staff coats and bags as they had nowhere else to store these. Hurst ward had a 'Gym room'. It was unclear whether this was being converted into a gym room or from a gym room into something else. The room contained an exercise bike and was also being used for storage. We later observed in the minutes for the ward community meeting that the exercise bike did not work.

The arrangements to monitor the safety and upkeep of the premises were not always effective. Staff reported areas that required maintenance and repair through a maintenance logging system. However, repairs often took a long time and there was a delay in parts becoming available.

Closed circuit television cameras were installed in seclusion areas on all wards and in both medium secure units courtyards.

The emergency bags were shared between 2 wards. For some wards this meant staff had to go up or down stairs to get the emergency bag. However, the provider demonstrated that standards are maintained regarding response times.

Some people told us there were not enough staff which meant their leave was cancelled or the time they were out on leave was reduced. People on some wards told us about restrictions on using the garden as they always needed staff to support so they could not access it except at set vape times. Other people said they couldn’t get to the gym or do activities as there were not enough staff. This meant they were bored.

Some people said that staff did not always understand what they wanted especially agency staff.

Some staff members’ and leaders' perception was that staffing levels and skill mix were not appropriate to ensure people received consistently safe, good quality care to meet their needs. Staff told us when agency staff were used there was less consistency, and they did not always have a rapport with people using the service which made the permanent staff job harder.

Ward managers told us that their established staffing levels had been reviewed and decreased. They said this was difficult if people were on enhanced observations to ensure people got their authorised escorted leave, their therapeutic observations were completed on time and staff had breaks. Senior managers told them to use the multidisciplinary team to increase their staffing. However, the team worked Monday to Friday 9am to 5pm so did not cover evenings, nights and weekends.

Staff did not always receive the support they needed to deliver safe care. Most staff said they did not have regular supervision with their line manager. They had monthly clinical supervision but should have management supervision every 3 months. However, staff on Lifford ward said they had regular supervision, reflective practice twice per month and regular team meetings.

Bank staff completed a 2 day on site 'Essential skills refresher’. They completed other mandatory training by e-learning which had to be completed during a shift.

The written process to escalate when staffing levels needed to change based on people’s acuity was detailed with clear escalation points and an emphasis to minimise agency use. Staff escalated staffing gaps to the duty manager and messages were sent out to staff to ask if they could fill the gaps. Staffing was discussed at daily huddles. The provider told us that staff had escalated that safe staffing levels were not met but the daily huddle had redeployed staff and used bank and agency staff to reduce the risks.

The provider told us how staff annual leave was planned and said that this ensured that there were not too many staff on leave at the same time.

The provider told us that nursing staff management supervision compliance ranged from 52% to 80% across the wards. The provider told us that during the last management supervision cycle the only ward where a large proportion of staff did not have supervision was Edgbaston ward which was due to the managers long term sickness.

Staff told us they received training in infection prevention and control. The provider showed us the figures for staff compliance with this training which showed that staff had completed this training.

People were not always protected from the risk of infection. The cleaning records for the off-ward gym by Edgbaston ward showed the gym was used 6 times in the two weeks before our visit. However, records showed that no wipes to clean down the equipment were available in that time.

Clinic rooms and equipment were kept clean. These were cleaned daily, and staff applied clean stickers to equipment when cleaned.

The approach to assess and manage the risk of infection was not always effective. Hand hygiene and infection control audits should have been completed monthly on all wards to ensure compliance. However, information provided showed there were gaps in these over the last few months. The provider told us they had now identified these gaps and the reasons for them. In the absence of the Quality Matrons, they had assigned other staff to do these tasks and allocated a lead for each ward in infection prevention and control.

People were involved in decisions made about changing their medicines. They said doctors discussed their medicines with them and only increased them with their permission. People said their views were listened to.

People’s relatives said their medicines were discussed during the meeting with the multidisciplinary team which they attended and were managed effectively.

Staff showed us how slow the electronic medicines recording system was. They told us that this impacted on the length of the medicines round. Staff demonstrated the electronic medicines recording system which was running slower than normal at the time. The provider told us following the assessment that they had addressed the intermittent and infrequent issues with the electronic medicines recording system.

Registered nurses told us the provider trained them in administering medicines and they had to complete competency assessments to ensure they were competent in doing so. They told us how they ensure that there was safe management, use and oversight of controlled drugs.

We saw medicines were stored and prescribed safely. However, we observed how slow the electronic medicines system was at the time, it “timed out” for the staff member and was not loading correctly. This meant that staff had to make retrospective entries of medicines administration. For some periods of time the system was unavailable.

The Pharmacy Technician visited the wards weekly. Nurses completed audits of the clinic rooms at weekends which included checking expiry dates of medicines and equipment. However, these systems were not always effective. On Moor Green ward most plasters and bandages in the first aid kit were past their expiry date, staff removed these and ordered replacements. There were 2 large and 1 small oxygen cylinders, 1 large was to expire 2 days after and the small one was out of date. The nurse in charge reported this to maintenance. On Speedwell ward there was an oxygen tank that had been out of date since February 2024. This was removed at the time of our visit and replacement ordered .

Staff showed us that they checked the temperature of the clinic room and medicines fridge daily to ensure medicines were safely stored. If medicines were above or below the recommended temperatures this was reported to a central maintenance company who were responsible for maintaining this. On most wards records showed these checks were completed daily however on Hazelwell ward we found an omission on 13/11/24, 1 omission in October and 3 in September 2024.