Meadow Park

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• 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

The previous rating for this domain was good. The infrastructure of the service was assessed. All furniture and fittings were deemed relevant to the service, furniture was in good repair. The location was clean, cleaning rotas showed a regular and maintained schedule.

Staff were interviewed regarding safeguarding at the service. Staff explained their safeguarding training, how it was monitored and maintained, as well as implemented. All staff interviewed were knowledgeable and up to date with their training. They were confident about the management of safeguarding and the support available.

They received annual safeguarding training modules on the "I learn" electronic system. There was a safeguarding lead at provider level who was accessible and responsive. Staff member knew how to access them. Safeguarding concerns would be raised with nurses and management. They were captured on the care records system. Staff with safeguarding concerns would also complete a significant event form which was reviewed by managers.

Staff members displayed a good understanding of risk management within the service and the individual and group risks within the patient mix. Staff members confirmed that health care assistants were involved in patient risk assessments and had the opportunity to contribute. Staff members confirmed that risk information and management plans were shared with health care assistants. Staff member felt that the service practised positive risk-taking where appropriate This was also shown by risk assessments recorded at the service.

The service had a full range of policies in place that were up to date and comprehensive, reflecting the consideration given to overall care at the service. These policies included a Mental Capacity Act policy, a Risk Assessment and Risk Management policy, a Therapy Strategy, and a Safeguarding policy. Minutes from meetings showed relevant and comprehensive consideration to aspects of patient safety.

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 did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We interviewed six patients and asked specifically about safeguarding incidents on the service. None of those interviewed were currently involved in the investigation of any safeguarding incidents. One patient told us of an incident that occurred in the past, but that it had been dealt with fairly and efficiently by the service. All patient stated that they felt safe at the service.

We spoke with staff at the service, interviewing nurses, health care assistants, the occupation therapist and the clinical psychologist. Safeguarding was recognised as a key aspect of patient care, and it was clear that those interviewed knew what safeguarding entailed, as well as the processes and reporting procedures should they feel an issue was present.

A senior nurse practitioner outlined the different types of abuse that staff should be aware of, stressed that this knowledge was refreshed during mandatory training for staff, where safeguarding was a key part of the training. There was a safeguarding lead at provider level, and staff knew how to contact the lead. Health care assistants were also able to give examples of the types of abuse that might be encountered, and how to ensure that a meaningful outcome was identified and implemented.

Staff told us there was a significant event form that would be completed for a safeguarding problem, and we reviewed this form and noted it was comprehensive and suitable. Staff as well as the service manager reported that the contacts with external safeguarding bodies was effective and worked well, and this was noted when reviewing minutes from meeting with external safeguarding bodies.

A staff member talked the team through a safeguarding incident involving the passing of illicit substances through a window by an outside source, and how the matter was reported and dealt with using the safeguarding process. This was one of several examples given, the actions taken were all deemed appropriate.

The service manager reported how safeguarding incidents and issues were recorded on care records to ensure that there was a full record as part of the patient journey, as well as the lessons learned aspect. A check of records confirmed that recording of safeguarding incidents was taking place. The service manager described how the local authority website was key in ensuring that the relevant external organisations were kept informed.

The Monthly Mental Health and Learning Disability Reporting Template (Host Commissioner Services) template for February 2024 showed safeguarding adults level 1-3 compliance remained at 82%, whilst the safeguarding children levels 1-2 compliance had increased to 84%. Some staff had yet to complete their training, but had been booked in for completion shortly after the assessment.

The Monthly Mental Health and Learning Disability Reporting Template (Host commissioner Services) is a monthly report that ensures a standard quality assessment framework is in place to monitor and inform commissioning services of the standard at which the service is operating, within the guidance of Care Quality Commission minimum standards and NICE guidelines. The report for January 2024 includes safeguarding information that is routinely monitored. The minutes included adults at risk (incorporating the Mental Capacity Act 2007), as well as mandatory training figures for safeguarding adults and children. The self-imposed target for the service is set at 90% completion.

Meadow Park has a standing Safeguarding Policy that was ratified in April 2023, for review in April 2024. the policy is in date. The policy has a comprehensive breakdown of relevant aspects of safeguarding that is easily read and understood. The policy gives proper and direct guidance that is designed to inform and outline the procedures necessary to not only identify safeguarding issues for adults and children, but also gives the rationale for the actions to be taken when confronted with safeguarding abuses.

Specific questions around risk management and involvement were not asked. However, no concerns were raised by patients regarding risk management. Patients we spoke with reported being involved in their care and were given information and advice about their health, care and support. One patient discussed their discharge plan and support to transfer between services. A review of care records showed that relevant patient involvement and information was taking place.

Staff members displayed a good understanding of risk management within the service and the individual and group risks within the patient mix. Staff members confirmed that health care assistants are involved in patient risk assessments and have the opportunity to contribute. Staff members stated that risk assessments are personalised, and that risk assessment and management is ongoing and completed on a daily basis. Formal risk assessment were updated ‘periodically’, but within the policy recommendations.

Risk assessments were discussed with patients in 1:1 Sessions and multi-disciplinary team ward rounds. Risk assessments were completed before any authorised patient leave. Patient capacity was assessed as part of assessment and care planning work.

Staff told us that de-escalation techniques were fully utilised, and records confirmed that there had been no recent uses of rapid tranquilisation at the service. Personal behaviour support plans were in place at the service, and were used as they related to each patient accordingly to prevent behavioural escalation, as well as My Safety Plans. Relevant risk assessment tools were in place at the service and were noted in care records. The care records system informed staff when a review date was due.

The service pushed to deliver care in the least restrictive manner. Observation levels were set by the nurse in charge and based on risk. Each patient has an observations care plan with instructions for staff.

The service Restrictive Practice document outlines the service approach to implementation and consideration for any restrictive practice or intervention. The process outlines all aspects to be taken into account before any restriction is implemented on a patient. All actions must be in place before consideration of such an intervention. The document defines restrictive intervention as well as each type of restraint, and an overall definition of why a restriction might be considered.

The service had a full MCA and DOLs policy that was in date, for review in 2025. The policy was comprehensive and applicable. The information from the service showed that, in February 2024, the mandatory training rate for this subject stood at 87%, and all remaining staff were booked into completion dates. . The policy noted the restrictions under the MCA that were displayed within the service.

Minutes of the clinical care group meeting in January 2024 has a number of relevant embedded documents regarding risk, including patient safety, and included the local risk register, organisational risk register. also outlining many patient safety factors. These include clear realistic discharge dates for patients, appropriate consent to care and treatment forms, a full set of recording criteria for serious incidents (including medication errors, full resuscitation policy and checks on equipment, reports re. infections). The service had a therapy strategy outlining the approach to risk assessment: 'As a team prioritise the access to advanced risk assessments, facilitating and managing any waiting list and detail any suggested contingency planning linked to unassessed clinical risk'. The therapy strategy was well written, concise, outlining the approach by the service towards the patient journey whilst considering aspects such as risk as standard. The service had a risk management policy in place that had been reviewed in July 2023 and was not scheduled for further review until 2026.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.