Kings Norton Hospital

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

We rated safe as good. Information about learning from incidents was shared with staff. There were systems in place to report to maintenance any work needed to ensure the environment was safe. Work was in progress at the time of our visit to ensure the staircases were safe. Staff had a good understanding of safeguarding and the procedures to follow if they witnessed or suspected abuse.

Staff received training appropriate and relevant to their role. Restraint was only used as a last resort. Managers were trying to reduce restrictive practices and staff used ‘Safewards’ interventions to help reduce restrictive practices. People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic. People had information about their medicines explained to them in a way they could understand.

However, people did not always feel their belongings were kept safe during their admission. Most staff had the information they needed in handovers about people’s needs and risks, however 3 staff said this could be improved. Staff assessed people’s risks, but 3 of 8 people spoken with said they were not always involved in these.

Staff were not always effectively deployed to ensure people had their leave from the hospital. However, the provider showed us staff training was ongoing to improve this.

The systems to record and store people’s medicines and record their physical health observations following taking them were not always effective at the time of our visit in September 2024. However, the provider has since demonstrated these systems have improved.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Safety and learning did not involve all people. Two of 8 people spoken with said that incidents were not managed effectively, which impacted on their wellbeing. People said they had a debrief following incidents.

Safety and learning involved all staff. Staff told us that they and people involved in incidents had a debrief soon after when the person was settled enough. Staff had requested refresher training following an incident where they had been assaulted and this had been given. Staff said they were supported following an incident.

Some staff had recently participated in reflective practice sessions with the psychologist and said this had been helpful in improving their practice when working and supporting people.

All staff were aware of how to report an incident. Staff told us of a recent incident which was followed by a rapid review. Staff met together to discuss what they could learn from it; the person’s observation levels were increased to ensure their safety and reduce the likelihood of it happening again.

Lessons learned from incidents were shared with all staff. Staff said that information and learning from incidents was emailed to all staff to share what went well and what did not go well. The manager told us incidents for the previous month are discussed in clinical governance which all staff are able to attend, the minutes and learning is available via the shared drive and in staff meetings. Safety alerts are circulated which shares learning across the company.

The processes in place to ensure there was learning from incidents were effective. The provider used the Patient Safety Incident Response Framework (PSIRF). Following an incident depending on the severity they had a rapid review or team incident review. This was shared with all staff and people using the service through the daily morning meeting, handovers, team meetings, community meetings and staff supervisions and they discussed any areas that needed to change.

The approach to identifying and managing people’s risks was effective. Staff told us they had the information they needed about people’s needs and risks. Most staff told us they were given information about people’s needs and risks at the handover at the beginning of each shift and these were typed and printed out to refer to. However, 3 staff said this could be improved as this information was not always detailed so they had to ask for further information. The provider showed us evidence that staff asked for further information where needed and this was provided.

Staff told us they could also access information about people’s needs and risks through the electronic patient records system, emails from external agencies such as commissioners, feedback from multidisciplinary team meetings and discussions during shifts. They also liaised with external agencies and people’s families to ensure people’s continuity of care.

Effective processes were in place to ensure people’s needs were identified prior to their admission to the service. Nurses received a telephone referral with details about a person before they were admitted. This included details about whether this was the person’s first admission, or they were known to mental health services and nurses reviewed this information. They then decided as to whether the referral was accepted or not based on if they could safely meet the person’s needs. Nurses then handed over to staff the person’s risks and staff had access to the referral document.

The provider trained staff in care planning. This included a collaborative, joined up approach to safety that involved the person, staff and other partners in their care.

Following a visit from the provider collaborative quality team in October 2024 partners had concerns about the ‘Clerking in’ process when a person was admitted to the service. This was also raised as a concern in their visit in June 2024. They identified from 2 people’s records that 1 person had not been clerked in by the doctor on admission and there was no medical entry documented for 6 days post admission. However, the provider told us this was clarified at the time of identifying, medics did not have a log in for the electronic records system and the summary had been added by another member of staff. Therefore, safety and continuity of care was a priority through people’s care journey.

People were not always supported to raise concerns when they felt unsafe. People expressed mixed views in relation to their safety at the service. Four people told us they did not feel safe, 1 person said this was because another person had accessed their bedroom and their belongings when they were on leave, and they felt their space was violated. They said staff had helped them to raise concerns about this and supported them. Another person said they felt safe, but they were unable to lock their bedroom door to keep their possessions safe which worried them.

One person said that some of the other people on the ward made them feel unsafe with shouting and if there were a lot of agency staff it made them feel scared.

Three people had mixed views about feeling safe and 1 person said that more privacy would help them to feel safer. One person said staff managed other people’s aggression well which helped.

Staff demonstrated an understanding of safeguarding and how to take appropriate action if they witnessed or suspected abuse. The provider told us they trained staff in safeguarding and staff knew how to report safeguarding incidents. They said that people’s care plans and risk assessments were updated if there was an incident. Staff were aware of the duty of candour and involved the person and their families where appropriate.

Staff discussed any safeguarding incidents at the daily ‘morning meeting’. The multidisciplinary team present at this meeting discussed if further action was needed to safeguard a person. They then reviewed all safeguarding actions weekly.

We observed staff working in a manner that protected people who used the service from abuse. During an incident of aggression between 2 people who used the service we observed that staff intervened to ensure the safety of other people and reduce the risks to their safety.

The systems, processes and practices to make sure people were protected from abuse and neglect were effective. Managers had a good overview of safeguarding incidents.

There was a shared online folder that all staff could access for safeguarding referrals. Managers were responsible for linking the referral back to the incident report which had an option for a wider review of the incident.

The Matron was the safeguarding lead for the hospital. They had tried to establish links with the local authority safeguarding team but had been unsuccessful. They submitted referrals to an email address to ensure they followed the process. They had recently established links with the head of safeguarding for the local adult mental health NHS trust and were developing a local safeguarding protocol with them.

People did not always understand their risks or how they were assessed. Most people said they were involved in their weekly ward round with the multidisciplinary team and spoke with their doctor there about their risks.

Three of 8 people told us they had not seen their risk assessment or been involved in it. However, 1 person said they planned to do it that day with staff.

Most staff knew about people’s individual risks and knew what items each person could have to ensure their risks of hurting themselves was reduced.

Staff assessed people’s risks daily and if their risks were reduced or increased, they informed the person’s doctor of this. The opinions of staff were listened to by the multidisciplinary team. However, agency staff were not always aware of people’s risks although they attended handovers.

Restraint was only used as a last resort. The provider trained staff in restraint which included de-escalation of the person to reduce the need for restraint. Staff told us that restraint was only used as a last resort. Most staff understood ‘Safewards’ interventions and techniques used to reduce the need for restraint. They had monthly meetings on ‘Safewards’ interventions and how they could implement these at the hospital. Staff said they did not like using restraint and would only use it for a short time if really needed. They rarely used holds of people on the floor and used seated holds if necessary. When holds were used this was planned as much as possible and responsive to people’s individual needs.

Managers told us how they were reducing restrictive practices. They had questioned why all the doors were locked and had gone through governance procedures to reduce the number of locked doors based on risk.

Staff were aware of the policy on therapeutic observations and followed this. They said each person’s observation levels were assessed daily to ensure it was not over restricting for the person.

People’s belongings that they couldn’t have on the ward such as cigarettes and lighters were kept in the ‘contraband cupboard’ which staff held the key to. Items were available to people when they request and dependent on risk presentation.

The provider had a restrictive practice policy in place which was comprehensive. This was reviewed in the monthly clinical governance meetings to ensure managers were aware how this policy was implemented within the hospital.

Risks were assessed but not easily understood by people. Records reviewed included a risk assessment for each person. However, these sometimes contained several pages and a list of incidents involving the person. It was difficult for staff to identify quickly the person’s current risks and how to reduce them. The person’s multidisciplinary team reviewed and updated their risk assessment weekly. Staff said this was when the person was involved but this was not recorded in the records we reviewed. Records reviewed did not show the person was involved in their risk assessment. Only 1 person had signed their risk assessment and were given a copy. We asked the provider for an immediate response to our concerns about risk assessments. They responded that all risk assessments would be reviewed and nursing staff were to be trained in the risk assessment process and the handover document reviewed within a week of our assessment. Following our assessment the provider demonstrated that all risk assessments have been transferred to a new template on the electronic records system. This was a clear process for staff to assess and show how the person's risks were to be managed with a space for comments from the person and their family.

The environment was not designed to meet all people’s needs. People said on Manor ward there was limited communal space.

People with limited mobility sometimes found it difficult to access the garden areas without staff support.

Since our visit the provider told us that improvements have been made by swapping Lakeside and Hope wards, so all male patients are upstairs, this allows more free flow of patients to use the dining room and spaces available.

People were not always cared for in environments designed to meet their needs. However, managers told us about the planned work on the ward gardens. This included keeping people safe from psychological harm in relation to sexual safety. They identified a privacy issue if all wards were using their gardens at the same time as the gardens merged and you could see people from other wards through the fencing. The wards currently worked together to reduce risks. The provider’s Head of Estates planned to visit the hospital to look at ways of enhancing the gardens using artwork and screening to reduce risks and create a better environment. Staff on Hope ward said there was no ramp to get out to the garden, so it was not fully accessible if a person used a wheelchair.

There were effective arrangements to monitor the safety and upkeep of the premises. For each shift on each ward there was an allocated security staff member. They completed a checklist which checked the ward environment for security and safety issues. This included checking the cutlery at each meal in and out. If there was cutlery missing, they may carry out a room search to find it and ensure safety on the ward. The ward staff reported any repairs to the maintenance team and logged this on the system. The maintenance team responded quickly to any repairs needed.

Staff on all wards knew where the ligature cutters were and how to access them. There were staff on the wards who trained other staff in reducing ligature risks. They were involved in completing ligature assessments and people’s risk assessments. They had ‘heat maps’ which detailed high, low and medium risk areas. Staff removed items of risk to a person and stored these safely in a room, so access was restricted, and staff supported the person when using.

Managers identified work was needed to ensure safety on the stairs to Manor and Lakeside wards. At the time of our visit, they were installing walls at the side of the staircases to reduce risk.

Work was taking place to improve the safety of the environment. Walls were being installed at the side of staircases during our visit. This was to reduce the risk of people jumping over the bannisters.

On all wards mirrors were positioned around the corridors to reduce blind spots.

The garden from Hope ward overlooked the Lakeside ward garden which meant there was reduced privacy from the male to female ward. Staff said there had been some issues with a person using the netting (to promote privacy) to jump over the fence, so the netting had been cut down to reduce this risk.

The environment was not designed to meet all people’s needs. On Hope ward there was a raised lip from the lounge area to the garden so it would be more difficult to get out to the garden when using a wheelchair or if a person had limited mobility. However, the risks of this were reduced as the person was on enhanced observations to ensure that a member of staff was always present to support mobility and access to all areas of the ward.

In the Hope ward kitchen, there was a ‘domestic type’ washing machine and tumble dryer which reduced the space in the kitchen. Staff said these were not used as people used the main laundry room upstairs. Following our assessment the provider told us renovation work had been financed to create a new area at the bottom of Hope ward which will create space for a patient gym and separate laundry.

Safewards systems were in place although these had not been developed across the hospital at the time of our visit.

Equipment used to deliver care and treatment was maintained and used properly. A digital system was used in people’s bedrooms to record their physical health observations where needed so that staff did not have to go in the person’s bedrooms to do these and disturb the person particularly at night. People were made aware of this and when it was being used.

Staff completed checks on electrical equipment used. People were risk assessed for use of electrical items and cables in their bedroom. Staff checked the water and fire systems regularly. Window restrictors were fitted on the first floor and staff checked a sample of these weekly, so all were checked monthly.

Managers ensured staff received fire safety training. Each ward had an evacuation plan, and each person had a personal emergency evacuation plan. The local fire brigade had information about the hospital and a map of the building. The local fire officer had visited and was satisfied that safe measures and plans were in place. The most recent fire alarm company inspection identified the policy needed to be updated and this was done.

Staff reported all maintenance issues on an online system, and these were also discussed at the daily morning meeting. Maintenance staff reviewed this daily and prioritised jobs that needed doing first.

People did not always have staff support that was effective to meet their needs. People told us that day and night staff were mostly approachable. However, 1 person said that agency staff at weekends were not always helpful as they did not always know the people and the running of the ward.

Four people we spoke with said that it felt like there were not always enough staff to facilitate their escorted leave from the hospital and this was sometimes delayed. They said the staffing levels were mostly safe but not always therapeutic staffing. People said doctors who authorised their escorted leave seemed detached from the ward as they authorised leave that staff on the wards could not facilitate.

Managers told us they used a ‘staffing ladder’ to assess how many staff were needed for each ward. Staff were not always effectively deployed to make sure people received consistently safe, good quality care to meet their needs. The staffing levels were appropriate to meet people’s needs. However, staff said there were not always enough staff to facilitate people’s escorted authorised leave from the hospital. Some staff were allocated to do people’s therapeutic observations for long periods of time without a break. The provider acknowledged that effectiveness of shift planning required development to enable to staff to use their time effectively. Staff were moved around wards if needed to cover gaps.

Staff told us they received the support and appropriate training relevant to their role. They had regular training, supervision and an annual appraisal. Some staff said they had recently started reflective practice on day shifts led by the psychologist which was helpful. Some staff said they always had a debrief after an incident, but other staff said this was not always. Staff on Hope ward said regular staff meetings were started by the new ward manager which was useful.

Internationally educated nurses told us until recently they had not had a mentor and the opportunities to gain the experience needed as a nurse working in the UK. The provider told us improvement work had taken place across the company for the provision of mentorship and support for international nurses. This included increased supernumerary time, financial support for exams, study leave to prepare for exams and increased supervision. Of the 12 international nurses, all but 2 have successfully completed the requirements to achieve a UK registration.

Staff were not always effectively deployed to make sure people received consistently safe, good quality care to meet their needs. On Manor ward during our visit, we observed staff tried to request extra staff to cover staff breaks but were unable to until later in the shift. Two staff had been covering 1 person’s observations for 3 hours without a break.

On Hope ward, community meeting minutes showed people had raised issues about staffing levels which had impacted on their leave from the hospital and smoke breaks.

Managers effectively managed staff turnover and sickness rates. Staff turnover rates had reduced during 2024 from 2023. Staff sickness rates for short term sickness were between 10 - 19% in June, July and August 2024 and there were no staff absent due to long term sickness.

Managers told us they were supported to increase staffing levels where needed. Agency staff had completed the hospital induction and training.

Managers reviewed the staffing and agreed with the provider that more leadership on the wards was needed. They were recruiting for 3 clinical team leaders for each ward and to 2 night coordinator posts. There was a full multidisciplinary team. There was 1 specialist doctor vacancy. There were full teams of administrative, domestic and maintenance staff. The head chef vacancy was being recruited to. The use of agency staff had reduced and there were more permanent, and bank staff employed. Following our assessment the provider told us they had recruited to all posts and there were no vacancies at the hospital.

The provider trained staff appropriately and relevant to their roles.

The cleanliness of the environment was discussed with people during the community meetings on each ward. The most recent minutes of Lakeside community meeting stated that people said the ward was much cleaner now than had been previously.

Staff told us they received training in infection prevention and control. They knew what their role was in preventing infection. This included hand washing prior to entering the ward, regular environmental checks and implementation of cleaning regimes.

People were protected as much as possible from the risk of infection because the premises and equipment were kept clean and hygienic. We observed that the wards were clean and there were no malodours present.

We saw that fridges where food was stored were clean, that food was labelled and in date and staff checked temperatures to ensure food was stored safely.

There were clear roles and responsibilities around infection prevention and control. The provider told us that 96% of staff had completed training in infection prevention and control at level 2. Ninety two percent of staff had completed training in food safety at level 2.

Cleaning schedules included cleaning extractor fans in bathrooms and kitchens.

Most people were involved in decisions about their medicines. One of 8 people spoken with did not understand the medicines they were prescribed or their dosage. They said staff had not explained these well to them.

The approach to staff administration of medicines reflected current professional guidance. Registered nurses received training in administering medicines. People came to the clinic room to receive their medicines, and their medicines were recorded on their individual prescription chart.

Staff said the pharmacist visited the hospital every week. The pharmacist reviewed people’s medicine records and pointed out any errors that needed addressing. Staff completed an audit of medicines every 3 months and said this included disposing of out-of-date medicines. Staff received online training from the pharmacists. Staff understood how the system worked to test people’s bloods who were prescribed Clozapine medicines. This flagged where there were concerns and staff needed to take further advice about the dosage or to stop administering. Pharmacists gave advice to doctors about prescribing where needed to ensure safety.

Staff completed observations and monitoring of people’s physical health needs. They discussed in the daily morning meeting where there were risks to people’s physical health needs and if changes were needed to the medicines prescribed for them.

People’s medicines were not always safely stored. We saw on Manor ward that the fridge used to store medicines was not working and medicines that needed to be stored there were transferred to Hope ward. However, the records of this and the dates the medicines were transferred did not match the dates the temperature was above safe storage limits. Records showed that the fridge temperature was above safe storage limits and staff had taken action to resolve this. Following our assessment site visit the provider told us they had installed air conditioning units on all wards to reduce the risks of the room where medicines were stored overheating. They had also increased oversight by the matron and ward managers to ensure action is taken when needed to store medicines safely.

In the glove dispenser in the medicines room on Manor ward we saw that there were no small or medium gloves available for staff to use when administering people’s medicines.

The monitoring of people’s medicines was not always effective. Records showed the pharmacist had emailed staff to say when a blood test for a person prescribed Clozapine was overdue. This was done by staff but there was not a clear audit trail in the person’s records or on the ward to show if there were any concerns. The records were passed to the administrator to scan into the system. We asked the provider about this and requested an immediate response. The provider showed us that systems were in place and since our assessment site visit, they have ensured that all staff are aware of the processes to ensure people’s safety.

Staff discussed at the daily morning meeting if a person was refusing their medicines. This was also discussed in the ‘safety huddle’ and minutes of these were kept in the ward nursing office. Doctors reviewed these people’s medicines and discussed them with the person and nursing staff and in the weekly multidisciplinary team meeting. This was also discussed and documented in the ward shift handover.

People prescribed rapid tranquilisation had another physical health monitoring sheet in the ward clinic. Staff reviewed at the daily morning meeting if a person was given rapid tranquilisation and reviewed their observation sheet which the doctor also checked. These were then scanned onto the computer system. However, these were not labelled with the person’s name, so each 1 had to be opened to review if a person’s observations had been completed.