Nelson House

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 Safe as inadequate. The service was in breach of regulation 12 . The service has made improvements and is now no longer in breach of the regulation. We assessed all the quality statements from this key question to assess the quality of the care. We found that the service had systems in place so that staff could learn from incidents and share the learning. There were clear admission criteria and the multidisciplinary team were involved in admission assessments so that staff could assess patients’ suitability for admission. The staff team had training in safeguarding and knew how to respond to safeguarding risks. Staff involved patients in managing their identified risks. There were appropriate numbers of skilled staff employed to work on the ward. The ward environment was well-maintained and suitable for caring for the identified patient group and there were good infection control processes in place. The unit had good systems in place to ensure medication was managed safely and staff understood their role in this process.

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.

People said the service met their needs and involved them in planning care and treatment.

People felt listened to and able to raise any concerns in confidence

Staff and leaders said the service had worked hard to make improvements and learn from previous incidents.

Action plans and shared learning had been developed to address issues and a new senior management team (SMT) had been embedded to oversee change.

Staff were positive about working at the service and said improvements had been made but that SMT were open to ideas for further improvements.

For example the learning from moving to individual risk assessments to prevent people smoking in their rooms had reduced blanket restrictions of room searches and worked with people to reduce restrictions significantly.

We saw evidence of learning from incidents and reporting which was shared appropriately at clinical governance meetings. The SMT had oversight of incident management and could flex both staffing levels, skill mix and staff training to meet changing needs of people using the service.

Staff and Leaders were involved in all decisions about peoples' pathways in the service. Staff were involved in multidisciplinary team meetings and regular daily discussions to enable current risks and any concerns to be addressed in a timely way. Staff had regular time talking with patients and 1:1 sessions with key nurses were booked in advance. People's needs and the ward dynamics were considered in all decisions and these were made in a person - centred way.

Partners including community mental health teams (CMHT) kept in regular contact with people and were instrumental in planning community leave and discharge planning. Some people were waiting for appropriate placements at other services and the CMHT with the ward team facilitated these discussions. People had care coordinators allocated from CMHT who could visit and attend meetings with people

We saw clear admission criteria for the unit with some exclusions for people for whom the service was not suitable.

Main admission criteria were a diagnosis of schizophrenia, psychosis or a dual diagnosis of mental health and substance misuse problems and all should have potential for rehabilitation.

All people had a comprehensive admission assessment and visit from the MDT prior to coming to Nelson House.

Where possible people were also encouraged to visit the unit before admission.

People moved to this service from acute mental health wards, secure forensic services and community placements.

Similarly people were discharged back to a range of settings including ongoing residential placements, supported living and other hospitals.

Some people were detained under Ministry of Justice sections of the Mental Health Act 1983 and appropriate safeguards were put in place with managing accommodation and placements.

People told us they were involved in their care plans and decisions made about risk.

People gave examples of when they had been safeguarded by staff and made to feel safe on the unit and in the community.

Staff were aware how and when to report any safeguarding concerns. All staff we spoke with gave us examples when they had done so and described the outcome. Staff described good relationship with Local Authority safeguarding teams. Staff had completed the level of safeguarding training appropriate for their role. This training was mandatory and regular refresher sessions also took place.

We saw evidence of effective safeguarding practice and this was reflected in a care plan regarding financial management

We saw staff had good knowledge of people's vulnerability and individual risks.

We saw a safeguarding policy and process for the unit and evidence of appropriately completed safeguarding referrals. There was a safeguarding log and we reviewed this with incidents and updated risk assessments following any incidents to ensure it was completed appropriately.

Most people felt they could challenge their care plans and any decisions made with staff and they would be listened to.

The reasons for assessments and reviews had been clearly explained to people by staff and people understood that they were important as part of their recovery pathway. People gave examples when they had been involved in risk assessments relating to increased level of leave and reduced levels of nursing observations.

Staff said there was a dynamic risk review process and people were involved as much as possible or as much as they wanted to be.

Initially on admission some people did not wish to be involved as they were too acutely unwell but this was reviewed regularly and most people chose to be actively involved in risk assessments and care plans.

Staff knew how to escalate any concerns due to changing risk levels and level of observations would be reviewed by the MDT.

We saw patient voice recorded in risk assessments and care plan process. There was also space for relatives' and carers' views to be recorded . People’s views were clearly recorded in care plans including where they may choose to live. Staff completed appropriate permission to share information forms with people and people's wishes were respected about involving relatives and carers. Section 17 leave forms for people detained under the Mental Health Act were completed appropriately and people were involved in risk assessments before a decision was made to facilitate section 17 leave in the community.

People said they felt safe on the ward and the premises and equipment met their needs.

There was a range of spaces for people to use including quiet areas and a garden

. People could access therapy spaces and a dedicated rehabilitation kitchen area.

Staff told us improvements had been made in the environment since the warning notice was issued. Staff said the ligature risks previously identified had also been addressed with mitigation in place including structural work, blind spot management by mirrors and levels of staff observation. Staff also knew how to use and where to access ligature cutters.

We saw a reduction in signs of smoking on the premises and incidents recorded. Staff and people explained the security searching process to us and we witnessed somebody returning from leave and being searched appropriately. The garden area which was previously identified to have several ligature risks had now been modified and an overhanging canopy removed. We saw the ligature risk had reduced significantly and any remaining risks were appropriately mitigated and recorded. Individual risk assessments for people also identified those who may be a risk of self-harm and care plans were developed to meet their needs.

Improvements included a reviewed process of people agreeing to be searched on return from leave for illicit smoking materials based on an individual risk assessment. People consented to these searches and smoking materials were stored in a security locker at the unit entrance. Searches were carried out in a private area and male staff were present. This intervention had significantly reduced the incidents of smoking in bedrooms and need for more restrictive bedroom searches The fire risk assessment had been updated and all the people and staff we spoke with were supportive and understood the need for the security process to reduce fire risk. The ligature risk document had also been updated to reflect improvements made with ligature management. Individual risk assessments for people recorded any risks within the unit environment. Details of environmental risks were recorded appropriately and any mitigation measures identified. There were copies of ligature risk assessments available for staff to read.

People told us staff were approachable and friendly.

There were examples of positive therapeutic relationships between people and staff which people had said helped in their recovery pathway.

For example working with people to increase their independence and community leave.

People said staff were responsive to their needs and they felt confident raising any concerns.

People said they could arrange their leave on a daily basis with staff as needed and it was very rarely cancelled due to staff shortages.

Staff knew people well and were skilled with recognising potential triggers and using appropriate de-escalation skills.

Staff said there were a range of staff with skills to meet people’s needs. The multidisciplinary team (MDT) consisted of registered mental health and physical health nurses, recovery support workers (RSWs), Occupational Therapist, psychologist, and doctors with other visiting professionals also able to see people at the service. Staff felt supported and valued in their roles and found the sense of team work positive and empowering. Some of the recovery support workers had specific roles within the service including reducing restrictive practice and running restraint training for other staff. All staff received regular training updates following induction and competency checking. The unit was within the top 5% of Priory sites for mandatory training compliance and staff had regular time allocated to complete training online or face to face. The provider introduced appropriate safety training following feedback from staff. Mitigation measures were also put in place to manage risk and a recruitment campaign positively advertised for and attracted more male RSWs. The senior management team was quite recently formed with a new Director of Clinical Services, a ward manager and 2 deputy ward managers. Staff said this was working well and recruitment to the service had improved and fewer agency staff were now employed at the service. Staff received regular supervision and also access to weekly debrief and reflective practice sessions with a psychologist. Staff had also recently attended motivational interview training and leadership in clinical practice updates.

We saw staff interacting warmly with patients in communal areas and engaging in one to one activities.

Staff were proactively encouraging people to meet for coffee and an activities coordinator had a range of planned activities on offer.

Staff were escorting patients on leave as appropriate to access the community.

We saw requests for support or items from the office etc from people met by staff in a timely manner and clear, honest explanations given when this was not possible.

Staff treated people with dignity and respect and listened to them.

There were clear processes around staff recruitment and competencies.

Staff had appropriate checks made by SMT prior to starting work and a comprehensive induction package.

Staff received appropriate training, support and supervision to do their roles well.

Nurses could adjust the number of staff and skill mix of staff on the unit in response to changing individual needs or observation levels.

SMT could easily check skills and competencies of staff by clicking on their name on rota which helped when planning shift cover.

Training and supervision records were comprehensive and up to date.

People said the environment was clean and tidy. People were encouraged to keep their own bedroom areas clean and tidy.

Support was provided by staff to do this.

Staff knew about prevention and control of infection. Staff told us about appropriate personal protective equipment (PPE) and cleaning up body fluid spillages.

All staff had received basic IPC training as part of their induction and were reminded of it by the physical health care nurse.

We saw ward staff bare below the elbow and using PPE appropriately.

There were handwashing posters on display for people and staff. Two Registered General Nurses were employed as physical health care nurses developing physical health care plans for people.

This had improved infection control with no infected wounds at the service for over a year.

There was a comprehensive infection prevention and control policy which staff were aware of and knew how to access.

Processes were in place for dealing with an outbreak of disease and had been used during COVID 19 infection.

There was an audit process in place for cleaning which was completed by staff and monitored by SMT

People said they understood the medicines they were taking and could ask staff any questions about them. People got their medicine dispensed on time and were encouraged to move towards self- administering medication as part of their recovery journey as their mental health improved. Some people had medicines given via a long acting depot injection and this was administered safely and sensitively by staff.

Staff had good knowledge and appropriate competencies to administer medicines

. Staff said they had regular updates from doctors and the MDT to improve and update their clinical knowledge.

Medicines were clearly labelled and regularly checked by staff.

Staff knew how to respond to a physical health emergency and knew where to access emergency equipment.

Two registered general nurses were employed on the unit and they led on physical health monitoring and developing care plans to meet individual needs.

We saw medicines stored safely and appropriately.

Safeguards and monitoring of stock were good with short dated items clearly labelled and stored.

Equipment was checked regularly and recorded with the last check being completed in the month of our assessment.

The area was clean and tidy and all items were easy to access.

Information was clearly displayed on the walls for staff including pharmacy contact details, rapid tranquillzation policy , resuscitation information and signs of sepsis infection. There was a dedicated system in place for night staff to check the room and this was effective.

There were clear processes for prescribing, ordering and receiving medicines on the unit.

Staff had their competencies checked following induction and prior to administering medicines independently.

Recording and reporting of any issues with medicines was completed appropriately and reviewed by SMT at clinical governance meeting.

Improvements and learning were shared following any issues and staff training and development was encouraged.

We reviewed medicine charts and associated legal Mental Health Act paperwork and these had been completed correctly and were all current.

Specific risks such as high dose anti-psychotic treatment had been clearly document and appropriate care plans developed for physical health monitoring.