Midlands Partnership University NHS Foundation Trust

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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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. The service was in breach of legal regulation in relation to staffing and safe care and treatment. The service had made improvements and is no longer in breach of regulations. At this assessment the rating has changed to:

Good: This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients were debriefed and offered post incident support.

All staff knew what incidents to report and how to report them. Staff and managers had good oversight of incidents across the wards. Across the 3 months prior to our assessment there were no serious incidents. We reviewed incidents during the assessment. They were appropriately documented within patients’ care records and the trust’s incident recording system. Incidents were discussed and reviewed in morning risk meetings, handovers, multidisciplinary team meetings and clinical governance meetings.

Managers told us that all incidents and complaints were investigated thoroughly with outcomes and feedback given to all involved. Staff and patients were debriefed and offered post incident support.

Staff said learning from safety incidents was shared, and they implemented this learning into their work practices. Staff received lessons learnt through various forms such as team meetings, staff huddles, emails, staff intranet and handovers. Staff gave us examples of recent learning and changes made to the service following investigation and lessons learnt. This included learning from other wards, sites and services.

Staff had developed several quality improvement projects to prevent further issues following learning from specific incidents and embed good practice and gave examples of changes that had been made.

The trust promoted a culture of safety and learning and provided information to staff to help ensure patients were kept safe, which included learning points, scenarios and raising awareness.

Referrals to the acute wards were initially assessed by the trust’s community teams to ensure the patient required admission and it was the most suitable setting for care and treatment.

The ward’s referral and admission processes ensured that all essential information about the patient was received to determine if the patients’ needs could safely be met.

Staff from Norbury psychiatric intensive care unit (PICU) provided support and advice to the acute wards when required and would assess any referrals both internally and externally to determine whether the care they offered was the most suitable environment for the patient and could arrange the transfer if required.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Internal trust partners such as community mental health teams and external partners such as the local authority attended multidisciplinary treatment reviews to enable continuity of care and support for discharge.

People told us they felt safe on the wards. Staff we spoke with had good knowledge about safeguarding and any potential safeguarding concerns were discussed in morning risk meetings, handovers, clinical governance and multidisciplinary meetings.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. The trust had a nominated safeguarding lead and staff knew where to get advice and guidance from. We saw examples of staff reviewing safeguarding concerns within patient care notes.

Staff received safeguarding training. At the time of our assessment, staff were 97% compliant for safeguarding adults level 2, 91% for level 3 and 96% for safeguarding children level 2.

Staff followed safe procedures for children visiting the service at both sites and there were areas where children could safely visit.

The trust monitored the use of restraint and restrictive interventions and worked closely with staff to ensure they were appropriately trained and up to date with relevant practice and policy.

Staff regularly reviewed blanket restrictions and when in place were clinically justified. The garden doors on Chebsey and Brocton wards were locked, although were opened when patients wanted to go outside. Staff said this was due to the risks of the patients on the ward and was done for patient safety.

We reviewed 19 patient care records across all 6 wards. Staff kept patients safe and involved them to help manage their risk. Staff knew patients’ needs well. Risk assessments were comprehensive, completed on admission and updated regularly, including after incidents. Risk management plans were created for current and ongoing risks. Each morning the nurse in charge attended a morning meeting to discuss matters that could impact on ward safety; for example, staffing or nursing observations. The wards worked together to support each other and share resources when required. At our last assessment, patient care records and related documentation failed to demonstrate that staff always assessed patient’s mental state when taking leave from the hospital. At this assessment, patient care records demonstrated that staff assessed patients’ mental state and risk presentation specifically for taking leave. Associated leave documentation such as leave monitoring forms were completed and staff completed a monthly leave audit. However, there were some gaps on the monitoring forms on Brocton ward. We reviewed 46 incidences from 23 to 28 January 2025. The time the patient returned had not been recorded 28 times and a description of the clothing the patient was wearing had not been recorded 20 times. At our last assessment, it was not always clear how staff acted to manage items of potential risk that were part of patients’ personal property. At this assessment, we were assured that staff followed the policy to ensure items of risk were managed and stored safely. Restricted items checklists showed staff had completed them appropriately. Staff were prompted to ensure restricted items were returned within the hourly ward checks. In the 3 months prior to our assessment there were 493 physical interventions. There were 46 episodes of seclusion. They were highest on Norbury PICU. Patients were encouraged to provide feedback through community meetings. Patients could access advocacy.

The environment was safe, clean and well maintained. Ligature and environmental risk assessments had appropriate actions where required. Staff had a good line of sight into the main ward area and were present in communal areas. Matrons completed quarterly environment audits. Climb points in the ward gardens were included on the risk register with appropriate mitigations. At our last assessment, the local fire service were concerned the Redwoods centre fire safety assessments were insufficient and improvements were required following fire setting incidents. The trust had made significant improvements and the trust were now compliant with the fire regulations. All the acute wards were mixed sex. They had separate single sex corridors and complied with national guidance regarding mixed sex wards. On occasion, patients of the opposite sex would need to be accommodated on the other corridor. Staff ensured patient safety using mitigation plans and

decision making was clinically justified and reported in the trust’s incident reporting system. We reviewed a female patient’s care record who had been placed on the male corridor. She said her privacy and dignity had not been compromised and she felt safe. Norbury PICU at St George’s hospital and Birch ward at the Redwoods centre had installed non-contact technology in patients’ bedrooms. This meant that patients could be observed by staff through video and sensor equipment from the nursing office when required. The system could take vital signs such as pulse and breathing rate. The camera was only activated when nursing staff required an observation. Information was given to patients and carers on admission to gain consent and they could opt out. The seclusion rooms were appropriate. Clinic rooms were fully equipped with accessible emergency equipment. However, clinical checks on Brocton ward were missing for resuscitation equipment 13 times and 16 times for temperature checks in a 3 month period.

Managers had calculated the number and grade of nurses and healthcare assistants required. Agreed staffing levels varied dependent on the ward. We reviewed staffing rotas for the 6 weeks prior to our assessment. No shifts were short of staff and were over the agreed established numbers due to ward activity and acuity.Ward managers could adjust staffing levels to take account of levels of acuity. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels and they received an induction and were familiar with the ward. Across the 3 months prior to our assessment all wards had used agency and bank staff. This was highest on Norbury PICU at 1703 shifts, followed by Brocton at 1361. The ward with the lowest usage was Chebsey ward at 454 shifts. Only 2% of shifts requested were unfilled, therefore the wards had enough staff.At the time of our assessment, Norbury had 4 qualified nurse vacancies and Birch, Brocton and Chebsey had 2 each. Birch and Chebsey had 1 healthcare assistant vacancy each, Brocton had 2 and Norbury had 3. Recruitment was ongoing. Newly qualified nurses received a 6-month preceptorship programme for extra support and continued learning. Average sickness rate across the service was 8%; highest on Pine ward at 10% and lowest on Birch ward at 4%. Average turnover for the service was 8%; highest on Pine ward at 13% and lowest on Laurel ward at 3%. We observed staff were present in the communal areas of the ward at all times. Staff said shortages rarely resulted in staff cancelling escorted leave or ward activities. There were enough staff to carry out physical interventions safely such as observations and restraint and staff had been trained to do so. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. Staff had received and were up to date with appropriate mandatory training. As of December 2024, training compliance was 94%. The training was appropriate for the patients using the service.

The wards were clean, tidy and well maintained. Staff demonstrated a good knowledge of, and adhered to, infection prevention and control principles, including handwashing. Staff had completed mandatory training for infection control. Domestic staff were visible during the assessment and cleaning records were up to date. Staff completed regular environmental and infection prevention control audits and actions and mitigation plans were in place.

Equipment used to monitor patients’ physical health was well maintained, calibrated regularly to ensure it worked effectively and kept clean.

Staff followed good practice in medicines management. They followed systems and processes and safely stored, prescribed, dispensed, administered and recorded medicines in line with national guidance. All clinic rooms were clean and staff had access to all appropriate equipment.

Some nursing staff had completed nurse prescribing courses and were able to prescribe medicines independently but under the supervision of medical colleagues.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication.

In the 3 months prior to our assessment, rapid tranquilisation was used 57 times which equated to 11% of all physical interventions. Staff completed appropriate post rapid tranquilisation physical health checks.

The trust had appropriate arrangements in place to enhance knowledge and ensure learning from medicine safety incidents was cascaded to staff. Pharmacy support and advice was readily available for all the wards.