Sussex Partnership NHS Foundation Trust

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 requires improvement because there was high use of medicines to reduce anxiety, agitation, and aggression on both Caburn and Regency wards. When rapid tranquillisation was used, the recording of post-dose physical health monitoring was sporadic and sometimes record to show the rationale for the use of when required medicines, were missing. Care plans for medicines were not always in place. Patients with dual diagnosis of mental health and substance misuse did not receive adequate withdrawal monitoring and their symptoms were not adequately monitored. Regency ward environment had potential risks that had not been sufficiently mitigated. There were some ligature risks in bathrooms. The general layout of Caburn ward did not allow clear lines of sight of all areas of the ward. Not all staff were aware of the environmental risks.. However, staff conducted multi-disciplinary team (MDT) meetings to review a patient’s treatment regularly. The provider had a policy which staff followed to ensure they had up to date information about a patient’s prescribed medicine when on transfer into the service. Staff had access to emergency medicines that were checked regularly. The wards had a good multidisciplinary team who worked well together and worked with external organisations to improve outcomes for people.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us they knew how to raise concerns about the service they received, and staff encouraged them to raise concerns. For example, patients told us they felt confident and were able to raise concerns and trusted that when they did, the manager would investigate it. Patients told us they could always refer to posters on the walls within the wards which directed them to how to make a complaint or how to reach an independent Mental Health Advocate (IMHA). Patients told us they had debriefs with the manager when they were involved in an incident as part of their recovery journey.

Staff knew how to raise concerns and what incidents and near misses to report but did not always report these in line with provider’s policy. One member of staff told us they sometimes reported incidents informally to the nurse in charge but did not formerly record the incident on an incident form therefore, there was no ownership of the incident reporting process by both staff and the nurse in charge. Staff told us they had received training on how to report incidents and staff discussed incident reporting as part of staff supervision.

Staff and leaders told us learning from incidents and complaints was shared during weekly team, reflective practice meetings, handovers, morning safety huddles and individual supervision sessions. Staff were able to give examples of lessons learnt from incidents which had taken place on the ward. However, one staff told us they did not always receive feedback from incidents and investigations.

Six staff told us they felt well supported by their immediate managers who gave them the opportunity to debriefs immediately following incidents and received regular reflective practice sessions led by the psychologist. Staff held weekly multi-disciplinary team meetings where the team discussed patient safety incidents. Staff told us that, even though they were encouraged to raise concerns, they were not confident that they would be treated with compassion and understanding. For example, there were three recent patient safety incidents that resulted in two dismissals due to inappropriate boundary breaches with patients and one dismissal which related to a fatal patient safety incident. Because of these dismissals, three staff felt there was blame culture within the senior management team and felt their concerns were dismissed by the senior management team. Also, staff said when they raised concerns about the availability of doctors to cover on-call duties, their concerns were dismissed by the senior team.

The service did not always have a culture of safety and learning. During our onsite visit, we saw that the staff and leaders had not always recorded and reported incidents appropriately in line with organisational policies and procedures. Staff did not always report incidents using the hospital’s electronic incident reporting system. For example, we identified three incident episodes which was reviewed by both nurses and doctors but had not been recorded on incident forms or completed on the electronic incident reporting system.

However, we looked at record of a range of recent incidents reported by the service and saw that they were open and transparent when investigating, and implemented change based on learning identified by the investigation. Managers completed audits for processes such a as care plans and risk assessments. Managers told us the provider held weekly action plan review meeting to review learning and to consider the audits that the team needed to complete. For example, managers planned to check and ensured staff had completed National Early Warning Score 2 (NEWS2) checks appropriately. Mangers investigated all incidents which met the threshold for patient safety incident investigation and Immediate Management Review, as per Patient Safety Incident Response Framework (PSIRF). Staff understood the Duty of Candour and their responsibilities. Staff we spoke with understood the need to be open and transparent when they made mistakes and to apologise to patients when required. The Duty of Candour regulation explains the need for providers to act in an open and transparent way with patients who use services. It sets out specific requirements that providers must adhere to when things went wrong with patients receiving care and treatment. The provider had a duty of candour policy in place.

Two patients told us they were positive about their experiences of living at Caburn and Regency wards and felt they would be appropriately discharged when they were ready. One carer told us staff encouraged them to visit the wards and to attend ward round for their relative.

Staff told us all admissions were planned and carefully assessed by the multidisciplinary team (MDT) who followed a clear admissions policy criterion and discussed referrals within the MDT.

Leaders told us they consult with other agencies about admissions when needed. For example, they contacted substance misuse services and community mental health teams. The provider had a dual diagnosis worker linked to Regency ward. Staff told us there were good inter-agency working arrangements in place to support the needs of patients.

Staff obtained information about patients’ risk from each patients’ previous placement, family and from the patient on admission. However, staff could not always capture all information about patients at the point of admission, and this posed a risk for the admissions. On the day of our inspection, the chief nurse requested the admissions team to pause patients’ admission for Regency ward for few days to address some issues such as the acuity and level of risk to patients. The pause on admissions was also to address the immediate safety concerns about the environment which we raised with the managers during our initial feedback session.

The MDT discussed patient discharge soon after a patient was admitted onto the ward and during weekly patient flow meetings. Managers told us they had reduced length of stay (LofS) on Regency ward from 100 days to 50 days and aimed to reduce the LofS on Caburn ward in the last six months. The team had good liaison with community teams whom they invited to attend ward reviews an initiative which had expediated discharges.

The discharge planning office worked with lead practitioners, social workers, community colleagues, other professionals, discharge coordinators and families to ensure patients experienced smooth transitions and ensured that discharges were planned. The team worked to ensure they only discharged patients when they were ready to be discharged.

Partners told us they were able to attend weekly ward rounds and regular care programme approach meetings. They felt staff involved all relevant partners and community teams at the appropriate times in patient treatment including housing teams and community mental health teams.

The provider had weekly ward round meetings that involved internal and external partners. Staff ensured all relevant partners had copies of discharge plans.

Staff used various screening tools with the help of nurses and doctors to assess patients’ risks on admission. The tools were appropriate for the patient group that were admitted onto the ward. For example, the provider aimed to complete admissions paperwork within first 24 hours and introduced a checklist for admissions after the first 24 hours. Some of the items on the checklist were Waterlow (for risk of developing pressure ulcers), Health of Nation Outcome Scale (HONOS), Malnutrition universal screening tool (MUST) risk assessment and ensured all patients were put on a food and fluid chart for the first 24 hours.

Staff alerted any physical health needs of patients during assessment to the physical health team. However, staff told us even though a physical health assessment was to be completed by the clerking in doctor, this was not always completed at the point of admission but rather left for the ward doctors to complete. This meant that physical health assessments were sometimes not completed, especially during weekend and evenings which put patients at risk. The MDT reviewed the list of patients clinically ready for discharge (CRFD) three times a week to ensure they were completing everything they needed to make patients ready for discharge. Managers monitored the number of delayed discharges and discussed delayed transfers at the senior leadership and clinical governance meetings and tracked the progress of each patient. The MDT reviewed length of stay for patients to ensure they did not stay on the ward longer than they needed to.

Ten patients we spoke with said they did not feel safe on the wards. One patient told us the ward environment could be chaotic. Two patients told us staff did not always deescalate situations before using physical restraint. Two patients told us they did not feel safe because some patients smuggled drugs onto the wards when they returned from unescorted leave and sight of the drugs gave them the urge to engage in drug use. One patient said, ‘The patients do drugs in the garden, some of the patients do crack and heroin when they go on leave, most of them are violent here.” Two patients told us they did not feel safe because they could access sharp objects such as screws and razors in the bathrooms and quiet room which they could easily use as a self-harming tool. One patient said staff sometimes shouted at them and they don’t like it. This was raised with the ward manager at time of our assessment . However, nine patients told us they felt safe, happy, well supported, staff were caring, and they enjoyed being on the ward. Patients felt the staff knew them well and that staff were able to effectively support them to manage their risks. Staff made time to listen to them and were genuinely friendly. Patients said they could raise concerns and felt when they raised concerns, the manager responded to and dealt with their concerns in a timely way.

We spoke with seven carers and received mixed feedback from them. Some carers said their relatives felt safe on the ward and staff were caring. Carers said they knew how to raise concerns if they needed to. One carer told us even though they had bad experiences with the ward, they had received a positive experience overall. However, other carers felt different and said their family members did not feel safe on the wards. One carer said their family member did not feel safe on the ward.

We spoke with 24 members of staff including senior managers, ward managers, nurses, healthcare assistants and members of the multi-disciplinary team. Staff told us they enjoyed working at both Regency and Caburn wards and that they received adequate training to carry out their role. Staff could give examples of how to protect patients from harm, harassment and discrimination including those with protected characteristics under the Equality Act.

Staff knew how to recognise adults and children at risk or suffering from harm and worked with other agencies and the local authority safeguarding team to protect them. Staff were able to demonstrate their understanding of the principles of safeguarding including neglect and risk to others. Staff knew the types of abuse and how to identify abuse. Staff encouraged patients to report any incidents where they were the victims of a crime or harassment to the police and staff supported patients where necessary to report such incidents. If a patient did not have capacity to make a report to the police, a staff member or the safeguarding lead reported the incident on the patient’s behalf. However, one staff member told us when they informed the nurse in charge about abuse or a safeguarding concern, they did not know whether a referral was sent to the local authority.

We completed observation of the wards using a Short Observational Framework for inspections (SOFI), which is an inspection tool that is used by inspectors to make a judgement as to what life is like for patients using services. We observed that the ward was generally calm and staff generally friendly and respectful to patients. We saw posters displayed on wards giving details of the safeguarding lead for the hospital and information about how to contact the Independent Mental Health Advocate. We saw information about patients’ rights displayed on the hospital wards and care records we reviewed, showed that patients had been given information about their rights under the Mental Health Act upon admission to hospital and on a regular basis afterwards.

The provider had two processes of reporting safeguarding. One process was for staff to send referrals to the safeguarding team’s email inbox and the other process was to fill in an incident report after the concern had been reported to the safeguarding team. The trust responded to safeguarding incidents well, investigated concerns and where lessons learnt were identified, appropriate actions were put in place. The hospital’s safeguarding policy was reviewed annually and gave staff clear guidance on types of abuse and how to report concerns. Safeguarding training compliance for staff was 93% for safeguarding adults and 89% for safeguarding children. As part of the inspection, we reviewed the hospital’s safeguarding log which was up to date and included details of the safeguarding incident, the incident date, and if the local authority had been made aware of the incident. .

We found that staff received and kept themselves up to date with training in the Mental Capacity Act and had a good understanding of the five principles of the Mental Capacity Act.

The consultants received regular Mental Capacity Assessment audits that was run through the Mental Capacity Assessment team, but these audits did not happen regularly. The provider had a ward round documentation which they needed to use to ensure the team had all information needed to highlight risks before a patient was given section 17 leave to go out to the community. The safeguarding team provided training sessions to support the staff with this documentation.

However, staff did not always assess and record capacity to consent clearly. We found that mental capacity assessment for three patients were not properly completed or not completed at all. For example, we found that one patient had fluctuating capacity but there was no capacity assessment for the patient to agree to their admission.

Patients told us they were actively involved in the development and review of their care plans and risk assessments so that they could be supported in the way they wanted. We reviewed 20 care records on both wards, and all included the patient voice The plans were personalised, and showed patients had been offered a copy of their plan. Patients said they were invited to contribute and attended their ward round meeting and staff were supportive and helpful. We saw evidence that patients were involved and informed about their risks and how to keep themselves safe and patients had the opportunity to discuss blanket restrictions during community meetings. Blanket restrictions are rules or policies that restrict a patient's liberty and other rights, which are routinely applied to all patients, or to classes of patients, or within a service. However, one patient told us staff did not help them to manage their condition very well. Two patients told us they were not involved in decisions about their medicines.

We spoke with seven carers who gave us mixed feedback about their involvement in managing risk. Most carers felt they were involved in managing the risks of their relatives. One carer said they had been invited to attend all ward rounds for their relative. Carers were also supported to get involved in the care planning process. However, one carer told us information about the care of their relative was not always shared with them and the ward did not have the right email address to contact them. Staff completed physical health checks for patients.

Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident. Staff could not easily observe patients in all communal areas of the ward but followed procedures to minimise risks in restricted areas including using regular observations at a frequency depending on each patient’s risk. The manager had updated risk assessments and care plans with a focus on improving observations. The ward manager ensured that staff recorded intermittent observations. The ward manager deployed staff and encouraged staff to be on the ward as much as possible and explained to staff why some patients had to be always observed. The management introduced safety huddles for staff to be able to raise any concerns regarding observations in a timely manner. The manager had also introduced new National Ealy Warning Score charts on Regency ward with a plan to review them at MDT meetings.

Staff told us they obtained information about patients’ risk from each patient’s previous placement, family and from the patient on admission. All risk assessments were kept on the electronic care planning system. Staff told us the ward staff did well in discussing risk as an MDT and everyone in the team contributed to the discussion of risks. Staff participated in the provider’s restrictive interventions reduction programme for Caburn ward, which met best practice standards. For example, staff used least restrictive options such as calm room, safety pods and sensory room to deescalate distressed patients. The manager told us Caburn ward was part of Collaborative of the Enhanced Therapeutic Observation & Care Programme ( ETOC Collaborative) which provides a more holistic and personalised approach to managing high risk situations.

Each ward had a restrictive practice lead. Managers held monthly meetings to review restrictive practice audits, identify lessons learnt and examples of good practice. Managers discussed restrictive intervention at MDT level meetings.

We saw evidence that staff completed regular risk screen reviews for patients. For example, staff regularly used MUST, National Early Warning Score (NEWS), Waterlow (a tool for pressure damage risk) reviews where applicable.

Staff completed risk assessments and care plans on admission and updated them after incidents. The provider had a policy on completing and reviewing care plans and risk assessments. The policy guided staff to provide care and treatment in the least restrictive way possible.

Even though patients were supported by staff who had completed restrictive practice training (PMVA), which taught them to use positive behaviour support plans and de-escalation techniques to reduce restraints, staff did not always follow processes to assess and manage risks to patients and themselves well. Staff did not always follow best practice in de-escalating and managing distressed behaviour.

We reviewed 20 care records, and they contained up-to-date risk assessments, care plans risk management plans which were comprehensive, informative, individualised and was regularly reviewed by staff and during MDT ward round.

Staff monitored patients’ physical health well and documented health concerns which included good escalation plans. For example, we saw good physical health care plan for diabetic patients and escalation plan in place for patients who used substances and were on opiate withdrawal.

However, the service did not ensure patients with dual diagnosis of mental health and substance misuse received adequate physical health monitoring. For example, there was no evidence of withdrawal monitoring in patients’ notes. We raised our concerns during our feedback session and managers assured us that the provider would train staff on dual diagnosis care. The managers confirmed they would work with their consultant nurse for dual diagnosis to review the assessment and treatment process for patients with dual diagnosis.

We spoke with 19 patients and received mixed feedback from the patients. Four patients on Caburn ward told us that they felt their care was provided in a safe, clean environment that was designed to meet their needs, and that facilities and equipment were well-maintained. However, three patients on Regency ward said the ward environment was not always clean. Two patients told us they sometimes found the ward environment to be noisy and couldn’t cope with the noise level due to their sensory processing difficulties.

Staff told us they knew where ligature cutters were and had received training on how to use ligature cutters. Staff said the prevention and management of violence and aggression (PMVA) team visited the ward and did simulate incident training with staff on how to use ligature cutters. However, some staff could not tell us what action they would take if there was a ligature incident or how to mitigate those risks. Staff completed security checks in between handovers. Staff told us the ward had a ligature heat map displayed in the office. However, some staff told us they had not seen the ligature risk assessment document and did not know whether there was a ligature point risk assessment document on the ward. Some staff were also not aware of the environmental and ligature risks.

On the day of our onsite inspection, the chief nurse made a recommendation to the admissions team to pause patients’ admission for Regency ward for few days to address the immediate safety concerns about the environment which we raised with the managers during our initial feedback session. The pause on admission was also to address the acuity and level of risk of some patients admitted onto the wards.

. Staff told us it was very difficult to manage or deescalate distressed patients in the Regency ward environment without infringing on their privacy and dignity.

Even though staff had access to toilet on the ward, other toilets and restrooms were located outside the wards which made it difficult for staff to access these whilst supporting patients on the ward. For example, staff told us they sometimes had to wait for staff to cover from another ward before staff could go out to use a toilet which was inconvenient for staff and sometimes posed a safety risk for the wards. Staff told us the lack of toilets and restrooms on the wards affected their wellbeing and morale.

The ward environment on Regency ward had long corridors with clear line of sight from the nursing office and had convex mirrors to monitor the blind spots. The layout of Caburn ward however, did not allow staff to have a clear view of all the corridors on the ward, from the nursing office. The ward had three different corridors which were difficult for staff to observe from the nursing office. The provider had installed convex mirror in the centre and other points of the ward to monitor the blind spots and other areas that staff identified as difficult to continuously observe. The provider had not installed a close circuit television (CCTV) camera on the ward.

Managers mitigated the risk of not having a clear line of sight of all parts of the wards by ensuring that staff consistently walked around the corridors and checked the location of patients to ensure patients were safe.

Regency ward had ligature anchor points without sufficient mitigations in place to manage the risks at the time of the assessment. Ligature audits identified bedroom doors as high risk, but not all staff knew the risks.

Regency ward did not have ensuite bathrooms but rather had seven toilets, three bathrooms and showers that were shared by the 20 patients. Caburn ward however had ensuite bathrooms with anti-barricade doors and collapsible doors installed with visual panels on doors with anti-ligature fittings.

We escalated our concerns about the environment to the senior management team during our feedback session. The management gave us verbal assurance to immediately mitigate the risks. We received an action plan which provided details of immediate actions the provider had taken to mitigate the ligature risks on the wards.

We observed that the ward areas and the clinic rooms were generally clean. However, Regency ward environment looked a bit tired and needed re-decorating.

As part of the short-term mitigation plan, the provider took decision to supervise patients to use bathrooms on Regency ward until ligature risks were fixed and proposed to reduce bed numbers by two. The provider aimed to urgently address these risks within one week and stated the managers would complete a full re-assessment for both wards on 25 June 2024. The provider confirmed the lead nurse for quality and compliance would support the staff with further face to face ligature awareness training sessions and that had been a priority for the organisation over the last year. The provider was in the process of developing online ligature awareness training for all staff.

The manager informed us refurbishment work was underway and was constructing a new therapeutic room to provide the right environment for patients. Fire doors on Caburn ward were being replaced at the time of our assessment

The housekeeper kept a cleaning record sheet which was used to monitor the cleaning schedule for the ward. We saw an up-to date recording sheet for fridge and freezer temperature checks in both clinic rooms and the kitchen.

The service had good process for maintenance works and had a maintenance log where staff reported maintenance issues. We saw evidence that environmental issues were reported on time to the maintenance team. The maintenance team ensured they promptly worked on maintenance issues raised by patients. Staff discussed maintenance issues as a standing item on the agenda during the morning flash meetings.

Staff had easy access to keys and alarms and patients had easy access to nurse call systems.

The service had a local risk register, which included the need to change the toilets on the ward following a serious incident on Regency ward.

Patients and their relatives told us there were times that the staffing on the ward was okay, and they could see enough staff, always two or three in each lounge. However, there were times that the wards were short staffed.

We spoke with 24 staff and received mixed views about the appropriate staffing levels and skill mix. Staff told us they worked 12-hour shifts with six staff on the day shift which included two qualified nurses and four health care assistants (HCAs). The night staffing was seven staff which included three registered nurses and four HCAs.

Most staff told us there was not enough staff on both wards to meet the needs of the patients. The provider relied on the use of bank and agency staff to cover night shift and periods of unexpected sickness or absence. One staff told us due to low staffing numbers, staff did not always have the time to have 1:1 time with their allocated patient.

Staff told us the ward manager increased staffing levels after a recent serious incident on the wards, but the numbers dropped again after a few days.

Most staff told us they felt respected and valued within the team and had a good rapport with the patients. One staff member told us they were in a happy, supportive team and most staff worked well together. Staff told us some managers followed an open-door policy and encouraged open communication between staff and managers. Staff described some wellbeing processes that were in place, including staff away days. Managers held weekly meetings with the night staff to ensure they received the right support. However, two members of staff told us sometimes staff overworked themselves and found it difficult to observe their breaks due to low staffing numbers on the ward. Staff said there was not enough rooms on the ward especially for the on-call doctors to work in during in and out of hours. The doctors occupied a room outside the ward which made it difficult for them to quickly attend to emergencies on the ward. Staff told us they felt there was a disconnect between doctors, health care assistants and nurses.

During the onsite inspection we observed that both wards were fully staffed and there were enough staff to make sure patients received consistently safe, high-quality care that met their needs, and staff were visible on the wards. We observed the correct levels of staff, and the right roles were available to meet patients’ needs. Patients using the service were actively engaged in activities and therapy that was on offer. We conducted a SOFI observation and found that staff interacted with patients in a kind, caring and respectful manner.

Both wards had appropriate staffing levels and skill mix to ensure patients received consistently safe, good quality care that met their needs. The manager had a staffing matrix, and managers met the minimum safe staffing numbers on most shifts. We reviewed the staffing establishment for both wards and found there were some vacancies. There was one vacancy for an HCA, one consultant , two junior doctors and two charge nurses. Senior managers told us staffing had been a challenge, but the team was nearly complete. The provider supported international nurse recruits and in the last six months, they had employed 30 internationally recruited nurses, most of whom were newly qualified. The service had a fully staffed multi-disciplinary team.

Not all bank and agency staff received a full induction and orientation of the wards and understood the service before starting their shift. For example, some of the agency and bank staff had not received full induction and orientation of the wards before they were deployed Some staff did not have awareness of the environmental risks and did not know what do if they saw patients self-harming or taking an overdose of medicines. For example, one staff told us an agency staff on more than three occasions watched a patient tie a ligature and did not respond accordingly to keep the patient safe.

Staff sickness levels were low. The sickness rate at the time of inspection was 2.9% for Caburn ward and 4% for Regency ward. Managers supported staff who needed time off for ill health. Staff received supervision, appraisal, and support to develop and improve services and to provide safe care. Staff received training appropriate and relevant to their relevant role. All mandatory training on both wards, as at May 2024, was above 80% compliance rate. Staff had excellent compliance with supervision and appraisal. Clinical and managerial supervision compliance was 100% on both wards.

Patients we spoke with gave us mixed feedback about the cleanliness of both wards. Some patients told us they felt the ward environment was reasonably clean. However, some patients felt the ward environment was not always clean.

Staff told us the environment was well cleaned. Staff were able to describe the actions needed to minimise the risk of infection to patients at the service. Staff continued with best practice when it came to washing their hands and changing their personal protective equipment (PPE) between tasks. Staff were wearing appropriate PPE and told us there was adequate supply whenever they were needed. The service was clean, and there were no concerns in relation to the management of infection control.

The ward had a dedicated housekeeping assistant who followed a planned cleaning schedule. We observed 2 house keepers who were sweeping and mopping the lounge. The cleaner had put a yellow sign on the floor to warn patients and staff about the wet floor. The manager completed weekly walkaround to check the level of cleanliness. Staff stored cleaning materials safely in a locked cupboard on the ward.

Staff had access to various detailed infection prevention and control policies. Staff followed infection control policy, including handwashing, cleaning door handles and completed enhanced infection control checklists every day. The staff managed infection prevention and control processes well and had access to personal protective equipment (PPE). Managers ensured staff used appropriate don on and don off clothing to prevent the spread of infection.

Where medicine was used to support patients experiencing anxiety or agitation, it was not clear why the medicine was administered to patients. Patients sometimes received a ‘when required’ medicine to control their behaviour despite the medicine not having been prescribed for this reason. Additional tools to support staff to manage anxiety and agitation were not routinely used on the wards. We were not assured patients received medicines appropriately.

Staff did not always rotate the site of the injection for patients who were prescribed long-acting depot injections. This could lead to the injection site no longer being able to be used and could cause discomfort for the person receiving the injection. There was a high use of medicines to manage agitation and aggression on the wards. Records we reviewed did not always support the use of these medicines. We could not be assured medicines were used appropriately. Records we reviewed showed that ‘when required’ (PRN) medicine was given to patients to manage their agitation instead of being prescribed to aid with sleep due to insomnia. This was against the prescriber's instructions and was an inappropriate use of chemical restraint. Care and treatment was regularly discussed with the multidisciplinary team as well as the patients. Patients’ medicines were reviewed at MDT meetings. Staff spoke to patients about how their medicines worked for them and if doses could be reduced to limit side effects and improve outcomes. Patients’ physical health was monitored routinely, and the provider employed a physical health team to support staff to manage people’s physical health. Patients’ prescribed medicines that could have an increased risk of side effects (high dose antipsychotic therapy (HDAT) or medicines such as clozapine or lithium) were appropriately monitored in in line with national guidance.

Staff were suitably trained to administer medicines. Staff were aware of aspects of physical health that could affect a person’s mental health and considered this alongside any treatment planned by the ward team. The wards had access to support from pharmacists who worked with the multi-disciplinary team. Staff conducted regular ‘mind the gap’ audits which helped identify errors or omissions in administration records and ensured staff were administering medicines as prescribed and it enabled ward managers to follow and act on errors to ensure patients received their medicines as prescribed. However, these audits were limited and did not always identify issues such as those found during the assessment. Pharmacy services were given by an onsite pharmacy team. The pharmacists and pharmacy technicians provided support to the ward including clinical support prescribers. They also offered education and training to staff on medicines optimisation. Supplies of medicines came from a pharmacy service supplied by an external provider. Staff told us they were able to order and receive medicines daily so that patients received prescribed medicines. Staff received a mixture of online and face to face training routinely to ensure competency and understanding of medicines optimisation and medicines management. There were regular audits conducted to review gaps in administration records. The ‘mind the gap’ audits identified areas where there were potential errors or omissions in records.

Staff were knowledgeable and gave medicines in a person-centred way where possible. However, liquid medicines did not have open/expiry dates recorded on them. Staff did not always have easy access to the correct Mental Health Act (MHA) consent to treatment documents at the point of administration. These should be regularly checked to ensure medicines were given safely and legally to people detained under the MHA. We observed that staff were sometimes unaware of whether patients’ physical health deterioration was due to side effects of a prescribed medicine which made patients slower to react to reduce or stop a prescribed medicine. We saw that medicines were stored safely and securely in temperature-controlled clinic room. Checks were completed for the environment routinely. However, the portable aircon unit in Caburn Ward’s clinic room was not working on the day of the inspection. There were gaps in records and where records indicated that medicines had been stored above the maximum recommended temperature there was no evidence that medicines had been assessed to ensure they would work as intended. Mental Health Act consent to treatment documents were not always accessible where medicines were prepared and administered. Nurses did not routinely check medicines being administered were legally authorised before the medicine was given. Most liquid medicines had a reduced expiry date once opened, and this should be clearly recorded to ensure the medicine being given was going to work as intended. Where patients were prescribed medicines with additional monitoring required such as the antipsychotic medicine clozapine or the antimanic medicine lithium, the appropriate monitoring was being completed by the provider. However, during the inspection we observed staff were not always able to identify when deterioration of physical health may be due to adverse reactions to a prescribed medicine and the need to review and stop treatment if needed in a timely way.

There were processes in place to ensure people were receiving their medicines safely and as prescribed. However, these were not always being followed. Care plans and risk assessments lacked detail about medicines with known risks and how these should be monitored by staff. Care plans and risk assessments to support staff to understand and identify these risks were not always updated when a new treatment was started. When a medicine was administered to sedate a person as rapid tranquilisation, the process to ensure a person’s physical health was monitored for their safety was not always followed or recorded. This placed people at an increased risk of harm due to adverse reactions to these medicines. There were processes in place which could support the safe and effective use of medicines. However, these weren’t always followed. There was an up-to-date medicines management policy in place at the service. We were not assured there was an overall robust audit process in place that identified areas for improvements and provided actions to improve practice. This is due to the number of errors we found during our inspection process. Care plans for medicines often lacked details about risks and side effects that should be considered by staff when supporting people. Where a medicine was administered as Rapid Tranquilisation (RT – where a medicine is administered via injection for the purpose of rapid sedation) the required post-dose physical health monitoring was not always completed. This placed people at risk of an adverse reaction to the medicine going unnoticed. Some patient’s records included calm cards which are tools to help staff to understand how to effectively support to de-escalate a person in a way which worked for them. However, these were brought over from other wards and none of the wards we assessed had a process for sharing person centred information about de-escalation at the point of administration.