Cheswold Park 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 assessed a limited number of quality statements in the safe key question and found some areas of good practice. The scores for these areas have been combined with scores based on the rating from the last inspection, which was inadequate. The assessment of these areas indicated some areas of good practice since the last inspection, our rating for the key question changed to requires improvement.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

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

Patients told us they felt safe and cared for and comfortable to raise any issues with staff or hospital management. Most of the families and carers also told us that they were kept informed, knew who to speak with if they had any concerns and were invited to relevant meetings.

Staff we spoke with told us they were confident in how to raise and report concerns. All staff completed Safeguarding Adults and Children training and were 98% compliant with this training. We completed a review of 4 seclusion suites as part of the onsite inspection and we found that documentation was robust, and policies followed to ensure the appropriate safeguards were in place.

During our onsite inspection we used the Short Observational Framework for Inspections (SOFI) on 8 occasions to capture the experiences of people who use services who may not be able to express this for themselves. We observed positive interactions between patients and staff, appropriate use of supportive observations and patients appeared well engaged and relaxed.

The provider had effective systems, policies, and processes in place to ensure that staff identified and reported concerns. The 17 care plans we reviewed detailed safeguarding concerns and how these were being managed. The provider had good record keeping and between 01/01/24 to 04/06/24 they made 94 safeguarding referrals and notifications were submitted appropriately.

Patients told us they felt safe on the wards. Patients were involved in community meetings and had access to advocacy services. Blanket restrictions were detailed on the ward for patients to see and were discussed with patients. Patients had up to date risk assessments and positive behaviour support plans that were specific to the individual and there was clear involvement or attempts to involve patients in creating these.

Staff completed an accredited training course on Prevention and Management of Violence and Aggression. Staff were 99% compliant with this training and staff spoke positively about the use of de-escalation. Patients were assessed and reviewed by specialist teams such as occupational therapists, psychologists and speech and language therapists, when appropriate. Positive and safe files with individual profiles were available on the wards and one page information about patients for any new or bank or agency staff.

The provider had effective systems in place to manage risks and used physical intervention and seclusion as a last resort. We reviewed 17 care records, and all had up to date risk assessments and positive behaviour support plans which were reviewed regularly. Personal Emergency Evacuation Plans (PEEP's) were in place and the 28 we reviewed were up to date. We reviewed 6 seclusion reviews and records showed, between January and June 2024, the service had used seclusion on 10 occasions. Physical intervention had been used on 94 occasions, in the same period. The service had no incidents of prone restraint and no use of rapid tranquilisation. Restrictive and physical interventions were monitored, and positive and safe reviews carried out by the prevention and management of violence and aggression team. Blanket restriction registers were in place on all wards and ligature risk assessments were completed and up to date.

The hospital involved patients to control potential risks within the ward environment and patients were encouraged to comment on the environments in community meetings. Most patients told us that staff were visible on the wards, they felt safe on the ward and all wards had rooms where patients could go if they needed a quiet space.

Staff we spoke with were clear on how to keep environments safe using patient observations and appropriate restrictions. All wards allocated a member of staff to ward security on each shift to complete relevant checks. However, ward managers stated storage of patient belongings was a concern as items were not being logged properly and they were unclear what belongings patients had.

We completed a tour of all wards and seclusion suites and observed the areas were clean and well maintained, however, the storage of patient belongings was a concern on 3 wards and on Aire ward most bedroom doors did not have viewing panel windows.

The providers processes did not always ensure that patients belongings were stored safely and securely on all the wards. On 3 wards there was either no system to log the storage of patient belongings or log sheets were not consistently filled out. Environment audits, completed in May 2024 identified some issues with patient property on most wards. However, we found improvement in some processes which kept environments safe, such as up-to-date ligature risk assessments, use of patient observations, environmental audits and staff had easy access to alarms and patients had easy access to nurse call systems.

Patients we spoke with raised concerns regarding cancelled Section 17 leave, which allows detained patients to be granted a leave of absence from the hospital in which they are detained, and cancelled activities as a direct result of staffing. Some patients also raised concerns about the employment of staff with a lack of mental health knowledge. However, patients did tell us staffing had improved since the last inspection. Patients told us that they had regular opportunities to meet with their responsible clinician and named nurse.

During our onsite activity staff told us that staffing numbers had improved since the last inspection. The provider held 3 staff engagement sessions in January and February 2024 and safety and staffing numbers was the highest ranked area of concern by the staff. The hospital introduced a new staffing tool which worked on the premise of optimum staff numbers rather than minimum numbers and the closure of 2 wards had increased the staffing on other wards. Nursing staff told us that improvements in staffing have had a positive effect on spending more time with patients and providing therapeutic activity.

We observed good levels of staffing during the inspection and there was enough staff to meet patient need, including activities, engagement, and Section 17 leave.

The provider still had some improvements to make to ensure they had enough qualified, skilled, and experienced people. Between 01 June 2023 to 31 May 2024 the service reported 155.8 leavers. Training records in May showed Immediate Life Support training on Aire ward was 78% and Breakaway training for nursing management and Aire ward was below the providers target at 66% and 33%, respectively. However, the hospital had implemented the use of a staffing tool which utilised a RAG rating (Red, Amber, Green) system to improve day to day staffing. The provider monitored mandatory training and alerted staff when they needed to update this, and the hospital was 99% compliant with training overall. The provider had made positive changes to recruitment and the induction of new starters.

We received feedback from 11 patients and 5 relatives who did not raise any concerns regarding the risk of infection. Patients told us that there was regular cleaning on the wards and relatives told us that the rooms they saw were always clean.

Staff we spoke with were aware of infection, prevention and control requirements and policies. However, managers told us they were are unclear who’s responsibility it was to label items for patients and clear the items from the communal fridges.

During our ward tours we observed the communal areas and bedrooms to be clean, well maintained and observed domestic staff cleaning. However, on Aire and Foss wards the communal fridges in the dining room and kitchen held some patient items which were not labelled to say who they belonged to and there were no dates on some items so it was unclear when they would expire.

The provider had some effective systems and processes in place to ensure they managed the risk of infection. A team of domestic staff carried out regular cleaning of the hospital. Managers completed hand hygiene audits and the audits on most wards were 100% compliant. Training statistics for May indicated 100% compliance with hand hygiene training. However, there were unclear processes and management of communal fridges and patient items.

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