Burton Park

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

Improvements had been made to the safe management of medicines, staffing and premises and equipment, the provider was no longer in breach of regulations. Staff and managers demonstrated a proactive and positive culture of safety. Safety events were investigated and reported thoroughly, and lessons learned. Safeguarding was high on all staff’s agenda with effective identification and reporting systems. Risks were assessed and managed, so patients were supported in the least restrictive way. Infection prevention and control practices reduced the risks of spreading infections.

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.

Patients felt safe and had confidence in staff taking action to promote their safety. We saw staff used equipment and technology to reduce risk where patients had been identified at risk of falling or hurting themselves.

Staff told us the different ways a learning culture was promoted. For example, staff meetings and handovers were used to deliver safety messages to staff. Staff were able to give examples of how changes had been made in response to safety concerns.

People’s safety was promoted because staff and leaders promoted an open proactive culture of safety. Incidents were reported and investigated. Lessons learned were shared and embedded into practice. For example, daily staff meetings known as ‘flash meetings’ involving staff from each department took place. Safety concerns and incidents arising over the previous 24 hours were discussed along with what action staff must take to reduce risk. For example, a medicines review was completed following a fall. The provider had produced and circulated safety bulletins / briefings when important messages have needed to be relayed to the whole clinical teams. These included learning from the provider’s other locations and from the wider sector.

Patients we spoke with told us about the progress they had made and the support they received for discharge planning and transition between services. Some people were frustrated because of delays to this process but these were out of the provider’s control.

Staff were able to describe action they had taken or were taking to ensure patients received effective safe care and support. For example, following a patient being admitted to hospital for a sudden onset physical illness, staff carried out a full review to ensure all safety concerns were fully addressed and ensured continuity of care on their return to Burton Park. The registered manager described the ongoing discharge planning for 6 patients. This included the service supporting and facilitating one patient with a 2-week trial period at another service.

Recent quality monitoring visits undertaken by partner agencies reported effective care and support. Progress and improvement for patients working towards being discharged or transitioning to other services was noted.

The provider had processes and systems in place to establish and maintain safe systems of care, in which safety was managed, monitored and assured. Continuity of care was supported through effective communication with other services and with patients and staff.

Patients told us they felt safe and felt staff would listen and take action if they raised any concerns. Patients’ relatives said the service was safe.

Staff knew how to recognise abuse and what action to take if they suspected it. They were confident any concerns they raised would be listened to and action taken. They were able to give examples of when safeguarding concerns had been raised and these were appropriate. The registered manager gave us an example of when a full safeguarding review was carried out following a patient admission to another hospital for a physical illness. They told us this had provided assurances to staff and to the patient’s family.

Staff supported patients in an appropriate way and took action to protect them from risk and harm.

Effective systems were in place to manage safeguarding risks. The provider had a comprehensive safeguarding policy in place. This policy included incident reporting and actions staff must take in relation to reporting, escalation and documentation. All staff undertook safeguarding training as part of the induction to the service. Staff compliance rates for safeguarding training were 100%.

Where possible, patients were involved in developing their care plans and risk assessments. Relatives told us the service felt safe and they were kept updated.

Staff were knowledgeable about patients’ needs and individual risks and knew what to do to minimise risks. For example, staff knew what level of support patients required and when and knew about their goals and aspirations. They were able to describe the progress patients had made and how care and support had reduced, as their confidence and daily living skills increased.

Staff completed risk assessments for each patient on admission using a recognised tool, and reviewed this regularly, including after any incident. Risks were assessed and care plans and risk management plans were developed. Information about each patient, what was important to them, how they preferred to be supported and triggers which may result in distressed behaviour were recorded so staff knew how to keep people safe and reduce risks. While records about individual risks were comprehensive, some details were not recorded on individual risk assessments regarding specific incidents. However, staff did know and understand patients’ current needs and risks. Following any incident of distressed behaviour, support was provided and consideration given to current risk and care planning. This included discussion and input from the patient where possible. Weekly and monthly meetings attended by the multi-disciplinary team took place where risks and risk management were discussed Physical risks were also assessed and managed. For example, there was clear written and pictorial information about how to reduce risk for patients with swallowing difficulties and when to escalate any concerns to a Speech and Language Therapist.

Patients were satisfied with the environment. All rooms were single and ensuite and some patients had personalised their rooms with pictures and photographs. The ward was separated into same sex accommodation.

There was an on-site estates team. The estates team manager had a good understanding of patients’ needs and how the premises and environment should be managed and maintained to promote safety and reduce risks. They attended daily meetings where any safety concerns in the environment were discussed. Staff we spoke with told us the premises and environment met patients’ needs and the estates team were responsive when any maintenance or repairs were required.

Cleves ward was mostly well maintained and areas of the ward had been redecorated, but there was further work to do with some furniture to be replaced.

There was a plan for ongoing redecorating and repairs across the site, which included all communal areas as well as patient bedroom areas. There was also a more detailed site improvement plan that identified other works required, for example, repairs to parts of the building; flooring; signage and replacement of furniture, where needed. Each task had a priority rating and completion dates were entered as appropriate. This enabled staff to keep a track of progress. Routine maintenance checks and safety certificates were in date for gas, electric, lifts and hoists. A fire risk assessment had been carried out with an action plan for any deficiencies identified and these were being addressed. For example, all fire doors were being replaced or repaired. Records showed weekly and monthly checks were carried out to ensure fire alarms and fire safety equipment were in full working order. The provider had a policy for the assessment and control of ligature points (A ligature anchor point is anything that could be used to attach a ligature ). A ligature risk assessment had been completed along with ongoing audits. Any rooms with high-risk ligature points were not accessible or were supervised access only. Mirrors were used in communal corridors to support staff observation of patients and reduce risk where staff did not have clear lines of sight. Medical equipment such as blood glucose monitoring machines were maintained and re calibrated monthly.

Patients told us they liked the staff and had confidence in them. Staff attended to their needs in a timely way. Relatives told us there were enough staff and they had confidence in their abilities and competence.

Staff told us they had enough time to meet the needs of patients and to keep them safe. Some staff felt that at times, staffing numbers were not sufficient to support patients to go out, however this had improved. There had been a significant decrease in the use of agency staff since our last inspection and staff told us how this had a positive impact on patients and staff because care and support was more consistent. The occupancy level at Burton Park was low. The registered manager told us staffing numbers including therapy staff such as psychologists and occupational therapist hours would be increased as patient numbers increased. There was 1 psychiatrist on-site 4 days a week and 2 other psychiatrists to cover on call duties. We were told additional medical staff would be employed as the patient numbers increased. Staff told us they received the training and support they required.

We saw staff spent time with people through the day and responded to calls for support quickly. Staff were knowledgeable about their roles and responsibilities.

Required staffing numbers to meet patients’ needs and keep them safe were calculated using a recognised staffing tool. Staffing rotas showed required numbers were achieved. Agency staff used were usually known to the hospital and booked for blocks of work to improve consistency . Staffing numbers were monitored and discussed within the daily flash meetings, as were any appointments, meetings, visits and planned activities. This enabled the team to identify what staff and from what discipline were able to facilitate each activity and to take action to address any staffing shortfalls. There was a safe recruitment process for new staff members which included all required checks and references. For staff on professional registers such as the Nursing and Midwifery Council, checks were carried out to ensure ongoing compliance and fitness to practice. Compliance with mandatory training was at 100 %. All new staff undertook induction training to prepare them for their role and awareness of expected safe standards within the sector. Staff received regular supervision to monitor their performance and discuss their learning and development needs. Compliance rates had consistently achieved over 75% since January 2024, with one exception in June 2024, when clinical supervision was recorded as 64% compliant, and management supervision as 69% compliant.

Patients we spoke with said they were satisfied with how clean and tidy the service was and felt this had improved since last year.

Staff knew how to reduce the risk of infection because they received training and were knowledgeable about the provider’s policy and best practice guidance. Housekeeping staff had the equipment and resources they required to carry out expected cleaning of the premises and equipment. They told us there were enough housekeeping staff for the numbers of patients, but expected that their hours would increase along with increasing numbers of patients.

The premises and environment were mostly visibly clean and fresh. There was a large build-up of ice in a fridge freezer in the satellite kitchen. The provider decommissioned the freezer during our site visit and ordered a replacement. Staff used personal protective equipment appropriately and practiced effective handwashing. The clinic room was visibly clean and hygienic.

The provider had an infection prevention and control policy for staff to follow. Staff received training about infection prevention and control. Separate housekeeping staff were employed. They followed daily and weekly cleaning schedules. Cleanliness and hygiene were monitored and audited to make sure policies and procedures were adhered to. Audit results showed compliance was above 95% in June 2024. The head of housekeeping also carried out weekly and monthly quality checks for the cleanliness of the premises and environment. The kitchen and food preparation had achieved a 5-star rating at the last local authority environmental health inspection. Catering staff carried out food and storage temperature checks to ensure safe guidance was followed.

Patients told us staff managed their medicines in the right way. They had their prescribed medicines at the right time and in the right way. Patients and relatives were invited to meetings to discuss medicines and any changes. Relatives told us they felt involved in their family member’s care.

Staff responsible for prescribing or administering medicines were knowledgeable about the safe use of medicines and about expected safety standards, policies and procedures.

Staff followed safe checking and administration procedures when managing medicines.

Medicines were only managed by clinical staff with appropriate skills and training. Medicines were prescribed and administered in a safe way. Systems were in place for reviewing and monitoring the effectiveness of prescribed medicines. A patient who received medicines through a percutaneous endoscopic gastrostomy (PEG) had a detailed care plan in place instructing staff how to ensure medicines given by this route followed best practice guidance. Medicines were stored correctly and safely in a clean and temperature-controlled environment. Administration records for prescribed medicines and controlled medicines were up to date and accurate. Oxygen was stored safely and with appropriate signage. Capacity assessments were carried out to ensure consent for medicines was lawful. Where medicines were administered covertly a best practice protocol was followed and best interest decision recorded. Emergency drugs and life support equipment were available, and staff knew how to access these.