Dorset Healthcare 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

We reviewed the learning culture, safe systems and pathways, involving people to manage risks, safe environments, safe and effective staffing, medicines optimisation and infection prevention, and control (IPC), quality statements for the safe key question.

We found a breach of the legal regulation in relation to safe care and treatment. We found that staff did not always provide treatment and care for patients in a safe way. Patients did not have risks assessed in a timely manner and there were concerns about medicines management.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Overall, patients were positive about staff training and learning, although there were some concerns raised about staff providing activities and knowledge about the management of diabetes on St Brelades Ward.

However, people and carers reported that they had benefited from recent changes on the ward. This included increased staffing and reducing the number of admissions.

Staff said a comprehensive learning and training package had been put in place after previous incidents. Staff and leaders said learning had included reducing bed capacity to 10 people and freeing up staff time to attend training to ensure their knowledge and skills to enable them to provide high quality of care for patients on the ward. This had been actioned following learning from incidents which had occurred.

Leaders said a new post had been created for a speech and language therapist (SALT) across the service to further improve access to services and quality of care for patients.

The service treated all incidents, concerns and complaints seriously and investigated them taking learning and driving improvements across the service, for example following the choking incidents in February 2024.

We saw that staff reported and reviewed incidents regularly and escalated any concerns appropriately. Clinical effectiveness meetings were held on both wards which senior leaders and staff attended.

We received mixed feedback from carers. Some were not confident that staff and leaders could keep their relatives safe and well cared for. For example carers felt agency staff didn’t know their loved one and this was impacting on their care. However, carers described being involved in the discharge process and being consulted about any plans which they valued.

Staff felt that the reduction in bed numbers and improved staff culture and morale had helped improve the quality of care on St Brelades Ward. Staff recognised they had more time to get to know the people well which helped them to recognise triggers and use de-escalation skills appropriately. However, they still relied on agency and bank staff and looked forward to the completion of substantive staff recruitment.

We did not receive and feedback from partners however, we saw examples of ward staff working with tissue viability teams, best interest assessors and social workers as part of partnership working providing hollistic support and care to patients.

Staff completed a risk assessment before each admission and this was shared with the executive team who decide whether the admission was appropriate.

However, staff on Herm Ward could not always access information about risk easily as it was recorded in many places. For example, risk assessments and care plans did not always include consistent risk information.

There were policies about the use of shared rooms but apart from the initial risk assessment, there was little evidence of patient consent to this. For example, some women could change their mind about sharing a room once they had experience of the shared living and an alternative single room may not be available.

Whilst some carers reported that their loved ones received safe and appropriate care, some were concerned about a lack of experienced staff with knowledge and skills to provide care. Carers reported there was not enough experienced staff who knew the job. They felt agency staff had not always been able to build up rapport with patients due to the ad hoc shift patterns they worked, some staff were inconsistent and some did not speak to patients with dementia in a kind manner.

Staff knew how and when to report safeguarding issues appropriately and could give examples on when they had raised concerns. Staff had completed safeguarding training appropriate for their roles.

We saw examples of actions being taken to safeguard patients, including financial safeguarding.

There were sufficient systems in place to ensure staff were able to report safeguarding referrals. Staff we spoke to were clear on their role and responsibility around this. There was a system of ongoing training for staff and a safeguarding lead within the trust they could access.

Carers described being involved in decision about their relative’s care including discharge planning.

The multi-disciplinary team, including a clinical psychologist, completed dynamic risk assessments for each person. Staff reported good communication about sharing risks and that these were managed appropriately. On Herm Ward there was a specific risk assessment for female patients sharing a room. This included considering the impact of a person’s behaviour on the other person. Staff said people and carer voice were central to all decisions.

Policies were in place, but they did not always protect people from potential risks.

There were policies about the use of shared rooms but apart from the initial risk assessment there was little evidence of consent. Especially if patients were admitted when all the single rooms were in use. This risk was mitigated by a plan for an additional 6 bedrooms as a result of planned redevelopment of the ward environment which had been approved by the board, with work to start in 2025/2026 financial year.

There was covert use of a camera in a room designated for patients at risk of falls. There was no signage or permissions in place for its use. A best interests meeting had not been held. This meant patients and relatives might not be aware a camera was being used and the staff had not considered whether the loss of privacy was in the person’s best interests. However, staff in the office could monitor the cameras.

We also reviewed the admission pack which included guidance and templates on several risk assessments. These included the room sharing risk assessment, monitoring of physical health, nutrition and falls risk assessments. There were also a moving and handling plan and carers pathway. However, we did not always see evidence that these had been completed.

The wards had dementia friendly environments and appropriate signage. The wards were both locked as most people were either detained under the Mental Health Act 1983 or subject to Deprivation of Liberty Safeguards (DOLS). Carers told us they felt the environment met the needs of their loved one.

Staff said they felt safe at work and that they and colleagues had skills needed to manage any risks appropriately.

The wards were settled and relaxed with levels of observations being carried out appropriately and discreetly. Several people were identified as ‘exit seeking’ and this was managed sensitively and approproately by distraction and de-escalation techniques.

Each person had a comprehensive risk assessment carried out before being considered for the ward. This included a ligature risk assessment.

Staff had completed an updated ligature risk assessment for the wards, which was dated 2024.

Carers on St Brelades ward reported not always having enough staff to care for their relatives. This included not always having time for activities. Carers noted improvements in staffing but stated low staffing levels sometimes made them anxious. They said if they were visiting and another patient came up to them it could be intimidating as they didn't know what they were going to do.

However, some described staff as going the extra mile for their relatives

Staff remained concerned about staffing levels. From January 2024 to April 2024, 17% of shifts were unfilled by staff, with a third staff shifts worked by bank or agency.

However, staff and leaders said the new ward managers and newly created Service Lead for Older Persons Organic and Functional Mental Health Inpatient Services post which also included the oversight of clinical care and quality were instrumental to improvements on the wards. They welcomed the proactive recruitment across all grades to try and reduce reliance on agency staff usage. Staff reported morale was slowly improving with more substantive staff joining the team. Senior leaders told us once the ward was fully staffed and all training was in place, patient numbers/restriction would be reviewed again.

We saw there was always a trained nurse present in the dining room during meals.

The multi-disciplinary teams were working well in the wards to meet the needs of patients. They included psychiatrists, clinical psychologist, physiotherapists and occupational therapists. Further improvement included the intended recruitment of a new post 0.6 full time equivalent role had been created for a speech and language therapist to join the team. Once in post this role would help with swallowing assessments and mitigate risks around incidents whilst eating. This post was created following the learning from the choking incidents in February 2024.

At St Brelades ward, the interim manager had introduced staff changes. At the time of the inspection, they were recruiting a further 6 registered nurses. Agency and bank staff were also block booked to cover the ward and to provide a level of continuity for patients and their care needs.

There was also an active recruitment plan in place with 4 registered nurses due to start work in the wards at the end of 2024. The trust planned to hold a recruitment open day for support workers in October 2024 to encourage people to come to work for the service.

Carers told us the felt the wards were well maintained and kept clean and tidy.

Staff said the wards were cleaned regularly with a domestic team. Leaders said these staff were integral part of the team.

On arrival on St Brelades Ward, the door was opened to us by a staff member wearing blue gloves who was carrying out personal care. The staff member returned to carrying out personal care and the door handle was not cleaned. This put patients, staff and visitors at potential risk of infection. We escalated this to the ward manager on the day of the inspection who took immediate action. At the time of our inspection training around infection prevention and control was ongoing for all staff. We did not see any other concerns with Infection, prevention and control.

The manager had started reviewing the oversight of the infection control procedures with additional staff training to alert them to possible infection control risks. However, they recognised this was still a work in progress and improvements were still being made.

There was a cleaning rota in place and all equipment was cleaned and maintained regularly. Cleaning audits took place and these were monitored by the leadership team at ward level. Action was taken to make improvements when required.

Some relatives told us they felt that staff did not have sufficient knowledge about diabetes care and management.

Staff welcomed the additional training the new interim manager had put in place to improve their knowledge and upskill them.

We saw staff sought professional advice, however, they did not always follow this advice. For example, a pharmacist stated in a best interest meeting that it was not in best interest of a patient to have a medicine given covertly. Staff had not recorded clearly in the records the rationale for this and the patient was still having this medication administered covertly.

In the second patients file, there was a list of medicines which were required to be given covertly, but no information as to how this should be done. This meant staff were choosing their own administration method. For example, Lorazepam was given in a sweet, but this was not recorded in the care plan. There was also no evidence this had been part of a best interest meeting.

In the third patients file, further medicines were recommended to be administered, however there was no evidence about a discussion whether staff had attempted to give the patient the medicine overtly first.

Following the inspection, the service provided evidence of updated patient care plans for the administration of medicines covertly.

The service did not have robust processes to manage the administration of medicines covertly.



On Herm Ward, there were clearer notes regarding the outcomes of administration of medicines, and the PRN (‘as and when’) medicine plans had more detail about staff trying to give medicines overtly first before giving them covertly. However, on St Brelades ward, patient files didn’t give this level of information.