St Matthews 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

Although we found areas of good practice at this assessment, until we have assessed more quality statements under safe, the rating for this key question will remain as requires improvement We identified that managers had failed to adequately mitigate against some specific ligature risks areas within the hospital. Four patients had unsupervised access to high-risk areas, as determined by the providers ligature risk assessment. Individual patient records showed that these patients had high risk histories, to include deliberate self-harm. We identified this as a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The safe key question was therefore not consistently good. However, managers ensured that all relevant health and safety checks across the hospital were completed as expected, with any outstanding actions being prioritised and allocated for action. Staff had a good understanding of safeguarding and escalated concerns in line with provider policy to make sure patients were protected from abuse and neglect. Patients’ human rights were upheld, and they were protected against discrimination. Staff were aware of and knew where to find information about patient risks. Staff discussed risks and relevant recent incidents and concerns during shift hand-over meetings and other internal meetings. Staff worked with patients to understand and manage risks in a person-centred way, evidenced with patient documentation viewed.

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.

We spoke with 7 patients. All patients interviewed said that they felt happy, safe, and supported in the hospital. All patients said they felt the staff knew them well which meant that staff were able to effectively support them to manage any risks. Patients also said that they felt the staff took the time to listen to them and were genuinely interested in whatever they had to say.

Staff completed safeguarding training and demonstrated an understanding of what they would report and to who, if they suspected any abuse. The hospital had a safeguarding champion as a resource who could be called upon for advice. Staff were aware of escalation procedures internally and were aware that the Local Authority were contacted as and when appropriate. Safeguarding incidents were discussed routinely during handover meetings, along with any actions which needed addressing.

We observed that patients were comfortable in the presence of staff. All patients we spoke with felt safe at the hospital and told us that staff supported them to manage any risks. The hospital displayed lessons learnt posters, which included information relating to safeguarding issues that had arisen across the hospital.

The provider had relevant policies and procedures in place to protect both staff and patients to keep them as safe as possible. All polices were available to staff. Senior staff monitored training compliance. All staff were up to date with relevant mandatory training as expected. All staff had received training in the Mental Capacity Act, Deprivation of Liberty Safeguards, as well as the duty of candour. There was a clear procedure of escalation which staff followed upon identifying a safeguarding concern.

All patients interviewed said that they were given copies of their care plans if they wanted these. Patients said that they did have input into their care planning and that if there was anything that they were not happy with the staff and doctor did listen and where possible changes were made. All patients we spoke with said they felt that they were supported by staff to be as physically, mentally and emotionally well as they could be.

There was evidence of patients having choice over their care. Care plans viewed showed that there had been patient involvement where possible, with examples of the patient’s voice / wishes. Patients were encouraged to attend multi-disciplinary meetings where care, treatment and progress was discussed.

The provider had appropriate policies in place for staff around care planning and expectations of collaboratively working with patients. Policy also related to individual assessment of need and the management of risk. The hospital works on a named nurse basis which offers consistency to each patient. Staff genuinely tried to ensure patients were able to do what really mattered to them, and if this was not possible, how the staff and patient worked together to achieve this in the future was considered.

All patients we spoke with said they felt happy, safe and supported at the hospital. Patients said that they liked the environment and that there was a nice friendly feeling to the unit. Patients said that due to the environment feeling nice it helped them to form good quality friendships with each other.

Staff were aware that the hospital had numerous health and safety checks with regards to the environment. This included, but not restricted to an annual ligature risk assessment. Managers ensured that all relevant health and safety assessments were completed, with outstanding actions taken forward.

There were ligature risks in isolated areas of the hospital which had not been adequately mitigated against. We reviewed the ligature risk assessment and noted some high risk and moderate risk areas (that is, rooms or areas which had scores of a high or moderate ligature risk) which patients had access too unsupervised. In particular, we were concerned that 4 different patients were placed in bedrooms with access to high-risk bathrooms and shower rooms. All 4 patients had some history of engaging in deliberate self-harm and / or had care plans in place around deliberate self-harm. While the provider submitted documents to show how they had considered this risk and put in place some measures to manage the risks, they had failed to make sure patients care plans and risk assessment reflected these overarching mitigation measures. This meant that if staff were not made aware of the overarching risk mitigation, they would not know what risk management practice to employ.

During the inspection we reviewed the health and safety folder for the hospital. This included legionella, Fire Risk Assessment, Gas safety certificates, Health and Safety certificates, PAT testing, lift inspection, gas safe service for boilers, Fire alarm service, Fire extinguisher service, and call bell system service. All were in date and where actions had been recommended, these had been undertaken.

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

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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