St Matthews Hospital

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. This was clear within care records viewed.