Southern Hill Hospital Also known as 1-4807189797

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

The service supported patients to be safe from abuse and neglect. Patient’s care records and risk management plans were person-centred, individualised, and staff reviewed these regularly, including after any incidents. The provider ensured there were enough staff to support patients. Staff completed induction and mandatory training was comprehensive and met the needs of patients and staff. Learning from incidents was shared across the hospital. However, this did not always reach frontline staff.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us that staff debriefed with them after any incidents if they were involved in the incident, one patient told us that the debrief they had with staff following an incident was very good.

Leaders told us there was currently no freedom to speak up champion within the hospital, this was a vacancy that had been advertised throughout the hospital. We spoke with 18 members of staff. Most staff were aware of how hospital learning was shared, through clinical governance and team meetings, posters, and the hospital director’s update. However, 6 staff members could not demonstrate any learning from incidents or complaints, showing that frontline staff were not always aware of learning outcomes. Staff told us they were able to continually improve their practice by attending specialist courses and training to benefit the patients. This included bitesize training for staff, online and face to face training. Specialist training included substance use. Staff told us they were encouraged to take part in e-learning, and they received notifications when there was new training available to enrol on to keep their knowledge up to date. Staff told us they were encouraged, and supported to raise concerns, and they felt confident that they would be treated with compassion and understanding if they did. Staff said that Incidents and complaints were appropriately reported and investigated.

The provider had a lesson learnt poster which was displayed in the staff room and in staff areas around the hospital, which was changed monthly. The hospital director also shared a regular all staff update which included lessons learnt. The provider completed regular case file audits; at the time of our assessment the case file audit compliance was 100%. Staff had access to regular team meetings. These were held both during the day and overnight to capture all staff. Team meetings did not follow a set agenda. However, we reviewed team meeting minutes for the three months leading up to the onsite assessment and all included hospital level learning and actions. The provider had a complaints log, which included the nature of the complaint, action taken, the outcome of the complaint and if any external agency referrals were required. The hospital reported 349 incidents between December 2023 and March 2024. In December 2023, Cavell ward had 11 incidents mainly consisting of alcohol and illicit substance use. January had a high level of 113 incidents, which included 12 incidents involving illicit substances and 25 incidents involving alcohol. March also had a high level of 15 alcohol incidents. To reduce risks involving alcohol and illicit substances, the provider had mutual aid groups attending the site on a weekly basis, which also incorporated substance use and the psychology team were facilitating substance misuse sessions for patients. We observed informal patients who were leaving the hospital for unescorted leave having discussions with staff around staying safe and reminding them about hospital rules of not using illicit substances

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 we spoke with told us they understood why they were in hospital, they were given information on admission to orient them to the ward, were told about treatments and had their rights under the Mental Health Act explained to them. All patients we spoke with said they felt safe on the wards, and they could speak to staff if they ever felt threatened. All patients reported they were able to live free from harassment and abuse.

The provider had a clear policy on Mental Capacity Act and Deprivation of Liberty safeguards, which staff could describe and knew how to access. Staff knew where to get accurate advice on the Mental Capacity Act and Deprivation of Liberty safeguards. Staff knew how to make a safeguarding referral and who to speak with if they had concerns. At the time of the assessment, 100% of staff had completed mandatory safeguarding training. During the assessment we spoke with 18 staff members, including ward managers, nurses, healthcare assistants and members of the multi-disciplinary team. Staff were able to describe examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to recognise adults and children at risk of or suffering harm and worked with internal departments and external agencies to protect them. Staff knew who the hospital safeguarding lead was and said they were approachable for advice and support. Leaders told us they had taken steps to reduce risks of closed cultures, this included inviting referring external agencies for quality visits, there was also a staff concerns box in reception for staff to communicate any concerns and a weekly patient meeting where patients could raise any issues.

We observed staff utilising de-escalation techniques to good effect and avoiding possible restraint on more than one occasion during our onsite assessment. we observed patients being supported by staff who understood how to protect people from harm. We saw posters displayed on wards giving details of the safeguarding lead for the hospital and information about how to contact the Independent Mental Health Advocate. Care records we reviewed, showed that patients had been given information about their rights under the Mental Health Act upon admission to hospital and on a regular basis afterwards.

The provider had a safeguarding policy in place that staff were aware of. Overall, 100% of staff had completed safeguarding children and safeguarding adults training relevant to their role. The provider had regular safeguarding meetings with the local authority, to discuss any new, existing, or emerging safeguarding concerns. As part of the assessment, we reviewed the hospital safeguarding log which was up to date and included details of the safeguarding incident, the incident date, Local Authority referral date and any learning outcomes. Staff received and kept up to date with training in the Mental Capacity Act and had a good understanding of at least the five principles. Overall, 100% of staff had completed Mental Capacity Act and Deprivation of Liberty safeguards training. Staff assessed and recorded capacity to consent clearly each time a patient needed to make an important decision. Staff recorded patients’ mental capacity to consent to treatment, in all 15 care records we reviewed.

All patients we spoke with confirmed they were involved in their risk assessments and early interventions plans. An early intervention plan is a person-centred framework for providing long-term support for people who have or may be at risk of developing behaviours that challenge. No patients we spoke with had been restrained but all patients told us that staff were caring and considerate and supported them when they were feeling angry or low in mood. Patients told us they understood their observation levels and why their observation levels may increase or decrease, depending on their risk.

Staff confirmed that they involved patients in their risk assessments and early interventions plans and this was carried out as a multi-disciplinary team. Staff told us each ward had 2 tablet computers, one for observations and one for everything else. For example, filling out incident forms, looking at patients notes and updating risk information. Staff were positive about the Patient Safety Officer role. The Patient Safety Officer team was introduced to Southern Hill to enhance the safety of the patients, the team sits outside of the numbers allocated to the wards. They ensured that all safety equipment was allocated to the wards and in good working order and that staff were complying with handover requirements including security checks. They also ensured the environment was clean and safe and any major damage to items or building were reported to the maintenance teams. They were also responsible for the ligature audit. Staff told us that they had received training in restraint and restraint was only used as a last resort. Staff were able to discuss patients’ individual preferences and how to de-escalate patients. For example, one staff member was able to describe the specific song that one patient had on their early intervention plan to support them when they were feeling irritated or low in mood. Some staff raised concerns about the patients access to metal cutlery on the wards, which had been recently introduced. Staff were unclear on the rationale of why cutlery had been introduced into the wards, rather than cutlery being in the nurse’s office where it was previously kept. The hospital had recently introduced metal cutlery onto the wards. This had been discussed through clinical governance and a multi-disciplinary decision had been made to introduce metal cutlery, rather than plastic cutlery and a case file and care plan audit had been introduced to monitor risk. No incidents involving cutlery had ben reported by the provider.

The provider completed a 6 monthly blanket restrictions audit, which was completed by staff with service user representatives and was discussed at monthly clinical governance meetings. The provider had a comprehensive ligature risk assessment in place for wards, communal areas, and vehicles. Staff completed and regularly updated thorough risk assessments of all ward areas and removed or reduced any risks they identified. Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Staff were being offered additional bite-size ligature training throughout April. As part of the assessment, we reviewed the hospital safeguarding log which was up to date and included details of the safeguarding incident, the incident date, and if the Local Authority had been made aware. The log also included a lessons learnt section which was disseminated to staff. We reviewed 15 care records and found that staff involved patients in completing risk assessments and planning how to manage their risks. Staff engaged with patients to complete detailed and personalised early intervention plans to agree what de-escalation techniques patients would prefer staff to use to prevent incidents of restraint or seclusion. These plans included what music a patient might like to listen to, or what television or film they could be encouraged to watch to help de-escalate tense situations.

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

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.

During our assessment we looked at the policies and procedures for rapid tranquilisation. We identified a breach during our last inspection due to staff not always following the provider’s policies and protocols for the use of rapid tranquilisation. We found no issues relating to the use of rapid tranquilisation during this assessment. There was an appropriate clinical governance structure in place to ensure information and risk was escalated and managed in a timely manner. The governance structure tracked data relating to incidents and accidents, use of restraint and rapid tranquilisation to ensure the hospital were aware of the most recent incidents and were reviewing these regularly. From audits completed in January to March 2024, we saw that there had been 12 occasions where rapid tranquilisation had been administered to six different patients. In all cases the legal authority was in place for administration and it was documented that less restrictive options had been attempted and clinical entries were completed. We found one instance where an incident recording form had not been completed for the use of rapid tranquilisation. Post rapid tranquilisation monitoring had occurred after administration in every case. During monitoring on three occasions, patients were recorded as being alert while they were sleeping but visual observations of respiration rate had been observed. where a patient’s physical health may be affected by restraint techniques the patient had a separate restraint care plan to take that into account. For example, a patient with hypertension had a care plan to say restraint must only be in a standing position. Overall, 100% of eligible staff had completed using medication to deal with acute disturbances training.