County Hospital

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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 assessed a total of 6 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was Inadequate in 2022. Our rating for this key question is good. We found safety was a top priority, and staff took all concerns seriously. When things went wrong, staff acted to ensure people remained safe. Managers investigated all reported incidents to reduce the likelihood of them happening again. Staff supported people and provided them with information on their care and treatment.

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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Staff were open and honest with patients and carers and took any concerns they had seriously. We spoke with three patients who told us they felt safe on the ward and that staff listened to any concerns they had and acted on requests. We spoke with three patients who told us they felt safe on the wards and that staff listened to any concerns they had and acted on requests.

Staff knew how to report incidents and said that learning was shared. They said they felt listened to by managers and were easily able to raise any concerns which were usually acted on. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. We spoke with qualified nurses and nurse assistants who told us that there was a positive culture based around support and learning. There were many opportunities to develop and learn new skills. Staff told us that managers were open and honest and felt able to go to them with any concerns about safety. They felt listened to and supported and felt that action was usually taken to address any concerns they had raised. Staff knew how to report incidents and said learning from incidents was discussed with staff as a group in meetings and huddles. Learning from lessons was shared with staff in ‘Improving Together’ meetings, team meetings and huddles. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

Staff had effective systems to raise concerns both formally and informally. Reports were analysed and urgent actions taken by leaders to manage or remove risks.

Patients being treated on the day we visited told us they felt safe on the ward. We saw how patients' information was shared with relevant health professions and that records were updated by the multi- disciplinary team members. Systems were in place to ensure sharing of patient information between relevant health professionals. For patients who had been admitted to the medical wards from the local mental health trust, their medical record relating to their mental health condition was shared with staff via an i-portal and this was used alongside the medical pathway to care for the patient.

There were systems and processes in place to ensure continuity of care, including when people move between different services. Senior leaders told us they had made significant improvements and now felt much more assured about the safety of their systems of care. Leaders and managers told us they had worked hard to make improvements to systems of care for patients. They had implemented a new document to assess the care needs and risks for patients being admitted to the medical wards. This ensured all mental health needs and risks were assessed as well as patients medical, physical and communications needs. Completion of the documentation including all risk assessments and follow up actions was monitored by managers on a monthly basis and reported in senior meetings. Spot checks were also carried out and discussed at team meetings.

Trust and partners communicated well and met often.

The service had a 24-hour access to mental health liaison and specialist mental health support. The psychiatric liaison team was available on site from 8am through to 2am each day. Between 2am and 8am, cover was provided by the local mental health trust. Records completed by the psychiatric liaison team showed compliance to the National Institute of Health and Care Excellence (NICE) standards of initial assessment within 1 hour and crisis assessment within 4 hours. Staff told us that delays in getting assessments for a patient to be detained under the Mental Health Act had improved significantly. We saw significant improvements since last inspection 2022. Staff knew about and dealt with any specific risk issues. Staff were fully aware of the mental health risk assessment and patient who presented at ED with physical health problems but also presented to the department with mental health symptoms was documented and assessments completed. Staff shared key information to keep patients safe when handing over their care to others. Staff handovers to AMU from ED enabled ward staff to understand patients with psychiatric support needs. Ward staff now routinely received handovers regarding psychiatric status from ED with relevant completed assessments.

Staff discussed people’s needs with them, and they were involved in how care and treatment was planned. They were confident they had been listened to and understood.

Staff assessed and acted on risks to patients of avoidable harm. Staff worked with other specially trained professionals to support people with additional needs.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff received training specific to supporting patients who may lack capacity to consent to treatment or care. Trust followed the 7 minute briefings, used nationally within safeguarding, as a quick and simple way of sharing learning. It is based on research which suggests that 7 minutes is an ideal time span to learn, providing information in a quick and easy format, resulting in memorable learning. The safeguarding team at the trust have adopted the 7 minute briefing template in particularly within supervision as a topic of discussion. The Lead Nurse for Mental Health and Learning Disability identified that the 7minute briefing template can be adapted and used within the vulnerable patient agenda, with the first 7minute briefing focusing on the Mental Health Act. The vulnerable patient team aim to produce a new briefing quarterly, sharing these across the trust for all staff to access.

Staff gave people clear information about their care and treatment needed to support both their physical and mental health.

Staff worked with people to understand their care needs and manage risks by utilising a newly amended care needs and risk assessment document. which was comprehensive and encouraged staff to think holistically to care meet patients’ needs in a way that is safe and supportive. The assessment document covered social and mental health needs and communication needs as well as a range of medical and physical needs. This document followed patient from each department to ensure those requiring additional support this was documented in their care records.

Staff completed and updated risk assessments for each patient. Staff identified and quickly acted upon patients at risk of psychological or behavioral deterioration. Patients attending the hospital with acute mental illness, whether attending primarily due to their mental health or physical health, generally arrived through the emergency department (ED). However, in particular cases some patients could be admitted directly to an inpatient ward or if attending for a specific clinical test or procedure such as blood tests. If a patient was admitted direct to a ward for example following a GP referral, ward staff would complete the relevant documentation to ensure patient was assessed on admission. When patients were identified as requiring enhanced supervision or observations to protect themselves or others, staff completed the required documentation to support this. Within the ‘Therapeutic and Engagement Observation of Adult Patients’ policy, a template was provided for staff to use for this purpose. We saw examples of policies in place, and all were up to date.

Patients we spoke with on the day we visited told us they hadn’t experienced any problems with hospital equipment and were happy with the facilities. We noted the ward environment to be safe for patients with a mental health issue. Patients could not leave the ward without the knowledge of staff, and those who required close observation were cared for in bays where they could be viewed by staff easily.

Staff told us the environment was safe and any problems they reported were addressed straight away. Staff held handover meetings and huddles outside of patient bays so that patients could be observed at all times. Where patients required close supervision and monitoring, an additional nurse provided 1:1 care where required.

We did not observe any immediate environmental risks to patients on any of the wards or departments we visited. Within the emergency department, we saw a designated room for patients with mental health conditions or symptoms or patients at risk of violence and aggression had two entrances, an alarm and heavy furniture. The wards was in line with standard acute hospital wards. This meant lines of sight could be compromised due to corners and cubicles. However, we saw that some patient spaces could be directly observed from the nursing station and those patients requiring additional support would be placed in an area close to the nursing station with full visibility.

There were systems in place to ensure the environment was kept safe. We acknowledged that an acute setting is not designed for patients with mental health conditions or symptoms. The trust carried out regular "mock inspections" to gain insight to each ward or department. Trust carried out regular environment based audits and all were within trust target of 90%.

Patients we spoke with on the day we visited told us they thought there were enough staff to look after them. Patients didn’t need to wait long when they asked for assistance from staff and staff treated them kindly. However, one patient told us they thought staff appeared overworked and always very busy

Staff told us there had been an improvement in staffing recently and there were enough staff to keep patients safe. Managers worked with matrons and other leaders to make sure there are enough qualified, skilled and experienced staff to care for patients. Staffing levels were monitored daily and adjusted where required to fill gaps in staffing levels. Bank staff were used where necessary to cover sickness absence. Staff received effective support, supervision and development. They worked well together to provide safe care that meets people’s individual needs. The mental health liaison team had extended their hours of work to provide an enhanced level of support to ward staff. Managers and staff said this had a significant positive impact on their ability to safely care for patients with mental health needs and enabled patients to receive input from mental health liaison team within 4 hours of admission. The trust had recruited 2 mental health specialist nurses for AMU to provide support, guidance and education for staff. Staff told us they had completed the required training to do their role and attend 1-1 and team meetings.

When we visited there were enough staff on all the medical wards. We found there was enough staff available, and staff delivered safe care which met people’s needs. We observed that staff had time to complete care for patients in a safe way and that staff were able to talk with patients in an calm manner and did not appear rushed. Where it was identified that patients required additional supervision, managers made effort to request additional staff including bank staff to cover this. However, this was not always possible. Where this was not possible, staff tried to cohort patients who required high levels of supervision in the same bay so that 1 member of staff may monitor the entire bay.

Staff from the psychiatric liaison team also supported with enhanced supervision if they were available. In some cases, where a patient was detained under the Mental Health Act and normally resided at a mental health hospital but was an inpatient at County Hospital for physical interventions, managers could request staff from the psychiatric hospital to attend to support with enhanced supervision. Staff also sought support from relatives to monitor patients when staffing was reduced. A representative from each medical area attend a daily meeting at 8.30am Monday to Friday. Staffing levels are discussed for that day and include an overview of patients requiring therapeutic observations, level of acuity and staff escorts required for that day. Matron provided updates on the staffing board and the site operational manager are informed of any moves that need to be carried out for the night shift. Issues throughout the day are escalated to Matron. Staffing levels are reviewed on the weekend. County site senior nurses, consisting of band 6 and 7 are on a weekend staffing rota cover Saturdays and Sundays 7am to 3pm to resolve and manage any staffing issues for that day. Changes or unresolvable concerns are discussed and handed over to the operational Matron of the Day who covers until 8pm.Staffing levels out of hours in the evening and overnight, medical areas escalate issue to site operational manager who will make decisions based on clinical risk in areas.

People told us they saw house keepers often and areas appeared to be clean and tidy. People said staff were seen to wash their hands.

We saw the service completed regular infection prevention and control (IPC) audits of the environment and were compliant. Staff completed IPC mandatory training and kept up to date. The service performed well for cleanliness. The cleaning was sourced inhouse, and all staff had access to their online portal. Cleaning records were maintained and kept up to date.

We observed staff during the inspection and saw they were always bare below the elbow, washed hands regularly and used hand sanitiser appropriately.

People told us they are supported to take medicines and had no issues with how staff support them with this. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. There were no patients receiving medicines relating to chemical restraint at the time of our visit.

Staff told us pharmacy came round regularly and staff felt they could approach their pharmacy colleagues if they required advice.

We observed safe practice from staff on the day we inspected, and when we looked at medicines records, we found no concerns with how staff administered and recorded medicines. We reviewed 5 medicines charts and found all medicines had been given in line with best practice guidance with regards to mental health provision.