Broomhill

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

We identified some areas of concern under the safe key question which will require an action plan under the medicine’s optimisation quality statement. Staff completed medicines audits but there was a lack of oversight of medicines management. Actions needed as identified through pharmacist audits had not been actioned by staff. Staff did not consistently adhere to the providers medicines disposal policy. Staff had completed some expiry date labels incorrectly. Care plans specific to certain high-risk medicines lacked detail. Four registered nurses we spoke with were unable to tell us what drugs should be used in the event of an opioid or benzodiazepine overdose. While the hospital had an identified infection prevention and control lead, they had not identified infection prevention and control champions, in line with their policy. Though staff told us they did have a plan in place to address this. We saw that clinical staff undertook the complex ligature risk assessment across all wards, but we were unclear if these staff had received relevant training to complete this task. Actions needed were recorded on a separate estates plan with anticipated dates for completion. We noted that many items needed removing from the environment. Estates staff were not involved in this assessment which was unusual. However, staff reported and investigated safety events and incidents. Emphasis was placed upon learning from incidents to improve practice. Staff told us they could and would raise concerns with senior staff. Staff had a good understanding of safeguarding and took appropriate actions. There were systems and processes in place to ensure people were protected from abuse and neglect. Staff assessed individual patient risks and reviewed these regularly. Restraint was only used as a last resort. Staff took a proportionate approach to imposing restrictions upon people. Leaders continued to work with partners to improve the quality and continuity of care.

This service scored 53 (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 they could get information about their health from staff, whether this be about their physical health or mental health. Patients felt staff listened to safety concerns. Most patients said that staff did the best for them and tried to keep them safe. Patients were aware that staff did investigate concerns and tried to learn from them.

Staff we spoke with knew how to report any incidents of concern involving safety. Staff told us that senior staff undertook investigations into concerns as and when necessary, with emphasis upon learning to improve practice. Staff discussed risks and safety daily during routine handover meetings, in safety huddles, in team meetings and through reflective practice and de-briefs. The frequency and any themes of incidents were discussed during the local governance meetings.

The safety of patients was a priority for staff. Managers produced regular lessons learnt alerts following incidents across the service which were cascaded to ward staff monthly. Senior staff had been raising awareness of the new CQC methodology by holding awareness months for different key questions, although this had only commenced in March 2024. Implementation of PSIRF was in progress but not all staff had received all relevant training. Managers were open and honest with patients and relatives if things went wrong. We saw letters relating to the duty of candour, which invited the offer of involvement within the relevant planned investigation.

Staff we spoke with described a joined-up approach to care. Patients’ physical health was routinely monitored by staff and through the visiting GP. Staff made any external referrals to specialist healthcare professionals as and when necessary. Staff ensured that if patients were transferred between wards or from the hospital, appropriate information would be available for the receiving staff. One concern voiced by staff was that when patients had transferred from one ward to another, all care plans and risk assessments were archived with staff starting afresh. There were some concerns that essential information could be potentially missed through this process.

Feedback from stakeholders was positive with regards to safe systems, transitions and pathways. The senior leadership team had been working collaboratively with the Integrated Care Board and other partners to ensure safety was appropriately managed and monitored. Partners acknowledged that the provider had relied heavily upon continued feedback from external sources to make improvements to care. In the absence of seeing how many of the actions would be embedded in practice and given the providers previous history of improvement followed by decline, partners were not assured that the provider would be able to embed and maintain the improvements on their own going forward.

All patients we spoke with felt safe at the hospital. Patients were able to discuss individual risks with staff and with the multi-disciplinary team during routine meetings. Patients said staff tried to keep people safe and responded to any incidents in a timely way to try to stop any harm. Patients were able to raise any concerns around safety, whether this be individual risks or risks associated with the environment.

Staff understood what safeguarding was and could describe actions they could take to keep people safe. Examples of this included the use of enhanced observations, or for patients to have restricted, or supervised access to items which could potentially cause harm. Any potential or active safeguarding concerns were discussed along with associated risks during shift-to-shift handovers. Staff updated care plans and risk assessments to reflect any new or emerging risks. Staff did not place restrictions upon people unnecessarily and considered positive risk taking on an individual basis with patients.

The provider had appropriate polices and procedures in place around the safeguarding of adults and children, risk management and equality and diversity. Managers ensured staff received relevant mandatory training which was up to date. The providers corporate induction included safeguarding training. Staff were trained in line with their responsibilities, in line with national guidance. Staff worked with the hospital safeguarding lead and with the Local Authority as and when needed to maximise patient safety.

Patients said staff supported them to manage any risks and explained any restrictions which may be placed upon them. Patients said staff gave them choices about their care and treatment. Risks were discussed during routine multi-disciplinary meetings. None of the patients we spoke with felt unsafe or overly restricted. Patients said staff would talk to them and try to calm them down if they were upset.

Staff completed risk assessments for each patient and reviewed and updated these regularly. Assessment of risk was seen to be a multi-disciplinary approach. Staff preferred not to use physical restraint and only used this as a last resort if absolutely necessary, and for the shortest time possible. Staff told us that because patient numbers were low at the time of assessment it was possible to do things with patients that were important to them, for example to attend a place of worship. They were not so sure that this could be continued when patient numbers increased.

The providers policies and procedures relating to risk management and clinical documentation encouraged collaborative working with patients. Staff adhered to the provider policy with reviewing risk assessments at regular intervals, or as and when new risks or behaviours emerged. The provider encouraged least restrictive practice, which staff appeared to adhere to in day-to-day practise, with any potential restrictions placed upon patients being carefully considered. The use of restrictive practices was routinely monitored by senior staff.

All patients we spoke with felt safe at the hospital. Patients did not report any deficits or concerns with the physical environment. Some patients told us that internet connectivity was problematic at times which they found frustrating. This had been reported to staff. All patients had their own bedroom and private bathroom.

Staff were aware of the ligature risk assessment which senior staff completed annually. One staff member was concerned about a metal freestanding cupboard on one of the wards as they felt this was unstable as it was unsecured. This had been reported, but we were unclear when. However, the following day inspectors observed this had been removed.

We saw some improvements to safety in the environment, such as mirrors installed where potential blind spots had been previously identified to aid vision. Most electrical appliances had been tested. We found a blender on one ward, which staff had used regularly to make smoothies, which had not been electronically tested as safe to use. A lack of robust pat testing was raised as an issue at our last inspection. We also saw some walk around checks on one ward which were inconsistent and incomplete. We were therefore unsure of the effectiveness of these.

We noted that while clinical staff undertook the complex ligature risk assessments across the hospital, we was not assured that these staff had relevant training to complete this task. Estates staff did not participate in the ligature risk assessment, which was unusual. While the ligature risk assessments had existing and mitigating controls identified, the actions that needed to be taken were recorded separately on an estates plan, which only gave anticipated dates of completion. This meant that anyone looking at the ligature risk assessment on its own would not be aware of what actions were required. If the estates team changed the dates or details of actions required on their plans, the actual ligature risk assessment may not be updated. We noted that many items which needed removing, or removing and replacing were outstanding. However, we saw that senior staff monitored actions through the patient safety committee meetings.

Patients we spoke with told us there were usually enough staff on duty each shift. One patient said that on one ward, they had been short staffed on occasion, which had led to the morning patient meetings being cancelled, and some escorted leave postponed. Patients said all new staff received training so they knew how to help them.

Staff we spoke with said that they had enough staff, although said this was because of reduced occupancy. Staff told us since there had been fewer patients, they had more time to spend with patients and to be able to help them. Some staff said that when the wards were full it could be more difficult to meet all patients needs in a timely way, if the ward was particularly busy, or if staff were responding to an incident, for example. Some staff told us they would like more regular staff, as agency staff continues to be used more frequently, which can put additional pressures on the regular staff due to having to induct them and explain what needs to be completed.

During the onsite assessment, we observed staff were visible and were in communal areas of the wards so that patients could access them easily. We observed some positive and responsive interactions between staff and patients. It was clear that some of the staff knew individual patients well and were at ease during interactions.

The provider had enough qualified, skilled and experienced staff to meet the needs of the current patients. Managers ensured staff received, and were up to date with mandatory and other training. The provider had processes in place which ensured staff received regular supervision. Annual appraisals of work were undertaken for all staff, which included any potential areas of development required. Managers managed any staff performance issues with assistance from the human resources department.

Patients we spoke with did not express any concerns around infection prevention and control. Patients had observed staff washing their hands and had also observed staff wearing aprons and gloves on occasions when assisting patients or during mealtimes. Patients said the wards were usually clean and tidy.

Staff told us that if patients had any infections, such as Covid-19, all staff would be made aware during shift-to-shift handovers. Staff said managers provided enough personal protective equipment which were easily accessible and restocked regularly. Staff said if a patient had a contagious infection, appropriate barrier nursing would be implemented, and a care plan produced so that all staff knew how to safely manage any risks of spreading infection.

During the onsite assessment we observed there were adequate hand washing facilities and paper towels across the hospital. Hand gel was also available. Staff had available bags for clinical and domestic waste. Bed linen and other washing were appropriately transported in designated bags. Staff had access to cleaning materials and chemicals to manage any bodily spillages safely. Bins were available within clinics for any sharps which required disposal. On one ward, we observed the nurses wearing a tabard to administer medicines. The tabard was stained, and staff were unable to tell us when this was last washed. Staff confirmed different staff used the tabard.

The provider has an infection prevention and control policy in place which staff could easily access. This had been reviewed and updated regularly. The policy refers to the hospital having a designated infection prevention and control lead, as well as having champions. We noted that in March 2024, during a local governance meeting, there was some uncertainty about who the lead was. This was however, later confirmed. In February 2024 during a local governance meeting, an action was to ensure the hospital also had infection prevention and control champions. This had still not been actioned at the time of assessment, although the provider did have a plan in place to address this.

Patients we spoke with did not express any concerns around any prescribed medicines. Patients could discuss any proposed or prescribed medicines with the doctor or nurses during the regular multi-disciplinary meeting.

Staff confirmed that they received medicines training and senior staff checked their competencies annually, or earlier if they had been involved in any medicine errors or near misses. Staff felt supported and said the training was good. However, when we asked 4 registered nurses what drugs should be used in an opioid or benzodiazepine overdose, they were unable to tell us. This was a concern as some patients had a history of drug misuse. Staff told us that regular audits of medicines management were undertaken by senior staff and any actions would be addressed.

Staff confirmed that they received medicines training and senior staff checked their competencies annually, or earlier if they had been involved in any medicine errors or near misses. Staff felt supported and said the training was good. However, when we asked 4 registered nurses what drugs should be used in an opioid or benzodiazepine overdose, they were unable to tell us. This was a concerns as some patients had a history of drug misuse. Staff told us that regular audits of medicines management were undertaken by senor staff and any actions would be addressed. We observed oxygen cylinders were not always secured to prevent them from falling.

Staff kept the clinic rooms clean and tidy. Medicines were appropriately stored. Staff disposed of medicines in appropriate bins, however the providers disposal policy was not consistently followed by staff. Two staff signatures should have been present as witness of removal and disposal. This had not always been followed. Staff monitored patients on high risk medicines appropriately, however corresponding care plans lacked detail. The last completed medicines management audit covered the period from 1 January to 31 March 2024 highlighted some issues where limited life medicines were not always appropriately dated. Unwanted medicines were not correctly documented and from the 6 wards audited, on average 20 per cent of queries/interventions made by the pharmacist had not been acted upon by ward staff. There was not robust oversight of medicines management.