Maister Lodge

We found the following issues that need to improve:

• When we arrived at the ward, staff showed us into the nurses’ office. There were documents and drawers lying on the floor from an incident that occurred in the office earlier in the morning involving a patient. Staff were currently managing the patient through one to one observations.

• Staff told us they were often understaffed, which meant they struggled to meet the high level of observations their complex patient group required. Staffing rotas showed a high use of bank and agency staff and 26% of shifts not filled to the minimum establishment required. There were no senior nurses or managers on duty over the weekend.

• The staffing levels on the day of the inspection were three qualified nurses and three health care assistants on duty. This included the nurse in charge, as the ward manager was not on duty that day. Seven of the patients on the ward required high-level one to one observations and one patient had developed a physical health condition that required immediate attention from a doctor.

• Staff were confused by the introduction of zonal observations to support one to one patient observations. The ward introduced this practice when they implemented the trust’s supportive engagement policy. The manager had plans to review how staff were implementing the policy.

• Staff did not routinely report patient restraint as an incident. They documented the use of restraint in individual patient records. This meant there was no way of monitoring the number of restraints occurring daily or identifying any themes arising.