Baldock Manor

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 observed that staff did not always conduct observations in line with policy and ligature risk assessments did not accurately reflect ligature anchor points. The service acted on these concerns promptly and ligature risk assessments were reviewed. Action had also been taken since inspection to reduce ligature anchor points. We also observed that medication was not always dispensed in a safe way. However, the service had a plan in place to improve this and since our inspection the clinic room has been relocated on the ward. We found that there had been security breaches , such as staff members leaving personal items in patient areas or patients being aware of door codes. Blanket restrictions were reviewed in monthly meetings and a blanket rules audit was completed twice per year. Patients had access to fresh air and water and overall blanket restrictions had reduced since our last inspection. The correct restraint techniques were used and restraint was conducted in the least restrictive way. Physical health checks were not always completed in line with policy following rapid tranquilisation, however there was no excessive use of rapid tranquilisation. During our site visit we inspected the emergency grab bag. We found the bag was heavy to carry. We saw evidence of emergency simulations being carried out. Staff were asked if the weight of the emergency grab bag was a concern and staff reported that they had no issues carrying the bag. The emergency grab bag was checked by staff monthly and expiry dates of items were recorded. The provider used appropriate recruitment procedures to employ staff and ensured that there were enough staff to support patients. Overall training compliance for permanent, bank and agency staff sat at 90%. Staff reviewed patient risk assessments regularly.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed patient feedback analysis from January to March 2024. The recommendations from this were that staff should have a debrief with patients following every incident of restraint and that a designated member of staff should take the lead and communicate clearly with the patient during restraint. During our assessment we did not have any concerns around restraint. One patient told us that the use of restraint had reduced. Patients involved in incidents were given an apology and written explanation of the event. Carers told us that they were posted information on their loved one’s admission to hospital, which explained the complaints procedure. Most carers felt they were able to give feedback to any of the staff at Baldock Manor.

We spoke with 16 members of staff. All staff we spoke with told us they felt supported. Staff told us they had regular reflective practice sessions and monthly supervision. Staff felt that leaders encouraged them to raise any concerns and felt supported to speak up if there were any issues. There was a freedom to speak up policy in place and staff reported that they knew how to raise concerns. Managers shared information about lessons learned with staff in various ways. A debrief was completed following an incident and lessons learned were also shared with staff through email, supervision and team meetings. Clinical governance meetings had lessons learned as an agenda item and we saw evidence that learning was discussed with staff.

We observed that the clinic room on Burberry ward was not used to dispense medication, due to it being off the ward and not fit for purpose. Managers had a plan to renovate the old kitchen on Burberry to a new clinic room. Since our onsite inspection we have had updates on the progress of the refurbishment from the provider, which has now been completed. Managers had an action plan in place, following their last CQC inspection. Routine walkabouts had been implemented; however they were not always effective. Observations were not always conducted in line with policy and staff did not always interact with patients on observation. We saw evidence of improvements, such as all patients having access to water on Radley ward. We saw evidence of systems and processes in place that supported a positive culture of safety. We viewed the hospitals complaints log, which detailed the nature of the complaint, the outcome and lessons learned which were then shared with the wider team. The hospital had a closed- circuit television (CCTV) audit process in place and following an incident this was reviewed, which helped them to identify good practice or areas for improvement.

Four of the 8 patients we spoke with told us they felt safe at Baldock Manor, while 3 patients told us they had felt unsafe when first admitted to hospital, at night or due to incidents on the ward. However, one patient we spoke with told us that they had absolutely not felt unsafe while at the hospital. Most carers told us they believe their relatives felt safe at the hospital and spoke positively about staff. Patients told us that they had good advocacy support at Baldock Manor. There was also an Expert by Experience in post.

Staff told us that patients had a care co-ordinator in place to support with their care. Staff told us that they worked with community teams to support admission and discharge from hospital. Staff also told us that patients were invited to attend multi- disciplinary meetings, that patients were involved in developing their care plan and were offered a copy. We received positive feedback about the therapy team at Baldock Manor. We saw evidence of a clear treatment pathway, which included occupational therapy support or psychological therapy support from assessment to preparing patients to move on.

Partners we spoke with told us they had good links with Baldock Manor and had weekly meetings to share information or raise concerns. Partners told us that staff at Baldock Manor were responsive. Another partner told us that a patient received treatment and care while at Baldock Manor that prepared the patient for a successful discharge to the community. A partner told us that communication was good and family and external services were involved in review meetings. The Independent Mental Health Advocate (IMHA) told us that they had regular meetings with the mental health act manager and safeguarding lead. They also told us that all patients had a weekly wellbeing visit.

The service offered a trauma informed recovery model, in line with national guidance recommended for this patient group. The service had clear and consistent processes for treatment pathways, transitions and discharges. The service received referrals from a range of external organisations which were triaged, assessed and agreed by the multi-disciplinary team. Staff completed emergency simulations, that had clear objectives, findings and recommendations. The service completed monthly CCTV audits which highlighted any areas of good practice or any systems or processes that needed reviewing.

Four of the 8 patients we spoke with told us they felt safe at Baldock Manor, while 3 patients told us they had felt unsafe when first admitted to hospital, at night or due to incidents on the ward. However, one patient we spoke with told us that they had absolutely not felt unsafe while at the hospital. Most carers told us they believe their relatives felt safe at the hospital and spoke positively about staff.

During the assessment we spoke with support workers, nurses, doctors and members of the multi- disciplinary team. The staff members we spoke with demonstrated a good knowledge of safeguarding, were able to tell us types of abuse and explain the hospital safeguarding procedure. The staff we spoke with told us that learning from safeguarding incidents was shared in team meetings, via email or in supervision.

Staff did not always complete observations in line with policy. Some patients on enhanced observations were being observed with their allocated staff members sat outside of their bedroom. We observed that ligature heat maps and risk assessments did not correspond with ligature risks on the wards. During the site visit we saw staff interacting with patients in communal areas. We saw information on the wards about patients’ rights and how to access an Independent Mental Health Advocate (IMHA).

The hospital had processes and procedures in place to support patients to live free from abuse, neglect and avoidable harm. This included a comprehensive safeguarding policy, which was available to all staff and gave details of key contacts at Baldock Manor. We looked at the hospital safeguarding log, which was up to date and included details about incidents, actions taken and the outcome. Safeguarding training compliance for staff was 90% for face to face safeguarding training and 95% for online safeguarding adults training. All patients had access to an Independent Mental Health Advocate (IMHA) during their stay and the hospital also had one Expert by Experience in post and were in the process of recruiting a second. Information was available to patients around the hospital on how to access an advocate. The hospital had a safeguarding lead, who met with Hertfordshire Partnership Foundation Trust Safeguarding Team weekly to discuss safeguarding concerns. The hospital safeguarding log reflected that safeguarding referrals were being made and actions and outcomes were recorded. However, the service lacked oversight with some elements of safeguarding that have been reflected in previous sections of the quality statement.

Two patients we spoke with felt that they weren’t involved in developing their care plan. A carer we spoke with told us that staff members had been good at completing observations while taking their loved one out for section 17 leave. They felt that staff had managed risk well by staying at a distance, which also allowed them privacy. A carer told us that their relatives care plan was explained to them clearly.

Staff we spoke with told us that there was a debrief for both staff and patients after an incident. Staff were able to identify patient’s triggers and attempted to use de-escalation techniques before physical intervention. Staff told us that they had alarms and radios available and that morning security checks were completed, however 1 member of staff told us that they were not able to get an alarm, as there were not enough available. Staff were able to describe their understanding of enhanced observations in line with policy.

The provider had a reducing restrictive practice policy, which was last reviewed in September 2023. We looked at minutes from the reducing restrictive practice monthly meeting, where actions from the previous meeting were reviewed and new actions were set following discussions. We reviewed the providers clinical governance meeting minutes. Safety and risk were discussed at these meetings, as well as the service improvement plan and feedback from patient community meetings. During our assessment we also reviewed CCTV audits, which identified areas of care that needed improvement as well as areas of good practice. During CCTV audits, there was evidence that staff were attempting to use de-escalation techniques to manage an incident before having to use physical intervention.

During our assessment, one patient told us they felt unsafe due to another service user’s behaviour and another patient told us that it could be scary when incidents were happening. Other patients told us they felt safe and had a positive experiences. Some patients told us that there can be limited access to daylight. This was due to mesh on some bedroom windows to prevent passing of contraband. During our assessment we were provided with evidence to show that this was recommended by Quality Network Psychiatric Intensive Care Units (QNPICU). One carer told us that the building was not fit for purpose, however there were no issues with the cleanliness of the environment. Other carers told us they felt the environment was safe.

Staff did not always ensure that the environment was safe for patients. We observed inconsistencies with our observations on the wards and feedback given by staff. Observations were not always completed in line with policy and ligature risk assessments and ligature heat maps were not accurate. However, staff demonstrated a good level of understanding of the observation policy and their responsibilities. Staff members told us that there was a rapid response team assigned for any incidents that might occur.

Ligature risk assessments and ligature heat maps did not accurately reflect ligature risks on the wards, which was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Room numbers on ligature heat maps did not correspond with bedroom numbers. Ligature risk assessments did not match the bedroom numbers not all furniture related risks were identified on risk assessments. Managers were made aware of the inconsistencies during our site visit and took immediate action. Not all patients on enhanced observations were being observed in line with policy. We observed some patients on enhanced observations with staff members sitting outside of the room with the door closed, which was a breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We observed a clinical waste bag present in a patients ensuite bathroom. There was no risk assessment for this, however when staff were made aware it was promptly removed. We observed the clinic room for Burberry patients, which was not fit for purpose due to being off the ward. Managers had a plan in place to refurbish the old kitchen and make this into an appropriate clinic room. Since our onsite visit the refurbishment has been completed. We observed that the wards were clean and tidy and cleaning records were up to date. All bedrooms had call bells and alarms. Mirrors were in place on wards to mitigate risks of blind spots and CCTV was in place and regularly audited. The seclusion room allowed for clear observation of the patient and the furnishings and fittings had been risk assessed. There was an intercom system to allow verbal communication between staff and patient. There was a bathroom facility in the seclusion room with toilet, sink and shower. The heat and ventilation were located outside the seclusion room in the nursing station and was operated by staff. There was a clock visible opposite the seclusion viewing panel that patients could see.

We found that security procedures had not always been followed. This included a patient being aware of a door code and a handbag being left in a patient area. This was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Governance and quality processes, such as management walkabouts did not identify any security breaches, concerns with ligature anchor points or with staff completing observations. However, closed- circuit television (CCTV) was reviewed following incidents to identify any lessons that could be learned. The service had a business continuity plan in place, which included an action plan to ensure essential functioning of the hospital in the event of an emergency such as loss of electricity. The action plan was detailed and included photographs to support staff in an emergency.

One patient told us that managers and doctors were not on the ward often enough. One patient shared concern that staff had not got to know them. However, most patients told us that staff were respectful. One patient told us that staff were brilliant and that privacy and dignity was respected. Most carers felt that their relatives made good progress while at Baldock Manor.

Out of the 16 staff members we spoke with, 1 staff member told us there had been times where they were short staffed but more recently this had not been an issue. Staff told us there were sufficient systems in place if additional staff were required, such as an overbooking system where two extra staff members were allocated to a shift. Staff reported that they received regular reflective practice, supervision and appraisals. Managers reported that the average turnover rate for the last 12 months was 2.11%. The average use of agency staff from January to June 2024 was 14.6% and the average use of bank staff was 25.3%. Managers attempted to use regular agency staff for consistency. There were vacancies for 8% support workers, 17% of senior support workers and 22% nurses. There were also vacancies across the wider team including a consultant psychiatrist, service lead, kitchen assistant and an activities co-ordinator.

We did not see good staff engagement with patients consistently on observations, however we did see staff engaging well with patients in communal areas. Wards were fully staffed and there were enough staff available to make sure patients received appropriate care. There was an appropriate gender mix on each of the wards.

At our last inspection, we found staff were not always able to have their necessary breaks whilst on enhanced observations. At this inspection, we found this had improved. Staff carrying-out enhanced observations told us they had comfort breaks every 2 hours. Comfort breaks were covered by floating support staff. The service had a rota coordinator who ensured suitable gender mix in terms of staffing appropriate to wards. We reviewed the duty rota for Radley ward and the ward was safely staffed during the day and night. We found and observed appropriate staff gender mix 60% female and 40% male. We observed a good number of female staff on Radley Ward allocated to enhanced observations. There had been 3 occasions over the last 6 months were there were not enough female members of staff on female wards. Staff had an appropriate skill mix to make sure patients received care to meet their needs. Overall training compliance for both bank and permanent staff sat at 90%. Initial training for Prevention and Management of Violence and Aggression (PVMA) was 100%, however refresher training was 85%. Intermediate Life Support (ILS) compliance was 92%, with only one member of staff to complete the training. There was an induction for permanent, agency and bank staff. We checked 4 staff recruitment files and saw that all appropriate processes and checks were in place. The service conducted enhanced disclosure and barring service (DBS) checks where necessary. DBS checks were renewed for all staff every 3 years.

All patients and carers we spoke with said the ward was regularly cleaned and maintained.

Staff and leaders told us that the hospital was regularly cleaned. Staff checked, maintained, and cleaned equipment and completed weekly checks of clinic rooms and equipment.

We observed a clinical waste bin bag in a patients ensuite bathroom with no risk assessment. Staff were made aware of this during our visit and the clinical waste bin was removed. We conducted a tour of the wards and found it to be visibly clean. Cleaning took place while we were onsite.

We viewed the hospitals infection prevention and control and hand hygiene audits. All of the audits we viewed showed 100% compliance. The hospitals Personal Protection Equipment (PPE) audit we looked at were at 93% compliance, due to staff not having FFP3 face masks. However, all other areas of PPE were compliant. Staff followed the providers infection control policy, including handwashing. However, there was a clinical waste bin in an ensuite bathroom on Burberry Ward. The pedal did not work therefore staff would need to lift the lid by hand compromising good infection control practice. On Radley Ward, the sharps bin was over-filled, which is a health and safety risk. We notified the staff of these concerns and staff took immediate action.

One relative told us that they felt that they were not listened to when their relative was experiencing side effects from medication. A patient told us that they had weekly meetings with the doctor and felt that their views were taken on board. Most carers told us that they were invited to ward rounds and felt involved in treatment.

Managers told us that additional Ashtons pharmacy training had been arranged for staff, following a medication error.

Medication was not dispensed in line with best practice. The clinic room for Burberry ward was not located on the ward and was cluttered. We observed staff dispensing medication into paper cups and taking this onto the ward in a locked box without medication charts to dispense to patients, which was a breach of the Health and Social Care Act 2008 (Regulated Activities) 2014 . Since our visit the hospital have now relocated the clinic room onto the ward. Staff completed physical health observations, consent to treatment and documented allergies.

We found that one patient did not have their physical health monitored in line with policy after rapid tranquilisation, which was a breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Prior to our inspection at Baldock Manor we had concerns about medication errors. The process of dispensing medication on Burberry ward increased the risk of medication errors occurring. We reviewed the hospitals rapid tranquilisation policy and found no excessive use of rapid tranquilisation. We reviewed the hospitals medicines management policy, which was last updated in November 2023.