Baldock Manor

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. A recent Mental Health Act review found there were blanket restrictions in place when searching patients. However, these restrictions have now been reviewed by the provider. 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.