To Be Confirmed
During a routine inspection
We rated St Matthews hospital as overall good because:
- The provider had established the staffing levels required to meet the needs of the patients. The hospital manager had the autonomy to increase staffing levels if required. Staff training was all above 75% compliant. Staff received regular supervision and annual appraisal in line with the company policy. All wards complied with the Department of Health guidance on eliminating mixed sex accommodation. There was suitable medical cover and on call cover throughout the week.
- We reviewed 11 care and treatment records and found evidence that patients received a comprehensive risk and physical health assessment on admission. Patients were involved in developing their care plans and were outcome focused. The hospital offered a range of psychological interventions recommended in the National Institute for Health and Care Excellence guidelines.
- Patients knew the complaints process and had access to an independent mental health advocate if requested. Staff were aware of the provider’s whistle blowing policy and knew their responsibilities in relation to safeguarding. Staff told us they felt confident to raise concerns to senior managers without being victimised.
- The manager had oversight of the hospital. Performance was monitored by completing regular audits and the outcomes were recorded on key performance indicator dashboards. This meant the manager could monitor performance over a period of time to ensure continuous improvement.
However:
- We found the provider had completed a ligature assessment and had taken steps to mitigate the risks. However, the provider did not have a formal action plan in place to remove ligature anchor points in line with NHS England’s standard contract for low secure services. This states that, Low secure services “will meet” the best practice guidance from the Royal College, and that in low secure service wards: furnishings minimise the potential for fixtures and fittings being used as weapons, barriers or ligature points.
- There were blind spots throughout the ward areas which meant staff were not able to have clear lines of site. There was evidence of some convex mirrors used however not all blind spots were mitigated appropriately.
- We found some maintenance issues that were not identified or reported. For example, Radiator covers throughout were damaged.