12 January 2022
During an inspection looking at part of the service
We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the service.
We inspected specific safe, effective and well-led selected key lines of enquiry for the service.
We rated safe and well-led domains as requiring improvement as breaches of regulation were found. The effective domain was rated as good. We did not inspect the caring and responsive domains. The overall rating for this service is requires improvement. The previous rating of good for the domains caring and responsive remain. The report for the previous inspection can be found here:
Southern Hill Hospital (cqc.org.uk)
We found the following areas the provider needs to improve:
- Staff did not always follow the provider’s use of rapid tranquilisation policy.
- Incidents were recorded and actions documented, however it was not clear from the documentation and staff meeting records if lessons learnt from incidents had been considered or shared with the staff team as this had not been recorded.
- There was a lack of information for patients informing them of their rights displayed within the wards, however managers advised that patients are given a booklet on admission telling them about their rights.
- Some areas of the wards needed redecoration.
However:
- At the time of inspection, we did not find that all records had been completed. However, following inspection the service provided evidence of a physical health check audit for 175 patients demonstrating the provider had followed its’ own policy and National Institute for Health and Care Excellence (NICE) guidance.
- Physical interventions were used as a last resort and the patient safety officer team provided regular and consistent support to staff on each ward. The service was also part of the restraint reduction network.
- Staff had completed and were kept up-to-date with their mandatory training. All compliance rates for mandatory training courses were above the hospital target of 85%.