Coventry and Warwickshire Partnership NHS Trust

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

Policies and the approach to care and treatment to support people when they were distressed, was not reactive or reliant on restrictive practices or seclusion. This was in line with CQC’s reducing restrictive practices policy position. We found a culture of safety and learning at the service. Safety and continuity of care was a priority for people throughout their care journey. We found staff had a strong understanding of safeguarding and knew what action to take to keep people safe. There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their care. Restraint and other restrictive practices were only ever used as a last resort. There were appropriate staffing levels and skill mix to make sure people received consistently safe, good quality care. People’s medicines were appropriately prescribed, supplied and administered. However, we found at Janet Shaw Clinic that staff did not always complete care plans to support people with specific risk and people were not always cared for in safe environments.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A person at Janet Shaw Clinic shared their experience of a safeguarding incident that happened previously and the action and learning that followed on from this. The person was happy with the outcome.

Ward managers told us staff attended a fortnightly learning from incidents group which provided a useful learning opportunity for staff, particularly for staff from wards with low rates of incidents. Senior leaders advised the group could recommend immediate changes following learning from incidents. A poster bulletin with highlights from the group was shared with all staff. Eden ward manager advised there was protected learning time for staff where they review peoples’ positive behavioural support plans. Staff will highlight if something doesn’t work and update the plan. This has resulted in less restraints and a calmer environment. Senior leaders described how they use after action reviews as part of the Patient Safety Incident Response Framework (PSIRF). This approach encouraged greater learning for staff and people using the service.

We reviewed 13 learning from incidents bulletins shared with staff between 1 September 2023 and 31 August 2024. These bulletins captured discussions of specific incidents in the fortnightly ‘learning from incidents group’. There was evidence of learning and actions taken. We saw evidence of discussion about relational security and tips for staff. We reviewed ward governance meeting minutes and saw evidence of incidents being discussed and lessons learned leading to changes to reduce risks to people, for example, ensuring people were not provided with inhalers with the lids on following an incident of a person swallowing the inhaler lid. We reviewed incident records and found staff reported incidents correctly with investigations carried out when required.

People told us that staff involved them and supported them with their transition into the service and their planned transitions out of the service.

We spoke with the clinical lead for Malvern ward who attended a transition meeting where the team discussed how to support a person in the service to transition to a community placement. The ward multi-disciplinary team and the person developed a presentation about the person and how they would like the transition to work to share with the potential new providers. Following this the providers were asked to send care plans to be reviewed with the person and a transition plan was then developed. The provider shared their acute liaison pathway for people requiring attendance at local acute hospitals. The trust employed acute liaison nurses at each of the acute hospital trusts and the pathway detailed escalation procedures should staff encounter any challenges accessing acute services for people.

NHS-Led Provider Collaboratives aim to ensure that people with specialist mental health, learning disability and autism needs experience high quality, specialist care, as close to home as appropriately possible, which is connected with local teams and support networks. The provider collaborative for Brooklands forensic wards worked closely with staff to ensure safe transitions into and out of the service for people.

We observed a person using the service on Malvern ward who was admitted from a medium secure ward last year into long term segregation with 3 staff observing them constantly. Staff ensured a safe transition into the ward by working proactively with the person. Staff supported the person to gradually reintegrate into the general ward and slowly reduced their observation levels. On our first day the person’s observations had been reduced from 1 staff observing them constantly to staff checking them 4 times an hour. During our visit to the ward on the second day we observed the person sitting with other people and staff in the lounge area, they appeared relaxed and were chatting to people.

The provider advised they used EssenCES (Essen Climate Evaluation Schema) quarterly to help capture people’s experience of using secure services. The provider’s review of the previous quarter outcomes suggested that people felt safe on all wards. Most people told us they felt safe and supported by staff.

The provider reported the trust’s Head of Safeguarding, Lead Nurse for Adult Safeguarding and Lead Nurse for Children Safeguarding attended the Brooklands site every other week to ensure there was a presence at the site to support staff with any safeguarding matters. The provider reported they have a good relationship with the local authority safeguarding team. The consultant for the male learning disabilities wards advised they supported ward managers to implement boundaries with people. This resulted in people feeling safer on the wards.

We reviewed an easy read format of ‘Coordinated Action against Domestic Abuse - Domestic Abuse, Stalking, Harassment and Honour Based Violence’ questions created by Speech and Language Therapists in the trust and used to support people when safeguarding concerns needed to be raised.

We reviewed the July 2024 ‘Assurance Update Brooklands Hospital’ report from the local authority Safeguarding Adults Board as part of a 6 month review process set up to provide assurance on aspects of quality of care and safeguarding oversight. A reduction had been noted in safeguarding referrals from the hospital from March to May 2024 which was attributed to new staff perhaps not understanding the need to refer to Adult Social Care. The hospital was holding awareness raising sessions to address this, promoting openness about safeguarding as a positive action. The board received evidence from the hospital team and the advocacy provider, that this was taken seriously with a culture of openness and access to support.

People shared experiences of staff creating their positive behaviour support plans with them to help them manage any risks. People were able to share what staff could do to help them when they experienced risky behaviours. However, on Eden ward one person told us that there are too many restrictions, and the ward felt more like a medium secure unit than low secure. We observed restrictions in place were in line with those expected for a low secure ward.

The provider reported a reduction in the use of restraint, rapid tranquillisation, seclusion and long term segregation across all secure wards between 1 September 2023 and 31 August 2024. This was in comparison to the previous inspection where the provider reported higher use of these restrictive interventions over a 12 month period. The manager of Janet Shaw Clinic took a least restrictive approach to managing people’s risk and reduced the number of people requiring higher levels of observations. Staff supported people to understand when restrictive interventions may need to be used as a last resort. Staff did this through care planning and providing ‘Use of Force’ leaflets, including an easy read version if required. The trust recently introduced 4 new ‘restrictive practice and security lead’ roles, to support a reduction in restrictive practices across all wards. These leads attended fortnightly ‘Reducing Restrictive Practice’ meetings with matrons, safeguarding representatives and ward staff. Managers on Eden ward allocated staff to peoples’ constant observations for more than 2 hours at a time. Senior leaders advised this was a move to more therapeutic engagement, instead of sitting and observing, and people wanted the same staff with them rather than lots of changes. Staff could swap out of people’s observations if they felt it was too much. Staff completed most observation records correctly, however we found gaps in records on Eden ward. Staff on Malvern did not always conduct 15 minute observations at irregular intervals, we found examples of these being carried out at set 15 minute intervals. Senior leaders advised relational security was covered in staff induction and continuously reviewed in reflective practice sessions. Managers encouraged temporary staff to engage with people in activities and feel part of the team. This ensured people saw them the same as permanent staff and reduced potential relational security issues.

We reviewed people’s risk assessments on all wards. On Malvern, Eden and Onyx staff assessed and understood peoples’ risks. Staff identified specific risks for people and implemented actions to reduce the impact of these risks. We saw evidence of staff involving people in their risk assessments and debriefing them after incidents. We saw de-escalation strategies being used as detailed in peoples’ Positive Behavioural Support plans. Staff detailed clear rationale for the use of any restrictive practices, for example, no private bathroom time for a person with an eating disorder after mealtimes. We reviewed 3 ‘All About Me’ documents for people on Janet Shaw Clinic. Staff developed these with the person and highlighted interventions to help the person deescalate if they were becoming distressed. We found that care records for people at Janet Shaw Clinic did not always include plans for staff to follow in relation to an identified specific risk or need. This included a lack of a specific plan for one person who had been identified as being at risk of choking. The ward manager was aware of these issues and actions were in place to make improvements. We reviewed the provider’s information on the treatment pathway for people in the secure wards, one of the underpinning philosophies was to “Provide the most proactive and least restrictive care and treatment”. We reviewed ward governance meeting minutes for all wards and saw evidence of restrictive practices, including blanket restrictions, being reviewed and reduced when able. Examples included reducing restrictions on e cigarettes which has resulted in people using them less. The provider reported 24 short term harm incidents which required treatment. Nine of these incidents were of moderate harm as they involved people inserting or swallowing items. Peoples’ observation levels and access to items were reviewed by the multi-disciplinary team following each of these incidents.

People had no concerns about the safety of the environments. One person on Onyx ward said they liked having their own living space and it was better for them to have their own space. They showed us their living space within the ward which consisted of an open plan lounge, kitchen and dining area with a separate bedroom and bathroom. They also had their own small garden area.

Arrangements to monitor the safety and upkeep of the premises were not always effective. We discussed the damaged and unsafe door frame at Janet Shaw Clinic with staff. They advised they reported to estates on 1 August 2024 and sent follow up emails. There appeared to be communication difficulties between the ward and estates department, and the ward failed to escalate this to senior leaders. Staff on Malvern ward raised concerns that repairs were not always carried out in a timely manner. Senior leaders expressed frustrations at the time it could take for repairs to be completed.

Most people were cared for in safe environments that met their needs. Onyx ward was safe and designed to meet the needs of people with autism. Eden and Malvern wards were clean and well maintained. Clinic rooms on all wards were clean and tidy. Seclusion facilities met the Mental Health Act Code of Practice, apart from on Malvern ward where there was no clock visible. However, on Janet Shaw Clinic, the décor was tired and outside areas were unkempt. There was a dilapidated outbuilding in the garden area. The outbuilding is condemned and not in use. Patients have access to this garden area under supervision of staff. We observed a doorframe in the bedroom corridor (room unused) that was damaged, with plaster coming away exposing screws and sharp edges. Staff were unable to describe how they would ensure people did not come to harm. We were told there was always a member of staff in the corridor, but there was no staff member in the corridor during our tour of the ward areas. People using the service had access to this corridor. We escalated this to senior leaders and the doorframe was made safe by the following day. Senior leaders advised a design for a new build to replace Janet Shaw Clinic was ready and work was ongoing to access funds to complete this. We observed the poor state of the driveway through Brooklands site and saw a person struggling to walk along. However, on our return visit in October work was underway to improve the driveway.

Although leaders implemented arrangements to monitor the safety and up keep of the premises, these were not always effective at Janet Shaw Clinic. Staff completed an electronic environmental checklist application daily which was monitored by ward managers. Actions required were highlighted as red until completion. The most recent NHS ‘Patient Led Assessment of the Care Environment’ reported an improvement of 85% in 2019 to 100% in 2023 for ‘condition, appearance and maintenance’.

Most people told us that they felt safe with staff on the wards. However, one person at Janet Shaw Clinic told us that agency staff sometimes fall asleep when they are meant to be observing them. They did not tell us if they raised this with anyone at the time and could not remember the staff involved. The ward manager advised any allegations made about agency staff would be reported as a safeguarding concern and the agency manager would be contacted about it. Another person told us they raised concerns with the ward manager about agency staff being ‘lazy’ and the ward manager spoke to the staff and this improved.

The provider reported staff vacancy rates for qualified staff reduced since the last inspection from 69% to 38%. The vacancy rate for unqualified staff was 30% at the time of the inspection. The provider completed a review of its workforce establishment and realigned budgets. The provider reported a reduction in staff turnover rates from 22% to 17% since the last inspection. Senior leaders reported improved recruitment processes, resulting in better quality staff. Staff retention improved as this had been poor. An improved preceptorship programme saw a big increase in retaining qualified staff. A recently qualified nurse on Malvern ward told us the preceptorship programme was excellent. The provider reported low numbers of unfilled shifts, at 0.6%, between 1 September 2023 and 31 August 2024. The provider reported 34% of shifts covered by bank or agency staff for the same period. 95% of bank or agency nurses worked regular shifts. The provider reported an average sickness rate of 8.45% between 1 September 2023 and 31 August 2024. The ward with the highest sickness rate was Malvern at 12%, this was an increase from the last inspection when Malvern had reduced sickness levels down to 5%. The provider reported mandatory training compliance at 93% and specialist training at 90% across all wards at the time of the inspection. Specialist training included trauma informed care and positive behavioural support. Staff spoken with told us they were well supported by managers with supervisions and access to training. Managers allocated staff to specific roles, for example, security lead, to ensure the safe and smooth running of the service. Managers told us they were able to adjust staffing levels to meet the needs of people using the service. The manager for Eden ward increased their staffing numbers. This made a huge difference in relational security, which resulted in a reduction in incidents. New staff completed a 4 day induction delivered by the multi-disciplinary teams.

We observed safe and effective staffing in place on all wards during our inspection. We reviewed quality reports completed by the provider collaborative following annual quality visits to all wards. On Eden ward they commented on the high vacancy rate for nursing staff and high use of bank staff but acknowledged the work going into recruitment and retention. The teams visiting Janet Shaw Clinic and Malvern noted improvements in the stability of the workforce.

The provider reported a clinical supervision compliance rate of 69% and a managerial supervision compliance rate of 83% between 1 September 2023 and 31 August 2024. The provider advised that the data included staff who were absent which created an artificially lower rate. The head of nursing provided clinical supervision to the secure ward managers and clinical leads.

People spoken with had no concerns about the cleanliness of the service.

Staff described the processes they followed to ensure effective infection prevention and control. These included hand washing prior to entering the ward, regular environmental checks and implementation of cleaning regimes.

We observed positive infection control procedures in place during our onsite visit. Staff followed procedures including hand washing and ensuring all areas were kept clean.

We reviewed cleaning audits shared by the provider. Between 1 September 2023 and 31 August 2024, the service scored an average of 98% for cleanliness. All wards scored 100% for cleanliness in the most recent NHS ‘Patient Led Assessment of the Care Environment’. We reviewed quality reports completed by the provider collaborative following annual quality visits to all wards. The team that visited Malvern ward noted that “The standard of cleanliness had improved significantly, and most areas were immaculate”.

People spoken with told us they were able to discuss their medication. People did not have any issues with medication. However, some carers spoken with said staff did not keep them up to date with medication their relative was taking, even when their relative had consented to this information being shared.

Staff on Onyx ward told us people would be given information about possible side effects of their medication, unless it wasn’t in their best interests. The consultant for Malvern and Janet Shaw Clinic advised that medication use for people was low and use of anti-psychotics was kept to a minimum with new anti-psychotics being used if needed. The consultant described how people were involved in making choices about medication, for example, one person tried a newer medication, but it did not suit them, so they asked to go back to their old medication and were happier with this. Staff ensured people were observed for possible side effects, especially as people with a learning disability may not always recognise when they experienced side effects. We spoke with a pharmacy technician who told us staff were very responsive to actions required following audits.

Across all wards we found that medicines were appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence, and in line with the Mental Capacity Act 2005. People’s behaviour was not inappropriately controlled by medicines. There were appropriate arrangements for the safe management, use and oversight of controlled drugs.

The pharmacy team visited regularly and carried out audits on all medication related processes. Leaders implemented processes to ensure people’s medicines were appropriately prescribed, supplied and administered. There were appropriate arrangements for the safe management, use and oversight of controlled drugs.