The provider had implemented a full program of staff training and awareness to address all the issues raised in the warning notice issued on 28th June 2018 in relation to medicines management and learning lessons from incidents. This included enhanced pharmacy support and liaison, a continuing review of policies and the employment of a health consultant to ensure the implementation of the action plan they had developed.

• The provider had ensured there was managerial oversight of the clinical monitoring and safety of patient’s medicines.

• The provider had ensured that all nursing staff had completed the competency assessment to administer and manage medicines.

• The provider had ensured that all staff were aware of the incident reporting policy and criteria for reporting incidents.

• The provider had ensured oversight of the reporting of incidents to identify themes and trends in their medicine management and that there was a process for learning lessons from these themes.

We found:

• There was no reliable system or policy for regularly checking emergency equipment. This was a requirement following the last inspection.

• Supervision levels for the majority of staff were below the local standard. Annual appraisal of staff performance and development needs levels were inconsistent, being lowest for the basic grade support workers. This left staff unsupported and management without a reliable way of assessing how well staff did their job.

• Clinical staff did not all know about the results of a check on ligature risks, in the clinical and public areas of the hospital. Ligatures are places to which patients intent on self-harm might tie something to strangle themselves. This made it more difficult for staff to manage risks created by the building when planning care for patients.

However:

• The hospital had increased the amount of emergency equipment. Each of the three wards and two cottages had immediate access to resuscitation equipment.

• The service had an up-to-date, full and detailed ligature risk assessment. Following this, managers had developed and carried out an action plan to reduce ligature points across the hospital.

• Permanent staff vacancies had gone down significantly since our last inspection and a full-time rota co-ordinator had reduced the use of agency staff. A robust system was in place to block book familiar bank staff to cover staff holidays, and long-term sick and study leave.

• Information on safeguarding people from abuse was on display throughout the hospital. Staff were aware of the forms of abuse they might come across working with vulnerable adults. They also knew how to report their concerns.

• There was evidence of a developing programme of activities for patients from Monday to Friday, and active monitoring of how many patients took part. Opportunities for weekend activities were limited and dependent on clinical staff rather than dedicated activity workers.

• This inspection was a focussed unannounced inspection in response to medicines safety concerns raised by a whistle-blower to the Care Quality Commission. During the inspection we found issues around the management of medicines across all wards.
• The provider’s safe and secure handling of medicines policy was not being followed by staff. We found there were systematic failures in the management of medicines that included:
• Medicine stocks not ordered in a timely manner that resulted in patients not receiving medicine as prescribed. Of the 53 patients in the hospital, 23 patients were affected by medication being out of stock on 207 occasions in the three months before our inspection.
• Medicines that had been opened or removed from the fridge did not have the patient name or new expiry date recorded on the packaging. This meant that staff could not be confident in the continued effectiveness of the medicine
• Procedures for the safe disposal of medicines were not followed, which is required for audit purposes and the protection of staff.
• Staff nurses had not received annual training on medicines competency in line with local policy.
• The actions from internal medicines audits and external pharmacy audits were not implemented to address non-compliance.
• There was a lack of equipment to monitor the physical observations of patients where an abnormal reaction may have been suspected.
• Staff did not routinely report the absence of medicines as incidents on the provider’s system and were unclear of the incident reporting criteria. Staff told us they raised incidents verbally with managers, who did not report them on the incident reporting system. This meant that the senior leadership team did not have oversight of emerging trends and themes for medicines incidents.
• Staff raised safeguarding concerns with the deputy hospital manager or registered manager, who spoke with the local safeguarding board. However, we found this was not a consistent process and not all safeguarding concerns had been raised to the safeguarding board in a timely manner.

However, we found:

• All the wards monitored and recorded the room and fridge temperatures, and records of these checks were completed daily by staff.
• Resuscitation equipment and emergency drugs were available in the clinic rooms and staff regularly checked the contents.

• The multidisciplinary team discussed patients and put risk management plans in place, which staff followed to keep patients safe from harm.
• Staff were able to describe how they identified safeguarding issues and how they received yearly safeguarding training.