Broomhill

We identified some areas of concern under the safe key question which will require

an action plan under the medicine’s optimisation quality statement. Staff completed

medicines audits but there was a lack of oversight of medicines management.

Actions needed as identified through pharmacist audits had not been actioned by

staff. Staff did not consistently adhere to the providers medicines disposal policy.

Staff had completed some expiry date labels incorrectly. Care plans specific to

certain high-risk medicines lacked detail. Four registered nurses we spoke with were

unable to tell us what drugs should be used in the event of an opioid or

benzodiazepine overdose. While the hospital had an identified infection prevention

and control lead, they had not identified infection prevention and control champions,

in line with their policy. Though staff told us they did have a plan in place to address

this. We saw that clinical staff undertook the complex ligature risk assessment across

all wards, but we were unclear if these staff had received relevant training to

complete this task. Actions needed were recorded on a separate estates plan with

anticipated dates for completion. We noted that many items needed removing from

the environment. Estates staff were not involved in this assessment which was

unusual. However, staff reported and investigated safety events and incidents.

Emphasis was placed upon learning from incidents to improve practice. Staff told us

they could and would raise concerns with senior staff. Staff had a good

understanding of safeguarding and took appropriate actions. There were systems

and processes in place to ensure people were protected from abuse and neglect.

Staff assessed individual patient risks and reviewed these regularly. Restraint was

only used as a last resort. Staff took a proportionate approach to imposing

restrictions upon people. Leaders continued to work with partners to improve the

quality and continuity of care.