Lincolnshire Partnership NHS Foundation Trust

We rated community mental health services for people with learning disabilities or autism as requires improvement because:

• Staff had not completed risk assessments consistently. Risk assessments were not all in date and varied in detail and format. Some staff were not aware of patient risk before seeing patients for the first time.
• Staff did not complete or record mental capacity assessments consistently.
• Trust data for compliance with supervision was unclear prior to January 2017, when the trust had introduced a new system to record this. Data showed variance in compliance between teams.
• Staff did not consistently record physical healthcare needs and assessments in patient notes.
• Staffing numbers in the south hub at Spalding were significantly under establishment due to long-term sickness and vacancies.
• Alarms in clinic rooms in Lincoln were not operational and staff could not summon help quickly in an emergency.
• Compliance with mandatory training did not meet the trust’s target. Training compliance for level three safeguarding children was 59%.
• Staff did not engage in clinical audits.

However:

• Multi-disciplinary team working was an integral part of all the teams and supported patients and staff effectively, through regular referral meetings and multi-disciplinary case discussions. Teams communicated effectively and understood their role.

• There was rapid access to a psychiatrist when needed.

• The teams had effective lone-working policies and followed them.

• Staff monitored waiting lists and patients and their carers could contact staff if their condition deteriorated.

• Staff reported incidents on the trust’s electronic recording system. Staff investigated incidents when necessary and lessons learned were shared within teams. Staff knew how to recognise abuse and make safeguarding referrals to the local authority.

• Staff were passionate about getting the best possible outcome for the patients they worked with and about providing them with high quality care.

• Staff knew their patients well and could demonstrate an understanding of their needs. Teams spoke about patients in a person centred way.

• Staff encouraged patients and their families to feed back about the service and that feedback was very positive.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We rated the trust overall as good because:

• The trust had responded in a positive way to the improvements we asked them to make following their last inspection. Improvements in most core services were noted across the trust.

• Patient care environments were clean, in good decorative order and appropriately furnished. Services had sufficient rooms for the safe care and treatment of patients, including private areas for patients to receive 1-1 support from staff or see visitors. All inpatient services had activities programmes for patients. There was access to activities over a seven day period. Each ward had timetables visible so that patients knew what was on offer. Patients could personalise their bedrooms and had lockable storage for their possessions. The trust was meeting Department of Health guidance for eliminating mixed sex accommodation.

• The trust had made significant improvements to the external courtyards on the adult acute wards since our last inspection. For example, installation of closed circuit television and two way intercom systems and removal of ligature risks. Works were still on-going. In the inpatient ward for children and young people, innovative observation panels were fitted on bedroom doors, which had privacy frosting on them that was removed electronically when staff pressed a button.

• The trust was opening a psychiatric intensive care unit for males in the summer of 2017 and had plans to provide a psychiatric high dependency unit provision for females.

• The trust had reviewed its management of ligature risks within services. Staff were aware of the risks in their environments and ligature assessments were re-assessed regularly. On inpatient wards, staff had quick access to ‘heat maps’, specific to their area, to assist in the safe management of patients presenting with high risk of self harm or suicide.

• Throughout the trust, staff treated patients with kindness, dignity and respect. Consistently, staff attitudes were helpful and understanding. Staff used kind and supportive language that patients would understand. Staff encouraged patients to give feedback about their care in a variety of ways. Information leaflets were available in easy read formats and we saw evidence of a variety of information available to patients, for example on how to access interpreters, make complaints, access to advocacy and Mental Health Act information.

• The trust employed suitably qualified and experienced staff to deliver safe care and treatment to patients and provided them with training and development opportunities. The trust had supported healthcare support workers to undertake training to become registered nurses, provided a robust induction programme and supported clinical apprenticeship to encourage young people to seek employment with the organisation. The trust utilised a values based recruitment checklist during their interview process and revisited this during staff induction. The trust also operated a rewards and recognition system, including individual and team recognition, thank you cards, hero’s awards and annual awards ceremonies.

• Managers ensured staffing levels across all core services were planned and regularly reviewed. The majority of services across the trust increased staffing based on clinical need and made arrangements to cover leave, sickness and absence. Local managers had authority to make these decisions. The trust employed bank or agency staff to fill vacancies. Where possible, managers ensured temporary staff were familiar with the patients and teams in which they worked. This ensured continuity of care for patients. Bank staff received appropriate training for their roles.

• Staff received mandatory and role specific training. As at 31 March 2017, the overall compliance across all core services was 92%. Staff had access to additional specialist training, relevant to their role and medical staff had protected time for training and development.

• Staff received an annual appraisal. As at 31 March 2017, 92% staff were compliant.

• The trust reported a reduction in staff sickness rates. In December 2015, staff sickness was reported as 5.1%. In February 2017, this had reduced to 4.5% as a 12-month average.

• The trust regularly reviewed caseloads for staff working in community teams. Where caseloads were high, staff were able to explain the rationale for this.

• Crisis teams were meeting commissioned targets for contacting patients within four hours. As of February 2017, 99% of patients were contacted within this time. Crisis teams had good working relationships with the local Police

• The trust had a robust governance structure in place to manage, review and give feedback from complaints. Staff consistently knew how to handle complaints, and managers investigated complaints promptly Patients and carers received timely responses and outcomes.

• The trust had safeguarding policies and robust safeguarding reporting systems in place and described how they worked with partner agencies to protect vulnerable adults and children.

• The trust used an electronic system for reporting incidents. Trust staff knew what incidents needed to be reported and how to report them. Managers monitored the reporting and recording of incidents. The trust had robust systems for sharing lessons learned from incidents. We saw evidence of compliance with duty of candour guidance related to investigations from serious incidents and complaints. Patients, families and carers were fully involved and informed throughout all processes. The trust board encouraged candour, openness and honesty from staff. Staff knew how to whistle-blow and staff felt able to raise concerns without fear of victimisation.

• The trust had robust process to monitor the fitness of senior staff to work within the service, under the principles of fit and proper persons requirements.

• Senior managers told us there had been much organisational change and transformation of care within the trust. Staff told us they accepted change and positively embraced the opportunity it provided. They felt supported by the board to work with change and felt able to provide feedback about their experiences. Overall, we found significant improvement to staff morale across most teams.

• The trust had robust systems in place to manage the prescribing, storage and administration of medication. We found good working practices between the pharmacy team and staff across all services.

• Overall, we saw good multidisciplinary working and generally patients’ needs, including physical health needs, were assessed and care and treatment was planned to meet them.

• Staff had a process in place to submit concerns and issues to the local risk registers which fed in to the trust wide risk register where appropriate.

However:

• Whilst there had been significant progress since the last inspection in 2015, the trust had not fully addressed all our previous concerns.

• The trust could not always provide a bed locally for patients who required admission to adult acute mental health beds. This meant that patients often received care and treatment outside of the trust. Between March 2016 and March 2017, there were 306 out of area placements from the trust to other providers of acute adult inpatient care. The trust did not have psychiatric intensive care unit (PICU) beds. Therefore, if a PICU bed was required, patients were placed out of area. Between February 2016 and February 2017, 63 patients were transferred to other providers when intensive care was required.

• Bed occupancy rates were above 100% on the adult acute wards. We saw that patient numbers exceeded the number of beds available on wards. Therefore, there were no beds available if patients returned from leave.

• The majority of beds within the adult acute admission wards were located in bays sleeping either four or five patients. These areas offered limited space and privacy.

• Within the forensic inpatient secure ward we found patients did not have free access to the garden. This was a blanket restriction. We were also concerned about the safety of the security fencing in the garden area. We raised this with the trust who made immediate plans to have this replaced.

• In the inpatient ward for children and young people, most doors on the ward were locked, this included bedrooms, toilets and bathrooms, dining room, the female only lounge and doors to the garden. There was no clinical justification for this practice and it was not individually care planned. This was a blanket restriction. We raised these concerns with senior managers and when we returned on 20 April, the trust had taken action to ensure patients were provided with wrist bands, programmed to allow access to specified areas.

• The trust had identified they need to take further actions to ensure the health based place of safety fully met the Royal College of Psychiatrist standards.

• Not all patients had timely access to psychological therapies as recommended by the National Institute for Health and Care Excellence.

• Information from April 2016 to March 2017 showed 242 patients were discharged from the health based place of safety within 72 hours. On 127 occasions, staff had not completed the patient’s discharge time on records.

• The trust provided data for staff compliance with clinical supervision; however, this showed significant variance in compliance across teams. The trust told us they had introduced a new method of recording supervision, which was not yet fully embedded. Clinical and managerial supervision data was not collected separately. However, data provided showed overall compliance with clinical supervision across all core services ranged from 7% in October 2016 to 88% in March 2017, with an overall average compliance across all core services of 48%, against the trust target of 95%. From data provided and on site findings, we were unable to determine how supervision was delivered, for example how often staff received one to one support, or whether managerial supervision was provided in accordance with the trust policy. It was equally unclear how outcomes from staff supervision were reviewed or acted upon. We were not, therefore, assured the trust had clear oversight of compliance with management supervision. The trust could not be sure that all performance issues, training requirements or professional development had been identified for staff working in the service.

• Not all staff had completed mandatory training in line with the trust target. For example, on the acute wards for adults only 58% of staff had completed safeguarding children level 3 training. We were concerned that only 63% of staff were compliant with basic life support training, meaning they might not have the required or up to date skills to support patients in an emergency. Equally, only 61% had completed conflict resolution (restraint) training, meaning they might not have the required or up to date skills to safely manage patients requiring physical interventions.

• The trust policy on the management of violence and aggression did not contain guidance from the Mental Capacity Act relating to the use of prone restraint and did not reference up to date National Institute for Health and Care Excellence guidelines. We found an increase since our last inspection in both incidents of restraint and the use of prone (face down) restraint.

• We found some errors on community treatment order paperwork. Seclusion paperwork did not always meet the guidance in the Mental Health Act Code of Practice and medical assessments were not always fully completed or recorded. Staff did not complete seclusion care plans for patients nursed in seclusion on the adult acute wards.

We rated child and adolescent mental health wards as good because:

• The ward was clean, tidy and well maintained. Observation mirrors and closed circuit television was used to assist nursing staff with observations.

• The ward had an up to date ligature risk audit, staff mitigated the risk on the ward by observing patients. Staff mitigated the risks posed in the garden area by accompanying patients when they wanted to access the garden.

• The ward had sufficient staff to provide good care and treatment to patients.

• The ward met the criteria for eliminated mixed sex accommodation in line with guidance contained in the Mental Health Act code of practice.

• Staff were 98% compliant for mandatory training.

• Staff undertook a risk assessment with every patient upon admission. Care plans were comprehensive, personalised, holistic, and recovery orientated.

• Staff provided a range of therapeutic interventions in line with the National Institute for Health and Care Excellence guidelines and there was a full education programme in place.

• Staff read detained patients their rights on admission and regularly thereafter. Staff gave patients an information leaflet explaining their rights and responsibilities as an informal patient.

• Overall, 100% of non-medical staff had an up to date appraisal.

• There was a well-functioning multidisciplinary team. Staff discussed patients’ care and treatment weekly in ward round. Parents told us that they felt involved in the care and treatment.

• Patients told us that they felt supported to make their own decisions and staff treated them with dignity and respect. Patients said they were involved in their care plan.

• Staff interacted with patients in a positive way. All staff demonstrated a good understanding of patients’ individual needs, including care plans, observations and risks.

• The ward had a range of rooms and equipment to support treatment and care. There was a large garden; with an area that had been made secure. Patients could personalise their bedrooms and could choose from a choice of bedding.

• There was a family room for parents, carers and siblings to visit. Visits within the community and the garden area were also encouraged.

• There was access to activity across the week with primarily nurse led sessions over the weekend. Patients worked with the activity coordinator to plan activities that they would like to do.

• All staff demonstrated the trust values in their behaviour and attitude. Staff we spoke with were passionate about helping patients with mental illness. Staff were proud of the work that they carried out and the care that they provided to patients.

• Managers told us they had sufficient authority to complete their role and they felt supported by senior managers.

However:

• Staff kept most doors on the ward locked. There was no clinical justification for this practice and it was not individually care planned. This was a blanket restriction.

• Seventy-one per cent of staff had undertaken training in clinical risk assessment and management. This was below the trust target of 95%.

We rated Lincolnshire Partnership NHS Foundation Trust specialist community mental health services for children and patients as outstanding because:

• Patients and carers told us that everyone was caring, compassionate, kind and treated them in a respectful manner. All feedback surveys collected by the trust were consistently positive about the way that staff treated patients.

• The service had established an innovative model of working using outcome measures at each appointment. This model was patient centred and holistic based around the child or young persons’ strengths and goals.

• Staff were open and transparent in relation to incidents and complaints. They acted on lesson learnt from incidents and complaints. They strived to continually improve the service they delivered by working closely with commissioners and other stakeholders.

• Managers and senior staff including board members were visible and approachable. Staff expressed they felt able to raise concerns without fear of reprisal. The managers and team co-ordinators were passionate about delivering high quality care and treatment and had funded 17 clinicians to undertake children and young people’s improving access to psychological therapies training. They had managed to recruit to the 17 vacancies with substantive posts therefore increasing the level of staffing within the service.

• Risk assessments and care plans were comprehensive and well written. They were developed in collaboration with the patient and, where appropriate, their carers. Staff were able to refer patients to the crisis and home treatment and resolution service within CAMHS if they were concerned about a young person’s presentation out of hours and at weekends. This service had been praised highly by senior staff at the local hospitals in relation to the responsiveness of the team Communication between the teams was excellent.

• The service had introduced an animal assisted therapy service to group work for patients.

However:

• Only 68% of staff had undertaken the children’s safeguarding training level 3B.This was below the trust target of 95%.

• Staff supervision rates were lower than the trust expectations and managers did not always keep a record of supervision sessions.

We rated mental health crisis services and health-based places of safety as ‘good ‘because:

•  The trust had taken actions to improve the environment of the health based place of safety and to increase the range of multi-disciplinary staff in crisis teams following our last inspection.
• Staff completed risk assessments for all patients and updated them as the level of risk changed.
• Many patients felt their mental health had improved as a result of the service they received from the crisis and home treatment teams.
• The trust took action to address the changes to the Policing and Crime Act 2017 and had identified inpatient beds to ensure patients were not kept longer in the health based place of safety than needed.
• Managers reviewed discharge processes for inpatients to ensure they did not remain in hospital longer than was needed. For example, they reviewed the use of the crisis house, improved communication with discharge coordinators and bed managers.
• The trust arranged crisis team support based out of hours with the police to signpost patients to mental health services.
• The trust met commissioned targets for contacting patients within four hours.
• The trust had plans to develop a clinical decisions unit in 2018 to further support patients in crisis needing hospital admission.
• Grantham crisis and home treatment team had achieved the Royal College of Psychiatrists home treatment accreditation scheme.

However

• The trust had not ensured that staff regularly received clinical and managerial supervision.
• Patients and carers did not have copies of their care plans explaining the support teams would give them.
• Staff did not consistently document that they had assessed patients’ physical health care needs.
• Crisis team staff said that patients could wait for hours to be transferred to out of area placements due to delays with the contacted transport service being able to respond and escort them.
• Crisis teams did not include psychologists which meant assessments of patients at the point of crisis were not fully multi-disciplinary.
• Staff morale in Louth was lower than other teams because of increased work due to the community mental health teams and difficulty accessing medical cover.
• The trust had not ensured that all staff completed mandatory training for their role.
• Trust information from April 2016 to March 2017 showed staff had not completed the patient’s discharge time on records on 127 occasions.

• Ligature points (places to which patients intent on self-harm might tie something to strangle themselves) were identified as part of the monthly environmental risk assessment audit and actions had been identified to reduce the risk to patients. These included enhanced observation levels. Wards complied with the Department of Health’s eliminating mixed sex accommodation guidance, which meant that the privacy and dignity of patients was upheld.
• Cleaning rotas had been completed and the wards were visibly clean and tidy. Nurse call systems were in place in bedrooms, communal and office areas.
• Staffing levels were appropriate to meet the needs of patients. There were low levels of both qualified and unqualified nursing vacancies. Ward managers were able to adjust staffing levels to take account of clinical need and said senior managers never refused a request for additional staffing if required. Escorted leave and activities were rarely cancelled due to staff shortages.
• Staff followed National Institute for Health and Care Excellence (NICE) guidelines in relation to practice and when prescribing medications. These included regular reviews and physical health monitoring. Patients were supported to access specialists when required for physical healthcare needs. Hydration and nutrition were monitored regularly and recorded in care records.
• Staff and patients interacted well. Staff managed distressed patients in a calm and responsive way and supported them to talk about the issues affecting them. Staff knew the patients very well and were passionate about patients' needs. Patients told us that they had good relationships with staff and they were very helpful, understood their problems and were always available. They said they felt safe and that staff took the time to listen to them when they had a problem.
• Hot drinks and snacks were available on request 24 hours a day. Patients were able to personalise their bedrooms.
• Staff told us who the most senior managers in the trust were and that they had visited the wards. Ward managers told us they felt well supported by their line managers.

However:

• Staff did not always review risk assessments following incidents.
• There was limited access to psychological therapies. The service had one whole time consultant psychologist and one whole time assistant psychologist for both community and inpatient older adult services.
• Trust data showed supervision rates across the service between January 2017 and March 2017 to be 66%. The trust could not be assured that performance issues and training needs were identified or acted upon.
• Capacity assessments were not decision specific, forms included more than one question.
• One patient was receiving covert medication, we did not find a capacity assessment form for this.
• There was little evidence of patient participation in care plans and risk assessments. Four patients reported that they had not seen or been provided with a copy of their care plan.
• Patients had a lockable drawer in their bedroom; however keys were not available for patients to lock the drawer.

We rated community based community mental health services for older people as good because:

• All patient information was stored electronically and was accessible to staff.

• The service followed National Institute for Health and Care and Excellence (NICE) guidance in prescribing medication and reviewing patients who had dementia.

• Patients were consistently positive about the centres and about the staff, patients felt understood and cared for.

• Patients told us that they felt involved in their care planning and that they had been offered a copy of their care plan.

• Staff were able to prioritise and see urgent referrals quickly.

• There was a safeguarding champion available to support staff with safeguarding concerns and safeguarding posters were displayed in the reception areas at each of the locations.

• Staff learned from incidents, complaints and patient feedback via the bi monthly lessons learned bulletin, at team meetings and during supervision. We saw examples of lessons learned and changes in practice as a result of this.

• Leaflets were available in different languages and information was available in different formats on request.

• Staff were passionate about their jobs and used the trusts’ vision and values in their everyday work.

• Senior managers were visible and known to staff. They visited the locations to update staff on changes within the service and the trust.

• Sickness and absence rates were low and clear strategies were in place to cover any staffing shortfalls.

We rated acute wards for adults of working age as requires improvement because:

• Bed occupancy rates were over 100%. Staff were using leave beds frequently to accommodate new admissions. There were a number of identified delayed discharges across the service. There were high numbers of patients in out of area beds at the time of inspection. There were 32 re-admissions to hospital within 28 days of being discharged, with half of all patients returning to the same ward they were discharged from. Fifty-five per cent of patients did not have discharge care plans in place.
• Sleeping areas consisted mostly of bays sleeping four or five patients. These areas offered limited space and privacy.
• Staff did not always assess or monitor the physical health of the patients. They did not always have a care plan in place for patients who had identified physical health problems. Staff did not always follow National Institute for Health and Care Excellence guidelines or trust protocol around the administration of rapid tranquillisation.
• Detained patients accessed leave without qualified staff having completed a risk assessment immediately prior to leaving the building.
• Staffing levels at weekends were lower than in the week. This affected staff capacity to escort patients who had leave.
•  There had been an increase in the use of restraint and prone restraint across this service, since the last inspection.
• Compliance with mandatory training was below the trust’s own target, and some compliance fell below 75%.
•  There was absence of care plans for patients being nursed, or had been nursed in seclusion across the service. We reviewed 18 records of seclusion. No patients had a care plan in place to reflect they were being nursed by staff in seclusion
•  Clinical staff did not receive regular supervision.
• Not all staff had received an annual appraisal.

However:

• Ligature assessments were robust and management plans were in place to manage risk.
• Clinic rooms were well equipped. Nursing staff checked emergency medications and equipment regularly.
• There were no blanket restrictions across the service. Any restrictions were individually risk assessed.
• Staff had a good knowledge of what constituted a safeguarding concern and the reporting process.
• Staff were trained to use restraint as a last resort. Staff used verbal de-escalation before resorting to physical contact.
• Doctors completed an initial physical health assessment for all new admissions where possible. If the patient declined, staff recorded this and attempted again at the earliest opportunity.
• The trust provided additional training for staff development to enhance their roles.
• There was good access to advocacy services, which was utilised by patients.
• There was appropriate involvement of families and carers.

We rated Long stay/r ehabilitation on mental health wards for working age adults as good because:

• All wards had detailed ligature risk assessments. Staff knew where the risks were and how they should manage them. Patients said they felt safe on the ward.

• The majority (94%) of staff had received training in safeguarding adults and were able to identify what abuse was.

• We looked at 15 patient records. The multidisciplinary staff team completed thorough, detailed assessments prior to and on admission. Staff updated these regularly.
• We saw staff treating patients with kindness and understanding.

• There were programmes of activities, both on and off the wards, with weekly plans for each patient. The service offered a programme of paid work opportunities for patients. These included jobs as a gardener and car valet. There was a patient run café at Discovery House. The café had recently employed a previous patient in a contracted paid role.

• Patients had access to independent mental health advocates. There were posters displaying this information on noticeboards in the ward. Staff asked all patients if they would like to be referred to the advocacy service.

• Staff were able to describe how they would apply the principles of the Mental Capacity Act in their roles. Patients had decision specific capacity assessments in their care records.

• Ten patients said they were aware of how to make a complaint and would be able to do so if they felt they needed to.

• Staff used a range of tools to measure patient outcomes. These included the recovery star, depression ratings, clustering and national early warning scores.

• Morale within all teams was high. Staff worked well together within a multi-disciplinary approach.

• Managers carried out audits of their ward performance, care records and safeguarding.

• The service had participated in the Accreditation for Inpatient Mental Health Service (AIMS). All wards had been accredited as excellent up to October 2017 when the review was due.

  However:

• At the time of our visit, Vale ward reported a vacancy rate for qualified staff of 15%. The manager advised she had raised this as a risk issue and had put forward a proposal to block book regular agency staff to keep staffing levels safe.

• Staff raised concerns at Maple Lodge about medical cover not being sufficient.

• Supervision rates were slightly below the trust target of eight supervisions a year in two of the five wards.

• On two wards food fridge temperatures were above the acceptable range.

We rated community based mental health services for working age adults as requires improvement because:

• Care plans were not always personalised, holistic or recovery focussed.

• Regular medication reviews and physical healthcare monitoring for patients did not take place consistently.

• The trust did not use any formal outcome measures to assess patient progress.

• Individual patient’s risk assessments were not reviewed consistently.

• We identified errors and omissions in Community Treatment Orders and this documentation was not fully audited by the trust.

• The service did not have an effective governance system. The balanced scorecard used to gauge the performance of the team was inaccurate and not shared with front line staff.

• Managers did not have an effective audit system in place to audit Mental Health Act paperwork.

• The trust had not proactively addressed the long waits for psychological therapies by some patients.

• There was no local risk register.

However:

• All teams had safe staffing levels, and ensured sufficient care co-ordination time for all patients.

• Patients had a thorough risk assessment completed at their initial assessment.

• Teams had good multi-disciplinary and interagency working, with close links to other teams within the trust and the local community.

• Local leadership was effective within teams. Staff felt supported and received supervision and appraisal in line with trust policy.

We rated forensic inpatient/ secure units as good overall because:

• Francis Willis was a slightly dated but pleasant environment. There were clear lines of sight throughout the ward. The trust has completed detailed ligature risk assessments and plans were in place to appropriately manage these risks within the unit.

• The defibrillator and essential safety equipment had been serviced and regular checks were undertaken.

• There was sufficient staffing during weekdays and the unit had medical support at all times. Staff had undertaken mandatory training and received regular supervision and appraisal

• Nursing staff on the wards were enthusiastic in their approach and patients spoke positively about them. The clinical team contained full multi-disciplinary representation.

• All admissions were planned following pre admission assessments. Local risk assessments were also carried out after admission. Patient care plans were personalised and based around the individualised risk.

• All patients had their physical healthcare needs met and there was an effective health care recording system

• Leadership on the unit was highly visible and managers had a positive presence on the ward.

• Areas of concern highlighted following our previous inspection had been addressed.

  However:

• We remain concerned about the safety of the garden area of the ward. This contained potential ligature points and additional safety risks that had not been addressed through environmental risk management plans. Staff managed these risks through restricting patient access.

• We found some other examples of blanket restrictions. These included access to mobile phones and set vaping times.

• While patients had a good level of activity and escorted leave during weekdays there were limited activities available at weekend.