Safeguarding patients at extreme risk

a herb garden with soft focused people in wheelchairs from behind, Safeguarding patients at extreme risk – a journey of service improvement

by Head of Safeguarding Sorin Neacsu

The Royal Hospital for Neuro-disability (RHN) is a specialist hospital and research centre providing care and rehabilitation for adults with acquired brain injuries and neurological conditions. Due to the very highly complex patient population, maintaining patient safety is equally complex and requires concerted multidisciplinary team efforts on a consistent basis.

The RHN gives a wide range of service provision including two ventilator units, two challenging behaviour units, a learning disability unit, two brain injury rehabilitation units and four long-term disability management units.

Patients managed at the RHN present with very complex conditions requiring specialist input in respiratory care, continence care and enteral feeding and nutrition. The hospital is currently managing a number of 61 patients with a tracheostomy, 160 patients with an enteral feeding tube and 36 patients with an indwelling urinary catheter.

At our inspection in February 2020, the Care Quality Commission (CQC) acknowledged the complexity of our patient population and the efforts that clinical teams were putting into ensuring effective safeguarding practices. However areas for improvement were identified such as increasing internal and external safeguarding assurance, more effective incident management, improving mandatory training compliance and appointing a dedicated safeguarding team.

Consequently, the newly appointed safeguarding team have concentrated their efforts on these priorities identified by the CQC. The NHS Safeguarding Accountability and Assurance framework was used to benchmark our work and progress, keeping in mind its seven standards.

For the safeguarding team, this journey of improvement followed a clear trajectory of change in three distinct stages: INFORMATION – REFORMATION – TRANSFORMATION


The information stage was the critical first stage in understanding what we wanted, using reason and experience to inform, understanding why we do things in a certain way and not another and how we can maximise information sharing amongst our staff at different levels of the organisation. The below reflects the changes that we made in an effort to maximise information at all levels of the organisation.

  • Safeguarding training – compliance increased significantly to above 95%
  • Updated policy and procedure with feedback from external stakeholders
  • Bespoke ward-based education and supervision sessions tailored areas of risk and/or concern relevant to the clinical area, enhancing level 1 mandatory training.
  • Weekly executive team report produced by the safeguarding team
  • Safeguarding quarterly and annual reports
  • Head of Safeguarding (HoS) became a member of the Safeguarding Adults National Network.
  • 2021 staff survey results indicate 99% of staff are aware of how to raise a concern


The reformation stage came as a natural building block following the improvement of information sharing within the organisation. The purpose of information is to bring about a change, to act upon the information now held. Sometimes this was a visible event, a desire which was expressed publicly; sometimes the changes were more subtle and in smaller circles. Nevertheless, reformation means to turn around, and as one of our hospital values is honesty and integrity, this demands intentionality of turning things around and change. And this is how we applied it in our safeguarding practice.

  • Permanent safeguarding team in place.
  • Safeguarding supervision provided monthly by HoS via the Safeguarding Operational Assurance Group to matrons and ward managers.
  • The Local Authority attends the Safeguarding Operational Assurance Group monthly meeting.
  • Director of Nursing (DoN) and HoS receive external supervision for safeguarding at least monthly from the Designated Safeguarding Adults Lead for Wandsworth and Merton CCG.
  • Safeguarding champions put in place, with a forum held annually.
  • Weekly patient safety and safeguarding meeting to review incidents, led by the Head of Patient Safety & Quality Assurance (PS&QA) and HoS.
  • External audit schedule to review decision making for potential safeguarding incidents.
  • Shared learning opportunities strengthened, evidencing where change has been driven in response to learning occurring from safeguarding cases.


The third and final stage of our journey of service improvement came almost naturally. With the information and reformation stages well established and interacting on an almost continual basis, transformation occurred. The below achievements reflect our transformation journey

  • Every safeguarding case has input from the safeguarding team to support staff in the management and oversight to ensure the protection of residents and patients.
  • Safeguarding supervision at all levels in place.
  • Safeguarding governance structure as per the NHS Accountability and Assurance Framework.
  • Patient and resident protection plans for all open safeguarding cases, reviewed by the safeguarding team regularly and monthly through SOAG.
  • Safeguarding agenda driving change in the organisation through findings of the upheld cases audit.
  • Putney Boards, a ward-based practice to share information,  used as a vector for safeguarding improvement projects at ward level
  • Training compliance exceeds the intercollegiate document requirements.
  • We have adopted South West London Safeguarding Threshold framework for pressure ulcers, medication errors and falls, and this is reflected in our policy and procedure.
  • We externally audit our practice through audit with our CCG colleagues.
  • We own a unique Patient Safeguarding Charter developed in collaboration with our patients and relatives that received feedback for outstanding practice.

The transformation stage is not a single event but is a journey of adaptability, dealing with unobservable events that if put together can only be described as metamorphosis in practice (transformational).

Our transformation journey and metamorphosis in practice made us realise that this resonates well with the overarching safeguarding principle of making safeguarding personal. We apply the best principles and practice to safeguarding a patient, not just because it worked yesterday, or the day before or with another patient. We adapt, and transform, our practice and reflect best safeguarding principles to protect the patient, recognising their uniqueness and specific needs.