Today (29/4/16) The Care Quality Commission published the findings of a short-notice, focussed inspection of Southern Health NHS Foundation Trust, conducted over four days in January 2016.
The CQC report details the findings of a team of 22 inspectors, which included several mental health professionals as specialist advisors. The inspection team spoke with patients, carers, staff, the Trust Board and whistle blowers. In addition, they reviewed patient records, serious incident reports, medication charts and policy and procedures including those relating to complaints and governance. They found that:
The Trust had not put in place robust governance arrangements to investigate incidents, including deaths. As a result, opportunities had been missed to learn from these incidents and to take action to reduce the likelihood of similar events happening in the future.
Effective arrangements had not been put in place to identify, record or respond to concerns about patient safety raised by patients, their carers, staff or by the CQC. The Trust had also failed to identify, record or respond effectively to staff who expressed concerns about their competence to carry out their roles.
Inspectors had serious concerns about the safety of patients with mental health problems and learning disabilities in some of the locations inspected. Action had not been taken to address known risks from the physical environment. For example, CQC had identified concerns relating to ligature risks in acute inpatient mental health and learning disabilities services in January 2014, October 2014 and August 2015. During the January 2016 CQC found that the Trust had still failed to make sufficient changes to address these risks with many potential ligature anchor points identified at one location. Immediately following the inspection, CQC issued a warning notice requiring Trust to take immediate action to ensure the safety of patients at Evenlode, Oxfordshire and Kingsley ward at Melbury Lodge.
Overall, the Trust’s governance arrangements did not facilitate effective, proactive, timely management of risk. Where action was taken by the Trust to mitigate risk, this was delayed and mainly done in response to concerns raised by the CQC.
You can access the report here.
Yesterday, the Chairperson of Southern Health NHS Trust resigned. The BBC News story about this is here.
The BBC news report on the CQC finding can be found here. It also reports that a second director of Southern Health has resigned.
Comments on these events are most welcome.