The Care Quality Commission today publishes the findings of a focussed inspection of Southern Health NHS Foundation Trust, conducted over three days in September 2016.
This inspection took place to ensure improvements were embedded and sustained following an inspection by the Care Quality Commission in January 2016. As a result of that inspection, CQC issued a Warning Notice. CQChas concluded that the trust had taken sufficient action to meet the requirements set out in the Warning Notice which was issued on 16 March 2016.
The inspectors who visited in January 2016 were concerned that little action was being taken to address the safety of patients. The trust did not have effective process to assess and manage risks, which meant there was no plan to remove or reduce the risk that were posed by ligature anchor points nor did it work closely with ward staff to improve ward safety.
Previous CQC inspections had also highlighted that the physical environment at some of the trust`s mental health and learning disability units posed a significant risk to the safety of patients and yet the trust had not taken the action required to ensure the risks were addressed and managed so that patients were safe.
During this most recent inspection (September 2016), inspectors found that there had been a number of significant improvements in identifying and prioritising risks arising from the physical environment more effectively. The risks identified included those posed by ligature anchor points, falls from heights and from patients absconding.
Inspectors also found clearer processes in place to ensure that the trust assessed the risks, followed up actions taken and that there were processes in place when actions had not been undertaken or there were delays.
There was evidence that there were more effective relationships between the estates and clinical teams. Inspectors found a range of anti-ligature work had been completed across the trust and that there was a better appreciation of the need to complete this work. Many staff and senior managers confirmed that it had become clear over the past six months that the trust was now more focused on patient safety.
The full report is available online.
Dr Paul Lelliott, Deputy Chief Inspector of Hospitals and Lead for Mental Health, said:
“Southern Health NHS Foundation Trust has been under intense scrutiny. I am pleased to report that during this inspection we have found signs that the trust’s management team was starting to get to grips with the underlying issues that were putting patients at risk.
“We found more effective relationships between the estates and clinical teams and a work across the trust to reduce risks associated with potential ligature points. There was also a much better appreciation of the need to drive forward and complete this work.
“Staff and senior managers told inspectors that they believed that the trust had become more focused on patient safety over the past six months and that they were hopeful that mental health and learning disabilities services were now a higher priority
“We still have some areas of concern about specific sites – particularly Elmleigh and risks posed by the environment. We raised these issues again at the time of our recent inspection so that the trust could take immediate action.
“The trust leadership has recognised that there is still significant work to do and that the new systems need to be embedded to demonstrate long term improvement.
“Overall, we have concluded that the trust had taken sufficient action to meet the requirements set out in the Warning Notice. The trust has assured us that it will continue to working on the outstanding breaches. We will be monitoring the trust’s progress closely - returning to check that the required improvements have been made and are being sustained.”
Ends
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The trust leadership has recognised that there is still significant work to do and that the new systems need to be embedded to demonstrate long term improvement.
Dr Paul Lelliott, Deputy Chief Inspector of Hospitals