CQC rings alarm bells over risks at local mental health trust - The Solihull Observer

CQC rings alarm bells over risks at local mental health trust

Solihull Editorial 21st Jan, 2021 Updated: 27th Jan, 2021   0

THE Care Quality Commission (CQC) has told Birmingham and Solihull Mental Health NHS Foundation Trust to make improvements following focused inspections at three of its services, and has taken action to ensure people’s safety.

In particular is wants it to address all ligature risks – areas which could be used as anchor points which could lead to choking.

On November 23, 2020, CQC carried out unannounced focused inspections of the trust’s community based mental health services and acute wards for adults of working age, psychiatric intensive care units and mental health crisis services and health-based places of safety.

The inspections were carried out due to insight and concerns received about the potential risk of harm to patients if action was not taken.




Inspectors looked at whether the services were safe, effective and well-led but no ratings were given at this time.

The trust’s overall rating of Requires Improvement remains.


Following the inspection, CQC put conditions on the trust’s registration.

The conditions required the trust to address all ligature risks by June 18, 2021. The trust must also implement an effective system to improve risk assessments and care planning by February 5, 2021.

CQC’s Head of Hospital Inspection (mental health and community health services), Jenny Wilkes, said: “During our inspections of Birmingham and Solihull Mental Health NHS Foundation Trust’s services, we found several concerns that needed addressing.

“We imposed urgent conditions on the trust’s registration as a result of our concerns about ligature risks, care planning and risk assessments.

“We took this urgent action to ensure that people using the services are not exposed to any risk of harm.

“The trust responded quickly to safety concerns in most cases but in some instances, such as the ongoing ligature risk presented by ensuite bathroom doors on the acute wards, no time frame was given for when this work would be complete.

“We have reported our findings to the trust leadership, which knows what it must do to bring about further improvements and ensure it maintains any already made. We will return to check on the trust’s progress.”

The latest inspections found that improvements were needed to ensure patients were receiving the care they were entitled to.

For example, in the acute wards for adults of working age and psychiatric intensive care units, ligature risks were present across the service.

Work had begun to address these but there was no clear time frame for when this would be completed.

Medicines were not always stored or transported safely in the community mental health service.

Inspectors saw staff at the Zinnia Hub transporting medication in bags with no locks.

At Northcroft Hub, inspectors saw the drug cupboard with keys in was left unattended.

Inspectors also noted some good practice across services.

Mental health crisis services and health-based places of safety were effectively managed and had governance processes that ensured team procedures ran smoothly.

Patients were treated with dignity and respect across all services and adjustments were made for those needing specific requirements. Leaders were visible and approachable for staff, patients and their families.

Roisin Fallon-Williams, chief executive of Birmingham and Solihull Mental Health NHS Foundation Trust, said: “We were pleased that the inspection team were positive about many aspects of the care they observed from our compassionate and committed colleagues.

“They were also positive about the leadership they saw and were impressed with the arrangements to keep staff and patients safe during the Covid-19 pandemic.

“The reports highlight a number of areas for improvement, for which we have a robust plan and work is already under way.

“The findings acknowledged our existing commitment to fit alarm systems on en-suite bathroom doors, for which we have a roll out plan to reduce ligature risks.

“We are implementing a range of other improvements alongside this to mitigate risk and improve the safety and quality of care.

“Additional therapeutic activities on wards will aid service users’ recovery, and we are recruiting more health care assistants as well as undertaking a comprehensive review of our approach to therapeutic observation.

“In relation to issues raised around transportation and storage of medicines, we already have Trustwide procedures in place, which we will continue to reinforce with all colleagues.

“We look forward to continuing our work with the CQC, our staff and local partners, all of whom share our unswerving commitment to continually improve, to ensure the highest quality and safest care possible to our service users and their carers.”

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