You are here

Trust Headquarters Requires improvement


Other CQC inspections of services

Community & mental health inspection reports for Trust Headquarters can be found at Birmingham and Solihull Mental Health NHS Foundation Trust.

Inspection carried out on 1 April 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Health Exchange in July 2018 as part of our inspection programme where the service was rated as inadequate overall. As a result, we issued requirement notices as legal requirements were not being met and asked the provider to send us a report that says what actions they were going to take to meet legal requirements. The full comprehensive report of our previous inspection can be found by selecting the ‘all reports’ link for Trust Headquarters on our website at

This inspection was an announced comprehensive inspection carried out on 1 April 2019 to check whether the provider had taken action to meet the legal requirements as set out in the requirement notices. The report covers our findings in relation to all five key questions and related population groups.

We based our judgement of the quality of care at this service on a combination of:

We have rated this practice as requires improvement overall due to concerns in providing safe, effective and well-led services.

We rated the practice as requires improvement for providing safe services because:

We rated the practice as requires improvement for providing effective services because:

We rated the practice as requires improvement for providing well-led services because:

These areas affected all population groups relevant to this service, so we rated the population groups as requires improvement.

We rated the practice as good for providing caring and responsive services because:

Staff demonstrated a wealth of knowledge, passion and commitment to working with people whose circumstances make them vulnerable. We saw several areas of outstanding features including:

The areas where the provider must make improvements are:

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 25 July 2018

During a routine inspection

This service is rated as Inadequate overall.

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Inadequate

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at The Health Exchange on 25 July 2018, in response to concerns received.

At this inspection we found a lack of a coherent plan for developing and monitoring the service and its contract:

  • The service did not operate an effective programme of quality improvement activities to measure performance or clinical effectiveness and were unable to demonstrate how they accessed national available data.
  • The service had oversight of some governance arrangements and used them to drive service delivery. However, we found that cohesive working between the service, Trust and commissioners as well as a clear understanding of the service was limited and this impacted on the services ability to develop effective governance arrangements. For example, management of staffing levels; clinical support as well as effective IT systems.
  • The service was unable to demonstrate awareness of the day to day management of infection control as well as an established programme of ongoing or periodic infection control audits. The service did not have a system for monitoring or checking whether general cleaning was being carried out in line with the Trust’s cleaning policy.
  • The service had some arrangements in place to enable appropriate actions in the event of a medical emergency. However, not all potential medical emergency situations were considered and a risk assessment to mitigate potential risks had not been carried out.
  • There were areas of environmental safety where the service did not carry out risk assessment to mitigate risk. For example, the service were unable to provide assurance that a legionella risk assessment had been carried out as well as fire drills. Following our inspection, the provider sent evidence of a legionella risk assessment carried out in February 2016 and explained that an annual review had been carried out following our inspection.
  • The service had clear systems to report and investigate safety incidents so that they were less likely to happen. When incidents did happen, the service learned from them and improved their processes.
  • Clinical staff ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Although the service operated an appointment system which allowed easy and flexible access to appointments during opening hours, the July 2017 national GP patient survey results were mainly below local and national averages for questions relating to access to care and treatment and the service had not analysed the results.
  • There was a focus on continuous learning from incidents at all levels of the service.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Take action to ensure advance training carried out by clinical staff is recognised and staff complete training recognised by the service as mandatory in a timely manner.
  • Take action to gain patient feedback and explore effective ways to act on feedback in order to improve patient satisfaction.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

During an inspection looking at part of the service

We undertook a review of Birmingham and Solihull Mental Health Foundation Trust, at trust level, in February 2011. To do this we visited a range of trust locations and made overall judgements about the extent to which the trust was complying with regulations. We judged that the trust was not compliant with regulations in the areas detailed above, at some of the locations we visited. The trust sent us an action plan following this review telling us the actions they would be taking. To check progress we reviewed three trust locations, Eden Unit, Mary Seacole House and The Barberry in July 2011. These reviews included visits to each location. We found that The Barberry was fully compliant with regulations but Eden Unit and Mary Seacole House were not. The trust continued to update us on the actions they had been taking. They commissioned an independent organisation to undertake a detailed analysis of these improvements. They have sent us a copy of this report. The independent analysis involved interviews with managers, staff and patients at three different locations, and noted broad progress throughout. This and other documentary evidence of their progress helped inform this review. We also considered information from visits to locations by a Mental Health Act Commissioner, direct feedback from the trust during a meeting with them on 10 July 2012 and comparative information with other similar trusts.

As part of this review we also visited two locations, where the need for improvements had been identified by inspections in 2011. These locations were both visited in July 2012. They were the Eden Unit, and Meadowcroft ward at Mary Seacole House. These are both Psychiatric Intensive Care Units (PICU). Reports on both of these inspections are available separately.

We saw the trust had made improvements in respect of the care and welfare of people who use services, safeguarding people who use services from abuse, staffing, supporting workers and notification reporting.

We particularly noted improvements with the activities available to people as part of their care, welfare and treatment.

We saw that there were sufficient staff available to support people based on their assessed level of need. We saw patients being observed and supported by staff on a one-to-one basis where this was a current requirement of their care. People told us and we observed that they were able to talk to staff about any concerns they had. We saw improved staff support and deployment and better care from patients.

Staff we spoke with were positive about their work and about the support they were able to give.