The Care Quality Commission has found that Southern Health NHS Foundation Trust has made a number of improvements in its investigations into serious incidents and deaths.
CQC has published a further report following an inspection of community health and community mental health services in March 2017. Inspectors also carried out a number of unannounced inspections of older people’s mental health and community inpatient wards. In total the inspection team visited 44 locations.
During previous inspections, CQC had found that the trust was not always undertaking effective investigations and learning from serious incidents. At the time the trust did not have effective arrangements to identify, record or respond to concerns about patient safety issues raised by patients, their carers, staff or by the CQC or other organisations.
During this inspection (March 2017), inspectors looked again at how the trust carried out investigations, responded to and monitored complaints and how it was involving patients within this process.
The inspection team found there was an improved focus on ensuring that specific actions produced in response to CQC and the serious incident and mortality review were being implemented and effectively monitored, with weekly reports to the trust board.
There had been a notable improvement in the timeliness and quality of investigation reports following serious incidents, including deaths. In January 2017, the trust had completed 97% of the required mortality reviews within 48 hours of the death occurring. Although there had been progress to improve learning from incidents there was still work to do to ensure learning was shared across the trust from less serious incidents.
In the past, patients, families and partner agencies had raised significant concerns about the trust`s complaints processes and the quality of their responses. CQC found that the trust had implemented changes to improve the complaints governance systems although further improvements were still required.
Inspectors found that there were still delays in provision of special mattresses and beds for patients approaching the end of their lives in both the community hospitals and at home. The trust was working with commissioners to address this. There were still significant delays in the provision and repair of wheelchairs, affecting the safety and well-being of a large number of patients.
Paul Lelliott, Deputy Chief Inspector of Hospitals (and lead for mental health), said:
“It is good to see the improvements that Southern Health NHS Foundation Trust have made but there is still much to do."
“The trust has recognised that there were significant concerns about how it had communicated with, and involved patients and families. To address this, it had formed a family engagement action group and appointed a family liaison officer. Our inspectors found that those families involved were positive that the trust was committed to driving this work forward and engaging more effectively with the patients, families and people who use services."
“However, some patients and families did express concerns that things hadn’t changed enough and they would like to see swifter action with more effective communications when things go wrong."
“The majority of staff we met told us that they believed that the interim chair and interim chief executive were making a positive difference in changing the culture. They reported that there was now a clearer focus on quality, and that the trust leaders were improving governance processes and supporting improvements in service delivery. We heard that they were more open and approachable."
“Overall we believe that the trust has made some improvements. The interim chair and chief executive had a clear vision and understanding of what was required to bring about further improvements and were committed to ensuring that improvement was made in a timely manner. The trust is certainly moving in the right direction and we hope this progress will continue under the new leadership team."
“We will continue to monitor further developments and return in due course to report on further progress."
As this was a focused inspection, CQC has not changed the overall rating of the trust, which remains Requires Improvement. The full report is available on our website.
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