CQC tells Southern Health to make further safety improvements

Published: 2 October 2015 Page last updated: 12 May 2022

The Care Quality Commission (CQC) has told the Southern Health NHS Foundation Trust that it must make further improvements to protect the safety of patients at three hospital units.

During unannounced follow up inspections in August 2015, a team of CQC inspectors returned to the Ridgeway Centre in High Wycombe and to the Ravenswood and Southfield secure hospitals in Hampshire to check that the trust had made the improvements that were identified at a previous inspection.

Full reports of the inspections have been published on the CQC website:

In October 2014, inspectors had raised concerns about the safety of patients on some wards at the Ridgeway Centre, which provides services for adults with mental health conditions, learning disabilities and autism.

During the latest inspection, CQC found that the trust had still not taken action to address all the main risks that had been identified within the centre, despite the trust's records showing that there had been a number of incidents in the past year where people had harmed themselves.

Although new observation mirrors had been fitted in communal areas, there were still too many blind spots within the unit. Some ligature points that could endanger people at risk of suicide had not been removed. Half of the unit’s front-line staff had still not completed training to help them identify and reduce risks.

In October 2014, inspectors had also identified concerns with the safety of patients at Ravenswood House, a secure hospital at Fareham. Although there were plans to relocate the service, inspectors had been concerned that the building was not fit for purpose.

At the most recent inspection, CQC were satisfied that safety improvements to the environment at Ravenswood were on schedule to be completed by February 2016. Although some ligature risks remained, it was observed that these were being managed appropriately by staff.

At both Ravenswood and Southfield, inspectors found that there was some confusion amongst staff about the use of seclusion, which should only be used to contain severely disturbed behaviour that poses a threat of harm to others. CQC found that patients held in seclusion were not always being appropriately reviewed.

In addition, the design of the seclusion room at Southfield did not allow for clear and effective communication between staff and patients.

Inspectors did find that staff on all wards were conducting observations of all patients, however observation results were not being recorded within patient care plans as a matter of routine.

Following the recent inspection, the trust sent has sent new risk plans, which are due to be implemented, to CQC.

The Chief Inspector of Hospitals, Professor Sir Mike Richards, said:

“It is disappointing that at the time of this inspection Southern Health NHS Foundation Trust had still not addressed all of the safety concerns which we had previously identified 12 months ago.

“The trust is aware that some patients who are admitted to the Ridgeway Centre pose a significant risk of harm to themselves.  Despite this, we have repeatedly needed to ask the trust to take immediate action to reduce the risk of harm.

“We do recognise that there have been some real improvements. Notably we found that there were sufficient staffing levels in the Ridgeway Centre to support people throughout the day.  Staff were more engaged and were learning from serious incidents taking place across the trust’s other learning disabilities services.

“We have identified a number of specific areas where the trust must improve. As a first step, the trust must provide a plan setting out how it will address each requirement. We will continue to closely monitor their progress.

CQC has told the trust it must make the following improvements:

  • The environmental risks at the Ridgeway Centre must be fully assessed and addressed to make the unit as safe as possible.
  • The trust must take action to protect the privacy and dignity of all patients being nursed within the seclusion suite at Southfield and provide access to appropriate toileting facilities.
  • Each patient must have an accurate and up to date care plan that details their observation levels and risk status.
  • The trust must take action to ensure that staff understand the differences between seclusion and de-escalation. Patients must only be secluded for reasons as defined by the Mental Health Act code of practice.


For further information please contact Yetunde Akintewe, CQC Regional Engagement Manager, on 07471 020 659. For media enquiries, journalists wishing to speak to the press office outside of office hours can find out how to contact the team here. For general enquiries, please call 03000 61 61 61.

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About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.