The Care Quality Commission (CQC) has told Southern Health NHS Foundation Trust that it must make significant improvements to protect patients who are at risk of harm while in the care of its mental health and learning disability services.
CQC has issued a warning notice requiring the Trust to improve its governance arrangements to ensure robust investigation and learning from incidents and deaths, to reduce future risks to patients.
CQC Inspectors visited the Trust as part of a focused inspection during January 2016. This inspection followed the publication of an independent report (the Mazars report) commissioned by NHS England that highlighted the failure of the Trust to investigate and learn from the deaths of patients; particularly those receiving care in its older people’s, learning disability and mental health services.
The team of inspectors were also checking on improvements, which had been required in some of the Trust’s mental health and learning disability services following previous inspections.
Inspectors found that the Trust had failed to mitigate against significant risks posed by some of the physical environments from which it delivered mental health and learning disability services and did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths. It did not adequately ensure it learned from incidents to reduce future risks to patients. In addition, inspectors found that the trust did not effectively respond to concerns about safety raised by patients, their carers and staff, or respond to concerns raised by Trust staff about their ability to carry out their roles effectively.
Dr Paul Lelliott, CQC Deputy Chief Inspector of Hospitals and Lead for Mental Health said:
“We have made it clear that the safety of patients with mental ill health and or learning disabilities, provided by Southern Health NHS Foundation Trust requires significant improvement.
“We found longstanding risks to patients, arising from the physical environment, that had not been dealt with effectively. The Trust’s internal governance arrangements to learn from serious incidents or investigations were not good enough, meaning that opportunities to minimise further risks to patients were lost.
“It is only now, following our latest inspection, and in response to the warning notice, that the Trust has taken action and has identified further action that it will take to improve safety at Kingsley ward, Melbury Lodge in Hampshire and Evenlode in Oxfordshire. The Trust must also continue to make improvements to its governance arrangements for reporting, monitoring, investigating and learning from incidents and deaths. CQC will be monitoring this Trust very closely and will return to check on improvements and progress in the near future.”
CQC expects to publish a full report of its January 2016 inspection of Southern Health NHS Foundation Trust in late April.