CQC finds improvement needed in Birmingham and Solihull Mental Health NHS Foundation Trust’s community-based services

Published: 29 November 2023 Page last updated: 29 November 2023

The Care Quality Commission (CQC) has told Birmingham and Solihull Mental Health NHS Foundation Trust they must make improvements after the rating for community-based mental health services for adults of working age has declined from good to requires improvement, following an inspection in August.

CQC carried out a short notice announced focused inspection due to receiving information of concern about the safety and quality of care being provided. This related to serious incidents involving people who use the service, including three deaths.

These deaths included concerns about the monitoring of clozapine (anti-psychotic) medicine. Monitoring is needed to ensure people are not at risk of harm to their physical health.

Due to issues found with its information systems around risk and medicines management, the trust was issued with a warning notice to focus its attention on making significant improvements. The trust responded to this with action plans to show what action was being taken to reduce these risks. CQC are monitoring their progress and will return to carry out another inspection to ensure these improvements have been made.

Following this inspection, as well as the overall rating declining from good to requires improvement, as have the ratings for how safe, effective and well-led the service is. Caring and responsive were not looked at during this inspection and remain rated good. 

The overall rating for Birmingham and Solihull Mental Health NHS Foundation Trust remains rated as require improvement.

Amanda Lyndon, CQC deputy director of operations in the midlands, said:

“During our inspection of the trust’s community-based mental health services for adults of working age, we found a deterioration in how well the service was being led. Our experience tells us that when a service isn’t well-led, this has a knock-on effect on the quality of care being received by people, which was happening here. 

“It was concerning to find adequate medicines management systems weren’t in place to ensure people received the right medicines in a timely way to treat their condition.

“For example, there wasn’t a system in place to monitor uncollected prescriptions. This meant people could collect prescriptions for medicines that were potentially no longer appropriate to treat their condition, as there was no set time period when they had to be collected. Also, medicines were stored in medicine cabinets and there was no audit trail showing why they hadn’t been collected or why they were there. Without adequate processes in place, people might not receive the right medication at the right time, which could potentially result in them coming to harm.

“We also found systems and processes didn’t identify when staff hadn’t updated or reviewed people’s risk assessments in a timely way, which could put them at risk if staff weren’t aware of their individual needs.

“However, most people told us staff had been very helpful and kind. They said the service had been very good and they had received amazing support.

“We’ll continue to monitor the service, including through future inspections, to make sure the trust has made the required improvements and people are receiving the safe care they deserve. We won’t hesitate to take further action if we find this isn’t happening.”

Inspectors also found:

  • The service did not have enough staff to safely care for people
  • Staff did not always assess and review risks for people who used the service and record these well
  • Staff did not always know the lessons learned from incidents and these were not always communicated well
  • Staff did not always record what care a person needed and did not always record care and treatment given to people
  • Managers did not always monitor the effectiveness of the service and staff did not complete audits which could be used to improve the service
  • Leaders did not have information from audit processes to be able to run the service well.


  • The environments were clean, well-maintained and fit for purpose
  • Staff had training in key skills and understood how to protect people from abuse
  • Staff worked well together for the benefit of people who used the service and advised them on how to lead healthier lives.

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.