- SERVICE PROVIDER
Birmingham and Solihull Mental Health NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Assessment report published 26 November 2025
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
We completed an assessment and inspection of Birmingham and Solihull Mental Health NHS Foundation Trust acute and psychiatric intensive care (PICU) services at Northcroft Hospital, the Zinnia Centre and Ardenleigh between 17 June 2025 and 11 July 2025.
Northcroft Hospital consists of 2 acute wards and 1 PICU. These are Eden male acute ward and George male acute ward and Eden female PICU. The Zinnia Centre consists of 2 acute wards, Saffron (male) and Lavender (female). Larimar ward is a female acute ward at Ardenleigh. We visited all of these wards as part of our assessment and inspection.
This assessment was carried out following CQC’s new approach to assessment; Single Assessment Framework (SAF). We looked at all quality statements under each key question. We carried out a mix of onsite and offsite inspection and assessment activity between 17 June 2025 and 11 July 2025. This was an unannounced assessment, which means the provider was not told an assessment was going to be starting beforehand.
Birmingham and Solihull Mental Health NHS Foundation Trust provides an acute and psychiatric intensive care (PICU) service for adults at Northcroft Hospital, the Zinnia Centre and Ardenleigh. The trust also provides this service at the Oleaster Centre, Mary Seacole House and Newbridge House. We only visited Northcroft Hospital, the Zinnia Centre and Ardenleigh for this assessment and inspection. We carried out a responsive inspection of the adults acute and psychiatric intensive care service at the Zinnia Centre in October 2024. Following that inspection the service was rated as requires improvement and safe was rated inadequate. We issued a warning notice for breaches of regulations 12 (safe care and treatment), 17 (good governance) and 18 (staffing). As part of this assessment and inspection we checked to see that concerns at the previous inspection had been addressed.
We rated the service as Requires Improvement. We found breaches of the regulations in relation to the trust not always ensuring staff met patient needs and preferences, the trust not always ensuring staff fully assessed and/or acted on all risks to the health and safety of patients receiving care or treatment, the trust not always ensuring arrangements were in place to respond appropriately and in good time to people's changing needs, the trust not always ensuring staff followed procedures for the proper and safe management of medicines, the trust not always operating effective systems and processes to make sure they assessed and monitored their service against Regulations of the Health and Social Care Act.
However, we found the trust now had anti ligature door monitoring alarm systems fitted to all bedroom and ensuite doors on the wards we visited. Staff were now updating patients’ risk assessments and management plans following incidents. The trust was now sharing learning from incidents with staff. The trust now ensured most staff completed Intermediate Life Support (ILS) training and supervision rates had improved.
We have asked the provider for an action plan in response to the concerns found at this assessment.
Action we have taken
During this assessment and inspection, the provider did not always:
- Ensure the care and treatment of patients was appropriate, met their needs and reflected their preferences (Regulation 9)
- Ensure care and treatment was provided in a safe way to patients (Regulation 12)
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care (Regulation 17(1))
We were concerned as this assessment service group (ASG) has a history of repeated breaches of regulations 9, 12 and 17. The trust’s audit and governance systems were not always effective in identifying and acting on risks. Our level of concern was mitigated as the trust took immediate action to start addressing the concerns identified.
Mental Health Act and Mental Capacity Act ComplianceMental Health Act
Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. The provider had relevant policies and procedures that reflected the most recent guidance that staff had easy access to. Patients had easy access to information about independent mental health advocacy. Staff explained to patients their rights under the Mental Health Act in a way that they could understand. Staff requested an opinion from a second opinion appointed doctor when necessary. Staff stored copies of patients' detention papers and associated records correctly. The service displayed a notice to tell informal patients that they could leave the ward freely. The Mental Health Act team did regular audits to ensure that the Mental Health Act was being applied correctly.
Mental Capacity Act
Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff took all practical steps to enable patients to make their own decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. The service had arrangements to monitor adherence to the Mental Capacity Act.
People's experience of this service
We spoke with 26 patients across the service about their experiences of care. Most patients told us that staff treated them with kindness, compassion and dignity. Most patients told us staff met their needs. Most patients said staff supported them to live healthier lives. Patients told us they were able to keep in touch with their family and friends. Patients said they knew how to raise concerns. Patients told us staff gained consent and explained their rights to them. Most patients said their ward environment was safe. However, not all patients felt safe on the wards, this was often due to other patients’ distress. Four patients across 3 wards told us they had seen staff sleeping when on shift. Patients told us there wasn’t always enough staff and this meant they were not always able to go out on their prescribed leave and their immediate needs were not always met. Patients on Eden acute ward told us some staff were unkind. Patients on Eden acute and George wards said there were not enough activities.