Birmingham and Solihull Mental Health NHS Foundation Trust

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This is because the trust made improvements following our last inspection. However, there were still some aspects of the service that were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We identified concerns relating to safe systems, pathways and transitions, safeguarding, involving people to manage risks, safe environments, safe and effective staffing and medicines optimisation.

The service was in breach of regulation 12 for safe care and treatment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The trust had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Leaders told us lessons learned were discussed at board level and cascaded down to heads of nursing to disseminate to their teams. Staff spoken with confirmed this happened. Staff told us they discussed safety events in safety huddles, team meetings and reflective practice sessions. Staff reported a positive culture change when discussing safety events, from a blame culture to a focus on identifying improvements to be made. One manager described it as a ‘just culture’ approach.

Leaders ensured safety was a top priority that involved everyone, including staff as well as people using the service. Staff told us they learnt from incidents through debriefs, safety huddles, team meetings, supervisions and sharing of safety alerts. The trust shared examples of safety alerts shared with staff. These included learning from safety events that occurred at other providers. Clinical nurse managers and ward managers were responsible for ensuring staff were aware and had the opportunity to discuss.

Staff did not overlook or ignore risks. They were dealt with willingly as an opportunity to put things right, learn and improve. Leaders and staff told us about improvements made following safety events. These included all grades of nursing staff completing ligature risk assessment training, implementing clearer escalation procedures, particularly for out of hours, improving access to maintenance teams out of hours, improving use of interpreters and the implementation of a local safety panel.

Leaders ensured incidents were appropriately investigated and reported. Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Staff learned lessons from safety incidents or complaints, resulting in changes that improved care. Examples included staff on Larimar ward updating all patients’ care plans to ensure improved safety checks were carried out following a serious incident that occurred.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Safety and continuity of care was not always a priority throughout people’s care journeys. We identified concerns on Eden acute, Saffron and Lavender wards relating to high acuity of patients, lack of seclusion facilities and difficulties accessing PICU beds when needed. Managers said they escalated these concerns but were not always listened to. Staff on Eden PICU also raised concerns about the bed management team admitting patients who they had flagged as inappropriate. There were 2 patients on the ward under Ministry of Justice restrictions that were ‘stuck’ due to a lack of secure beds. This was not in the trust’s control, however leaders told us about a new standard operating procedure developed with the forensic service to establish appropriate pathways for patients subject to Ministry of Justice restrictions. The concerns regarding high acuity and issues with the admission process were escalated to senior leaders within the trust. Leaders advised they recently added a new consultant role to oversee the admission and flow process to ensure admissions were as appropriate as possible, but with a focus on what was best for the patient. Leaders shared long term plans for a new hospital build which will include seclusion facilities.

Staff demonstrated a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was proactive and effective. Staff told us information about new admissions was shared by the bed management team, Home Treatment Team (HTT), families and community teams. Leaders told us at preadmission, a 5 point plan would be created for the patient which included risks and levels of observation required for the patient. The junior doctor would complete the admission process for the patient and the admitting nurse and doctor would update the patient’s risk assessment and care plan. Multi-disciplinary team (MDT) staff told us about improved working with community teams to ensure earlier intervention when a community patient’s mental health was deteriorating. The aim was to start treatment as soon as possible to avoid an admission or reduce the length of stay. Staff on George ward told us potential barriers to discharge were discussed early on, for example, accommodation issues. A third sector discharge navigator attended George ward to complete a housing needs assessment for a patient. Staff on Lavender wards described good links with community teams in planning patient care and managing risks.

Staff shared concerns about the difficulties in accessing statutory support from the local authority, which sometimes delayed patients’ discharge from the service. On Larimar ward staff had been unable to complete a Mental Health Act medical recommendation for a patient, due to a lack of beds and no available Approved Mental Health Practitioner (AMHP).

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Not all staff demonstrated a strong understanding of safeguarding and how to take appropriate action. We identified safeguarding concerns on one ward, whereby staff had not acted in the best interests of 2 patients. We shared these concerns with local leaders who did not take appropriate action to safeguard the patients. We escalated this to senior leaders within the trust who took immediate action to make sure the patients were safeguarded from further harm. They said safeguarding of patients had improved since the appointment of the trust Lead Nurse for Adult Safeguarding last year. Staff also improved reporting of patients assaulting patients to the police.

We spoke with 14 patients across the wards we visited and asked them if they felt safe. Seven patients said they felt safe, and 1 patient said they sometimes felt safe. Six patients told us they did not always feel safe, 2 of these were patients on Saffron ward who both expressed concerns about the levels of violence on the ward. They both said staff work hard to manage violence and aggression, but they don’t always feel safe.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. We spoke with the trust Lead Nurse for Adult Safeguarding. They told us they lead a team of 15 staff who run the trust’s safeguarding advice line, which was open between 0900-1600 each day, staff could leave a message outside of these hours and one of the team would get back to them. The lead was on site as part of the monthly safeguarding supervision offer. The lead advised they present to the safeguarding adult boards for the 2 local authorities that cover the trust area, and they worked closely with their counterpart in children’s services. We spoke with the manager for Saffron ward. They told us they would contact the trust Lead Nurse for Adult Safeguarding to raise any safeguarding concerns. They said the trust Lead Nurse for Adult Safeguarding would contact ward managers to make sure all necessary actions have been taken. They gave an example of a patient who had assaulted family members prior to admission which generated a safeguarding case. They made sure the family and all relevant parties were informed about the patients planned discharge date to enable any required actions to be put in place in the community. We spoke with an external professional. They told us staff were responsive to safeguarding concerns they raised. The trust reported a continued increase in safeguarding adults referrals, from 80 reported in Q4 2024/25 to 96 reported in Q2 2025/26.

Mental Capacity Act

• 93% of staff had had training in the 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 were aware of the policy and had access to it.
• Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.
• Staff took all practical steps to enable patients to make their own decisions
• For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.
• When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.
• Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.
• The service had arrangements to monitor adherence to the Mental Capacity Act.
• Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

When people communicated their needs, emotions or distress, staff on Eden PICU were not always able to manage this in a positive way. We reviewed a Positive Behavioural Support (PBS) plan for a patient on Eden PICU. The plan referred to staff using Prevention and Management of Violence and Aggression (PMVA) techniques to restrain the patient. The trust trains staff to use AVERT to reduce patient distressed behaviours, when required. AVERT is aimed at preventing the use of physical restraint, focusing on positive behaviour support and de-escalation techniques. The PBS plan was difficult to find, and staff spoken with were not aware that this plan existed. This meant there may not be a consistent approach to supporting the patient when distressed. The records of observation of the patient reviewed did not evidence that staff were undertaking any activities within the green areas of the plan. Staff spoken with did not see activities as a measure to reduce distressed behaviours from escalating. The first action in the section "How to help me when I am finding it hard to cope" is to offer PRN (as required) medicine instead of first using other methods. There was a lack of detail on how to identify "red behaviours”, and the action staff were to take to reduce the behaviour from escalating.

Most patients told us they were informed about risks and how to keep themselves safe. We spoke with 4 patients about their involvement in managing risks and 3 said staff involved them in managing their risks. Staff on Eden PICU did not record patient involvement in managing their risks in 2 records reviewed. Staff on Eden acute ward told us ligature risks were discussed with patients on admission.

Staff assessed and updated risks in most patient records reviewed. Out of 9 records reviewed across the wards we visited, we found 1 on Eden PICU where staff had not completed an initial risk assessment for a patient admitted 5 days prior. Staff were formulating risks and included presenting, predisposing, precipitating, perpetuating and protective factors. This was in line with National Institute of Clinical (NICE) guidance. Staff on Saffron ward told us about risk huddles where the team (MDT plus managers, the matron, healthcare assistants (HCA’s) and students) would review 1 patient to formulate a risk assessment based on the 5 P’s (predisposition, presenting problem, precipitating, perpetuating, protective factors). We reviewed an audit of care records on Larimar ward completed a few days before our inspection visit. The audit indicated staff reviewed all patients’ risks within the week preceding our visit. However, staff did not always include all relevant information when required. On George ward, 1 patient’s risk assessment did not accurately reflect historic risks, this was raised with staff, who updated the risk assessment accordingly. On Larimar ward we reviewed the observation care plan for a patient. The care plan did not detail what staff needed to observe when on the patient’s observations. In another care record on Larimar ward staff had not included the risk of substance misuse in the patient’s care records, despite the patient having a history of this. Staff at all levels shared concerns about patients accessing illicit substances whilst on the wards. The trust implemented actions to try and address, including improved search procedures and involving the police. However, we saw evidence that staff regularly discussed patients risks. On Eden acute ward we reviewed minutes from 3 times daily safety huddles for May 2025 and June 2025 to date. Staff discussed specific risks for patients and any support and interventions required. Nurses described updating patients risk assessments weekly during MDT reviews. Staff told us they received detailed handovers for each patient at the start of their shift.

The trust reported using seclusion 55 times between 1 December 2024 and 31 May 2025. Eden PICU reported the highest use at 43. The remaining 12 seclusions took place on the acute wards, that had no seclusion facilities. Although acute wards are not required to have seclusion suites, it was not clear where these patients were secluded. Eden acute last used seclusion in February 2025, Larimar in May 2025, George ward in April 2025, Lavender in January 2025 and Saffron in December 2024. There was no detail on whether seclusion facilities on other acute wards (that we did not visit) were used or if these patients were secluded in their bedrooms. There was 1 seclusion room on Eden PICU. Staff on the acute wards raised concerns about the difficulties in supporting patients who expressed distress through violence towards others. On Saffron ward we heard about numerous incidents of violence and physical assaults on staff. Staff told us that the ward was admitting patients with higher acuity, some of which required a PICU bed and they were unable to safely manage this without a seclusion room. Staff were off sick due to being assaulted. We heard there were not enough staff to safely manage the patients’ risks, baseline staffing is 5 staff on shift and there was a recent incident which required 9 staff to restrain the patient. However, we also heard that the lack of seclusion facilities improved staff de-escalation skills. We had concerns about patients being secluded in their bedroom and whether this was safe. Staff feedback and patient care records did not evidence that the trust’s ‘Seclusion and Segregation policy’, in relation to bedroom seclusion, was being followed. Staff secluded 1 patient in their bedroom on Eden PICU as the seclusion room was already in use. We reviewed an incident report for this patient where staff stated it was not safe to seclude the patient in their bedroom, although staff did not detail why it was unsafe. During our visit we observed staff sat outside the secluded patient’s closed bedroom door. Staff were unable to explain why they were sat outside the patient’s bedroom with the door closed. We were concerned how staff were managing the patients risks if they could not observe them. Senior leaders advised that the use of bedroom seclusion had decreased and there was a policy in place to manage this. We reviewed the policy, which stated “any seclusion or segregation occurring outside of a designated seclusion suite must be recorded as an adverse incident. There should be particular attention to the risk of self-harm where the patient cannot be seen in some parts of the room (eg bathroom) and how this will be managed. Where seclusion continues beyond 24 hours in a room not exclusively used for seclusion, the Clinical Director, local Head of Nursing/AHP, the Medical Director and the Director of Nursing must be informed by the Responsible Clinician, setting out detailed reasoning and at least one of these people should attend the ward in person to support staff and ensure that any risks are mitigated.” We reviewed the incident report for the bedroom seclusion on Eden PICU, there was sparse information and no detail recorded as to whether the patient was searched before seclusion commenced, as required by the policy. We reviewed the seclusion records for the 2 patients secluded on Eden PICU at the time of our visit. Staff notified the consultant and carried out required reviews in line with the MHA Code of Practice. Staff created seclusion care plans for both patients, however the patients had not been involved in these. We reviewed a seclusion care plan for a patient secluded on Larimar ward. Staff had not detailed what the patient needed to do to come out of seclusion. Nurses completed 2 hourly reviews as required by the MHA Code of Practice, however, doctors were only completing 1 review each day when these are required every 4 hours or at least twice a day after the first MDT review. The consultant for Saffron ward was chair of the trust’s Reducing Restrictive Practice steering group and was promoting the use of sensory spaces, rather than seclusion. The trust risk register included the use of bedrooms for seclusion and rated this risk as low due to mitigations in place and use of bedroom seclusion reported as low.

Staff told us restraint was only ever used as a last resort after de-escalation attempts had failed. The trust reported staff physically restrained patients 504 times between 1 December 2024 and 31 May 2025. Larimar acute ward reported the highest number at 199. George acute ward reported the lowest at 12. Staff restrained 1 patient on Larimar ward 160 times during this period. Of the 504 restraints reported, the trust advised staff restrained patients in the prone position 153 times. Larimar ward reported the highest use at 52, with staff restraining 1 patient in the prone position 44 times. The data reviewed did not include the length of time patients were restrained in the prone position. The CQC expect providers to ensure staff only use prone restraint in exceptional circumstances. We reviewed the trust procedure for the administration of rapid tranquillisation medicine. The policy was up to date and written in line with NICE guidance. It included clear prescribing and monitoring guidance. We completed an audit of rapid tranquillisation. Staff administered rapid tranquillisation medicine 360 times over the past 6 months. One patient on Larimar acute ward accounted for 144 of these, another patient on Lavender acute ward accounted for 84. The trust advised whilst levels of restraint, prone restraint and rapid tranquillisation for some patients seemed unusually high, on review of each patient’s notes it can be confirmed that these interventions were undertaken appropriately and were proportionate. From the data provided it was evident that the use of restraint and prone restraint for the 1 patient on Larimar ward decreased over the reporting period, with 7 restraints in April and 4 in May, and none of them in the prone position. The trust patient participation and reducing restrictive practice leads reported that “physical restraints were mainly discussed when the patient went into seclusion, and many felt that staff treated them well. Seclusion was discussed, but some patients did not always have activities or access to fresh air.”

Staff were reporting incidents as required. The trust reported 2,188 incidents between 1 December 2024 and 31 May 2025 on the wards we inspected. Eden PICU ward reported the highest with 562. George ward reported the lowest with 160. The most common incident type was “assaults, violence or harassment” with 719. We reviewed 21 incident reports and staff completed them as required. However, staff on Eden PICU told us about an incident whereby a patient attempted to “murder” a member of staff, resulting in serious injuries. We reviewed the incident report and were concerned about the lack of information included, given the seriousness of the incident.

However, we found examples of a balanced and proportionate approach to risk that supported patients. On Eden acute ward we observed a slushie making activity. We observed staff promoting positive risk taking through supporting the patient to use a blender to crush ice cubes and use their mobile phone to access the internet. Most staff followed the trust policy on therapeutic observation and engagement when allocated to observe patients who may be at risk of harming themselves or others. We reviewed observation records for a patient on Eden PICU, we identified 4 gaps in the hourly records on 1 day. Staff completed in full for the other 2 days reviewed. We reviewed intermittent observation records for another Eden PICU patient and staff completed these correctly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Leaders did not always ensure facilities and equipment were well maintained. Clinic room temperatures on Saffron, Lavender and Larimar wards were above the acceptable range (25 degrees centigrade) on several days before the inspection. On Saffron and Lavender wards staff recorded this but did not take the required action in line with trust policy. Action was only taken after CQC raised concerns. On Larimar ward staff escalated the high temperature to the estates team 4 times in the week preceding our inspection, it was not clear what action was then taken to rectify the issue to ensure medicines for patients were safe to be administered. Following the inspection the trust reported the following actions “Daily monitoring of temperatures and discussed in handovers; Reinforce trust policy on environmental safety; Train staff on escalation procedures for temperature breaches; Conduct weekly regular audits of clinic room conditions for next 2 months and review; Ensure timely maintenance and equipment support.”

Most patients were cared for in safe environments designed to meet their needs. We asked 10 patients across the wards we visited if they thought their ward environment was safe. Seven patients said their ward was safe, 1 said it wasn’t safe and 2 patients on George ward said the ward was noisy. Eden PICU was the only ward with seclusion facilities on the Northcroft site. We were unable to check these during our site visit as they were occupied.

Most managers completed risk assessments of the care environments, identified risks and implemented controls to manage them. Controls included individual patient risk assessments, observations, anti-ligature fittings and door top alarms. The trust installed anti ligature door top alarms to all bedroom and ensuite doors in the wards we visited. Staff checked these on most wards in line with trust policy and manufacturers guidance. We saw evidence of staff escalating when they identified issues with the alarms not working and a quick response to rectify. However, on Larimar ward staff had not clearly recorded all checks of the anti ligature alarms.

We were concerned about the layout of Eden acute ward which included lots of corridors with blind spots with some of these areas not observed by staff. We were not aware of any incidents as a result of this. Staff raised concerns about this and said there were not enough staff available to observe all areas of the ward with blind spots. We reviewed the ligature risk assessment that was completed for Eden acute ward during the inspection. The assessment was completed by local managers and staff from the Health and Safety and Estates teams. In the assessment, corridors were described as an open space with staff observing. This contradicted what we saw during our inspection. This risk was not included on the risk register. Senior leaders advised findings from environmental and ligature risk assessments were shared with staff, including bank staff, via team meetings, safety huddles, handovers and risk mitigation meetings. Staff met in safety huddles 3 times a day and any environmental safety concerns were discussed. We saw evidence of this in the minutes of safety huddles reviewed. Staff spoken with were able to describe environmental safety risks on their wards, for example, blind spots and ligature risks.

Staff ensured most equipment used to deliver care and treatment was suitable for the intended purpose. Staff completed the required checks for medical equipment, including in emergency bags on most wards. However, on George ward staff had not completed the monthly checklist for physical heath equipment since April 2025.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The trust provided vacancy rates as of the 30 May 2025. The trust reported -3% nursing vacancies across the service. This meant across the service there were more nursing staff than the agreed establishment. Despite this, Larimar acute ward reported nursing vacancies of 21%. The trust reported a vacancy rate of 5% for HCAs across the service. Lavender ward reported the highest vacancy rate for HCAs at 18%. All wards except George ward were fully staffed with occupational therapists (OT). Lavender ward was overstaffed by 1 whole time equivalent (WTE) OT, this was due to an OT fulfilling the deputy ward manager role during the recruitment process for a permanent nurse to fill the role. The trust provided data that ‘additional clinical services’ roles were fully recruited to, with no detail of what these roles were. There was no data provided in relation to psychologists, but staff told us there were concerns around the lack of psychology provision and this was a risk on the trust’s risk register.

The trust reported an average sickness rate of 10% between 1 December 2024- 30 May 2025. Lavender acute ward reported the highest rate at 14%. The trust reported a turnover rate of 2.8% across the service. The trust reported 1874 qualified shifts were filled by bank staff and none by agency staff between 1 December 2024- 30 May 2025. The trust reported 6978 HCA shifts were filled by bank staff and none by agency staff between 1 December 2024- 30 May 2025. The trust reported 8% of shifts were unfilled between 1 December 2024- 30 May 2025.

There was not always an appropriate staffing mix on all wards to ensure patients received consistently safe, good quality care that met their needs. We checked staffing gender mix on Eden PICU female ward during our site visit on 18 June 2025. There were 13 staff rostered on shift throughout the day. Of these staff 7 were male and 6 were female. Only 2 staff were permanently recruited to the ward. The other staff on duty were bank staff and ‘over recruited’ staff. Senior leaders told us ‘over recruited staff’ were permanent staff who received the same induction and training as substantive staff but were used to cover shifts across different wards. Staff on the ward told us it was not unusual for shifts to be entirely run on bank and ‘over recruited’ staff. Staff raised concerns that ‘over recruited’ staff allocated to work shifts on their wards, did not always have the relevant experience. We were concerned about the potential impact on female patients’ privacy and dignity with a majority of male staff being on shift. Male staff shared concerns with us about sometimes being the only staff available to support a female patient. Female staff said they took on a greater workload as male staff were not able to carry out all required support duties. We did not see any evidence of impact on patients’ privacy and dignity during our site visit and none of the 4 patients spoken with raised concerns. We discussed our concerns with senior leaders and they took immediate action to adjust rosters to ensure an appropriate gender mix of 70% (female) and 30% (male). The trust shared staffing rosters with us for 3 weeks following our concerns and achieved this ratio for most shifts. The trust advised there had been no incidents reported where patients’ privacy or dignity had been impacted by there not being sufficient female staff available to support or observe. Leaders shared the process for staff to follow in the event of a gender imbalance which also stated male staff would not be used to observe disinhibited patients in seclusion. Senior leaders also advised they had established reporting through the daily ‘safe care’ dashboard, which reported into the trust Safer Staffing Committee monthly. Any escalations for staff additions or swaps would follow a divisional process with oversight of leaders for that division. We checked staffing levels and skill mix on the days we visited the other wards and found these to be appropriate. During our visit to Saffron ward we saw that all staff on duty were substantive staff for that ward. Ward managers told us the trust increased establishment numbers by 1 staff per night shift, which had a positive impact, however they said there were not always enough staff on the day shift to manage incidents or facilitate leave and activities. Managers shared concerns that some of the internationally recruited nurses often required more support which impacted on colleagues’ workloads. The leader with oversight of Eden acute, Eden PICU and George acute wards (all on the Northcroft site) told us the trust used a safe staffing tool to set establishment staffing numbers, these could be increased if more than 1 patient required a higher level of observation or to enable activities and leave for appointments.

We asked 17 patients across the wards we visited if they thought staffing was safe and effective. Thirteen patients said staffing was not always safe and effective on their wards. Two patients on George ward, 1 patient on Larimar ward and 1 on Eden acute ward told us they witnessed staff falling asleep when on shift. Two patients on Eden PICU said there were not enough staff to keep them safe. Two patients on George ward said their leave was sometimes cancelled due to lack of staff availability. A patient on George ward said staff were too busy to talk to patients and 3 patients on George ward told us not all staff knew what they were doing. Patients on Eden PICU said there were not always enough staff to facilitate access to leave, the phone and activities. However, both patients we spoke to on Saffron ward said there were enough staff. We escalated the concerns about staff sleeping on shift to senior leaders who advised they had initiated a comprehensive investigation into the reported incident of staff sleeping during duty hours as per trust policy.

Staff did not always receive the support they needed to deliver safe care. This included supervision, appraisal and support to develop, improve services and where needed, professional revalidation. Between 2 December 2024 and 2 June 2025, the trust reported a compliance rate of 76% for clinical supervision and 56% for management supervision across the wards we inspected. Eden PICU reported the lowest clinical supervision rate at 55% and Eden acute reported the lowest management supervision rate at 36%. Between 2 December 2024 and 2 June 2025, the trust reported a compliance rate of 83% for appraisals. Eden PICU reported the lowest rate at 64%. The trust advised that there were high levels of long term absence on Eden PICU and appraisals would be scheduled in for those staff on their return to the ward. The trust advised that supervision compliance had been a concern. They discussed this at their Acute and Urgent Care Leadership Forum, leading to the implementation of a supervision tracker. All Clinical Nurse Managers ensured weekly updates were provided, including reasons for missed supervision and rescheduled dates. Clinical supervision rates improved from 71% in December 2024 to 82% in June 2025. Management supervision rates improved from 40% in December 2024 to 83% in June 2025.

Staff received training appropriate and relevant to their role. The trust reported a mandatory training compliance of 94% across the wards we visited at the time of the inspection. Staff completed 22 different mandatory training course which included safeguarding adults and children, Intermediate Life Support (ILS): 92%, Emergency Life Support (ELS): 84%, Infection Prevention and Control (IPC): 100%, Risk assessment: 83%, AVERT (safety intervention):96% and Learning disability and autism: 92% for level 1 and 100% for level 2. The trust reported one mandatory training course compliance to be below 75%; Patient Safety level 3 at 73%. The leader with oversight of Eden acute, Eden PICU and George acute wards told us all bank staff completed mandatory training, including training on the observations and therapeutic engagement policy, and must be signed off as competent by the bank staff manager before working on the wards. Permanent staff completed this training as a refresher. Staff training time was built into their contracted hours.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. The trust carried out regular audits of Infection prevention and control, cleanliness and hygiene across the wards we visited. The trust hygiene audits completed between January 2025- May 2025 identified an improvement in compliance from 90% to100%. However, the environmental audit for wards decreased slightly over the past 6 months from 100% to 95%. Audits reviewed identified any actions required that were actioned by ward managers.

Patients were protected as much as possible from the risk of infection because premises and equipment were mostly kept clean and hygienic. We observed most ward areas to be clean and well maintained during our inspection visit. However, we identified some areas that required attention, including on Eden acute ward a shared bathroom ward not being clean and the shower room had mould in the corner and cracked lino around the drain, and Saffron clinic room not being clean, which we raised with staff who rectified immediately. Three patients on Eden acute ward told us the ward was not always clean.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Most patients were appropriately involved in decisions about their medicines. We asked 11 patients across wards we visited if staff talked to them about their medicine and 8 said they did, including all 4 patients asked on Eden PICU with 1 telling us how staff sorted out their medicine, so it worked better for them. Three patients on Eden acute ward said their medicine was not discussed with them. Two other patients on Eden acute ward raised concerns about administration of their medicine, 1 said they were given the wrong medicine and the other said their medicine was given at the wrong time. We checked incident records and there were no reports of this nature. A patient on Lavender ward said the doctor had taken them off their medicine and they now felt terrible. A patient on Larimar ward said they were forced to take medicine.

Whilst patient’s medicines were appropriately prescribed, occasionally they were not appropriately supplied and administered. On a few occasions we identified that staff on Lavender ward administered two out of date medicines to patients. These were opened eye drops that expired in March 2024 and pain relief gel that expired in May 2025 but was not opened until June 2025. There was no evidence of impact on the patients. We raised this with staff who contacted the pharmacist in our presence. The pharmacist advised staff to remove the out of date stock. We do not know if staff followed duty of candour with the patients affected. Following our site visits we requested pharmacy audits to review. The evidence shared showed that the trust pharmacy team had oversight of the medicines management processes and, through the trust’s medicines audits, were aware of which wards were facing higher compliance challenges. The trust was aware of the shortfalls and where concerns on medicines management were.

Apart from the high room temperatures recorded in 3 of the clinic rooms, we did not find concerns with medicines management on the other wards visited. Patients were given their medicines prescribed, following national guidance and local policies. Medicines administration was recorded accurately and contemporaneously. An accurate record was made when medicines were not given, for example, the person was asleep, a medicine was out of stock or medicines or was refused. Patient’s allergies were accurately recorded. Medicines were accurately reconciled and recorded on admission. When required medicines were administered when patients needed them. The maximum doses to be given each day was stated and were not being exceeded. Staff described how patients who were given medicines to manage their violence and aggression had their vital signs monitored. What staff told us was in line with the trusts policy. When patients were detained longer than 3 months under the Mental Health Act, appropriate Mental Health Act forms were available to staff administering the medicines. Medicines, including Controlled Drugs (CDs), were stored securely, at an acceptable temperature and within their expiry date. Medicines with a limited shelf life were dated on opening. Records of Controlled Drugs handling were accurate and made in line with legislation and trust policies. Staff on the other wards were supported by pharmacy staff to manage medicines processes, such as ordering and receiving medicines. The pharmacy team attended the MDT meetings and consultant ward rounds. Staff could access pharmacy advice, emergency medicines and critical medicines out of hours. The trust’s role in relation to people’s medicines was clearly defined and described in relevant policies and procedures. Current and relevant professional guidance about the management of medicines was being followed. The use of patients own medicines was described in the trust’s ‘Medicines Code Policy’. No patients were managing their own medicines. The trust had a medicines self-administration policy supporting its use as part of rehabilitation.