Birmingham and Solihull Mental Health NHS Foundation Trust

On this page

• 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 requires improvement. At this assessment the rating has remained the same.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service did not consistently follow appropriate systems and processes to ensure the safe administration, recording and storage of medicines. Not all the teams were fully staffed and caseloads across the service were generally high, often resulting in patients experiencing long delays for appointments. There was evidence within patient care records that the service did not always adequately assess and manage risk, with some identified risks lacking adequate control measures.

However, all areas of the environment were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed safety incidents well.

The provider was previously in breach of the legal Regulations in relation to safe care and treatment (Regulation 12) and remained in breach of this regulation.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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.

Staff knew how to report incidents and recorded them on an electronic incident record. They were aware of the different types of reportable incident and reported all incidents that they should report.

Most incidents related to expected deaths. For example, in Solihull, 55 of the 67 incidents reported by staff in December 2025 and January 2026 involved the expected death of a patient. Other commonly reported incidents included failures to record information, such as progress notes following appointments, delays in administering depot injections, safeguarding incidents and breaches of the 13-week waiting time target for psychology services.

Staff understood the duty of candour and demonstrated openness and transparency, providing patients and families with a full explanation when things went wrong. For example, when a letter was accidentally sent to the wrong patient, resulting in a confidentiality breach, the service acted promptly and honestly. Staff contacted both patients to explain what had happened and offered a sincere apology.

Staff received feedback from investigation of incidents, both internal and external to the service. All incident reports were read and signed off by the team manager. Serious incidents were escalated to a more senior level for investigation. Information from investigations was shared with staff at team meetings. Structured judgement reviews were conducted by the patient safety team to assess the quality of care, identify any concerns and ensure learning was used to improve patient safety and clinical practice.

There was evidence that changes had been made as a result of feedback. For example, the service had identified a medicines error in relation to a nurse administering a slow-release intramuscular injection. In response to this, the service introduced new arrangements to ensure that the administration of the medicine was checked by a second nurse, at the time the medicine was being given.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Referrals to the service were made by GPs or psychiatric liaison teams that worked in general hospitals. Each morning, staff held an allocations meeting to review new referrals. Within this meeting, staff assessed the urgency of the referrals. Any referrals that required an immediate response were referred on to the home treatment team. The community mental health teams aimed to visit high priority referrals within 7 days, and routine referrals within 4 weeks.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. All patients receiving anti-dementia medication were seen by a doctor at least once a year. These patients remained on the caseload of the teams. Each team allocated a nurse or occupational therapist to patients who required additional treatment, support or therapy. Casework for brief interventions, such as starting a patient on medication, lasted for between 4 and 8 weeks. Longer interventions lasted between 6 and 9 months. Staff aimed to discharge patients when the specific interventions were complete. Once these interventions were complete, the patient would be transferred to the doctors’ caseload for outpatient appointments or referred to primary care services.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Throughout 2025, a total of 45 safeguarding referrals were made across the service.

Staff reported that the primary safeguarding risks for patients were self-neglect and financial abuse. A review of the 2025 safeguarding data supported this view, with self-neglect accounting for 39% of all safeguarding referrals, making it the most frequently reported type of concern. Financial abuse was the second most common category, accounting for 14% of all safeguarding referrals during the year.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. All staff were required to complete mandatory training in safeguarding. All staff had completed Level 2 safeguarding adults training, with 95% completing Level 3; for safeguarding children training, 97% had completed Level 2 and 98% Level 3.

Staff received advice and support on safeguarding patients from the safeguarding team within the trust and from the local authority safeguarding team.

Staff were able to identify and support adults and children at risk of, or experiencing, significant harm, working collaboratively with other agencies. For example, when a patient was subject to domestic abuse, staff involved the police and local authority, discussed the case in a multidisciplinary team meeting, and put appropriate safety measures in place. In another instance, a staff member sought advice from the safeguarding team and the fire service to support a patient at serious risk from hoarding.

The service did not always work well with people to understand and manage risks. The service did not consistently seek or record patient involvement, including their views and wishes.

We reviewed 14 patient’s care records, including their risk assessments and risk management plans during the assessment.

Staff carried out an initial risk assessment when they received the referral and allocated the patient to a member of staff. A comprehensive risk assessment was completed with the patient at the first appointment.

Generally, risk assessments were detailed and informative; however, some identified risks lacked adequate control measures. For example, 1 patient was identified as at risk of mismanaging diabetes when mentally unwell but there was no additional information given how this risk was being managed.
Another patient’s risk assessment noted verbal aggression, sexual disinhibition, and inappropriate touching, yet the risk management plan only recommended continuing current medication and reviewing in 4 to 6 months, lacking guidance on mitigating these risks or ensuring staff safety.

The layout of the risk assessments often made it unclear which identified risks were current and which were historical.

Staff informed us that they were required to review risk assessments at least every 6 months, or sooner if required. Most risk assessments we reviewed had been updated within this timeframe; however, we noted that a small number had not been reviewed within the last 6 months. The Trust’s Clinical Risk Management policy did not specify fixed timescales for updating risk assessments; instead, it outlined circumstances when reviews should take place, such as when there was a change in clinical presentation.

Staff responded promptly to any deterioration in a patient’s health or increase in a patient’s risk. When staff became aware that a patient’s situation was deteriorating, either the duty worker or the patient’s nurse would take action to address this. This action could involve bringing forward a planned visit, arranging an urgent visit from a doctor, reviewing the patient in the multidisciplinary team meeting or reviewing the patient’s formulation. If the patient required more intensive support, staff could refer the patient to the community enablement and recovery team or the home treatment team. If a patient needed an admission to hospital, this was arranged by the home treatment team.

Staff monitored patients on waiting lists for changes in their level of risk and responded when risk increased. All patients received a letter to say that they were on the waiting list for the service. This letter included information about what patients should do if their condition deteriorated to their level of risk increased.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

All the services we visited were clean, bright and well-maintained. Interview rooms and waiting areas were fitted with good quality furniture. During our inspection, we noted that a routine deep clean was being carried out in one of the offices.

Staff had easy access to alarms. Interview rooms were not fitted with alarms. However, all staff wore a lanyard that was fitted with a call button they could use to activate an alarm or call for immediate assistance. Personal safety alarms were provided to staff to help maintain safety when lone working in the community.

The services in South Birmingham and Solihull shared their clinic rooms with other services. The clinic rooms we observed were clean and well-maintained, containing medication storage facilities and physical health monitoring equipment, such as electrocardiogram (ECG) machines and blood pressure monitors. Records showed that this equipment was regularly serviced.

The service did not always make sure there were enough qualified, skilled and experienced staff, as a result caseloads and waiting times were consistently above the trust’s operational targets.

Multidisciplinary teams comprised of registered nurses, advanced nurse practitioners, consultant psychiatrists, specialty doctors, occupational therapists, psychologists and administrative staff. The teams did not employ social workers, although staff could refer patients to social workers based in the local authorities.

In May 2025, vacancy rates across teams ranged from 1.9% to 13.8% and turnover from 0% to 7.1%. Sickness rates across the teams ranged from 0% to 11.5%. Solihull reported the highest rate at 11.5%, followed by West at 9.4%. Both figures were substantially above the typical sickness benchmark for NHS Community Mental Health Teams, which was approximately 4-5%.

Not all the teams were fully staffed. For example, the community mental health team in Solihull had 3 community psychiatric nurses out of an establishment of 6. Staff told us the team had been short of staff for some time. Managers had sought to address this by recruiting more staff. Two nurses were due to join the team shortly after the inspection. Whilst the service had been short-staffed, nurses from other teams provided support. For example, staff from the memory service carried out 5 new assessments for Solihull each week, and staff from other teams provided duty cover 3 days each week. The service reported difficulty recruiting a manager for the Solihull hub, with the post vacant for approximately 1 year before a recent successful appointment. During this period, managers from other areas provided interim cover. Staff in the other teams felt these arrangements added to their already high workloads.

High caseloads across teams were recognised and formally recorded on the Trust’s risk register, with particular pressure arising from commissioning requirements for annual dementia reviews. Leaders reported that caseload volume was further increased by a significant proportion of patients prescribed dementia medication who required ongoing monitoring, including some who were stable and low risk, which staff felt could contribute to unnecessarily high caseloads for doctors. The service responded through regular caseload supervision to monitor workload weighting and staff wellbeing, alongside measures such as limiting or reallocating cases, strengthening clinical supervision, and undertaking senior-level caseload reviews supported by mitigation plans.

The overall caseload for older people across the trust was approximately 7600. Most of these patients were seen by doctors for outpatient appointments. For example, in Solihull there was a total caseload of 1487. Of these, approximately 250 were assigned to a community psychiatric nurse, occupational therapist or advanced nurse practitioner for ongoing casework. The remaining patients were seen by doctors in outpatient clinics.

The service did not use agency staff and bank staff were rarely used. When the service did use bank staff, it tended to be on a long-term basis. For example, in Solihull, a member of another team provided a bank shift one day per week.

Each doctor had a weekly work plan setting out the times for clinics, multidisciplinary team meetings and clinical supervision. Doctors were available to provide urgent visits or appointments at least once a week. Urgent visits outside office hours were assigned to the home treatment team.

Compliance with mandatory training across the service was high, with some variation between hubs: The South Hub achieved the highest rate at 99%, followed by East at 98% and North at 97%, while West and Solihull Hubs both recorded 89%, resulting in an overall training compliance rate of over 94% across all teams.

The service assessed and managed the risk of infection. They detected and controlled the risk infection spreading and when necessary, promptly shared concerns with appropriate agencies.

All areas of the services were clean, had good furnishings and were well-maintained.

Staff completed an infection, prevention and control audit each month.

Staff training compliance for infection prevention and control was 96%.Food hygiene training compliance was 100%.

The evidence showed some shortfalls. The service did not always make sure that medicines were managed safely and securely.

Compliance with medicines awareness training among staff was 100%.

Patients and carers reported that medicines were reviewed with them regularly, and information was provided in a way they could understand.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance. For example, patients prescribed lithium received regular tests to measure the concentration of the medicine in their blood. These tests were carried out to ensure levels were within the therapeutic range and to avoid toxicity. The administration and monitoring of clozapine was carried out through the clozapine clinic. This clinic provided a service for adults of all ages.

However, Staff did not always ensure the safe management of medicines.

In the South Hub, clinic temperatures consistently exceeded the 25°C safe storage limit, and no action had been taken to address this. South Hub medicines were stored alongside inpatient stock, causing confusion among staff about which medicines belonged to each service. Depot drug cards in the South and East Hubs were incomplete, although digital records confirmed that depot injections had been administered correctly. There was no authorised staff signature list or record identifying which team members were permitted to administer medication. There was no system to record medicines received and stored on site, or to track their removal for delivery to patients, including quantities and staff accountability. At the East Hub, medication cabinet keys were kept in a defective, unsecured safe.

We saw evidence of annual medicines audits for all teams, together with associated action plans. Medication audits identified an average overall compliance rate of 91% across the service, with compliance rates ranging from 81.5% in the North Hub to 100% in both the East and South Hubs.

The audits highlighted areas for improvement, including the need for a clear audit trail for the delivery and receipt of all medicines, improved prescription pad logging and monitoring processes, and the completion and documentation of annual stock list reviews. However, they did not identify several concerns found during our assessment, including high clinic room temperatures, incomplete depot medication cards, and the insecure storage of medication keys.

Although the audits stated that each team maintained a list of trained nurses with a sample of their initials, we were unable to locate evidence of this during the assessment.

Following our assessment, the service reported that actions had been taken to address some of the medicines management concerns we identified. These actions included addressing the recurring issue of high clinic room temperatures by relocating the drugs cupboard to an alternative room, and implementing measures to respond when clinic room temperatures exceeded the maximum permitted 25 degrees Celsius. These measures included moving medicines to an alternative air‑conditioned clinic room and using a portable air‑conditioning unit.

The service also reported that a weekly audit had been put in place to provide greater assurance regarding the safe management of medicines. In addition, medicines optimisation had been strengthened through input from pharmacy colleagues, with agreed actions monitored via the Medicines Optimisation Group.