Black Country Healthcare 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 requires improvement. At this assessment the rating has remained requires improvement.

This meant people were not always safe and were at risk of avoidable harm.

There was limited assurance about safety. Physical health care plans lacked the level of detail for staff to safely support patients to manage conditions. Incidents lacked appropriate follow-up action. Medicines were not always managed safely. Reportable safeguarding incidents had not been escalated. There were concerns relating to fire safety, with several fire doors being wedged open, not closing properly and in a poor state of repair. There were concerns around low staffing levels and the impact this had on staff wellbeing and patient care. However, the trust had established governance and learning processes to support the review of incidents and promote improvements in practice. Staff demonstrated a good understanding of incident reporting processes, and the trust had implemented actions to address identified risks and improve patient safety.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service promoted a learning culture where staff understood how to report incidents and concerns. Learning from incidents was reviewed and used to improve care, safety and organisational processes. Although learning processes were established, follow-up actions and evidence of learning were not always consistently reflected in care records. Staff were generally supported following incidents, although debriefs were not always delivered consistently.

We reviewed incident data from June 2025 to June 2026 across all five sites. The most commonly reported incidents involved violence, aggression and inappropriate behaviour. Incidents relating to self-harm and patient searches were also reported frequently.

Staff understood how to report incidents and what should be reported. They explained incidents were graded according to risk level, which determined who within the organisation was notified.

Staff told us they discussed incidents and learning during reflective practice sessions, team meetings, daily handovers and through staff communications. Learning was also reviewed through Quality and Safety Meetings and Mortality Review Groups. Themes and lessons from serious incidents, including inquest findings, were shared through newsletters and trust-wide briefings.

Staff provided examples of learning leading to improvements in care. Following repeated incidents involving a patient becoming distressed about leave arrangements, staff reviewed the patient's needs and introduced shorter, more frequent periods of leave. This reduced frustration and the number of incidents. Incident reviews had also led to improvements in the electronic patient record system, making risk assessments, safety plans and discharge information easier to access.

Learning from ligature incidents was shared through staff guidance, practical learning resources and trust-wide communications. Following incidents involving deterioration in patients' physical health, the trust strengthened guidance and support around the use of NEWS2, improved escalation processes and introduced a Memorandum of Understanding to support the timely transfer of patients requiring specialist physical healthcare.

The trust had a team of trained debriefers available to support staff after incidents. However, staff gave mixed feedback about the consistency and quality of debriefs. Some staff described debriefs as valuable opportunities to reflect and learn, while others said they did not take place routinely or felt rushed. Staffing pressures were reported as a barrier to carrying out debriefs consistently.

The evidence showed some shortfalls. Delays in patient flow and discharge meant some patients remained in hospital longer than clinically necessary. Information used to monitor discharge delays did not always reflect the situation found during our assessment.

Staff at the Macarthur Centre Psychiatric Intensive Care Unit (PICU) told us patients sometimes experienced significant delays transferring to acute wards because of a lack of available beds. Staff said prolonged stays in PICU could negatively affect recovery and increase the risk of relapse. At the time of our visit, managers reported that 7 of the 9 patients on the ward were ready to transfer but remained in PICU due to a shortage of acute beds.

However, trust data showed that between November 2025 and May 2026 only 1 patient at the Macarthur Centre had been recorded as ready for discharge but awaiting transfer. This was inconsistent with evidence gathered during the inspection and suggested the data did not fully capture the extent of delays.

Staff identified other factors affecting timely discharge, including the complexity of patients’ needs, a lack of suitable onward placements and delays by external agencies in arranging care packages or housing.

Trust data showed significant variation in average lengths of stay across wards. Friar Ward had the shortest average length of stay at 30 days, while Abbey Ward had the longest at 111 days.

The trust had measures in place to improve patient flow and support timely discharge. Weekly bed flow meetings reviewed patients who were clinically ready for discharge and monitored progress with external partners. Multi-Agency Discharge Events (MADE) brought together partner organisations to address barriers to discharge, including care packages, accommodation and onward placements.

Leaders told us medical reviews were requested for patients whose length of stay exceeded 60 days to identify opportunities to support discharge where appropriate.

The evidence showed some shortfalls. Although safeguarding training compliance was high and safeguarding processes, oversight and staff knowledge had improved, safeguarding procedures were not always followed, and some safeguarding concerns that met referral thresholds had not been reported appropriately.

Training compliance was high across all sites. All staff had completed Level 1 safeguarding training for adults and children. Compliance rates were 96% for Level 2 adult safeguarding and 95% for children’s safeguarding, while Level 3 compliance was 91% for adults and 90% for children.

Managers at Hallam Street Hospital told us safeguarding concerns had previously been under-reported because staff did not always recognise when issues met safeguarding thresholds. In response to previous inspection findings, the service strengthened its safeguarding arrangements by introducing routine safeguarding screening on admission, regular reviews during patients’ stays and improved liaison with local authority and trust safeguarding teams.

The trust had also increased its focus on safeguarding through team discussions, safeguarding supervision and attendance by safeguarding specialists at multidisciplinary team meetings. Staff told us these initiatives had improved their knowledge, awareness and confidence in recognising and reporting safeguarding concerns. Early feedback indicated these changes were helping to strengthen safeguarding practice.

However, our review of incident reports identified concerns. On Friar Ward and Clent Ward, we found incidents that met the threshold for safeguarding referrals, but referrals had not been made. The trust acknowledged that safeguarding procedures had not been followed and told us retrospective referrals would be submitted, an internal investigation undertaken and staff statements obtained where necessary.

The evidence showed significant shortfalls. The service did not always work effectively with people to understand and manage risks. Risk assessments and care plans were not always clear, up to date or reviewed following incidents, reducing assurance that risks were consistently managed.

Staff continuously monitored patients' risks through observations. When a patient's risk increased, staff took immediate action, such as increasing observation levels and supporting the patient to de-escalate distress and agitation. Handover meetings included discussions about risks presented by patients, particularly where risk levels had increased. Multidisciplinary teams reviewed risks, incidents and safeguarding concerns and agreed changes to care and treatment where required.

Between December 2025 and May 2026, staff used physical intervention on 632 occasions to prevent harm to patients or others. This included 64 incidents of prone restraint. The use of physical intervention varied across wards, ranging from 17 incidents on Kinver Ward to 111 incidents on Charlemont Ward. The trust monitored restrictive interventions through monthly divisional governance processes, with restraint data reviewed through Quality and Safety meetings. All prone restraints were reviewed by the Safety Intervention Team to ensure they were clinically justified and proportionate. Reviews identified that prone restraint was most commonly used to administer intramuscular medication or support the safe exit of patients from seclusion. The trust had implemented and was developing a range of quality improvement initiatives to reduce restrictive practices, including promoting alternative techniques and strengthening staff training in least restrictive approaches to care.

However, most risk assessments we reviewed did not provide a clear, up-to-date overview of patients' current risks. Changes in risk were often recorded as separate chronological entries rather than being incorporated into revised risk assessments. The quality and completeness of care plans also varied. Care plans and risk assessments were frequently recorded as a series of chronological updates rather than being routinely reviewed and updated to reflect patients' current needs, risks and progress. As a result, staff were often required to review multiple records to understand current risks, the actions needed to manage them and the care being provided.

Although we saw some examples of personalised care planning, several care plans lacked sufficient detail to reflect patients' current circumstances. This was particularly evident in some physical health, discharge and crisis care plans. For example, one patient did not have a condition-specific care plan to support the management of diabetes, while another patient's physical health care plan had not been updated to reflect changes to their medication.

Our review of care records and incident reports also identified examples where follow-up actions following incidents were incomplete or ineffective. Records did not always demonstrate that risks had been adequately reviewed or that care plans and risk assessments had been updated to reflect incidents and emerging risks. We also found occasions where safeguarding or police referrals had not been made when required and where services had not developed care plans to address risks identified following incidents. These issues reduced assurance that identified risks and needs were consistently recognised, assessed, reflected in care plans and managed effectively.

We also identified concerns relating to medicines risk management, where required risk assessments, documentation and care planning had not always been completed in line with trust policy. This reduced assurance that risks were being effectively managed. We found an example of a patient experiencing symptoms that could indicate poorly controlled diabetes, but there was no evidence these concerns had been recognised, assessed or incorporated into care planning. Although staff reported escalating concerns to the physical health team three days before our inspection, there was no evidence this had resulted in a review of the patient's needs or an update to their care plan. Consequently, the provider could not demonstrate that risks associated with the patient's diabetes were being effectively monitored and managed.

Following the previous inspection at Hallam Street Hospital, the service had strengthened oversight of care planning, risk assessments and clinical documentation through revised inpatient documentation audits. Managers told us these audits had improved oversight of compliance with clinical standards. Staff also described a quality improvement programme focused on improving the quality of clinical records, including the development of guidance templates to support more comprehensive care planning.

During our review of observation records, approximately 60% of nursing observations were completed at predictable time intervals. Not all staff demonstrated an understanding of the need to vary observation times to maintain their effectiveness and reduce predictability. Staff carried out patient and environmental searches where required and used drug detection dogs and urine drug screening to help manage risks associated with illicit substances.

Following feedback, the trust provided assurances that risk assessments and care plans would be updated retrospectively where required, record alerts added where appropriate, and staff reminded through supervision of the importance of maintaining accurate risk management documentation. The trust had also introduced risk formulation training to improve staff skills in risk assessment and had identified further improvements, including mandatory suicide prevention training and increased support for developing effective safety plans with patients.

The evidence showed significant shortfalls. The service did not always identify and manage environmental risks effectively or ensure facilities and equipment supported safe care. There were persistent delays in addressing maintenance issues.

We identified fire safety concerns across several sites. On Clent Ward, some fire doors did not close or lock properly, while others were left open despite signage indicating they should remain closed. At the MacArthur Centre, several fire doors damaged by patients had been repaired using wooden panelling, raising concerns about their effectiveness in a fire. We also observed fire doors being propped open with furniture on multiple wards, increasing fire safety risks.

At Penn Hospital, walking frames, wheelchairs and raised toilet seats were stored in the activities of daily living kitchen. This reduced the kitchen's intended use and created potential health, safety and infection control risks because equipment was stored in a food preparation area.

The MacArthur Centre contained the trust’s only seclusion room. Leaders acknowledged it was not fit for purpose and had plans to develop a new seclusion suite with two rooms. Seclusion audits had been introduced to improve oversight and compliance with the Mental Health Act Code of Practice, and leaders planned to digitise seclusion documentation to strengthen governance and monitoring.

Patients and staff consistently raised concerns about the condition of ward environments. Leaders acknowledged that parts of the estate required refurbishment and described planned improvements, including refurbishment works at Ambleside Ward and environmental upgrades at the MacArthur Centre. Patients on Clent Ward also raised concerns about the lack of en-suite facilities and the poor condition of bathroom areas.

The trust risk register identified significant concerns at Hallam Street Hospital, including blind spots, ligature and fire risks, limited patient facilities, poor accessibility and environmental features that did not always support safe, therapeutic care. The trust had begun addressing these issues through refurbishment programmes and longer-term discussions regarding the future of the site.

Staff reported significant delays in the completion of maintenance requests, including repairs to damaged doors and windows. Leaders acknowledged weaknesses in oversight and had introduced actions to improve monitoring, including weekly site inspections, a maintenance tracking system, enhanced estates meetings and daily environmental audits.

We also identified concerns regarding ligature risk management. At the MacArthur Centre, ligature cutters were not stored in all locations identified within risk assessments. On Abbey Ward, some staff, including the ward manager, could not describe the ward ligature risk assessment or explain where it was located. On Clent Ward, ligature risk assessments referred to photographs of ligature anchor points that were not included in the document. These issues limited the effectiveness of environmental risk management arrangements.

Following inspection feedback, leaders immediately reviewed ligature risk assessments and storage arrangements for ligature cutters. Updated assessments were issued, guidance was recirculated and plans were developed to improve staff awareness through training and team briefings.

Staff carried personal alarms linked to ward systems, enabling colleagues to respond quickly during emergencies or incidents requiring additional support.

The evidence showed some shortfalls. The service did not always ensure there were enough qualified, skilled and experienced staff to meet patients' needs. Staff reported that workforce pressures affected opportunities for therapeutic engagement, access to activities and the timely delivery of care. Although the trust had processes in place to monitor and address staffing pressures, these had not fully mitigated their impact on patients and staff.

Staff across several wards raised concerns about staffing levels and workload. They consistently described feeling under pressure and said workforce shortages reduced opportunities for direct patient care, therapeutic engagement and meaningful support. Staff and patients reported delays in meeting patients' needs, difficulties facilitating Section 17 leave and reduced access to activities, particularly at weekends.

Staff told us staffing levels did not always reflect the complexity and acuity of the patient group, particularly when multiple patients required enhanced observations. This reduced staff availability for other patients, limited therapeutic engagement and affected the wider ward environment. Several staff linked ongoing staffing pressures to stress, low morale and increased sickness absence, although they remained committed to providing good care and supporting patients. Staff at the MacArthur Centre reported increased staffing challenges since becoming a standalone service and said support from other trust sites was not always available promptly.

Workforce pressures also meant staff from a range of roles, including managers and activity coordinators, were regularly required to support ward staffing. This affected service delivery, reduced opportunities for therapeutic activities and limited managerial oversight. Ward managers frequently relied on bank staff to fill staffing gaps, and some patients told us they were often supported by unfamiliar staff.

We reviewed each ward's staffing establishment figures, which were informed by the Mental Health Optimal Staffing Tool (MHOST). Agreed staffing levels were generally lower at weekends than during the week and included provision for a set number of enhanced observations, with additional staffing required when this threshold was exceeded. Staff on most wards felt baseline staffing levels did not fully reflect patient acuity, occupancy levels and operational demands.

Between December 2025 and May 2026, average staff sickness rates across services were 8%, ranging from 4% on Charlemont Ward and 5% on Friar Ward to 10% on Abbey Ward and 14% on Clent Ward.

Vacancy rates were low, at less that 1% for registered nurses and 2.5% for health care assistants.

Staff reported good access to both mandatory and specialist training. Training included areas relevant to the patient group and service provided. Compliance with mandatory and statutory training averaged 91% across services, ranging from 83% on Clent Ward to 96% on Friar Ward.

Staff received induction, attended team meetings and had access to specialist knowledge and support through multidisciplinary working. However, compliance with supervision and appraisal requirements was lower than the trust's expected standards. Supervision compliance averaged 76%, ranging from 42% on Clent Ward to 90% on Charlemont Ward, below the trust target of 85%. Appraisal compliance averaged 78%, ranging from 47% on Clent Ward to 100% on Kinver Ward, below the trust target of 95%.

The trust maintained oversight of staffing through daily staffing reviews, safer staffing reports and governance processes, alongside ongoing monitoring of workforce capacity, training compliance and sickness absence. The trust provided a range of specialist training and implemented actions to mitigate staffing pressures, including flexible redeployment of staff, the use of senior staff to support wards and recovery plans for services experiencing the greatest workforce challenges.

The evidence showed a good standard. The service managed the risk of infection through effective infection prevention and control practices, although some environmental issues required attention.

Compliance with Infection Control Training across the services averaged 98% for Level 1 and 89% for Level 2 training.

The service had made improvements to infection prevention and control (IPC) practices. These included, the completion of deep cleans, revised cleaning schedules, the undertaking of IPC audits, and increased matron input and oversight in this area.

While we found some environmental issues, including damaged doors, worn and stained flooring, and bathrooms that required refurbishment, all wards were visibly clean and infection prevention and control practices were being maintained to a good standard.

The evidence showed significant shortfalls. The service did not always ensure medicines were managed, stored and monitored safely. Policies and procedures were not consistently followed, creating risks to patient safety.

At the MacArthur Centre and Hallam Street Hospital, medicine stocks were well managed and medicines were readily available when required. Resuscitation equipment was in date, routinely checked and appropriately monitored. Staff participated in emergency scenario training, and pharmacy teams regularly reviewed prescription charts to promote safe medicines management.

At Penn Hospital, clinical areas were clean and organised, with effective systems for stock control, expiry date monitoring and routine temperature checks.

However, we identified a number of concerns across services. At Hallam Street Hospital, elevated room temperatures were not always escalated in line with trust procedures, creating a risk that medicines could be stored outside the manufacturer's recommended temperature range and potentially affect their safety and effectiveness.

We found inconsistent practices in the prescribing and management of insulin. Emergency medicines for hypoglycaemia were not always prescribed, potentially delaying treatment during a hypoglycaemic event. Policies did not provide sufficient guidance on prescribing emergency medicines, and diabetes care plans did not consistently contain the information required by trust policy. Staff also reported delays in specialist review of patients with diabetes, and we identified examples where treatment reviews had been delayed.

We also identified concerns regarding the prescribing and monitoring of valproate. Trust policies were still being developed at the time of inspection. Documentation of annual reviews and the rationale for continuing treatment was inconsistent, and records did not always demonstrate that patients had received appropriate counselling about the risks associated with valproate. This reduced assurance that prescribing and monitoring complied with national safety guidance.

At Penn Hospital, clinic rooms were not always adequately equipped for the care being delivered. Although examination couches were available on the wards, they were not being consistently used in practice, and staff were administering depot injections in environments that did not fully support privacy, dignity or optimal clinical practice.

Medicines management processes were not always followed. Patient-specific medicines, including inhalers, were not consistently labelled with patient identifiers, and opening dates were not always recorded on medicines with a limited shelf life, including controlled drugs. Stock management and expiry date checks were inconsistently completed, and out-of-date items were found in some storage areas. Documentation relating to sharps containers was also incomplete.

We observed unsafe storage practices, including oral and injectable syringes being stored together, medicines and clinical supplies stored above cupboards, and unclear processes for transferring patient-labelled medicines into ward stock. These arrangements increased the risk of error and reduced assurance that stocks were appropriately managed.

Although rapid tranquillisation was used as a last resort, we found one record where post-administration physical health monitoring had not been completed in line with policy, increasing the risk of avoidable harm.

At Dorothy Pattison Hospital, medicines management was generally effective, although improvements were needed to ensure medicines opening dates and clinic room temperatures were recorded consistently.

At Bushey Fields Hospital, we found additional concerns, including medicines that were not labelled with patient details, missing opening and expiry dates, a loose blister pack of medication within a medicines trolley and inappropriate storage of ice packs in a medicines refrigerator. We also found alcohol breathalysers and blood glucose monitoring devices without evidence of calibration.

Collectively, these issues reduced assurance that medicines were consistently managed, stored and monitored in a way that supported safe care.