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

Staff did not always understand how learning from incidents was shared and what needed to be done to make improvements. Sufficient staff had not been trained in immediate life support to ensure they could take appropriate action in an emergency. Some staff were not aware of the wards ligature risk assessments and how to minimise risks to people using the service. Some staff did not understand the process to use when completing randomised therapeutic observations on people prescribed 4 observations an hour. Some staff understood how to complete people’s risk assessments and involved the person in these. However, some staff particularly bank staff were not involved in these.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were unable to tell us how learning from safety incidents was shared effectively to reduce the likelihood of reoccurrence. Managers told us how learning was discussed in team meetings, through emails and in clinical governance meetings. However, most staff were unable to give us examples of how learning was shared and what was done to improve care for others. Staff said they had debriefs following incidents but were unaware of learning following these. Staff knew how to report incidents and complaints from people who used the service. Staff told us they were supported following incidents and always had a debrief and often reflective practice sessions led by the psychologist. However, as detailed above, effective learning did not always take place, increasing the risk of reoccurrence.

There were ‘Learning Connect’ newsletters and leaflets about learning from incidents. There was fortnightly reflective practice sessions led by the psychologist. However, it was unclear how this information was understood by staff and used to make improvements to the service and reduce further incidents. They had recently implemented ‘weekly risk huddles’ and ‘daily safety huddles’. These were meetings where people’s risks and any risks relating to staffing, or the environment were discussed and what needed to happen to ensure safety.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

Some people and their families were involved in their risk assessments and understood these. One person said that staff listened to them, understood their risks and managed these in a positive way. However, some people said they were not involved and did not know how staff supported them to manage their risks.

Staff told us that people’s risks were discussed in the handover at the beginning of each shift. Some staff attended daily ‘safety huddles’ which helped them to understand people’s risks. However, some staff had a limited understanding of people’s risks and how to manage these. Bank staff had limited access to people’s risk assessments and care plans. Some staff encouraged people’s families to attend their ward round meetings with the multidisciplinary team and at this meeting people’s risks were reviewed and updated. Some staff told us about ‘risk huddle meetings’ led by psychologists where they discussed a person’s risks in line with the Trust risk assessment policy and discussed formulation of the persons’ risk to develop a risk management plan. This included the 5 P’s, presenting problems, predisposing factors, precipitating factors, perpetuating factors and protective factors. Staff had online training in risk assessments. Staff used an online portal to record people’s therapeutic observations. Staff completed the e-learning about the therapeutic observations policy and how to record these on the portal. Most staff understood the levels of therapeutic observations and how these would be assessed and reviewed for individuals. However, staff did not complete people’s observations at random intervals in line with the Trust’s policy, as they followed the monitor from the portal in the office. When a person on 15 minute/ 4 observations an hour had gone 15 minutes without an observation the monitor alerted staff to do their observation. Staff told us, it was at this point they did the next observation, meaning people could anticipate the next observation. This increased the risk of harm to a person as they could predict when staff would be next observing. The Trust told us they advised staff to record variable/random observations, but staff told us they recorded at 15-minute intervals to ensure they were not overdue or before the prescribed time on the portal.

The therapeutic observation portal which staff used to record observations allowed staff to complete random observations during a defined period. It reset to a new time each time an entry was made. However, not all staff were aware of this or using the system in this way. This meant that people may have been able to predict when their next observation was due and increased a risk to their safety. The portal did not always work due to intermittent connectivity which meant staff had to write people’s observations on paper and add to the system when connectivity was restored. This increased the risk of peoples assessed observations not being consistent, within their prescribed times and additional risks of staff miscommunicating. Meaning people’s risks were not always managed safely. Risk assessments were not always updated in a timely way on Saffron ward to respond to people’s changing needs. However, on Lavender ward 10 people’s care records reviewed included a risk assessment which was up to date. On Saffron ward we found when a person had returned later than they had agreed from unescorted leave their risk assessment had not been reviewed or updated. Staff had not reviewed or updated another person’s risk assessment since their admission 6 days before our visit. Another person’s records showed their relative had told staff in their community team they were at risk of falls. However, staff had not completed their falls risk assessment. This meant that staff may not have the accurate and updated information they need to safely manage people’s risks and reduce the risk of harm.

People told us they felt safe on the wards and staff showed them around when they first arrived. People said there were a few rooms away from the main lounge area to spend time in for activities. People told us there was a room where they could spend time with their family when they visited.

Managers did not always proactively address potential environmental risks which impacted on people’s safety and welfare. Staff and managers were not updated on or aware of systems and processes in place to reduce ligature risks. The trust had a programme for installation of anti-ligature devices for bedroom doors and completed environmental ligature risk assessments. However, managers and staff were not aware of progress with the installation programme, or the contents of the ligature risk assessment. Following our visit the trust told us that staff were sent the door installation programme and it was discussed in team meetings. They also said ward managers had attended the ligature risk assessment training designed to support them in the process of completing assessments led by Health and Safety team and Estates colleagues. Staff said they completed daily environmental checks of the ward, and these checks included checking the anti-ligature devices worked on the ensuite doors. Staff told us they knew where the ligature cutters were kept on each ward.

The wards were clean and generally well maintained. We observed there were some risks in people’s bedrooms which had not been assessed on the ligature risk assessments including furniture. This increased the risk of harm to people.

The trust had a programme for installation of anti- ligature devices to be fitted to bedroom doors on both wards. The wards at the Zinnia Centre were planned to be fitted by end March 2025. They had assessed the priority of this for each of the acute wards within the trust based on incident data. This meant the ligature risks remained on bedroom doors because remedial action had not yet been taken. Staff told us they were not aware of the identified risks, or proposed actions they should take to mitigate or reduce these risks. Following our visit the trust told us that the ligature risk assessments were made available to staff and were discussed at least monthly in team meetings. The ward ligature risk assessment was available to staff on the staff board in the ward managers office. Each ward had a ligature risk assessment which was reviewed in September 2024. However, this did not include an assessment of the bedroom furniture. Following our visit the trust showed us that bedroom furniture was now included on the ward's ligature risk assessment.

People said staff helped them to feel safe and understood their needs and how to support them. They said that staff engaged with them well. However, community meeting minutes involving people on Lavender ward showed there were not always appropriate staffing levels and skill mix to make sure people received consistently safe, good quality care to meet people’s needs. People regularly raised the issue there were not enough staff to support them to go out on escorted leave from the hospital. People said staff did not have enough time to spend with them and there were a lot of bank staff who did not know them, and they found this unnerving.

Staff told us that staffing levels were not always appropriate to make sure people received consistently safe, good quality care to meet their needs. We heard staff on Saffron ward on the first day of our visit tell people that there were not enough staff to facilitate all escorted leave, and these may need to be adjusted or postponed. Staff said they often did not get their breaks during the shift. Occupational therapy and activity staff told us they sometimes had to work as part of the numbers to ensure that people’s observations were completed as needed. They said it could be challenging but all staff worked as a team to benefit the people who used the service. Staffing levels at night were not appropriate to ensure people received safe care. Staff said at night it was more difficult if there was an incident that needed response from other wards or teams within the building, as there was only one other ward for staff to respond from. During the day members of the multidisciplinary team can respond or community teams working in the building. However, we discussed with the Trust following our visit and they ensured there would be an extra staff member on each night shift to respond where needed. Staff told us recruitment was taking place which would increase the number of permanent staff working there. They said on some days there were mostly bank staff working although some of these were regular which helped to ensure safety. Staff said the quality of care can be limited if all bank staff are working, as some things are overlooked. For example, people do not have an opportunity to complete their menu choices or bank staff may not know where people’s belongings are when they are discharged.

Sufficient numbers of staff had not been trained in immediate life support. On Lavender ward only 43% of eligible staff had received training and on Saffron ward only 70%. Due to the acuity of patients on these wards and in line with national guidance on immediate life support for staff that may be involved in restrictive interventions it is essential that staff are able to respond to a medical emergency. Following our visit the trust told us that most staff had been trained in immediate life support, on Lavender ward 92% of eligible staff had received training and 100% of staff on Saffron ward. Staff had not received adequate supervision to enable them to carry out the duties they were meant to carry out. On Lavender ward only 55% of staff had received management supervision. On Saffron ward only 42% of staff had received management supervision. Following our visit the trust told us this had improved to 88% of staff on Lavender ward and 90% on Saffron ward. Regular staff meetings were not held and on Lavender ward there had only been two since April 2024. Managers had sent staff information via email instead of having a meeting in October 2024 as there were not enough staff available for the meeting. Staff had been recently recruited on Saffron ward and Lavender ward, increasing improving vacancies rates. Additionally, retention of staff was good, and turnover had improved. Each morning managers rated the staffing as Red, Amber or Green which is sent to service managers and discussed within the local safety huddle on the ward. Any issues are escalated to senior managers if not resolved locally. Agency staff were not used to cover vacancies or sickness absence. The Trust used bank staff to cover. On Saffron ward in October 2024 88% of bank shifts requested were filled and 85% on Lavender ward. However, this did carry risks as bank staff were not always familiar with people and their needs.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.