Birmingham and Solihull Mental Health NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The governance, management and accountability systems were not always effective in assessing, identifying and managing risks to the safety of people using the service.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff did not always understand their roles and responsibilities. Some staff did not know they needed to randomise people’s therapeutic observations when they were prescribed 4 observations an hour. Systems in place were not robust and managers had not identified this. There was an audit programme which included care plans, risk assessments, infection control and the Mental Health Act. These were completed by deputy ward managers, ward managers and matrons. However, staff spoken with particularly bank staff were not aware of feedback from these and how they were used to improve quality and safety.

Governance systems were not always clear and effective in managing the safety of the environment and identifying risks to people’s health, safety and welfare. Managers had not identified some ligature risks, and we found these were not included in the wards ligature risk assessments. Processes in place had failed to identify this concern and placed people at risk of harm. However, following our visit the trust showed us that all areas including bedroom furniture were now included in the ligature risk assessments for each ward.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.