A recent Care Quality Commission (CQC) report raised major safety concerns over the mental health services at one local trust. The results particularly highlight problems in Regency and Caburn wards. During the inspection in May 2024, the risks to the environment were so severe, they posed a direct threat to patient safety. History of instructive safety regulations breached by the CQC Inspect ligature risks in Regency ward’s bathrooms. They highlighted spots on Caburn ward where sight lines aren’t clear, again important for staff to be able to monitor patients effectively.
The report expressed concerns about the management of environmental risks, stating that “staff weren’t always managing environmental risks to people’s safety.” Yet when the CQC visited these wards, they found that they were not doing enough to mitigate these hazards. Patients characterized the environment as “loud and chaotic” and reported alarming experiences with exposure to illicit drug use and access to harmful devices.
Even with these conclusions, the report admitted that the trust has made considerable progress since the inspection. Once again, the staff have worked half-assed to deeply embed their improvements. Through this process, they have bolstered their medicine management process, ramped up education and training efforts, and revised care planning protocols.
The CQC noted that both Regency and Caburn wards were fully staffed, with the appropriate roles filled to meet patients’ needs. In addition, the wards delivered high-quality, dependable care, as consistent care is a vital driver of patient recovery. Much work remains to be done. Other findings from the report revealed that staff were not always following the trust’s medication management policies. Care plans and risk assessments frequently did not have all of the necessary information.
Following the inspection results, the trust temporarily suspended on-boarding new patients so they could tackle urgent safety issues. They told the CQC that they are now moving forward on all of these matters. As the report noted, incident reporting still has big gaps and lots of room for improvement. “Staff didn’t always report incidents or near-misses, which meant they couldn’t be properly investigated,” said Serena Coleman, a representative of the CQC. Suspended administrator — Mixed reviews from patients on how safe they feel adds urgency for continued improvements.
CQC were pleased to see that the trust had been proactive in responding to all safety issues identified. “Staff have worked incredibly hard to embed their improvements,” said Teresa Barker from the trust, highlighting their commitment to advancing care quality.
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