Report: Safety ‘big concern’ for Care Quality Commission
One of the Care Quality Commission’s (CQC) ‘biggest concerns’ is about patient safety and risk assessment in specialist mental health services, it has stated in a major report.
The study, called The State of care in mental health services 2014 to 2017, outlined the CQC’s findings from its programme of comprehensive inspections of services. It said safety was ‘the key question that we most often rated as requiring improvement or inadequate’.
The body’s conclusions followed earlier findings on safety in care homes, and stated 36% of NHS and 34% of independent core services required improvement and 4% of NHS core services, with 5% of independent services rated as inadequate on safety.
Outlining its findings, the CQC said the reasons for poor ratings were:
- the physical environment of many mental health wards located in older buildings are not designed to meet the needs of acute patients
- some services struggle to ensure wards were safely staffed at all times
- staff in both inpatient and community services not always managing medicines safely.
Physical environment and risk assessment
The body said the design of old buildings ‘does not permit staff to observe all areas easily’ and many wards contained fixtures and fittings that people who are at risk of suicide could use as ligature anchor points.
It said such facilities could not be modified to eliminate these features and the associated risk – but that it made risk assessment even more important.
The CQC said: “This makes it even more important that staff assess and actively manage and mitigate risks in the ward environment. This was sometimes not the case. An example is one independent acute service where senior staff had inadequate knowledge of ligature risks and were unable to identify them appropriately.”
Same sex wards
Additionally, despite NHS guidance barring same sex wards, these still existed, and it said in such wards ‘staff have a heightened responsibility’ to ensure patients are safe from sexual harassment and sexual violence.
It said that it had taken action against services which had not eliminated mixed sex accommodation.
It also said that ‘in the worst cases’ the national shortage of mental health nurses could affect safety – particularly on wards where safety was already compromised by a poor physical environment. Also, staff in both inpatient and community services did not always manage medicines safely.
The CQC found examples where staff did not store or transport medicines securely or keep them at the correct temperature, and did not keep accurate records when they administered medicines, and did not monitor patients’ physical health necessary to keep them safe.
Technology and IT recording of risk
It also found a number of providers needed to improve their risk assessment and management, with ‘particular difficulties with recording risk assessments on IT systems’.
This was especially acute in community services, where staff could not find risk assessments, either because they were not easily accessible or they were not routinely recorded.
It said there was a ‘broad awareness’ of safeguarding procedures and protocols were in place with staff aware of how to make referrals to local authority safeguarding teams. But it also claimed some services needed to improve.
The commission reported it was ‘particularly important’ staff on old age mental health wards carry out thorough risk assessments. This is because many older people admitted to a mental health ward are at risk both from the ‘consequences of their mental health condition and from the effects of physical ill-health and frailty’.
Some patients told inspectors other patients made them feel unsafe, and the CQC was concerned that in some services staff had not carried out a risk assessment – or had recorded one that was formulaic or lacking in detail.
The CQC did point to some best practice though, highlighting how one trust used a board that was a ‘quick visual guide’ to risk for all patients on the ward, and this was discussed daily in a multidisciplinary meeting.
Crisis team risk
Due to the risk to people being in a distressed state dealt with by crisis teams, such as people at risk of suicide or self-harm, the CQC said ‘high-quality risk assessments’ were important and should be ‘collaborative assessments’ managed with the patients and with carers and family members.
Although it said most staff in crisis care services were assessing and managing risk well, it said it was an area for improvement for some providers.
The report said: “The crisis care teams of one provider had different approaches to engaging people who were not attending appointments. The provider had no clear criteria that guided teams in the measures they should take to ensure these people were safe before discharging them.”
It said managers had not always ensured staff had undertaken training that is essential for this type of service, including in the prevention and management of violence. Also, staff in mental health crisis care services often did not receive regular supervision.
The commission also criticised some providers in the area of lone working practices, stating they ‘did not do all they could to ensure staff safety’ – although it did admit some followed good practice in this high-risk area of mental health services.
It said: “Both policy and practice varied, with a lack of consistency in how teams were managing risks to staff.
“For example, one service had good lone working policies in place that staff followed; in another, there was a lone worker policy but staff did not appear to be following it.”
Although there were exceptions, the environments of most health-based places of safety were clean, safe and comfortable, and they promoted patients’ dignity. Staff had assessed ligature risks and there were appropriate alarms systems that staff could use to summon help in an emergency.
The commission said that although there had been improvements in safety across some services when they were re-evaluated, only 10 of the 25 trusts were able to improve their overall safety rating.
But it did say learning was improving.
“We have seen a large number of trusts that are actively seeking to learn and improve, and many have approached the outstanding trusts and others in a spirit of collegiate learning and a willingness to work together to improve the quality of mental health care.” It said.
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