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Dear colleague,
My predecessor Dr Paul Lelliott wrote to you last year about our concerns about the quality and safety of care provided on mental health wards. The Independent Review of the Mental Health Act and the NHS Long Term Plan both cited concerns about the physical condition of wards and the need for them to be improved. We set out a number of actions that we would take as the regulator of healthcare in mental health settings, that focused on safety and leadership within organisations.
I am pleased to say that progress has been made and it is clear that some organisations have made a very real public commitment to change. The work undertaken in partnership with NHSE/I, the Royal College of Psychiatrists, the Nursing and Midwifery Council and other stakeholders to reduce restrictive practices and to improve sexual safety on mental health wards is hugely important. There is still significant variation in the quality and safety of mental health services across the country, but where organisations have adopted a collaborative approach and Quality Improvement (QI) methods using a defined methodology, there has been real progress.
Many organisations have made significant improvement in the ligature risks in there is facilities and where new risks have been identified have acted very promptly to reduce and remove the risk. However, we remain very concerned about a lack of improvement in some estates and the absence of a sense of urgency that change is needed in these organisations. Sadly, we are still being notified of deaths on inpatient units by suicide where high risk ligature points have been identified but no effective action has been taken to manage the ligature points. We are often told that the mitigation is a variation on “staff to be more vigilant” and that the issue is on the capital projects register. However, leaving such an issue on the capital projects register for a prolonged period when they have been identified as requiring urgent resolution, risks serious harm to patients.
We are also concerned at the number of trust policies that still see lower level ligature points as ‘low risk’. This is not the case - all ligature points in areas where patients vulnerable to self-harm will spend time unobserved, such as toilets, bathrooms and bedrooms are high-risk. Trusts should have revised their policies after the NHS Estates & Facilities Alert 2018 and should not be using any traffic light system or scoring tools that suggest such ligature points are low risk. This does not appear to have universally occurred; the NHS England and Improvement Alert issued in March 2020 reinforced the need for this to happen, as many examples of trust policies that had not been updated were identified.
The importance of this is summarised in our 2020 brief guide for inspection teams and it is a concern to us that many trust polices still reference much earlier versions of this guide. Ligature points are of course only one means of self-harm; trust policies need to encompass other environmental risks of self-harm.
We are aware that estates progress will be a challenge during the Covid-19 pandemic and that addressing these issues is not entirely within your control. However, we would expect to see evidence of plans having been put in place to resolve these issues as quickly as reasonably possible now that restrictions are easing.
As the regulator our role is to protect patients and to make sure that they receive high quality and safe care. To ensure that this is the case we are going to take the following actions:
As part of our Well Led inspections:
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Look at the Capital Projects Allocation for each organisation and the prioritisation of the allocation.
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Explore the non-executive directors’ understanding of the estates’ risks and how these impact on the safety and quality of care.
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Consider the degree to which the quality and finance sub-committees of the board have considered individual notified estates risks e.g. ligature points and the actions that they have subsequently taken.
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Look at the pathway from ward to board of risk information about estates.
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Critically assess the transparency and openness of board papers dealing with quality and safety that are in the public domain.
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Seek confirmation that trusts have environmental risk assessment policies that comply with the alerts listed above and the wider guidance summarised in our brief guide for inspection teams.
As part of all our inspections to wards:
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Discuss concerns about patient safety with staff and people using the service.
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Assess the degree to which concerns raised about safety and quality are listened to and acted upon.
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Determine the effectiveness of ligature audits and their mitigations, including an assessment of the human factors involved in their mitigations and their impact upon staff. By this we mean the relationship between staff, the equipment they use in the workplace, and the environment in which they work.
We expect that providers will understand why this work is critically important for patients and will respond accordingly. We will follow up progress made by trusts through engagement and inspection activity, and where necessary we will take enforcement action to ensure people are receiving safe care.
Yours sincerely,
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Dr Kevin Cleary, Deputy Chief Inspector Mental Health and Community Services |
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