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CQC's damning criticism of Southern Health leadership

CQC releases report after Southern Health inspection

The Deputy Chief Inspector of Hospitals and Lead for Mental Health with the Care Quality Commission issued the following statement on the release of the CQC's interim inspection report of the Southern Health NHS Trust.

Dr Paul Lelliott, said that in his opinion the trust's leadership showed few signs of being proactive about identifying risks to the people in its care - or for taking action to address such risks, unless concerns are raised by external organisations:

“Since the failings identified in the Mazars report, this Trust has, rightly, been under intense scrutiny. In December 2015 it introduced a new system for reporting and investigating incidents, including deaths. It is too early to gauge the effectiveness of the new process. However, our inspectors found that the quality of the incident reports and initial management assessments, conducted both before and after the introduction of the new procedures, varied considerably.

“We found that in spite of the best efforts of the staff, the key risks and actions to address them were not driving the senior leadership or board agenda. It is clear that the Trust had still missed opportunities to learn from adverse incidents and to take action to reduce the chance of similar events happening in the future.

“For example, although the Trust had identified that when people did not attend appointments, they could be at high risk of harm, there was no clear guidance for staff working in community mental health teams about what they should do when a patient does not attend an appointment.

“While all clinical staff had been informed of the new system for reporting incidents and patient deaths, we found on our inspection in January 2016 that some staff were still unsure of when and how to involve families, and it was not always clear what discussions or communications had taken place to involve families.

“We were also very concerned about the lack of action taken to address risk to people posed by the physical environment in which they were being cared for. For example, we asked the Trust to take immediate action to ensure patients who access the garden at Melbury Lodge do not climb onto the low roof. There have been a number of incidents of patients injuring themselves, some seriously, by falling from the roof, and of patients detained under the Mental Health Act absconding by that route. We issued a warning notice immediately following this inspection requiring the Trust that they must make improvements to ensure people’s safety. We also told the Trust that they must put in place effective governance arrangements to ensure that patient safety incidents are investigated and learned from.

“I am concerned that the leadership of this Trust shows little evidence of being proactive in identifying risk to the people it cares for or of taking action to address that risk before concerns are raised by external bodies. Along with partners including NHS Improvement and NHS England, we will be monitoring progress extremely closely. We will be looking not only for evidence of improvements, but for evidence that this Board is actively planning to protect patients in their care from the risk of harm.”

– Dr Paul Lelliott, Deputy Chief Inspector of Hospitals and Lead for Mental Health


A look ahead to CQC's report into Southern Health

Tomorrow sees the publication of a long-awaited report - into the quality of care - at the Southern Health NHS Foundation Trust.

The organisation looks after people with mental health and learning disabilities - and adult social care. It is facing damning criticism for failing to investigate hundreds of unexpected deaths, with serious concerns about leadership. Our reporter Rachel Hepworth looks at the story so far.


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