A an NHS trust where a teenager drowned in the bath is still failing to protect patients from risk of harm, a watchdog has found.
The Care Quality Commission has published the findings today of a short-notice inspection of the Southern Health NHS Foundation Trust.
The visit by 22 inspectors took place at the request of the Secretary of State after an independent review. The Mazars report found a number of serious concerns regarding the way the Southern Health NHS Foundation Trust reported and investigated hundreds of deaths, particularly the deaths of people using its mental health and learning disability services.
The Mazars report also identified that the Trust had failed to consistently and properly engage families in its investigations into the deaths of their relatives.
The CQC inspection happened over four days in January 2016. Officers also checked whether the Trust had made improvements called for following a previous full inspection back in October 2014.
Southern Health offers services and support for people in Berkshire, Oxfordshire, Hampshire, Buckinghamshire, Wiltshire and Dorset. The CQC inspection team spoke to patients, carers, staff, the Trust Board and whistle blowers; as well as reviewing patient records, serious incident reports, medication charts and policy and procedures - including those relating to complaints and governance.
Today's CQC report found that:
- The Trust had not put in place robust governance arrangements to investigate incidents, including deaths. Thereby losing opportunities to reduce the likelihood of similar events happening again.
- Effective arrangements had not been put in place to identify, record or respond to concerns about patient safety raised by patients, their carers, staff or by the CQC. The Trust had also failed to identify, record or respond effectively to staff who expressed concerns about their competence to carry out their roles.
- Inspectors had serious concerns about the safety of patients with mental health problems and learning disabilities in some of the locations inspected. Action had not been taken to address known risks from the physical environment. For example, CQC had identified concerns relating to ligature risks in acute inpatient mental health and learning disabilities services in January 2014, October 2014 and August 2015. During the January 2016 CQC found that the Trust had still failed to make sufficient changes to address these risks with many potential ligature anchor points identified at one location. Immediately following the inspection, CQC issued a warning notice requiring Trust to take immediate action to ensure the safety of patients at Evenlode, Oxfordshire and Kingsley ward at Melbury Lodge.
- Overall, the Trust’s governance arrangements did not facilitate effective, proactive, timely management of risk. Where action was taken by the Trust to mitigate risk, this was delayed and mainly done in response to concerns raised by the CQC.
Concerns were first raised about the Trust after the death of 18-year-old Connor Sparrowhawk, who drowned in a bath at a care home in Oxford in 2013. In October, a jury inquest ruled that neglect contributed to the death of Connor.
It's previously been revealed that the Trust knew there were concerns from staff about conditions at the home, ten months before his death, but bosses failed to take effective action.
The CQC inspectors found that some improvements had been made to the environment in the child and adolescent mental health inpatient and forensic services. Also, that the Trust had improved the extent to which children and young people were involved in developing their plans of care.
Improvements had been made to support patients better who were acutely unwell in community services in Southampton, and to ensuring that patients did not experience multiple transfers between teams when they needed to be admitted or discharged from hospital.
The CQC said it was too early to tell the effectiveness - at the time of the inspection - of new procedures being introduced at the trust to provide more robust oversight and assurance of its services.
Former Liberal Democrat Health Minister Norman Lamb has called on the board and Chief Executive of Southern Health to step down in light of the report.