Safety watchdog reviews mental health inpatient settings

A new report from the Health Services Safety Investigations Body examines patient safety in mental health inpatient settings. It arrives at a time when the Government is addressing Lord Darzi’s independent investigation of the NHS in England.

The report highlights challenges around workforce, the built environment and social and organisational factors impacting inpatient care.

Overview

Over the course of a year, the Health Services Safety Investigations Body (HSSIB) reported having visited at least 40 care areas across 30 mental health care providers.

HSSIB’s report follows the Secretary of State for Health and Social Care’s announcement in June 2023 that they would undertake a series of investigations focussed on mental health inpatient settings. This report describes the findings of the first of those investigations. It is focused specifically on conditions that contribute to the delivery of safe and therapeutic care to adults who are staying in mental health wards or units.

It was preceded by an interim report, Learning from inpatient mental health deaths and near misses: assessment of suicide risk and safety planning. 

HSSIB state that the intention of the report is to support improvements in safety and to realise a culture of care within inpatient settings that everyone wants to experience.

It examines workforce challenges, wider workplace conditions and the organisation of care.

The findings are intended:

• For the Secretary of State, healthcare policy makers and organisational leaders to help influence improvements in the delivery of therapeutic care that delivers patient safety.
• To contribute to the Government’s long-term plans in relation to mental health settings.
• For those who work in and engage with mental health in patient settings, such as Integrated Care Boards.

Findings

Mental health inpatient workforce

These are set out in the executive summary:

• Best practice standards for care were not embedded across inpatient settings.
• Some inpatient models of safety continued to focus on restrictive approaches, rather than relational approaches.
• Workforce challenges negatively influenced the ability of staff to develop therapeutic relationships with patients and therefore patient safety has been affected.
• Staff were not always equipped with the required knowledge and skills to understand and meet the mental and physical needs of patients.
• Wards were not always staffed to ensure patients could access the knowledge and skills of a multidisciplinary team (MDT).
• There were conflicting views about how best to educate pre-registration nursing students and where responsibility should lie to support their development.
• Registered nurses may be being promoted to supervisory roles with limited experience.

These other points of interest are within section 2 of the report:

• The Royal College of Psychiatrists highlight a true vacancy rate of 28.6%.
• Some sexual safety risks had been normalised with variation in the work undertaken by providers to achieve the National Sexual Safety Collaborative standards noted.
• Stakeholders questioned whether the NHS’s workforce model is flawed and whether it is able to create a workforce that can provide safe and effective care.
• The healthcare workforce model is different to models used in other safety critical industries – reference to the “Christmas tree” model of skill mixes in healthcare.
• Differing views among stakeholders as to whether the acuity of patients in inpatient settings was increasing, or whether this was a staff perception. The investigation was unable to draw a clear conclusion that acuity had increased.
• HSSIB heard from several providers that they aimed to staff wards for safety, but could not always staff for therapy.
• They heard that “other” professionals were “nice to have” but nursing staff kept patients “safe”. Stakeholders challenged this as to whether a ward could be considered safe without input from an MDT and felt it did not align with efforts to be least restrictive.
• Several stakeholders opposed the Nursing Midwifery Council’s “generic” approach to nursing education.
• The Long-Term Workforce Plan was felt by stakeholders to set expectations that were potentially unachievable and falling short of what will be required in the future.
• The workforce challenge is a complex “sociotechnical problem”.

Built mental health inpatient environments

These are set out in the executive summary:

• Some environments were not therapeutic and created situations where patients and staff could and had been harmed.
• Short, medium and long-term investment requirements for safe and therapeutic built environments were not always known at regional and national levels.
• Hazards could not always be removed or mitigated, and environments could not be improved.
• Concerns about the long-term ability of some high secure built environments to maintain patient, staff and public safety.
• Limited evidence about how to best design therapeutic built environments.

These other points of interest are within section 3:

• Mental health providers described writing multiple business cases for capital funds that were not successful. This was resource intensive, and they felt they could not compete against bids from the physical/acute sector.
• Challenge heard from Integrated Care Boards that NHS England’s joint capital resource plans felt bureaucratic when there were limited capital funds available.
• Department of Health and Social Care told HSSIB that the health service had been “undercapitalised”.
• There was limited awareness at national level of the highest risk areas and therefore overall capital needs.
• Specific challenges faced by secure settings. Provider collaboratives for medium/low secure services were not part of capital funding pathways via Integrated Care Boards. 

Social and organisational factors influencing mental health inpatient care 

These are set out in the executive summary:

• Providers were not always able to accommodate patients in single sex spaces.
• Approaches to accommodating patients who were transgender and non-binary varied.
• Digital systems contributed to incidents where patients had been harmed.
• Availability and access to physical healthcare varied.
• Care pathways between different care providers were limited.

These other points of interest are within section 4:

• Further examples of a therapeutic social environment will be described in HSSIB’s future “learning from deaths” investigation.
• Technology (or lack of it) had contributed to patient harm where it created barriers to accessing patient information.
• Out of area placements will be considered in a future HSSIB investigation.
• Poor usability of EPRs had not supported decision making.
• Lack of interoperability between different digital systems meant staff did not have access to information held in other EPRs.
• EPRs were rarely used for handover of patient information between staff at change of shift.
• There are plans to launch a programme to improve the quality of EPRs in mental health settings.
• HSSIB identified patient safety incidents where limited integration of care across providers had been a contributing factor, eg delays in referring or transferring.
• There may be opportunities to bring some services to patients in mental health in patient settings to reduce the need for transfers. Integrated Care Boards are in a position to support the formation of cross provider pathways.
• CQC’s special review into Nottingham highlighted concerns that aligned with what the investigation heard.
• Delivery of mental health inpatient care needs to be considered with an acknowledgement of its position within the wider health and care system and of the influence of cultures on the quality of care.
• Stakeholders expressed concern that limited longer term investment had led to normalisation of lower quality care in some providers. This coupled with workforce challenges had the potential to create conditions for the workforce to use more restrictive practices.
• The Equality and Human Rights Commission told HSSIB about the influence of closed cultures on blanket restrictions.

Recommendations

So, there is a lot to unpack here and more to come from HSSIB. 

We work with both mental health providers and Integrated Care Boards daily and recognise many of the challenges highlighted here.

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