Our report provides evidence that the safety of care varies widely across England. This variation can have an impact on how well a patient is supported in their recovery and, as shown in several examples in the report, can mean patients are placed in situations that could lead to mental, physical or sexual harm.
Over a period of almost a year we visited at least 40 care areas across 30 mental health care providers, speaking with multiple patients, families and staff working in those settings. The report emphasises the increasing demand and pressure on mental health services, and that the systems in place do not always support staff to deliver the therapeutic care that is needed to keep patients safe.
The investigation also found that risks relating to delivering safe and therapeutic care are not always fully understood or managed effectively. A key priority for us is to support organisations in taking a more proactive approach to managing safety in all areas of care, including mental health, through the implementation of safety management systems.
Mental health inpatient workforce
Our investigation found that workforce challenges across the multidisciplinary workforce had negatively influenced the ability of staff to develop therapeutic relationships with patients and therefore patient safety had been affected. Challenges included workforce shortages, limited experienced supervision, and the training and support provided to staff.
Built mental health inpatient environments
The investigation identified that the built environments (buildings and the physical ward environments) of inpatient settings varied. Some environments were not therapeutic, did not contribute to the formation of therapeutic relationships between patients and staff, and had created situations where patients and staff could and had been harmed.
Social environments and organisational factors
The investigation looked at how the social environment influenced therapeutic care and engagement. Staff described how a therapeutic “social” environment was fundamental when seeking to support patient and staff interactions. HSSIB concluded that the development of psychologically safe and therapeutic social environments was not always possible because of demands on services, workforce constraints, workforce knowledge and skill development, and cultural influences.
Safety recommendations
The report sets out five safety recommendations to national bodies aimed at addressing the issues identified in each of the focus areas in support of the delivery of safe and therapeutic care. We have also set out work that ICB’s could do to improve outcomes for patients in their regions.
Nick Woodier, Senior Safety Investigator, says: “ Our investigation highlighted that therapeutic care is absolutely crucial to ensure patients feel safe and are safe during their time in mental health units or wards. We describe cases in our reports where patients had come to harm or feared for their safety, and this is distressing for them and their families.
“The staff we spoke to at units across England endeavour to spend time with patients and to support them through the developing of therapeutic relationships. However, many felt that the challenges they faced on a daily basis meant there was not always the opportunity to take the time needed, and that patient safety and their recovery was affected as a result.
“Mental health providers do recognise the risks to patient safety, but told us that addressing them is sometimes beyond their control, for example due to the lack of an available workforce or limited funds to make environments safer. Our findings and safety recommendations show what needs to be prioritised at a national level to reduce the likelihood of harm to patients and support the future delivery of safe and therapeutic care.”
