HSSIB investigation report - Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024)

Summary

This investigation by the Healthcare Service Safety Investigation Body (HSSIB) is one of a series on the theme of patient safety in mental health inpatient settings. This investigation focused specifically on the conditions that contribute to safe and therapeutic care for adults who are staying in mental health wards or units.

The demand on mental health inpatient services in England is high and has been increasing. It is reported that the quality of care received by patients admitted to these services varies, meaning patients may not receive the therapeutic care they need. Issues include limited shared decision making and a lack of consideration of recovery-focused goals. Patients may also be placed in situations that create safety risks associated with mental, physical or sexual harm.

This investigation examines the impact of workforce challenges on the delivery of safe and therapeutic care to adult patients in acute mental health inpatient settings (settings for people who need urgent care and are experiencing a severe mental health problem). It also looks at the wider workplace conditions and the organisation of care to see how these factors affect care. The investigation’s scope included adults, older-adults and secure (adults who pose a risk to the public) inpatient settings.

The investigation's findings and recommendations offer opportunities to make improvements to systems, practices and future plans to support the delivery of therapeutic care, and therefore safety, in mental health inpatient settings.

Content

Findings

Mental health inpatient workforce

• Patients in mental health inpatient settings did not always feel safe and staff were not always able to develop therapeutic relationships with patients in support of their care and safety. 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. Approaches were influenced by the ability of the workforce to form therapeutic relationships with patients.
• 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.
• Workforce challenges included difficulties recruiting staff and retaining experienced staff, and concerns around the knowledge and skills available to support therapeutic relationship formation and trauma-informed care.
• The mental and physical health care needs of patients cared for in acute inpatient settings may have changed and acuity may now be greater than in the past. 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. Some patients had no or limited access to professionals such as dietitians or speech and language therapists.
• Workforce challenges varied across regions. Barriers to region-wide coordinated workforce planning included unclear national expectations, difficulties predicting workforce needs, limited provider engagement, and a lack of available staff.
• The goals of the NHS Long Term Workforce Plan may be unattainable if barriers to implementation are not recognised and addressed. Barriers found included education capacity to build the workforce and poor working conditions affecting retention.
• There were conflicting views about how best to educate pre-registration nursing (mental health) students and where responsibility should lie to support their development of mental and physical health care skills.
• Registered nurses (mental health) may be being promoted to supervisory roles with limited experience. Inexperience influenced the supervision and development of new staff, and leaders may be reluctant to challenge attitudes that undermine the quality of care.

Built mental health inpatient environments

• The built environments (estates and physical environments) of inpatient settings varied. Some environments were not therapeutic, did not contribute to formation of therapeutic relationships, and had created situations where patients and staff could and had been harmed.
• The short-, medium- and long-term investment requirements for safe and therapeutic built environments across mental health inpatient settings were not always known at regional and national levels.
• Capital funding for the NHS to maintain, improve and create new built environments was finite and unable to meet the needs of mental health inpatient settings. Hazards in built environments could not always be removed or mitigated, and environments could not be improved to be therapeutic.
• There were concerns about the long-term ability of some high-secure built environments to maintain patient, staff and public safety. There was no specific process for high-secure services to access the capital funds they required for long-term estate planning.
• There was limited evidence around how best to design therapeutic built environments to meet potential changes in patients’ needs and acuity. Providers wanted clarity on design standards and on the role of technology to support the safety of patients experiencing mental health problems.

Social and organisational factors influencing mental health inpatient care

• 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.
• Providers of mental health inpatient care were not always able to accommodate patients in single-sex spaces. Best practice standards in relation to ensuring sexual safety were not always embedded.
• Approaches to accommodating patients who were transgender and non-binary varied in mental health inpatient settings. Staff wanted to meet the needs and preferences of all patients but this was not always possible.
• Digital systems had contributed to incidents where patients had been harmed. Clinical information was not always easily accessible in electronic patient records or had not been shared across different care providers’ systems.
• Availability and access to physical healthcare services for mental health inpatients varied. Access was influenced by how providers designed and set up their services, the knowledge and skills of staff, and collaboration between acute and mental health care providers.
• In some locations, care pathways between different care providers were limited. This reduced continuity of care and made it more difficult to access physical health services, which increased the need for patients to be transferred to acute physical health hospitals.
• Inequalities continued to exist in the care of patients experiencing mental health problems. Availability and access to services for different patient groups further influenced the ability of inpatient providers to deliver safe and therapeutic care.
• Some organisational cultures and individual beliefs surrounding people experiencing mental health problems continued to negatively influence attitudes towards their care, including access to physical healthcare.

Safety recommendations

HSSIB makes the following safety recommendations

Mental health inpatient workforce

• HSSIB recommends that The Shelford Group reviews and updates the Mental Health Optimal Staffing Tool on a regular basis following collection of recent data from mental health inpatient settings. This is to ensure the tool remains valid for potential changes in patients’ needs and the level of care they require, and to support providers to make decisions about workforce requirements that support therapeutic and therefore safe care.
• HSSIB recommends that NHS England works collaboratively with relevant national bodies and stakeholders including professional regulators, the Department of Health and Social Care, and relevant royal colleges to:

1. Identify and clarify the goals of acute mental health inpatient care and the roles, required skills and ongoing professional development needs of the multidisciplinary workforce team.
2. Review and update the NHS Long Term Workforce Plan with consideration of the concerns around changes in patients’ needs and the need for a multidisciplinary approach to ensure therapeutic care is provided.
3. Develop a strategic implementation plan to address workforce issues in mental health inpatient settings that identifies the social and technical barriers to implementation and sets out actions to address them.
   
   This is to develop, enable, support and retain a future multidisciplinary mental health inpatient workforce that is able to deliver therapeutic and safe care to patients.

Built mental health inpatient environments

• HSSIB recommends that the Department of Health and Social Care, with input from stakeholders including NHS England, identifies the short-, medium- and long-term requirements of NHS mental health built environments to ensure they enable delivery of safe and therapeutic care to patients, and create a supportive working environment for staff. This is to support the development of a strategic and long-term approach to capital investment and prioritisation for NHS built environments.
• HSSIB recommends that the Department of Health and Social Care undertakes assessment of the capital requirements of the built environments across high-secure services in England and develops plans to ensure the long-term safety of patients, staff and the public.

Social and organisational factors influencing mental health inpatient care

• HSSIB recommends that NHS England, working with relevant stakeholders, develops guiding principles for providers of mental health inpatient care to support local decision making when accommodating patients, including patients who are transgender and non-binary. This is to ensure a provider’s equality and human rights obligations are considered, and all patients are cared for in environments where they feel safe and that are therapeutic.

Safety observations

HSSIB makes the following safety observations

• Providers of mental health inpatient care can improve patient safety by ensuring that where professional judgement is used to help make workforce decisions, this accounts for ward physical environments, changes in patient acuity, and the individual mental and physical health care needs of patients that require support from a multidisciplinary workforce.
• Those involved in the provision of undergraduate and pre-registration education (educational institutions and placement providers) and preceptorship/induction programmes can improve patient safety by collaboratively ensuring that staff entering mental health related professions are developing the required knowledge and skills, including in trauma-informed care, to care for patients with mental and physical health care needs.
• Those involved in healthcare research can improve patient safety by seeking to understand the design principles for mental health inpatient settings that underpin safe and therapeutic care. Research should include consideration of sensory environments, the role of technology, and the changing needs of patients.
• Those involved in the design of new and upgraded built environments for mental health inpatient settings can improve patient safety and the delivery of therapeutic care by involving relevant stakeholders in design processes. Stakeholders include people with lived experience (patients and staff) and experts in human factors and ergonomics. Any design should also consider the changing needs of patients.
• Providers of mental health inpatient care can support patient safety by evaluating and addressing local barriers to the effective use of technology to support patient care, including through gaining insights from people with lived experience (patients and staff) and ensuring the digital infrastructure is available, usable and reliable.

Safety responses

HSSIB proposes the following safety responses for integrated care boards

• HSSIB suggests that integrated care boards work collaboratively with the NHS and independent sector to review their system-level workforce plans to ensure they recognise and mitigate the safety challenges in mental health inpatient settings and agree how variation across a geographical area can be mitigated.
• HSSIB suggests that integrated care boards: 1) ensure system-level infrastructure strategies clearly reflect the risks across their mental health inpatient built environments, and 2) ensure prioritisation of capital funding is equitable across different healthcare settings in a geographical area.
• HSSIB suggests that integrated care boards: 1) work with mental health inpatient providers to identify patient needs that require input from other providers and agencies, and 2) facilitate cross-provider working arrangements between mental health, acute and primary care providers to minimise the need for transfers of care unless clinically necessary.