Updated: NHS Improvement threatens 'management changes' at Southern Health

The Care Quality Commission has today issued a warning notice to Southern Health, requiring the troubled organisation to take urgent action to improve its arrangements for ensuring patient safety.

NHS Improvement said it intends to put a new condition on the trust’s licence which will allow it to make “management changes” if progress is not made on fixing the concerns.

In a statement on Wednesday afternoon, the CQC said the trust had failed to address “significant risks” posed by the physical environment and its arrangements to ensure proper investigations of incidents, including deaths, were inadequate.

The regulator visited the trust in January as part of a focused inspection after the publication of a report by the audit firm Mazars, which highlighted failures at Southern Health to investigate and learn from patient deaths.

The inspection report is not expected to be published until the end of the month, so the CQC is restricted in what detail it can currently share on its findings.

However, the CQC issues warning notices where it is concerned that a provider must make urgent changes after an inspection which cannot wait for the publication.

In its statement the CQC said it had issued Southern Health with a warning notice “requiring the trust to improve its governance arrangements to ensure robust investigation and learning from incidents and deaths, to reduce future risks to patients”.

Inspectors found the trust had “failed to mitigate significant risks posed by some of the physical environments”.

The trust “did not operate effective governance arrangements to ensure robust investigation of incidents, including deaths” and did not ensure it “learned from incidents to reduce future risks to patients”.

Paul Lelliott, CQC’s deputy chief inspector of hospitals, said the regulator had found “longstanding risks to patients, arising from the physical environment, that had not been dealt with effectively”.

He added: “It is only now, following our latest inspection, and in response to the warning notice, that the trust has taken action and has identified further action that it will take to improve safety at Kingsley ward, Melbury Lodge and Evenlode in Buckinghamshire.”

NHS Improvement said it had informed Southern Health of its intention to take further regulatory action, but the trust had the opportunity to comment on its proposals before a final decision is made on whether to put the additional condition on its licence.

Kathy Mclean, NHS Improvement’s medical director, said it was “worrying” the CQC has identified “patient safety concerns which have still gone unaddressed at the trust”.

She added: “The trust needs to ensure that it fixes these issues quickly and that it can spot and quickly mitigate any future risks to patients and service users.

“If we don’t see enough progress on this we will consider taking action on behalf of patients.”

Katrina Percy, Southern Health’s chief executive, said: “I have been very clear and open that we have a lot of work to do to fully address recent concerns raised about the trust.”

She said “good progress” had been made but accepted the ”CQC feels that in some areas we have not acted swiftly enough”.

“My main priority is, and always has been, the safety of our patients. We take the CQC’s concerns extremely seriously and have taken a number of further actions.”

She added: ”I want to reassure our patients and their families that I, and the board, remain completely focused on tackling these concerns as quickly as possible.”

The Mazars report was commissioned by NHS England following the death of 18 year Connor Sparrowhawk, who drowned in a bath at Southern’s short term assessment and treatment unit in Oxfordshire in July 2013.

A jury inquest found that Mr Sparrowhawk, who had autism and epilepsy, died as a result of drowning following a seizure, and that his death was contributed to by neglect.