Southern Health NHS Foundation Trust

We found that the trust had not put in place robust governance arrangements to investigate incidents. As a result, the trust had missed opportunities to learn from these incidents and to take action to reduce the likelihood of similar events happening in the future.

The trust had not put in place effective arrangements to identify, record or respond to concerns about patient safety raised by patients, their carers, staff or by the CQC. We found examples of this in a number of the trust’s mental health and learning disability services. Where the trust and others, including CQC had identified risks to the delivery of safe care arising from the physical environment, the trust had not ensured that these risks were mitigated in a timely and effective way. The trust had also failed to identify, record or respond effectively to staff who expressed concerns about their competence to carry out their roles.