Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to adults — HSSIB

The Shelford Group welcome the findings of the recent investigations and subsequent report into mental health inpatient settings by the Health Services Safety Investigation Body. The Mental Health Optimal Staffing Tool (MHOST) was developed by the Shelford Group in partnership with NHS England and launched in 2019. It is widely used in the NHS in England via a licence provided at no cost by Imperial College Innovations. It is also available for a fee to NHS and non-NHS organisations outside of England as well as private healthcare providers. The Shelford Group is committed to the ongoing sustainability and development of the suite of Safer Nursing Care Tools (SNCT), including the MHOST. We recognise the impact that new healthcare policies as well as changes to the way care is delivered and the introduction of new roles can have on safer staffing requirements. The SNCT and the MHOST calculate clinical staffing requirements based on patients’ needs (acuity and dependency) which, together with professional judgement, guides chief nurses in their safe staffing decisions. This professional judgement is paramount in ensuring that the tool is applied appropriately. Plans are in place to review and refresh the MHOST, with the inaugural meeting of an expert project review group in October 2024. The review process is expected to take 18-24 months with an intended launch in late 2026. Details of the scope of the review are included in the below action plan. Actions planned to deliver safety recommendation: Phase 1. Agree scope and research approaches. The inaugural meeting of an expert project review group took place in October 2024. Organisational lead: Shelford Group, Subject matter expert and NHS England. Resources in place to deliver actions: Project lead Safer Staffing Faculty, NHS England Shelford Group SNCT committee (oversight) Shelford Group Secretariat (admin, project management and comms) Expert project review group Safer Staffing Faculty Fellow. Additional comments: The scope of the review has been agreed as follows: Reviewing the skills in ward teams, such as nursing associates and allied health practitioners, to develop a multidisciplinary toolkit if appropriate. Reviewing the classification and recording for 1:1, 2:1 and 3:1 enhanced care with associated multipliers (staffing resource) Generating Care Hours per Patient Day (CHpPD) metrics based on acuity and dependency to support interpretation of the Carter CHPPD. Reviewing the current speciality specific decision matrix for the following settings: 1) adult in-patients 2) Older adults 3) Psychiatric Intensive care, 4) Child and Adolescent Mental Health 5) Eating Disorders 6) Forensic Medium/ High Secure patients 6) Perinatal (Mother and Baby) and 7) Forensic Low Secure/ Rehabilitation Wards, to agree if all these specialties are relevant and required in 2024 mental health care service provision Reviewing all the above settings to provide a speciality specific decision matrix and multipliers in the agreed specialties in number. Phase 2. Infrastructure development. Education & data collection. Data analysis, building new multipliers for each specialty & initial testing, by 2025. Phase 3. Approval to move to Beta testing (SNCT steering committee) Beta test and User Acceptance: Testing (UAT) & incorporation of feedback from alpha pilot Public launch of the refreshed version of the MHOST, by 2026. Response received on 27 December 2024.

We welcome the opportunity to formally respond to safety recommendation R/2024/038 and are already delivering a number of education and training opportunities aimed at supporting the optimisation of the delivery of mental health inpatient safe and therapeutic care, including for people living with a learning disability and/or autism who are in receipt of such care and for all adult inpatients who are detained under the Mental Health Act. We remain committed to support the development and transformation of the mental health inpatient multidisciplinary team, including the medical workforce and the aspired models of care within the current Long Term Workforce Plan and further current/emerging policy. The goals of acute mental health care are outlined within NHS England MHLDA guidance: NHS England » Acute inpatient mental health care for adults and older adults which was published in July 2023. This includes appendix 5 of the guidance which focuses on the skills and competencies for the inpatient workforce. NHS England have commenced further work to scope principles to support organisations to provide a workforce with the values, experience and skill mix needed to support and prioritise therapeutic care and relationships. At the time of responding to this recommendation, resource constraints mean that this work is currently unable to progress. The NHS England MHLDA Quality Transformation Team have also developed a set of principles for the use of digital health technologies within mental health inpatient services . These have been co-produced with people with lived experience and frontline clinicians, are based on human rights principles and align to the Culture of Care Standards for mental health inpatient services . Actions planned to deliver safety recommendation: Publication of principles for using digital technologies in mental health inpatient treatment and care. NHS England » Principles for using digital technologies in mental health inpatient treatment and care , by February 2025. Organisational lead: NHSE MHLDA Quality Transformation Team. This action is completed. Following publication of ‘Acute inpatient mental health care for adults and older adults’ in July 2023, launch of further work to scope principles to for organisations to provide a workforce with the values, experience and skill mix needed to support and prioritise therapeutic care and relationships, by March 2026. Organisational lead: NHSE MHLDA Quality Transformation Team. Additional comments: At the time of responding to this recommendation, resource constraints mean that this work is currently unable to progress. We will work with Integrated Care Boards/systems via our regions to support a multidisciplinary approach to the delivery of safe and therapeutic care, including the transition of young adults (18-25yrs) to adult services, by continuing to provide whole team learning opportunities to meet their Continuing Professional Development needs via a variety of learning opportunities ranging from short online modular courses to doctorate level in response to ICB/system Integrated Workforce Plans. By when: on-going. Organisational lead: NHSE WTE E&T MHLDA portfolio. Additional comments: Funded & commissioned activity in place for 24/25 25/26 - to be confirmed. All mental health care providers, including CYP residential and youth justice settings will have access to NHS England autism training via the national autism trainers programme and Oliver McGowan Mandatory Training (learning disability & autism focused). Organisational lead: NHSE WTE E&T MHLDA portfolio. Additional comments: Funded & commissioned activity in place for 24/25 25/26 - to be confirmed. Psychiatrists will undertake training leading to an Autism Credential aimed at improving care and treatment management in mental health care settings. Further expand the Approved Clinician to support the enactment of the current MH Act and the MH Bill currently being read in both Houses, which is expected to shortly attain Royal Assent. To support increased and improved clinical leadership, reductions in patient placement breakdown, inappropriate admissions, reduce length of stay, solitary confinement and improvements in early discharge and health inequality, mortality and morbidity rates, we will continue to offer 3yr Level 7 multidisciplinary Advanced Practice Learning Disability and Autism Practitioner upskilling. By when: on-going. Response received on 22 January 2025 and updated on 3 June 2025.

The Department accepts this recommendation. NHS Trusts conduct an annual survey of NHS estates, known as the Estates Return Information Collection, that is reported to NHS England. The data collection includes an assessment of the level of backlog maintenance (including critical infrastructure risks) and maintenance costs, which is used to inform fiscal events, understand the needs of local estates and has at points informed the allocation of capital. In March 2024, NHS England asked every Integrated Care System (ICS) to develop a 10-year system-wide infrastructure strategy that aligns to its clinical vision, delivers the NHS Long Term Plan and sets out how the local estate will be used. Through the ICS Estate Strategy programme, NHS England has asked systems to identify capital needs across all estates, including mental health services (excluding high secure hospital estates which are retained by NHS England commissioning). These returns will be reviewed and refreshed on a periodic basis. NHS England, working together with DHSC, will build on this work to explore how the returns from the ICS Estates Strategy Programme could be used to inform the long-term strategic approach at a national level to capital investment in the mental health estate. This will include a gap analysis of the ICS Strategies against national priorities and clinical strategy, so we have sufficient detail and consistency on capital demand information to inform future Spending Reviews and ensure that investment is directed towards long-term clinical priorities. As announced by the Government in the autumn budget, we are also investing £26m to open new mental health crisis centres to reduce the pressure on A&E services and offer support to people in mental health crisis. Funding for investment in the MH estate is dependent on future funding settlements. Actions planned to deliver safety recommendation: Estates Return Information Collection. By when: ongoing. Organisational lead: NHS England. ICS Estates Strategy Programme. By when: ongoing. Organisational lead: NHS England. Building on ICS Estates Strategy Programme to inform long-term approach to capital investment. By when: Q2 2025. Organisational lead: DHSC and NHS England. Response received on 3 February 2025.

The Department accepts this recommendation. High secure hospitals play an important role within the wider mental health system and it is important that the needs of the high secure estate are understood. As part of the Department’s oversight and NHS England’s commissioning role for high secure hospitals, we continue to keep the physical environment under review. We commit to continue engaging with high secure hospital stakeholders across government and locally to establish the current physical condition and requirements of each hospital estate and the impact on staff, patients and public protection. This engagement will continue via official governance and at a working level. The assessment of high secure estate needs will be informed by the Estates Return Information Collection, an annual survey of NHS estates conducted by NHS Trusts which is reported to NHS England. This includes an assessment of the level of backlog maintenance, including critical infrastructure risks, and maintenance costs. We will work with high secure hospital commissioners (who will work with providers) to collaboratively develop a range of options for the high secure built environment, which ensure the safety of staff, patients and the public. We will work with criminal justice partners to ensure these options meet the needs of high secure hospital patients and align with prison estate security. The options will be used to inform future fiscal events and outcomes will be dependent on future funding settlements. Actions planned to deliver safety recommendation: Work with NHS England, who will engage hospital commissioners and providers to establish the work each high secure hospital built environment would benefit from. This will be informed by data on the high secure estate from the annual Estates Return Information Collection submitted to NHS England by NHS trusts. The data collection includes an assessment of the level of backlog maintenance (including critical infrastructure risks) and maintenance costs. By when: Spring 2025. Organisational lead: DHSC. Resources in place to deliver actions: DHSC and NHS England staff, Broadmoor, Ashworth and Rampton commissioners and providers, Safety and Security Directions, High Secure Service Specification. Work with cross government criminal justice partners to understand current security arrangements and future security planning for the Category A and B prison estate. By when: Autumn 2025. Organisational lead: NHS England. Resources in place to deliver actions: DHSC and NHSE teams, Prison Building Standards. Other dependencies identified: Cross government criminal justice partners. Additional comments: High Secure Hospitals are the same level of security as Category B prisons, but have to be equipped for patients from Category A prisons. Work with commissioners for the high secure hospitals to understand the numbers of and needs of the high secure patient group. This information will be used as part of NHSE five year capacity planning undertaken in collaboration with commissioners and providers, with the next update due to begin in 2026. By when: Autumn 2025. Organisational lead: NHS England. Resources in place to deliver actions: NHSE, DHSC and cross government criminal justice teams and Hospital staff and commissioner capacity. Other dependencies identified: Available data, Prison capacity data, Impact of reforms. Work with NHS England and each hospital commissioner to establish a set of options for addressing needs of the high secure estate, with patient, staff and public safety as the priority. Use information gathered from actions 1-3. The options will be used to inform future fiscal events and outcomes will be dependent on future funding settlements. By when: Winter 2025. Organisational lead: DHSC and NHSE. Resources in place to deliver actions: DHSC and NHSE staff (policy, analysis and finance teams), Broadmoor, Rampton and Ashworth hospital commissioners, Architectural planning. Other dependencies identified: Approach to future capital funding bids within DHSC and NHSE, Broadmoor rebuild lessons learnt report will inform options development, Architectural input and funding. Additional comments: Will also require engagement with criminal justice partners. Response received on 3 February 2025.

NHS England will revise and update guidance pertaining to ‘delivering same-sex accommodation’. This guidance prioritises the privacy, dignity and safety of all patients, including those in mental health settings. It is believed that this will meet the expectations of HSSIB’s safety recommendation and will be published shortly. Action planned to deliver safety recommendation: Revise and update guidance pertaining to ‘delivering same-sex accommodation’. By when: awaiting EHRC publication first. Organisational lead: Nursing Directorate. Additional comments: Final stages of NHSE sign off process and pending DHSC sign off. Response received on 30 May 2025.