Mental health inpatient settings

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.

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 is working with all NHS and major Independent Providers to deliver the Mental Health, Learning Disability and Autism Inpatient Culture of Care Improvement Programme. This includes support in removing away from risk stratification towards personalised safety planning alongside the role of information sharing and involvement of families, carers and relevant agencies in safety planning. Separately, NHS England has been working to draft - Staying Safe from Suicide: Best Practice Guidance for Safety Assessment, Formulation and Management. This guidance augments NICE Guidance NG225 which recommends a move away from risk prediction and stratification to a psychosocial assessment and formulation-based approach, and will be published shortly. Safeguarding is already part of the NHS commissioning guidance, the standard NHS contract and expectations are set out in the NHS England Safeguarding Accountability and Assurance Framework (SAAF). The requirement that each person requires a unique safeguarding approach is already contained in the SAAF. The contract and SAAF are reviewed annually to reflect any evolving statute and will support the review and update of service specifications and commissioning guidance. There is a National NHS England Clinical Lead for Safeguarding Adults and Transition. Regarding training to support any needs-based rather than age-based transition, the intercollegiate documents for Safeguarding Adults, ‘Adult Safeguarding: Roles and Competencies for Health Care Staff’ (2024), supports the delivery of safeguarding education and training across child and adult safeguarding but does not include any specific guidance for safeguarding young adults in a child focused setting. The current intercollegiate document for safeguarding children includes the needs for all professionals to understand the needs and legal position of young people, particularly 16-18 year olds, and the transition between children’s and adult legal frameworks and service provision. The guidance is currently being revised by the Royal College of Paediatrics and Child Health. NHS Safeguarding will update the NHS Safeguarding Accountability and Assurance Framework (SAAF) to include the need to consider best practice in safeguarding across the transition between young people and young adult services, and that where services are provided across the young people and young adult age ranges, that both child and adult safeguarding competencies are achieved and maintained. This will be approved and assured via National Safeguarding Steering Group (NSSG). NHS Safeguarding will ask the Royal College of Paediatrics and Child Health to consider the findings of this document in their review of the intercollegiate document (‘Safeguarding children and young people and looked after children and young people: Competencies for Healthcare Staff’ - RCN, 2019). Actions planned to deliver safety recommendation: Deliver the culture of care improvement programme, with a specific focus on personalised safety planning as an alternative to risk stratification, by end 2025/26. Organisational lead: NHS England. Resources in place to deliver actions: Funding secured. Update the NHS Safeguarding Accountability and Assurance Framework (SAAF), by end 2025/26. Organisational lead: NHS England. Resources in place to deliver actions: Nil. Response received on 7 March 2025. ------------------------------------------ May 2026: HSSIB has been notified by the NHS England that all actions have been completed.

We recognise that, across health services and system partners, we do not have one clear and coherent picture of mortality data which is required to improve system-wide visibility, co-ordination and collaboration. However, we know that lots of data is collected by providers and commissioners of mental health services, and so we think the best first step towards developing a unified dataset is to consider how we can make the most of the data we already collect. To most effectively work towards addressing this recommendation, it is important that DHSC brings together the appropriate range of expertise to understand how data is used operationally by various partners to support effective decision-making. Any solutions proposed to develop a comprehensive and unified data set need to account for the needs of all system partners to ensure these solutions are effective and do not encounter unexpected barriers on implementation. As a first step to meet this recommendation, DHSC convened a meeting in May 2025 with stakeholders including NHS England, CQC, HSSIB, the Independent Advisory Panel on Deaths in Custody, and other system partners to discuss how the health system collectively can best deliver improvements in the recording and reporting deaths in mental health services. As a result of this meeting, we recognised that, while a uniform dataset is a desirable end-goal, there are challenges which will require long-term actions to address. Many of these challenges were identified in HSSIB's report, including inconsistent definitions, challenges with the timeliness of the data and classification of deaths. However, in the meeting, system partners also recognised that there is more we can do in the short term with the data we do already have available to improve system-wide visibility, co-ordination and collaboration to improve learning from deaths. It was agreed that health system partners should focus in the immediate term on triangulating the key data sources that are currently available to develop a comprehensive picture of mortality data in mental health services. This includes identifying what different definitions are currently used in the reporting and recording of mortality data and mapping the flow of existing data between systems. DHSC will convene a workshop in the autumn to bring colleagues together from across the health system to develop this comprehensive picture. We will use the outcomes from this workshop to identify how to more efficiently use the data we have available. Actions planned to deliver safety recommendation: Creation of a unified data set with agreed definitions for recording and reporting deaths in mental health services to be discussed at a stakeholder meeting convened by DHSC, by May 2025. Additional comments: This meeting has taken place, and it has been agreed that DHSC will convene a further workshop in the autumn to map existing data flows. DHSC, CQC, and NHSE to liaise separately to discuss next steps from Mortality Data Working Group and potential timelines, by June 2025. Additional comments: Agreed that DHSC will convene a further workshop in the autumn to map existing data flows. DHSC workshop on mortality data, by Autumn 2025. Additional comments: As above. The purpose of this workshop will be to map existing mortality data flows across the healthcare system to inform future action to improve mortality data. Mortality Data working group meeting to be reconvened in six months to establish how we can build on the existing data flows to deliver improvements to mortality data, by November - December 2025. Response received on 25 August 2025.

DHSC is taking forward work to design an oversight mechanism that supports the effective implementation and learning from safety recommendations. The mechanism will enable the tracking, prioritisation and oversight of safety recommendations to implementation. This work builds on the work of the HSSIB-led Recommendations to Impact Group and wider Government plans for the oversight of government-led inquiries. It also aligns with the outcome of the Dash Review published on 7 July and its findings and recommendations relating to the oversight and prioritisation of recommendations. As part of this work, DHSC is working with the cross-organisational Recommendations Working Group (DHSC, HSSIB and NHS England) to review a cohort of recommendations made by national organisations specific to mental health services, including mental health inpatient settings. A project will be established in partnership with NHS England leads for mental health policy and patient safety policy to conduct the review and identify what actions if any have been taken in response to the cohort of recommendations. The review will allow us to pilot the proposed approach for a recommendations hub, which is intended to form part of the national oversight mechanism and provide useful learning about the barriers and enablers to implementation. The National Quality Board (NQB) will be responsible for reviewing, analysing and taking forward recommendations as outlined in the 10 year health plan and the Dash review of patient safety across the health and care landscape. Action planned to deliver safety recommendation: Undertake a review of a cohort of mental health recommendations to understand what actions have been taken in response and identify any barriers or enablers to their implementation, by November 2025. Other dependencies identified: Work programme to implement Dash recommendation that the National Quality Board takes responsibility for the oversight of implementation of recommendations and that it builds and maintains a repository of recommendations from multiple sources. Response received on 28 August 2025. -------------------------------------------- May 2026: HSSIB has been notified by the Department of Health and Social care that all actions have been completed.