CQC calls for new national guidance to improve sexual safety on mental health wards

Care Quality Commission | September 2018 | Sexual safety on mental health wards

The Care Quality Commission (CQC) report -Sexual Safety on Mental Health Wards report- shares  findings and recommendations after reviewing incidents related to sexual safety on mental health wards. 

Their analysis of almost 60,000 reports found 1,120 sexual incidents involving patients, staff, visitors and others described in 919 reports – some of which included multiple incidents. More than a third of the incidents (457) could be categorised as sexual assault or sexual harassment of patients or staff.

Image source: cqc.org.uk


Providers and people who use services told CQC:

  1. People who use services do not always feel that they are kept safe from unwanted sexual behaviour
  2. Clinical leaders of mental health services do not always know what is good practice in promoting the sexual safety of people using the service and of their staff
  3. Many staff do not have the skills to promote sexual safety or to respond appropriately to incidents
  4. The ward environment does not always promote the sexual safety of people using the service
  5. Staff may under-report incidents and reports may not reflect the true impact on the person who is affected
  6. Joint-working with other agencies such as the police does not always work well in
  7. practice (Source: CQC)

Read the press release in full from CQC 

The report is available as a summary, easy to read format or in full from CQC

Of interest:

The BMJ  CQC: Trusts must do more to protect mental health patients from sexual abuse

Nursing Times CQC warning on sexual incidents in mental health settings

In the media:

The Guardian NHS care regulator says sexual incidents ‘commonplace’ in mental health units

Resources to support safer bowel care for patients at risk of autonomic dysreflexia

NHS Improvement | July 2018 | Resources to support safer bowel care for patients at risk of autonomic dysreflexia

A Patient Safety Alert has been issued signposting resources to support safer provision of bowel care for patients at risk of autonomic dysreflexia (AD).

The Patient Safety Alert can be read here 

NHS Improvement has also signposted a number of resources on their website 

Resources to support safer modification of food and drink

NHS Improvement | June 2018Resources to support safer modification of food and drink

NHS Improvement has  issued a resource alert to eliminate use of the imprecise term ‘soft diet’ and assist providers with safe transition to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework, which introduces standard terminology to describe texture modification for food and drink.

Resources to support safer modification of food and drink are here

In the media:

BBC News Patients ‘choked on hospital soft food’

The Telegraph  Safety alert after hospital patients choke on hash browns and peas

Mail Online Hundreds of NHS patients have choked, with two DYING, after being fed solid food when it should have been minced or puréed because they had difficulty swallowing, reveals damning report

Community pharmacies in England providing improved asthma and dementia care, NHS England figures show

NHS England | Improved asthma and dementia care from community pharmacists under new quality scheme |

Since April 2017, over 97 per cent of pharmacies – 11,410 out of approximately 11,700 – took part in the The Quality Payments Scheme, this  provides an incentive to deliver new clinical services, to encourage more people to use their local pharmacist.


The scheme had three key foci:

  •  patient safety
  • patient experience
  • clinical effectiveness

Over 12,500 asthma patients at high risk of suffering a severe asthma attack have been identified and referred for a full asthma review, whilst 70,000 pharmacy staff have become ‘Dementia Friends’ in order to offer greater awareness regarding the needs of people with dementia. ​
The scheme ran between December 2016 and March 2018,  NHS England is currently considering how best to implement the successes of this scheme over the long-term.

The full details are available from NHS England 

Revised Never Events policy and framework

The Never Events policy and framework sets out the NHS’s policy on Never Events. It explains what they are and how staff providing and commissioning NHS-funded services should identify, investigate and manage the response to them.

Never Events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.

The main changes to the revised policy and framework are:

  • the removal of the option for commissioners to impose financial sanctions on trusts reporting Never Events
  • to align the Never Events policy and framework with the Serious Incident framework, to achieve consistency across the two documents (a revised Serious Incident framework will be published later in 2018)
  • revisions to the list of Never Events, including two additional types of Never Event.

Full document: Never Events policy and framework – revised January 2018

See also: Never Events list 2018


Urgent and emergency care: best practice

This CQC report offers practical examples of how leading emergency departments are meeting the challenges of managing capacity and demand, and managing risks to patient safety .

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This report from the Care Quality Commission details the good practice identified following the Commission’s work with consultants, clinical leads, senior nursing staff and managers from leading emergency departments in 17 NHS acute trusts.

This resource identifies:

  • strategies staff use to meet the challenge of increased demand and manage risks to patient safety
  • positive actions to address potential safety risks and to manage increased demand better
  • how working with others can manage patient flow and ensure patients get the care they need
  • that rising demand pressures in emergency departments are an issue for the whole hospital and local health economy.

Full report: Sharing best practice from clinical leaders in emergency departments