12 February 2018

A focused Care Quality Commission inspection of wards in Luton and Bedfordshire has provided assurance that the Trust is learning from serious incidents and taking steps to keep patients safe. The CQC inspectors did not issue a rating for the services but noted improvements in the acute wards for adults of working age and psychiatric intensive care units (PICU).

Learning from Incidents

The Trust had carried out a series of serious incident investigations following four unexpected deaths that occurred between December 2016 and July 2017.

Dr Navina Evans, Chief Executive said, “The loss of life of any patient is a tragedy and my heart goes out to the family and friends of those individuals. We have been focussed on learning lessons following these incidents and are encouraged that our progress has been recognised by inspectors.  We will continue to work to improve how care is provided and to embed improvements across our services.”

The CQC noted that the Trust had used the learning from these to make improvements including working in partnership with the police to reduce patient access to illegal substances on the wards. Staff have received additional training on suicide prevention and the management of physical health conditions. It found we had also made progress in addressing the recommendations from a previous CQC inspection in June 2016.


The inspectors found:
•Staff thoroughly assessed risks to patients and provided care which addressed their needs
•Improvements in staff updating risk assessments
•Patients reported that staff involved them in planning their care and treatment.
•Ward procedures have changed across the service with more focus on the security and safety of wards
•Measures in place to restrict contraband items but this still needs further embedding.

The size of Ash ward has been reduced from 27 beds to 19 beds which allows staff to have better oversight of patients. However, the inspectors noted that some wards continue to have bed numbers in excess of Royal College of Psychiatrist guidance.

Recruitment and Morale

The CQC acknowledged that the recruitment and retention of nursing staff continues to be problematic for the Trust but noted a number of initiatives were underway to recruit staff. In the interim, we have opted to employ locum agency nurses to ensure that patients are cared for by a consistent staff team. Staff reported that morale was good and they themselves felt that the service was improving.

The Trust is grateful to the staff and service leads who have worked hard to address issues and make our wards safe therapeutic spaces for inpatients.

You can read the full report here