PFD report

Stephen Keith Harte · Prevention of Future Deaths report

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Issued 1 Feb 2019•Birmingham and Solihull

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
23

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to search takeaway food arriving at the unit
  2. Failure to effectively search staff entering the unit
    Part of recurring concern: Unreliable searches and screening for drugs and prohibited items in controlled environments
  3. Failure to search staff food brought onto the unit
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Provide each service user with at least one random monthly drug screen, varied according to individual risk and care plans.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  2. Action

    Search service users returning from unescorted leave, in addition to scanner screening.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  3. Action

    Conduct random clothing searches after unescorted community leave when individual concerns are identified.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Staff are not routinely searched; scanning, drug-dog detection and risk-based searches are relied upon to address drug-entry concerns.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to search takeaway food arriving at the unit

Wider context from the report

“1) I heard evidence about the potential routes for drugs to enter the medium secure unit. This included: (a) Residents are allowed unsupervised telephone calls to order food from external ‘takeaways’ of their choice and the food is not searched upon arrival. Historically, residents were only allowed to order from an approved list of ‘takeaways’. However, following a Care Quality Commission inspection the CQC deemed this was too restrictive and asked that the unit relax its rules. The evidence was unclear whether the CQC had similarly asked other units to relax their rules. (b) Those residents allowed unsupervised leave are not typically searched upon their return. They walk thought a scanner, but this is unlikely to reveal small quantities of drugs on their person. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to effectively search staff entering the unit

Wider context from the report

“3) I also heard evidence that staff are not typically searched upon entering the unit. They also walk thought the scanner, but this is unlikely to reveal small quantities of drugs on their person. Further, whilst they are required to leave personal belongings in lockers, they are allowed to take their own food on to the unit which is also not searched. ”

Is this part of a recurring concern?

Yes — Unreliable searches and screening for drugs and prohibited items in controlled environments.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to search staff food brought onto the unit

Wider context from the report

“3) I also heard evidence that staff are not typically searched upon entering the unit. They also walk thought the scanner, but this is unlikely to reveal small quantities of drugs on their person. Further, whilst they are required to leave personal belongings in lockers, they are allowed to take their own food on to the unit which is also not searched. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to effectively search residents returning from unsupervised leave

Wider context from the report

“1) I heard evidence about the potential routes for drugs to enter the medium secure unit. This included: (a) Residents are allowed unsupervised telephone calls to order food from external ‘takeaways’ of their choice and the food is not searched upon arrival. Historically, residents were only allowed to order from an approved list of ‘takeaways’. However, following a Care Quality Commission inspection the CQC deemed this was too restrictive and asked that the unit relax its rules. The evidence was unclear whether the CQC had similarly asked other units to relax their rules. (b) Those residents allowed unsupervised leave are not typically searched upon their return. They walk thought a scanner, but this is unlikely to reveal small quantities of drugs on their person. ”

Is this part of a recurring concern?

Yes — Unreliable searches and screening for drugs and prohibited items in controlled environments.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide each service user with at least one random monthly drug screen, varied according to individual risk and care plans.

Verbatim wording from the response

“• Service users have at least one random monthly drug screen, but may vary dependent on individualised risk and care plans”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Search service users returning from unescorted leave, in addition to scanner screening.

Verbatim wording from the response

“The Trust Policy on the searching of service users in our secure care inpatient wards states that a search will be conducted on all service users returning from unescorted leave. This is in addition to service users walking through the scanner. We recognise that service users may at times secrete drugs in body cavities and that our regular search approach may not identify these. In addition to this, we have therefore implemented a wide range of additional controls to detect any drugs entering the unit. These include:-”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct random clothing searches after unescorted community leave when individual concerns are identified.

Verbatim wording from the response

“• Random change of clothes search following service users returning from unescorted community leave if particular concerns are noted about individualised patients”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Directed the trust to assess individually the risks posed by patients returning from leave.

Verbatim wording from the response

“Because of our findings we told the trust that they must ensure that it undertakes active individual assessment of risks posed by patients returning from leave. We told the trust that they should review practice of not allowing patients to buy food from a takeaway shop of their choice.”

Source location

2019-0077-Response-by-CQC
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conducted a comprehensive inspection of the trust and published the inspection reports.

Verbatim wording from the response

“The Care Quality Commission commenced a comprehensive inspection of Birmingham and Solihull Mental Health Foundation NHS trust 27th–31st March 2017 and published the reports 2nd August 2017. At that inspection we found the trust had implemented blanket restrictions with regards to the ordering of food from takeaways and in relation to patient searches. We informed the trust that it was appropriate for them to provide patients with information on hygienic ratings and to explain the benefits. However, patients with mental capacity had the right to order takeaways from the shop of their choice, and the policy did not promote an individualised approach to patient’s choice or risk. We”

Source location

2019-0077-Response-by-CQC
Page 1 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conducted a comprehensive follow-up inspection of the trust and assessed its search and security arrangements.

Verbatim wording from the response

“We visited the trust in November and December 2018 and carried out a comprehensive inspection as part of our regular inspection programme. At that inspection we found the trust had reviewed and implemented a new search and security policy based on risk assessment. We did not find any breaches related to blanket restrictions.”

Source location

2019-0077-Response-by-CQC
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Staff are not routinely searched; scanning, drug-dog detection and risk-based searches are relied upon to address drug-entry concerns.

Verbatim wording from the response

“Our current arrangement within our inpatient facilities is that staff are not typically searched upon entering the unit and that this would only occur if we had clear grounds for concern that particular staff members were facilitating access to drugs on the unit. We do however have the drug dog which visits our secure care and acute care wards and would detect any traces of drugs or illicit substances on members of staff.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 4 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The CQC is responsible for responding to concerns about takeaway ordering and food-search restrictions.

Verbatim wording from the response

“Following the CQC inspection of Birmingham and Solihull Mental Health NHS Foundation Trust in March 2017, the Trust received notification from the CQC that it was in breach of regulation 13 due to the restrictions that it had in place for service users to select takeaway food from establishments with a hygiene rating of 4 and above. This was considered to be a ‘blanket restriction’. The CQC stated in their report ‘The trust had taken a blanket approach to searches and ordering of food from takeaway restaurants. The decisions made at board level in relation to the restrictions did not take account of individual risk assessment or patient choice’. The Trust was required to remove this restriction and service users now have the ability to order takeaway food from any establishment of their choice.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 1 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Decisions about searching staff entering units are assigned to each individual organisation, not made by the CQC.

Verbatim wording from the response

“The Care Quality Commission did tell the trust that it must ensure that active and individual assessment of risks posed to patients who return from leave and use this to base decision on searches. The trust carried out a comprehensive review of its search policy and implemented a security policy and a new search policy in response to our requirement notice. During our inspections we do not review the searching of staff entering units although for some services we would review the security arrangement. Any decisions to search staff would be a decision taken by each individual organisation. The Care Quality Commission would review what action an organisation was taking if they informed us they had a problem of drugs entering their units and would comment on them within our reports.”

Source location

2019-0077-Response-by-CQC
Page 2 · response
Published 9 June 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.17

  1. 1

    Increase on-site security, including around the inpatient unit perimeter.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  2. 2

    Operate a multidisciplinary, multisite substance use programme across the secure-care pathway.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  3. 3

    Provide patient and staff leaflets on the overdose risk from opiate use after abstinence.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  4. 4

    Develop a comprehensive risk assessment tool to identify patients at high risk of drug overdose.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  5. 5

    Hold a monthly substance misuse meeting.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  6. 6

    Conduct site-wide urine drug screening when intelligence or other information suggests drugs may be present.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  7. 7

    Use a drug dog fortnightly and work with police liaison to assess whether police dogs can also be used on site.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  8. 8

    Maintain dedicated substance use practitioners, clinical leadership and ward substance use leads.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  9. 9

    Develop and regularly update guidelines covering substance use.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  10. 10

    Finalise and obtain approval for the overdose harm-reduction strategy, targeted for implementation from January 2020.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
  11. 11

    Deliver regular substance use education and supervision for staff, patients and programme members, including bespoke training where required.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  12. 12

    Purchase and provide a drug amnesty box.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  13. 13

    Conduct intelligence-led and random environmental searches of rooms and wards.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  14. 14

    Test wastewater to detect potential substance use within the unit.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  15. 15

    Provide structured substance use assessment, treatment, relapse prevention, peer support and pharmacological interventions according to patient need.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  16. 16

    Asked the trust to review its practice of restricting patients from buying takeaway food of their choice.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  17. 17

    Required the trust to address its breach of Regulation 13 through a requirement notice.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The CQC did not ask the trust to relax takeaway rules; it required review based on capacity and individual risk.

    Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Increase on-site security, including around the inpatient unit perimeter.

Verbatim wording from the response

“• Increased security on site including the perimeter of the grounds of our inpatient unit”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate a multidisciplinary, multisite substance use programme across the secure-care pathway.

Verbatim wording from the response

“In addition to the above, we now have a substance use strategy in place in our secure care services. The substance use programme in the BSMHFT secure services is a multidisciplinary and multisite programme. It supports the patients throughout their care pathway. The programme operates on principles of harm minimisation. The intervention starts before admission to the units, at time of assessment.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide patient and staff leaflets on the overdose risk from opiate use after abstinence.

Verbatim wording from the response

“1) The first step was development of patient and staff information leaflets about the risk of opiate use after a period of abstinence. The leaflet was co produced by the substance use lead and a patient. The leaflet has been available in the Trust since the Summer of 2018.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 3 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a comprehensive risk assessment tool to identify patients at high risk of drug overdose.

Verbatim wording from the response

“2) One of the significant outcomes has been the development of a very comprehensive risk assessment tool to identify patients all high risk of drug overdose.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 3 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Hold a monthly substance misuse meeting.

Verbatim wording from the response

“• Implementation of a monthly substance misuse meeting”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct site-wide urine drug screening when intelligence or other information suggests drugs may be present.

Verbatim wording from the response

“The Trust Policy on the searching of service users in our secure care inpatient wards states that a search will be conducted on all service users returning from unescorted leave. This is in addition to service users walking through the scanner. We recognise that service users may at times secrete drugs in body cavities and that our regular search approach may not identify these. In addition to this, we have therefore implemented a wide range of additional controls to detect any drugs entering the unit. These include:-”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use a drug dog fortnightly and work with police liaison to assess whether police dogs can also be used on site.

Verbatim wording from the response

“• The drug dog attends fortnightly. We are working closely with our local police liaison officer to see whether we can use their police dogs on the premises in addition to our regular search dog”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain dedicated substance use practitioners, clinical leadership and ward substance use leads.

Verbatim wording from the response

“1) Currently the substance use programme has two dedicated band 7 nurses and two dedicated band 5 substance use practitioners. The programme is led by a consultant forensic psychiatrist and supported in advisory and development capacity by a psychologist, an occupational therapist, a senior nurse and a pharmacist. Every ward has a minimum of one identified substance use lead.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 3 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and regularly update guidelines covering substance use.

Verbatim wording from the response

“2) Specific guidelines are developed and regularly updated on various aspects of substance use.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 3 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Finalise and obtain approval for the overdose harm-reduction strategy, targeted for implementation from January 2020.

Verbatim wording from the response

“Reduction in risk of deaths by a drug overdose strategy”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 3 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver regular substance use education and supervision for staff, patients and programme members, including bespoke training where required.

Verbatim wording from the response

“1) An educational programme relating to substance use runs regularly including 2 day training sessions for clinical staff at all levels (level 2) and supplementary ward based training sessions.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 3 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Purchase and provide a drug amnesty box.

Verbatim wording from the response

“• The purchase of an amnesty box specifically for drugs. This idea came from a presentation at the Physical Health link workers day, from a gentleman from City Hospital who spoke about how an A&E department trialled it and it was successfully implemented.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct intelligence-led and random environmental searches of rooms and wards.

Verbatim wording from the response

“The Trust Policy on the searching of service users in our secure care inpatient wards states that a search will be conducted on all service users returning from unescorted leave. This is in addition to service users walking through the scanner. We recognise that service users may at times secrete drugs in body cavities and that our regular search approach may not identify these. In addition to this, we have therefore implemented a wide range of additional controls to detect any drugs entering the unit. These include:-”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Test wastewater to detect potential substance use within the unit.

Verbatim wording from the response

“• Testing of the waste water supply to try to detect whether substances are potentially in the unit.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide structured substance use assessment, treatment, relapse prevention, peer support and pharmacological interventions according to patient need.

Verbatim wording from the response

“1) There are specific parts in the admission assessment documentations dealing with the substance use. This helps to identify the immediate needs and identifies patients in need of more detailed substance use assessment.”

Source location

2019-0077-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Asked the trust to review its practice of restricting patients from buying takeaway food of their choice.

Verbatim wording from the response

“Because of our findings we told the trust that they must ensure that it undertakes active individual assessment of risks posed by patients returning from leave. We told the trust that they should review practice of not allowing patients to buy food from a takeaway shop of their choice.”

Source location

2019-0077-Response-by-CQC
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Required the trust to address its breach of Regulation 13 through a requirement notice.

Verbatim wording from the response

“We found that the blanket restrictions imposed on patients was a breach of Regulation 13 HSCA (RA) Regulation 2014 Safeguarding service users from abuse and improper treatment. A requirement notice was placed on the trust for them to address the breach of Regulation 13.”

Source location

2019-0077-Response-by-CQC
Page 2 · response
Published 9 June 2019

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The CQC did not ask the trust to relax takeaway rules; it required review based on capacity and individual risk.

Verbatim wording from the response

“The Care Quality Commission did not ask the trust to relax its rules in relation to takeaways but as stated above the trust was asked to review its practice of not allowing patients to buy food from a takeaway shop of their choice if they had capacity to make that decision. In the case of other health providers who had similar blanket restrictions the Care Quality Commission would ask them to consider those restrictions in relation to people’s capacity to make their own informed decision or where the organisations mental health assessment shows there is a risk to that patient.”

Source location

2019-0077-Response-by-CQC
Page 2 · response
Published 9 June 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026