Website: https://www.nicheconsult.co.uk/
The complications of getting to the root causes of mental health safety issues are generally well-known:
Is the issue due to staffing levels, staff vacancies, and the use of banks and agencies? Perhaps affected by the seniority and longevity of ward and team managers?
Is it an issue of clinical practice pertaining to the therapeutic model of care e.g., the use of restraint or the use of drug therapy as a single modality?
Is it an issue of a closed culture that has allowed such practices to go unchecked? This may be impacting incident reporting, resulting in safety flags not being raised.
Are there much softer issues that can potentially be explanatory, such as a lack of MDT working, the absence of nurses in MDT meetings, poor staff survey results, or a lack of service user engagement? Do these softer issues all point towards a problematic care environment resulting in poor patient safety?