The Healthcare Commission's investigation into mental health inpatient services paints a troubling picture.
The challenges for staff in these units are immense. The growth of community-based support means service users admitted to hospital are at an acute stage of illness, often with complex needs such as drug and alcohol abuse exacerbating mental problems.
The good news from the report was the evidence that personalised, safe and successful acute care can be and is being provided. But major weaknesses were also exposed. A pattern emerges of hard-pressed staff struggling to cope in a tough environment.
The levels of violence on the wards are shocking, with almost half of nurses and one in seven patients being attacked. Two thirds of providers were rated only weak or fair on safety, and the commission was particularly concerned about sexual safety, obviously a serious danger on wards with highly disturbed patients ("The safety scandal").
Many patients did not have a single one to one session with a health worker in their first week, and not a single trust was rated excellent for the effectiveness of its clinical pathways.
Training emerged as a significant impediment to improving services, with managers struggling to release hard-pressed ward staff. The training levels for dealing with drug and alcohol abuse were shocking; every trust was scored weak. Suddenly the reasons for the high number of assaults become easier to understand.
The report highlights the plethora of policies encouraging training for staff who have to cope with patients with a dual diagnosis, but there has been too little action to make these wishlists a reality.
The commission highlights innovative training techniques such as e-learning, but that is hardly a comprehensive solution to the need for more capacity to enable far more training to be delivered.
A handful of trusts did not even bother to assess their staff's training needs, which for such an intensive and high risk environment is bordering on negligence.
The ingredients of first class services are well known, but for mental health services there is an additional factor: poor services often rely on excessively traditional medical models of care and are ineffective at multidisciplinary teamwork.
Mental health inpatient facilities are on the road to improvement, but drastic shortcomings need to be addressed. The first is training.