The Care Quality Commission (CQC) has recently set out its main concerns about the care provided to people detained under the Mental Health Act. 

It is releasing the final biennial report from its predecessor regulator, the Mental Health Act Commission (MHAC), covering the two-year period to 1 April 2009.

CQC says the report provides an authoritative narrative on the care of people detained under the Act.

The report shows that during its visits to services and meetings with patients, MHAC found examples of people receiving effective treatment in appropriate and safe environments. But it also indicates that there is variation across services.

Publishing a 13 page response alongside the MHAC report, CQC says it is most concerned about: safe practice; the quality of inpatient care and people’s experience of services; and how people’s human rights are protected.

CQC Chairman, Barbara Young, said: “I am concerned about the safety and quality of care provided to some people who are detained.  These are some of the most vulnerable people for which the NHS is responsible.  We have got to ensure that services meet their needs more effectively.

“There is lots of good practice out there, but this report shows where change is most needed. We want to see change happen much faster than in the past. We have a range of new powers and we are fully prepared, where necessary, to use them to drive up standards.”

Drawing on evidence from the report, CQC outlines the areas of most concern:

Control and restraint practices

In some services, MHAC found some staff who might be engaged in restraint practices without having received training.  It also found evidence of worrying and poorly documented practices. The report states:

Three inquests into deaths of patients who died while being treated under the Act during 2008 found a lack of training and staff knowledge contributed to the deaths of these patients. 

MHAC states it is not confident that staff caring for detained patients have sufficient training or support to rule out further tragedies.

In its response, CQC says it is concerned the sector is not learning from these incidents, and is calling for an accredited training programme. This was first recommended following the death of Rocky Bennett in 1998, who died after being restrained face-down. CQC would like to see this programme rolled out without delay.

Observation of patients

The report says services are not always clear about levels of observation appropriate to prevent harm. It emphasises the need to eliminate, as far as possible, all load-bearing points that may be used to inflict self-harm. It says:

Thirty-nine percent of deaths on wards by hanging or self-strangulation between 2001 and 2008 happened when the patient was subject to observation by staff at 15-minute intervals or less, including some under continuous observation. In the case of one suicide, there was evidence to suggest the patient was not checked for three hours, despite being subject to 15 minute observations.

Six patients who died of hanging or self-strangulation since 2005 were supposedly under continuous observation.

CQC urges services to ensure they have adequate levels of fully trained staff to allow for proper observation of patients. Services need to pay more attention to the ward environment to ensure it is safe and secure.     

Safeguarding women and children

The Government has made a commitment to end the admission of children under 16 to adult wards from November 2008, and any 16 or 17 year old by April 2010. When children are admitted to hospital, managers must consult with a person who has knowledge or experience of cases involving children. However, the report states:

Between October 2008 and February 2009, 80 under-18s were admitted to adult mental health facilities, four of whom were 15 years old.

Sixty (75%) of these young people were placed in mixed-sex wards.

The clinician responsible for 67 (84%) of these under-18s was not a specialist in Child and Adolescent Mental Health Services. 

On too many wards there is a culture of women being subjected to low-level harassment and exposed to men who may take advantage of them. Some women say they feel unsafe and vulnerable in these mixed environments.

In its response, CQC says it will monitor how well services are safeguarding vulnerable groups. It will monitor how well services ensure children’s emotional and developmental needs are met in a place appropriate for their age. It will continue to highlight where services are not making progress in reducing mixed-sex accommodation. It says it will take swift action where there is cause for concern.

Informing and involving patients

Detained patients are not consistently given information about their rights under the Act and more can be done to ensure these rights are explained in a way the person can understand. The report highlights that:

Nearly a quarter of a sample of 500 detained people had not received information they were entitled to, such as information on their legal status and rights (including rights to appeal for discharge), and about treatments prescribed to them.

Ten percent of 6,705 case notes reviewed by MHAC contained no formal record that a person’s rights had been explained to them. This ranged from 30% to 100% at some trusts.

MHAC frequently met with patients who seemed to have little understanding of their medication, through lack of information given to them rather than incapacity to understand. This means genuine consent could be questionable in some cases, breaching human rights.

CQC is developing methods to ensure findings from its monitoring of the Act are more directly incorporated into its assessments and judgements about organisations. It will also publish information sheets to inform patients about their rights. It says the explanation of rights is not only important as a legal duty, but also to ensure people receive personalised and appropriate care.

Community Treatment Orders (CTOs)

The CQC is concerned that there is not enough information available on how CTOs are being used, and what conditions are being treated in this way. This is particularly concerning given that the number of people treated under a CTO has risen steeply since they were first implemented.

CTOs are designed for patients who still require treatment for a mental disorder but where treatment can be given outside of hospital without the need for detention. Since CTOs were implemented in November 2008, MHAC has been notified of 2,868 orders issued – far above the predicted 200 – and this has put strain on the service.

Furthermore, Second Opinion Appointed Doctors (SOADs) are required to assess all patients on a CTO to review their care and treatment plan, but the unexpected numbers have created pressure on the service leading to some delays in this happening.

To address these problems CQC is currently considering what further work is needed to get a clearer picture of the use of CTOs and their effectiveness. It also continues to recruit more SOADs.

Quality of inpatient care

The report suggests an increasing trend towards more defensive practices. Defensive practice and use of physical interventions do not complement care that is focused on respect, patient choice, involvement and freedom to make decisions.  The report identified:

An increasing trend towards locked wards in acute care, giving a heightened sense of containment that can be counter-productive to recovery. Of the wards visited by MHAC, the percentage of unlocked wards has decreased from 35% in 2005 to 26% in 2008.

The need for inpatient settings to provide more structured therapeutic activity, greater access to psychological therapies, access to exercise, fresh air, and healthy diet choices, all of which contribute to the quality of care and help recovery.

Equality and diversity

The over-representation of some BME groups within the detained patient population has been identified before, but the report also suggests this may be even more pronounced among people subject to Community Treatment Orders. 

Recent studies have also shown that social and psychological problems occur for some young black people before they become users of mental health services. In its response, the CQC says health and social care services need to adopt better preventative strategies that focus on young people from BME communities who may be at risk. Commissioners and providers should also use information on service users experiences and from the public about how they would like services to meet their diverse needs.