CQC - MHA reports
- Care Quality Commission, 'Monitoring the use of the Mental Health Act in 2009/10' (27/10/10). CQC's first report on the MHA
- Care Quality Commission, 'Monitoring the Mental Health Act in 2010/11' (8/12/11). The detailed findings in this report are set out under the following chapter headings: (1) Patients' involvement and protection of their rights; (2) Consent to treatment; (3) Patients' experience of care and treatment; (4) Promoting patient safety; (5) Deaths of detained patients
- CQC, 'Monitoring the Mental Health Act in 2011/12' (30/1/13). The following are the report's key findings for each chapter, and its concluding recommendations: (1) Use of the Act: (a) The number of people subject to detention under the Act is rising. The number of detentions rose by 5% on the previous year; the number of community treatment orders rose by 10%. (b) Of the 4,576 patient records checked in 2011/12, 4% showed irregularities that called the legality of the detention into question. (c) Care planning was the most frequently raised category of concern; 85% of the care plans examined showed evidence of individualised planning, regular review and evaluation, 15% did not. This was no change on 2010/11 and amounted to just over 650 patients where basic expectations about care planning were not met. (d) The greater detail now available in the Mental Health Minimum Data Set has exposed a number of data quality issues that must be addressed before the data can realise its full potential. (2) Participation and Respect: (a) CQC’s MHA Commissioners visited many mental health wards where a great deal of respect was given to patients. (b) Patients were able to influence the running of their ward in almost all cases – 94% of all wards in 2011/12, up from 90%. (c) Patients were more involved in planning their own care: their views were recorded in 63% of care plans, a rise from 58%. But this means an unacceptably high proportion – more than a third – did not have their views written down. (d) More than half of patients were still not given a copy of their care plan. (e) Most patients (90%) were given general information about their rights when they were first detained. (f) But one patient in five was not informed of their right to an Independent Mental Health Advocate (IMHA). (g) This may reflect continuing difficulties that some services have in accessing IMHAs. There was no evidence of an IMHA service in one in seven of the wards CQC visited. (3) Coercion in practice: (a) The human rights of patients are often affected by controlling practices that only seem to serve the hospital’s needs. Hospitals have a difficult task in balancing the realities of detention and compulsory treatment with the requirement that they provide services according to a principle of least restriction on patients. But it has proved all too easy for cultures to develop in which blanket rules deny people their basic rights – especially the right to dignity. (b) In one in five visits – an unacceptably high number – MHA Commissioners thought that patients who were in hospital voluntarily might be detained in all but name. For example, in 88 out of 481 visits there were no signs on locked doors that explained to voluntary patients how they could leave the ward. (c) On 24 occasions, patients had been secluded but the ward staff had not realised this was classed as seclusion and they had not applied the proper safeguards. (d) In many hospitals restraint practices are generally safe and appropriate. Almost all staff will now have some degree of training not only in physical methods of restraint, but in ways to prevent confrontational situations. (e) However, CQC is still concerned at the lack of regulation of training programmes with regard to restraint. Safeguards could be improved. (f) CQC is talking with the Department of Health about how to promote best practice around support for positive behaviour. (4) Care pathways (a) CQC saw evidence that many Approved Mental Health Professionals are trying to find alternative care for people that avoids them having to be detained in hospital. (b) Pressures on beds continued to put services and patients under stress, making it harder to provide appropriate care for people in times of crisis. In 2011/12, 93 wards (6% of all wards) visited had more patients than beds; a further 10% were at full capacity. (c) Patients are being affected by reductions in staff numbers. For example, MHA Commissioners raised concerns in 77 visits that a lack of staff prevented patients taking escorted leave. (d) In some services MHA Commissioners saw excellent examples of patients benefitting from psychological therapies. But in others, services were too ready to rely on psychiatric medication as their response to patients’ distress. (e) Patients are benefitting from good discharge planning in a number of units – with considerable investment in time and effort being spent in identifying step down accommodation and suitable support arrangements. But an unacceptably high proportion – more than a third of care plans – still showed no evidence of discharge planning. (5) Consent to treatment: (a) Consent to treatment discussions (before the first administration of medication) improved in 2011/12 – 55% of records showed these, up from 46% in 2010/11. But this means that in almost half of cases there was no evidence that doctors had talked to patients about whether they consented to proposed treatment. (b) There was better evidence of consent discussions after the first use of medication (72% of records). But still this means consent was not discussed in more than a quarter of cases. (c) One patient in 10 (receiving medication for three months or more) was prescribed medication above the legally authorised care plan. (d) In CQC’s view, the assumption of a patient’s capacity to consent to or refuse treatment should be backed up by a written record. More than a third of records did not show any evidence of a capacity assessment (42% on admission; 36% at the end of three months or the last administration of medication). (e) Patients may be reluctant to say what they think about their treatment in public, particularly in a traditional ward round. CQC saw some good services that have developed private arrangements instead of ward rounds. (6) Community Treatment Orders: (a) CTOs are used widely by some providers, and used little by others. In an analysis of NHS organisations, the lowest reported ‘discharge rate’ onto a CTO was 4.0%; the highest was 45.5%. (b) There were also a number of NHS organisations – with considerable rates of detention under the Act – that provided nil returns for the use of CTOs. (c) A number of patients are worried that it isn’t clear when a CTO will have served its purpose – and therefore they do not know what they have to do to come off a CTO. (7) Recommendations: (a) Policy makers must consider the reasons why there are rising numbers of people subject to the Act and develop an appropriate policy response. (b) The Boards of mental health trusts, independent providers of mental health care, and community trusts are responsible and accountable for the quality of care people receive. They must drive the changes needed in their organisations. In particular they need to recognise and promote good practice and ensure that robust mechanisms are in place to understand individuals’ experience of their services. CQC reminds providers of their own duties to monitor how they use powers derived from the Act (see the Code of Practice) and their duties under the Health and Social Care Act 2008 to demonstrate how they have learned lessons from practice and have made consequent improvements. This is an area that CQC will focus on in the next 12 months in its regulatory activity. (c) The NHS Commissioning Board, local authorities, clinical commissioning groups and specialist commissioners must commission services that guarantee a person’s dignity, recovery and participation. Clinical commissioning groups and local authorities must ensure that local needs assessments for community services and commissioned models of care are informed by an understanding of their statutory duties under the Act and by the experiences of people who use services.
- CQC, 'Mental health services must improve the care they provide to patients' (news item, 30/1/13). This web page contains a brief summary of the report plus links to: (a) the report, (b) a summary document, (c) an easy-read version, and (d) the CQC's press release
- CQC, 'Monitoring the Mental Health Act in 2012/13' (January 2014)†. The following are the report's key findings for each chapter, and its concluding recommendations: (1) The use of the Mental Health Act in 2012/13. (a) The number of detentions continued to rise, with the highest number of uses of the Act ever recorded. The national statistics on use of the Act showed a rise in detentions, whether these are at the point of admission to hospital or subsequent to informal admission. (b) In 2012/13, 27% of recorded outcomes of section 2 detentions showed that the patient continued to be detained. This is a small but significant rising trend from the 24% in the previous year. (c) Since the introduction of community treatment orders (CTOs) in 2008, the power had been used 18,942 times by 31 March 2013. (d) Data available for 2012/13, as in previous years, showed a continuing trend in high rates of detention among certain black and minority ethnic groups. (e) Data on self-harm, restraint, assaults and seclusion, which were previously collected for inpatients in the Count Me In census, are now being collected through the Mental Health Minimum Data Set. CQC is looking at how we can use this data to monitor the experience of inpatients, including any associations with ethnicity. (2) A service responsive to people’s needs. (a) Some progress has been made in this area, although there is still a long way to go, with evidence that care plans and risk assessments had not considered the principle of least restriction in 10% of wards visited. (b) 27% of care plans we reviewed in six months of 2012/13 showed no evidence of patients being involved in their creation. And at least 22% of care plans showed no evidence of patients’ views being taken into account. This is no improvement on our finding in 2011/12. (c) Inadequate discharge planning can lead to prolonged periods of detention and we are very concerned there was a lack of evidence of discharge planning in 29% of the care plans we viewed. The Code of Practice is clear in its expectations for providers to consider aftercare with all detained patients and we expect this to be evident for all patients subject to the MHA. (d) We are pleased to report almost all wards had access to Independent Mental Health Advocacy (IMHA) services. This is a considerable improvement in basic access to IMHAs with 92% of wards reporting direct access for patients to IMHA. (e) However, there was no improvement in evidence of patients’ rights being explained to them. In the last two years we have not seen adequate evidence of discussions with patients about their rights in at least one in 10 wards. (3) Ways in which people are subject to restrictions. (a) We continued to see widespread use of blanket rules. Some type of blanket rule was in place in more than three quarters of the wards we visited. Such practices have no basis in law or national guidance on good practice and are unacceptable. (b) In 46% of cases reviewed the reason given for the blanket rules was ‘hospital policy’. We were also told it was because of a historical incident, or in 13% of cases no-one seemed able to give a reason. (c) The most common restrictions related to using the internet and mobile phones, smoking, and access to secure outdoor space and communal rooms. In many cases these rules applied across the ward to both detained and informal patients. (d) Overall, about a third of ward managers told us the police had been called to their ward at least once in the previous 12 months to help contain patient behaviour. (e) We continue to hear accounts of patients’ experiences of being restrained. We promote examples of good practice where providers of inpatient mental health services have taken positive steps to reduce the use of restraint. (4) Consent to treatment. (a) We continue to observe that in a significant proportion of records there are no recorded assessments of patients’ consent or capacity at the point of admission or at the three month stage in detention. (b) We noted improving good practice in helping patients to draw up advance statements of their preferences for care and treatment. (c) In 2012/13, we arranged 13,520 visits by Second Opinion Appointed Doctors (SOADs). This is the heaviest demand for second opinions to date. This was despite an amendment to regulations that, from June 2012, removed the legal requirement for second opinion certification in the case of consenting CTO patients. (d) Where the treatment plan proposes medicine above BNF limits our SOADs are twice as likely to make significant (8%) or slight changes (32%) to the prescribed treatment as when it falls within BNF limits. This gives an indication of the safeguard provided by our SOADs against unwarranted treatment. (5) Access to care during a mental health crisis and the Mental Health Act. (a) In some areas difficulty in accessing Approved Mental Health Professionals (AMHPs), with waits of over four hours out of hours, are being reported. (b) In 2012/13, there were 21,814 uses of section 136, with over 7,500 estimated to involve the use of a police cell. This is a decrease of 7% on the previous reporting period. (c) Only 17% of recorded uses of hospital- based places of safety under section 136 resulted in further detention, following assessment by mental health professionals. (d) In one area police told us that 41 young people had been detained in police cells over the previous year, the youngest of whom was 11. This is unacceptable. (e) Health-based places of safety are often not staffed at all times. This has led to hospital places of safety lying empty while a patient is taken to police custody. (f) When we met with carers through our MHA monitoring they told us they were not always provided with enough information to understand the role and function of services or how to get help in a crisis. (6) Deaths of patients subject to the Mental Health Act. (a) In 2011/12 and 2012/13 we were notified of 595 deaths in total. There were 511 deaths of detained patients, and 84 deaths of patients subject to CTOs. (b) We support the recommendation of the Ministerial Board on Deaths in Custody that, NHS England - with input from CQC and the Coroners Society - should produce clear and consistent guidance on how all mental health providers should undertake investigations following the death of a detained patient. (c) We will be working with others to review national data and how this can be combined and shared to improve scrutiny and embed learning. We believe this will improve national understanding and our ability to work together to protect patients’ rights and increase safety. (d) We have introduced a patient safety outliers programme in mental health and will be using the data from this and our collaborative work with other national organisations to inform our understanding of providers and our assessment of how safe their services are. (e) The total number of reported deaths by unnatural causes for detained patients deaths reported to CQC rose from 36 to 48 in 2012/13 compared to the previous year. (7) Conclusions and next steps. We expect to see change in the following areas: (a) Hospitals must ensure that their policies promote the principle of least restriction and that their staff are supported to promote the dignity and autonomy of people in their care. (b) Hospitals must promote cultures that support therapeutic practices and reduce to a minimum the use of restraint and seclusion. The principles of the Code of Practice and the emerging national evidence on restraint need to be considered by all services. We expect detaining authorities to audit and review their local practices to minimise the use of restraint and seclusion. We expect to see evidence of coordinated care planning that allows patients’ preferences to be taken into account. This is to promote individual choice and involvement in avoiding or managing episodes that may otherwise result in restraint or seclusion. (c) NHS and local authority service commissioners of mental health services must act on these findings and on guidance in the Implementation Framework to the national mental health outcomes strategy to improve access to services and outcomes for people with mental health problems. We expect Clinical Commissioning Groups to ensure that local special urgency arrangements (section 140) are clear and provided to local authorities. (d) Commissioners and providers of mental health services must be proactive in initiating and embedding learning from the deaths of people subject to the MHA. We expect to see alignment of local preventative and investigative work with the national findings on mental health related deaths. This includes emerging guidance from national bodies and the use of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness toolkit. We expect services to notify us of deaths of detained patients and patients who are on a community treatment order at the time of their death.
- CQC, 'Monitoring the Mental Health Act in 2014/15' (10/12/15) . Overview: "There are 57 mental health NHS trusts and 86 independent mental health hospitals registered with CQC. Throughout the year we visit these services to interview patients and review practice. During 2014/15, 51% of all mental health inpatients were subject to the Mental Health Act 1983 (MHA) with 19,656 detained inpatients on 31 March 2015. We carried out 1,292 MHA visits, meeting over 5,900 patients to discuss how the MHA and its Code of Practice were being applied to them. Our Second Opinion Appointed Doctors also made 14,375 visits to patients in hospital and the community and we received 227 notifications following the death of people detained in hospital." Findings (headings from Summary chapter): (1) There is unacceptable variation in the way providers are applying the Code of Practice; (2) Providers are failing to make sure patients receive the support they need to be involved in their care; (3) Greater priority needs to be given to deaths in detention; (4) Providers must manage and monitor their use of the MHA better; (5) Understanding and improving the way the Mental Health Act is being applied for patients must be a priority for all.
- CQC, 'Monitoring the Mental Health Act in 2015/16' (21/11/16) . These are the key points from Part 1 ("The Mental Health Act in action") and Part 2 ("CQC and the Mental Health Act") respectively: (1) We have seen examples of good practice and innovative approaches to overcoming areas of concern highlighted in our previous reports. We have met thousands of staff who are compassionate and dedicated to providing the best support and treatment they possibly can for their patients. (b) Staff had received training on the changes in the Code, or the revised policies and procedures to reflect its guidance, on less than half of wards we sampled. From 2016, we have taken these failings into account and use them to inform the ratings we issue to providers. (c) Overall, the figures for care planning, patient involvement and discharge planning subject areas show unacceptable variation in meeting the Code’s expectations, similar to those recorded in the 2014/15 report. Some services need to address the quality of care in these areas for people detained under the MHA. (d) One in 10 records do not show evidence that patients have had their rights explained to them at the point of detention. This leads to patients not knowing what to expect, or understanding their rights under the MHA. (e) We were notified of 201 deaths of detained patients by natural causes, 46 deaths by unnatural causes and 19 yet to be determined verdicts. (2) In 2015/16: (a) We carried out 1,349 visits, met with 4,282 patients and required 6,867 actions from providers. (b) Our Second Opinion Appointed Doctor service carried out 14,601 visits to review patient treatment plans, and changed treatment plans in 27% of their visits. (c) We received 1,422 complaints and enquiries about the way the MHA was applied to patients. Issues identified included medication, care provided by doctors and nurses, leave arrangements and safeguarding concerns.
- Amended version of report. CQC, 'Monitoring the Mental Health Act in 2016/17' (amended version, 9/1/19) — "This document has been amended after our analysts found that we had displayed some data gathered by Mental Health Act reviewers on their visits in an inaccurate way." See CQC, 'Monitoring the Mental Health Act in 2016/17 - amendment list' (31/12/18) for details.
- List of amendments. CQC, 'Monitoring the Mental Health Act in 2016/17 - amendment list' (31/12/18) — This document contains the amendments which have been incorporated into CQC, 'Monitoring the Mental Health Act in 2016/17' (amended version, 9/1/19). "An explanation for the amendments: (1) Up until 2015/16, we used ‘Yes/No’ categories to document specific types of data gathered by Mental Health Act Reviewers on their visits. In 2015/16, we added an option for Reviewers to use a category of ‘Requires improvement’. This gave Reviewers the option of documenting that the provider had shown some evidence of meeting requirements, but that it still required improvement. (2) When working on the 2016/17 report, our analysts found that Reviewers had been inconsistent in how they had documented this information. Some had recorded results with just ‘Yes’ or ‘No’, while others had recorded ‘Yes’, ‘No’, or ‘Requires improvement’. (3) In preparing the report, we sought to present the information in the ‘Yes/No’ style to show a trend from past results. However, in doing so we combined the responses of ‘Requires improvement’ with the ‘No’ responses, which was inaccurate. As a result, we have amended the report."
- Annual CQC report on MHA. CQC, 'Monitoring the Mental Health Act in 2017/18' (26/2/19) — The two parts of this report contain the following headings. (1) Part 1: Key findings from our MHA activities: (1.1) National figures on the use of the Mental Health Act; (1.2) What are the key issues we have found in people's experience of the MHA? (1.21) How is information being provided to patients? (1.22) How are people being involved in care planning? (1.23) Are people accessing Independent Mental Health Advocacy? (1.24) How are services challenging restrictive practices? (1.25) Are physical health issues being identified on admission? (1.26) How is the Second Opinion Appointed Doctor service working for patients? (1.27) How are people being supported in discharge planning? (2) Part 2: CQC and the Mental Health Act: (2.1) Deaths in detention; (2.2) Complaints and contacts; (2.3) Absence without leave; (2.4) Children and young people admitted to adult mental health wards; (2.5) The First-Tier Tribunal (Mental Health).
- Press release about MHA report. CQC, 'CQC finds improvements in use of the Mental Health Act but remains concerned about safety' (26/2/19) — Extract from press release: "In its Monitoring the Mental Health Act in 2017/18 report published today, CQC has concluded that there has been an overall improvement in some aspects of care in 2016 to 2018, compared with findings in 2014 to 2016. They found: (1) Some improvement in the quality of care planning and patient involvement. A higher proportion of care plans are detailed, comprehensive and developed in collaboration with patients and carers. However, there is still considerable room for further improvement. (2) The provision of information about legal rights to patients and relatives is still the most frequently raised issue from visits. In many cases, patients may struggle to understand information given to them on admission because they are most ill at this point. (3) The greatest concern from Mental Health Act monitoring visits is about the quality and safety of mental health wards; in particular acute wards for adults of working age."
- Annual CQC report on MHA. CQC, 'Monitoring the Mental Health Act in 2018/19' (6/2/20) — The Foreword to the report states that the CQC found: "(1) Services must apply human rights principles and frameworks. Their impact on people should be continuously reviewed to make sure people are protected and respected. (2) People must be supported to give their views and offer their expertise when decisions are being made about their care. (3) People who are in long-term segregation can experience more restrictions than necessary. They also may experience delays in receiving independent reviews. This is particularly true for people with a learning disability and autistic people. (4) People do not always get the care and treatment they need. Some services struggle to offer appropriate options, both in the community and in hospital. (5) It is difficult for patients, families, professionals and carers to navigate the complex laws around mental health and mental capacity."
- Annual CQC report on MHA. CQC, 'Monitoring the Mental Health Act in 2019/20: The Mental Health Act in the COVID-19 pandemic' (26/11/20) — "This annual report on our monitoring of the Mental Health Act (MHA) puts a specific focus on the impact that the COVID-19 pandemic has had on patients detained under the MHA, and on the services that care for and treat them."
- Annual CQC report on MHA. CQC, 'Monitoring the Mental Health Act in 2020/21' (21/2/22) — Key messages are: (1) The workforce is under extreme pressure; (2) Community services are key to reducing levels of detention in hospital; (3) Urgent action is needed to address longstanding inequalities in mental health care.
- Annual CQC report on MHA. CQC, 'Monitoring the Mental Health Act in 2021/22' (1/12/22) — Key messages: (1) "Workforce issues and staff shortages mean that people are not getting the level or quality of care they have a right to expect, and the safety of patients and staff is being put at risk"; (2) "Gaps in community mental health care are compounding the rising demand on inpatient services, with delays in admission, transfer and discharge"; (3) "Urgent action is needed to tackle the over-representation of people from some ethnic minority groups and, in particular, the over-representation of Black people on community treatment orders"; (4) "The quality of ward environments is an ongoing concern, with many inpatient environments in need of immediate update and repair"; (5) "Despite the challenges facing services, we have seen examples of good practice around advance planning and applying the principle of least restriction".