South West Yorkshire Mental Health NHS Trust. Care Quality Commission Annual Report. Action Plan period November 2009 October 2010

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1 HEALTH CHECKS Managers should develop a system to ensure that annual physical health checks for detained patients take place and are clearly recorded. The Trust has a policy outlining the requirement for physical health checks to be undertaken on admission and it recommends that an annual health check is undertaken for those patients who remain in hospital for long periods. The policy also requires health checks to be undertaken where specific treatments are to be prescribed. There is a medical physical examination document available for the recording of the assessment. The Trust is currently reviewing the document with an aim of having it as a template within the electronic clinical system (RIO). The Trust is Nisreen Booya Medical Director Acting Director of Nursing, Innovation and Compliance Review of documentation to be completed end of June 2011 CQC Audit to be completed by end of April

2 currently undertaking an audit of the clinical records based on the Mental Health Act Commissioners audit. SERVICES Managers should ensure that staff at ward level are familiar with the role of IMHAs, who the commissioned IMHA provider is and how the IMHA service can be accessed. The Trust has reviewed and up dated the patient s rights policy section 132 to reflect the patient s right to access to an IMHA, the recording forms have also been amended and staff are now required to confirm that a leaflet has been given to the patient and they have been informed of their rights. Posters and leaflets have been redistributed to services through individual ward managers for display in ward areas. The Mental Health Act Administrators have been requested to enclose IMHA leaflets when acknowledging the patients Acting Director of Nursing Compliance & Innovation Actions completed except Audit to be completed by end of April Action plan to be developed following audit results. 2

3 request for a hospital manager s appeal / review. The Trust is currently undertaking an audit of MHA issues. (The audit tool being used is the one used by the MHA Commissioners). PATIENTS RIGHTS Managers should ensure that the good practice on some wards in respect of recording informing detained patients of their rights is replicated across all wards where there are detained patients. The policy relating to patients rights has been reviewed, updated and distributed to all clinical services. The policy will be redistributed through all ward managers. Acting Director of Nursing Compliance & Innovation Policy to be redistributed with guidance note by end of March completed CODE OF PRACTICE Managers should ensure that conditions on wards that are due for closure meet all the Code of Practice requirements for detained-patients environments right up to the time of closure. We understand that this comment was relating to the re provision of St Lukes. The Trust no longer has any operational services at this site. The Trust does however note the Alan Davis Director of Human Resources and Work Force Planning Completed December

4 Commissioners comments and will aim to keep conditions on our wards to a high standard. CATERING Managers should continue to review its catering provision to ensure that all detained patients are given choices of a variety of healthy and culturally appropriate food, and that portions are adequate to meet patients nutritional needs. There are service user menu group meetings every 8 weeks which provide a forum for service users, housekeepers, unit managers and dieticians to raise any concerns, address any general catering issues and look at replacing any unpopular dishes. In conjunction with this meeting there are also regular contract meetings and catering liaison meetings between the contracted catering manager, Trust dieticians an the Trust contract manager. Alan Davis Director of Human Resources and Work Force Planning. Completed Ongoing review as indicated in the response All portion sizes have been 4

5 agreed with the Trust dieticians and are based on the British Dietetic Association publications in particular the estimated average requirements (EAR) for food energy and the recommended nutrient intake for all other nutrients. The food service provision is bulk service to the ward areas with service user choice at point of service. There is a comprehensive menu which includes Halal, Caribbean, vegan and vegetarian. SMOKING POLICY Managers should complete the review of the smoking policy and continue to re-examine its smoking arrangements for detained patients with a view to ensuring adequate shelter and Review of smoking policy and environments completed. Dr Nisreen Booya Medical Director Completed December

6 dignity and to enhancing the quality of life of smoking and non-smoking patients. SECURITY Managers should ensure that the security needs of one patient group do not impact negatively on the needs of another patient group for access to fresh air and outdoor exercise. The Trust acknowledges and agrees with the comments of the Commissioner. Where an incident occurs that has an impact on other patients the Trust does and will continue to make necessary adjustments so that there is minimal impact on other patients. Alan Davis Director of Human Resources and Work Force Planning Acting Director of Nursing Compliance & Innovation Completed 6