Hywel Dda Health Board Mental Health Act Monitoring Visit St Caradog Ward, Canolfan Bro Cerwyn Date of visit: 1 November and 17 December 2012
Contents Chapter Page Number 1. Introduction 1 3. Findings St Caradog Ward 4 4. Recommendations 17 5. Next steps 19 Appendix A Roles and Responsibilities of Healthcare 20 Inspectorate Wales Appendix B Mental Health Act Monitoring 22 Appendix C Action Plan 24 ii
1. Introduction 1.1 On 1 November and 17 December 2012, Healthcare Inspectorate Wales (HIW) undertook an unannounced Mental Health Act Monitoring visit to St Caradog Ward, Canolfan Bro Cerwen, Withybush Hospital, part of Hywel Dda Health Board (HDHB). Background to the Mental Health Act 1.2 The Mental Health Act (the Act) gives organisations the legal power to detain people under certain circumstances or place conditions on them whilst they are in the community. Since April 2009, HIW 1 has undertaken the monitoring of the Act on behalf of Welsh Ministers. Further information is provided at Annex B of this report. Methodology of the Inspection 1.3 HIW recruits a number of Mental Health Act Reviewers who carry out both announced and unannounced visits to settings in Wales. They monitor that the correct legal processes are being adhered to; patients understand their rights and receive the care and treatment that is appropriate to their needs. 1.4 We visit and talk to individuals who are subject to restrictions made under the powers of the Act in hospitals, registered establishments and the community. These discussions are mainly held in private and only take place when the individual consents. We explore the individual s views on their care and treatment and will ensure that they understand their rights and the reasons for the restrictions placed on them. 1 Prior to this date the responsibilities had been taken forward by the Mental Health Act Commission who fulfilled the role on an England and Wales basis. 1
1.5 In addition, we check all records and paperwork related to the restrictions placed on the individual and ensure that the requirements set out in the Act and the Code of Practice for Wales (the Code) have been met. We can require the production of any records in relation to a patient s detention for inspection. 1.6 We also explore other pertinent issues related to an individual detained under the Act which include the environment of care in which a patient is detained, patients privacy and dignity, food and nutrition, access to general healthcare, care and treatment planning. 1.7 Detailed findings and associated recommendations were provided through verbal feedback throughout the inspection and more formally at the feedback meeting at the end of the visit, so that immediate action could be taken to discharge the recommendations. HIW issued a management letter to ABHB following the inspection in relation to care plan documentation. St Caradog Ward, Canolfan Bro Cerwen 1.8 Canolfan Bro Cerwen is a psychiatric service providing health services to mid and west Wales, consisting of two inpatient wards and a day centre and is situated on the same site as Withybush General Hospital, Haverfordwest. 1.9 St Caradog ward is an in patient facility providing 16 beds, specialising in assessment, and short term care and treatment for patients, usually through an acute stage of their mental illness. The ward team works closely with the crisis team and other agencies in the provision of after care and support for the patient on their return to the community. 1.10 The ward team told us that the recently opened Psychiatric Intensive Assessment and Care Unit (PIACU) on Cwm Seren Ward, St David s Hospital, is working collaboratively with them and has provided much needed 2
support and short term specialised care for some of their patients, who sometimes require the skills and facilities of a dedicated intensive care unit. 3
2 Findings 2.1 This chapter sets out the findings from our visit. The recommendations arising from these findings are covered in Chapter 3 of this report. Application of the Mental Health Act 2.2 The of two sets of detention papers we reviewed included a full record of the patient examination that took place on detention, at least one of the two sectioning doctors was approved under Section 12 of the Act 2. There were clear reasons given for the detention of the patient and why detention under the Act was the most appropriate way of providing care. 2.3 In both sets of records reviewed the Approved Mental Health Professional (AMHP) 3 had identified the Nearest Relative. In one case it had been difficult to contact the Nearest Relative, however there was evidence that the AMHP had made multiple attempts to do so and contact was eventually made. 2.4 Both patients had been subject to a renewal of detention; the correct prescribed forms had been completed within the legal timescales. There was evidence of a record of examination by the patient s Responsible Clinician 4 prior to the renewal of detention and a record of the Responsible Clinician s consultation with a second professional. 2 A doctor who has been approved by the Welsh Ministers (or the Secretary of State) under the Act as having special experience in the diagnosis or treatment of mental disorder. 3 A professional with specialised training in the use of the MHA and approved by a local social services authority to undertake a number of functions under the MHA. 4 The approved clinician with overall responsibility for the patient s care. 4
2.5 A Section 132 5 checklist, developed by the Mental Health Act Administration Team, contained within each of the examined records incorporated details of every aspect of the section of the Act that the patient was detained under, and set out their rights within that section of the Act. 2.6 There was evidence that patients had been informed verbally of their rights under Section 132 of the Act. They had also received their rights in writing and there was evidence in the patients records that this information was discussed with the patient and re-presented on a regular basis. 2.7 There was evidence that mental capacity assessments were carried out and these had been recorded appropriately within the patients records. 2.8 Patients had discharge plans in place, these were detailed and comprehensive. They had been developed collaboratively with the Crisis Team, who were based on the ward, and other services and agencies appropriate to the individual patients and the patients relatives. 2.9 A daily meeting was held between the Ward Team and the Crisis Team to ensure patients care pathways are discussed on a regular basis. This process had enabled more effective, timely and appropriate discharge and after-care plans. 2.10 In one case, a patient s Community Treatment Order 6 (CTO) had been revoked, because the team involved in the patient s care had concerns about the patient s behaviours and safety. Subsequently, clinical decisions were made following consultations between the Crisis Team and the Ward Team. The patient was recalled to the ward for a short period of time before returning 5 A section of the MHA dealing with patients rights under their detention order. 6 A treatment order whereby patients can be discharged in to the community, while continuing to be subject to certain criteria laid down within the MHA. 5
to the community, this highlighted the close liaison between inpatient care and the Crisis Team. 2.11 A protocol had been developed by the Health Board that ensures that when a patient has their CTO revoked a Hospital Manager s Hearing 7 and a Mental Health Review Tribunal 8 (MHRT) is automatically applied for by the Mental Health Act Department. This process ensured that the team s decision can be reviewed and challenged if necessary; providing the patient with an independent system of appeal. 2.12 Hospital Manager s Hearings were applied for within relevant timescales. The relevant documents and reports were of a good standard and where applicable detailed the reasons for declining the application, which was subsequently communicated to the patient concerned. 2.13 MHRT appeals had been held within appropriate timescales and there was evidence of patients being actively supported by representatives of their Independent Mental Health Advocate 9 (IMHA) service. 2.14 From the patient records reviewed all Mental Health Act documentation was compliant with requirements; correct forms had been used, completed fully and within timescales. 2.15 Staff told us that the Health Board s Mental Health Act Administrators provide excellent support and regular on ward training. They had also provided training to Accident and Emergency staff and local police, who regularly deal with patients who may require detention under the Act. 7 A hearing held by a panel of people, formed by the hospital, which enables patients to have the right of appeal against their continued detention. The panel has the power of discharge from some sections of the MHA. 8 A judicial body that has the power to discharge patients from detention, supervised community treatment, guardianship and discharge of the Act. 9 6
2.16 The Mental Health Act Department also undertakes regular audits of all areas of the Act and its application. They had recently introduced a system where each Mental Health Act Administrator is allocated a case load, so they are able to follow individual patient s journey from their admission to discharge. 2.17 Four sets of patient care plans were reviewed on the electronic record database. The computerised system, the Functional Analysis of Care Environments (FACE) was used throughout the Health Board and Social Services. This enabled the Multi-Disciplinary Team (MDT) and other agencies to maintain collaborative and up-to-date records, as a basis for good communications, integral to the patients care pathway. 2.18 All records reviewed, showed that patients were allocated a Named Nurse, Associate Nurses and an advocate on their admission. A care coordinator (who can be of any profession and often from the wider community care teams) had also been appointed. As part of the care planning process, information and views obtained from the patient and their family were incorporated. 2.19 The records showed that the patients physical and mental health had been fully assessed, together with the identification of social, emotional, psychological, communication and disability needs. 2.20 Observation levels, together with risk and relapse triggers were clearly identified. Goals and outcomes, along with after-care/discharge plans had been agreed early on in the patients stay and incorporated identification of needs and future support with accommodation, finances, professional support etc. 7
2.21 Nursing records were updated on each shift and there was evidence of regular reviews being undertaken with the MDT and relevant agencies such as housing, advocacy and social services. Good relationships and communications were noted with voluntary agencies, such as HAFAL 10. The Ward 2.22 On the first day of the visit the ward was at full occupancy with 16 patients. Eight patients were detained under the Act with the remaining eight patients being treated as informal patients. In addition five patients were on extended leave. Patients on leave may be required to return to St Caradog if their health deteriorates. This will cause pressures on available in-patient beds, to minimise the risk of these pressures a good working relationships between the in-patient team and community teams had been established through daily communication and integrated working. 2.23 The ward was purpose built, clean, well decorated and maintained to a good standard. The ward was light, spacious and bright with small activity areas and communal, quiet and living areas. 2.24 There was a picture gallery, where patients, under the guidance of the Occupational Therapy department had painted pictures directly on to the wall of a long corridor, which brightened the ward significantly. The artwork was extremely creative and had been designed so that patients could not pull them off the wall. 2.25 There were quiet rooms available where visitors could visit patients in private, but there was no identified child visiting area. The ward had a 10 A charity that supports individuals recovering from serious mental illness and their families. 8
children s visit policy, which reflects the safety and best interest of the child. Patients wishing for their children to visit may access the Day Care Centre facilities adjacent to the ward, based on individual patient risk assessments. However if this was not possible any children visitor would be required to come through the ward, as there was no alternative access to the ward available. 2.26 The ward had a garden area which was open and easily accessible for patients. Patients were able to smoke in this area and appropriate facilities were provided. The garden area was pleasant, but on the day of the visit was littered with cigarette ends and litter. Privacy and Dignity 2.27 All patients had their own bedrooms with en-suite shower facilities. The rooms were suitably furnished with appropriate privacy measures for bedroom windows and there were controllable privacy shutters on bedroom doors. 2.28 Patients could lock their rooms from the inside, but had to ask staff to lock their doors when they were not in their rooms. Patients told us that on occasions they had forgotten to ask for their rooms to be locked and found that their belongings had gone missing. 2.29 The bedroom lights had no dimmer switches or night-lights, this caused problems at night when patients were awoken from their sleep while staff undertake observations. 9
2.30 The ward had mixed gender patients and the team had made an effort to maintain gender specific areas of the ward, these were clearly identified with appropriate signage. Following our visit undertaken in 2011, a womenonly lounge has been created on the ward, however the room, although well decorated and furnished lacks homely touches. 2.31 There were laundry facilities for patients so that they can maintain self care and independence. 2.32 During the inspection, patients were observed to be treated with respect. Good relationships between staff and patients were noted and the maintenance of patients privacy and dignity was actively promoted. 2.33 There was a ward phone which was out-of-order on the day of our visit and we were informed this had been out of action for some time. As an alternative arrangement patients could use the ward office phone, however this was unsatisfactory as the ward office was busy and noisy and provided no privacy for patients. 2.34 Patients were allowed their personal mobile phones however staff raised concerns that patients had in the past used them to acquire alcohol and illegal drugs from outside the ward. 2.35 One patient raised with us concerns regarding the manner in which a member of staff had spoken to them. This was addressed with the Ward Manager on the day of the inspection and followed up later to ensure the patient was satisfied with the action taken. The patient told us they were satisfied with the outcome and did not wish to make a formal complaint. 10
2.36 The patient also felt that they did not see their Named Nurse or Responsible Clinician often enough. We reviewed the patient s records and these evidenced that the patient was seen daily by their Named Nurse who had recorded a summary of each engagement. The Consultant Psychiatrist held weekly ward-rounds and had also recorded the details of each engagement and outcomes of their weekly clinical review. 2.37 Another patient advised that they did not agree with their diagnosis and although they had discussed it with their Consultant Psychiatrist, they wished to have a second opinion on their diagnosis. We informed the patient of the process that they should follow within the Local Health Board to apply for a second opinion on their diagnosis and we also provided with further information whereby the patient could apply to an independent agency for this if they wished. The Multi-Disciplinary Team 2.38 The members of the team that we met were professional, caring and knowledgeable about their patient group. There was evidence of a balanced and appropriate skill mix with collaborative and effective multi-disciplinary and multi-agency teamwork. 2.39 The MDT members told us that they felt respected and valued within the team and felt empowered to work closely with patients and their families in developing and supporting their care plans and pathways. 2.40 There was evidence of strong and inspired clinical leadership and the staff we spoke with felt that they were well supported in their role, there was 11
clarity of direction, responsibilities were delegated appropriately and supervision and support was available. 2.41 Communications and relationships within the team and with other services and agencies such as housing, police, advocacy services and St Johns ambulance was noted to be effective and well coordinated. 2.42 The local police participated in training held regularly by the Health Board and spent some time on the ward as part of this training. We have highlighted this ongoing initiative as notable practice previously. 2.43 There were excellent working relationships between the Ward Team and the Crisis Team, who were based on the ward. There was evidence that this close working relationship together with good communication systems had helped with bed and risk management issues and had improved delays in the discharge process. 2.44 Further to our visit in 2011, a successful recruitment campaign had resulted in the appointment of a number of additional Registered Nurses. At the time of our visit the nurses were mainly newly qualified and were subject to a preceptorship programme 11. 2.45 An additional Occupational Therapy Technician had also recently been appointed to the ward team. 2.46 Staff morale within the ward and the Crisis Team was noticeably good. Staff appeared happy in their work and stated they were well motivated. Collaborative team working was observed and the ward manager reported that there was low sickness rates and high retention rates. 11 A formalised supervision process for newly qualified nurses 12
2.47 A clinical supervision, both group and individual, and performance review processes were being gradually implemented for all staff. This process was linked in to continuing professional development programmes and compliance was regularly audited by the Health Board. The team psychologist facilitated a monthly supervision group and staff were encouraged and supported to attend this along with individual supervision sessions. 2.48 Staff told us that the mandatory training (for example fire, health and safety, Cardio Pulmonary Resuscitation (CPR) management of violence and aggression) continues to be fully funded by the Health Board. However we were informed that the training budget for further professional development, vocational training, etc, had been significantly reduced in comparison to previous years. Safety 2.49 The team use a wide range of skills in the management of violent and aggressive behaviour including de-escalation, diversion and as a last resort, Restricted Physical Intervention (RPI). All staff were trained in this method of restraint and had regular training updates. We were pleased to note that the ward does not use seclusion. 2.50 A high risk ligature point identified on a previous inspection had been removed and the Health Board carried out regular ligature point risk assessments as part of a general health and safety audit. 2.51 The Occupational Therapy department had moved from the far end of the ward to a central, far more accessible area of the ward. However, although there was transparent glass surrounding the Occupational Therapy 13
department, this had been covered with pictures and the Occupational Therapy area could not be observed by people outside in the corridor. We strongly feel that this obstruction creates a significant safety and security risk for both patients and staff. 2.52 The ward was locked on the day of our inspection, as a patient had absconded the previous night. There was a locked door policy in place; and there were notices informing informal patients of their rights and how they could leave the ward if the door was locked. A record of when the ward was locked was maintained and this is monitored by the Mental Health Act department. 2.53 There were appropriate personal alarms available for staff and visitors and an inbuilt ward call systems was in place, which could be accessed throughout the ward. Patients had a personal call system in their bedrooms. Patient Therapies and Activities 2.54 Individual and group therapies were observed to be available for patients. There was a Ward Psychologist, Occupational Therapists, Physiotherapists and Nurses with specialised skills, who provided therapeutic programmes based on patients assessed needs. 2.55 Basic life skills, social and community skills, together with behavioural and rehabilitation programmes, drug and alcohol programmes, were also available to patients. However, for some conditions, such as eating disorders, appropriate therapies and skills were limited due to the skill set of ward staff. 14
2.56 The Occupational Therapy Team provided a flexible and responsive programme of activities to meet the needs of the individual patient rather than having a strict timetable of activities for a group of patients. 2.57 There was evidence of detailed occupational therapy assessments and individualised programmes reflecting the patient s rehabilitation and recovery needs. The Occupational Therapy Team work closely with the Ward Team, the Community Mental Health Team (CMHT) and the Crisis Team, along with voluntary and statutory agencies to support patients to return to their home or community placement. 2.58 Since our previous Mental Health Act visit undertaken in March 2011 the space, facilities and available activities had been much improved. A ward based gym had been introduced, which patients, further to a physiotherapy assessment, could use under supervision. 2.59 A nurse-led activity programme, an initiative where nurses were allocated time to facilitate small scale activities was popular with both patients and staff, particularly during the evenings and weekends. General Healthcare 2.60 Robust physical healthcare assessments were carried out for all patients, including specific, evidence based assessments for diabetes and obesity. A doctor with a special remit in relation to physical health attended the ward daily. 2.61 There was a ward physiotherapist and patients had access to chiropody services. 15
2.62 There was still some difficulties in relation to accessing services from the neighbouring general hospital. However, staff reported that some improvements had been made and a physical healthcare group, led by the County Head for Mental Health Services, was working on a number of joint initiatives and protocols. The recent introduction of a protocol for the therapeutic management of acutely disturbed service users in Adult Mental Health services and Accident and Emergency departments was noteworthy practice. Food and Nutrition 2.63 Some patients felt that there was not enough variation in menus and so meals could be a bit repetitive. We were informed by staff that this issue was being reviewed by the ward team as part of a Fundamentals of Care Audit. 2.64 Patients had access to a small ward kitchen throughout the day, which had tea and coffee making facilities and facilities for patients to make light snacks. 16
3. Recommendations 3.1 Findings and associated recommendations were provided through verbal feedback throughout the inspection and more formally at the feedback meeting held at the end of the visit. 3.2 In view of the findings arising from this review we make the following recommendations. Reference Recommendation Paragraph Reference The Ward 1.1 The Health Board should review and monitor bed 2.22 capacity management across the Health Board to ensure that there are available beds should a patient be required to return from Section 17 Leave earlier than initially planned. 1.2 The Health Board should ensure that family and 2.25 child visiting facilities are provided as set out in paragraph 20.7 of the Code. 1.3 The Health Board should ensure there is an appropriate system for maintaining the cleanliness of the garden area. 2.26 Privacy and Dignity 2.1 The Health Board should ensure that patients are 2.28 able to lock their rooms when they leave them. 2.2 The Health Board should ensure that there is 2.29 suitable lighting so that staff can undertake observations at night without disturbing patients sleep. 2.3 The Health Board should ensure that the female lounge is redecorated so that it is welcoming and comfortable for female patients. 2.30 17
Reference Recommendation Paragraph Reference 2.4 The Health Board should ensure the ward 2.33 telephone is repaired. 2.5 The Health Board should review the use of mobile 2.34 phones to ensure staff are able to individually risk assess the appropriateness of access for each patient. 2.6 The Health Board should ensure that staff are aware of the importance of treating patients with dignity and speaking to them with respect. 2.35 The Multi-Disciplinary Team 3.1 The Health Board should review the staff training 2.48 budget, particularly in areas of further professional development and vocational training. Safety 4.1 The Health Board must ensure that there is appropriate visibility in to the Occupational Therapy Room from the adjoining corridor. 2.51 Food and Nutrition 5.1 The Health Board should monitor the outcome of its audit of the quality of patients food and nutrition, particularly with regards to choices and repetition. 2.63 18
4. Next steps - Update 4.1 The Health Board has submitted an action plan to address the key issues highlighted in this report and it is available at Appendix C. HIW has reviewed the action plan and is satisfied that the concerns raised by the inspection will be appropriately addressed. 4.2 Hywel Dda Health Board has confirmed that all actions will be completed by xxx, within xx months of the inspection. 4.3 HIW will monitor progress In relation to the implementation of actions and will undertake further visits as necessary. 19
Appendix A The Roles and Responsibilities of Healthcare Inspectorate Wales Healthcare Inspectorate Wales (HIW) is the independent inspectorate and regulator of all healthcare in Wales. HIW s primary focus is on: Making a significant contribution to improving the safety and quality of healthcare services in Wales. Improving citizens experience of healthcare in Wales whether as a patient, service user, carer, relative and employee. Strengthening the voice of patients and the public in the way health services are reviewed. Ensuring that timely, useful, accessible and relevant information about the safety and quality of healthcare in Wales is made available to all. HIW s core role is to review and inspect NHS and independent healthcare organisations in Wales to provide independent assurance for patients, the public, the Welsh Government and healthcare providers that services are safe and good quality. Services are reviewed against a range of published standards, policies, guidance and regulations. As part of this work HIW will seek to identify and support improvements in services and the actions required to achieve this. If necessary, HIW will undertake special reviews and investigations where there appears to be systematic failures in delivering healthcare services to ensure that rapid improvement and learning takes place. In addition, HIW is the regulator of independent healthcare providers in Wales and is the Local Supervising Authority for the statutory supervision of midwives. HIW carries out its functions on behalf of Welsh Ministers and, although part of the Welsh Government, protocols have been established to safeguard its operational autonomy. HIW s main functions and responsibilities are drawn from the following legislation: 20
Health and Social Care (Community Health and Standards) Act 2003. Care Standards Act 2000 and associated regulations. Mental Health Act 1983 and the Mental Health Act 2007. Statutory Supervision of Midwives as set out in Articles 42 and 43 of the Nursing and Midwifery Order 2001. Ionising Radiation (Medical Exposure) Regulations 2000 and Amendment Regulations 2006. HIW works closely with other inspectorates and regulators in carrying out cross sector reviews in social care, education and criminal justice and in developing more proportionate and co-ordinated approaches to the review and regulation of healthcare in Wales. 21
Mental Health Act Monitoring Appendix B The role of the Review Service for Mental Health, within Healthcare Inspectorate Wales, is to keep the use of the Mental Health Act 1983 under review and check that the Act is being used properly. The Review Service for Mental Health is independent of all staff and managers of hospitals and mental health teams. We use Mental Health Act Reviewers which could include doctors, nurses, social workers, lawyers, psychologists, service users and other people with knowledge of the Act and mental health services. Reviewers can visit all places where patients are detained under the Mental Health Act, and meet with them in private. In certain circumstances, the Review Service also arranges for an independent doctor to provide a second opinion if a patient is not able or willing to consent to their treatment. The Review Service may investigate certain types of complaints. The Review Service publishes a report of its activities and findings every year. How do the Reviewers do it? Reviewers can visit all wards where patients are detained under the Mental Health Act 1983 and may also visit other settings to meet with patients subject to Guardianship or Supervised Community Treatment (SCT) to check: that such patients are lawfully detained and well cared for that such patients are informed about their rights under the Act that such patients are given respect for their qualities, abilities and diverse backgrounds as individuals, and that account is taken of their 22
needs in relation to age, gender, sexual orientation, social, ethnic, cultural and religious backgrounds that the Mental Health Act Code of Practice for Wales is being followed that the right plans are made for patients before they are discharged from hospital. During visits, Reviewers meet and talk to detained and informal patients in private. Reviewers also meet with managers and other staff to talk about things that affect patients care and treatment, and to raise issues on behalf of patients. What the Review Service for Mental Health cannot do The Review Service: cannot discharge patients from their section under the Mental Health Act 1983 cannot discharge patients from hospital cannot arrange for patients to have leave cannot transfer patients to another hospital cannot offer individual medical advice cannot offer individual legal advice cannot help informal patients This is because the law is very clear about what we can and cannot do, not because we don t want to help. The Review Service can advise where else help could be obtained from. 23
Appendix C Action Plan Reference Recommendation Action Responsible Timescales Officer The Ward 1.1 The Health Board should review and monitor bed capacity management across the Health Board to ensure that there are available beds should a patient be required to return from Section 17 Leave earlier than initially planned. 1.2 The Health Board should ensure that family and child visiting facilities are provided as set out in paragraph 20.7 of the Code. 1.3 The Health Board should ensure there is an appropriate system for maintaining the cleanliness of the garden area. Privacy and Dignity 2.1 The Health Board should ensure that patients are able to lock their rooms when they leave 24
Reference Recommendation Action Responsible Officer them. 2.2 The Health Board should ensure that there is suitable lighting so that staff can undertake observations at night without disturbing patients sleep. 2.3 The Health Board should ensure that the female lounge is redecorated so that it is welcoming and comfortable for female patients. 2.4 The Health Board should ensure the ward telephone is repaired. 2.5 The Health Board should review the use of mobile phones to ensure staff are able to individually risk assess the appropriateness of access for each patient. 2.6 The Health Board should ensure that staff are aware of the importance of treating patients Timescales 25
Reference Recommendation Action Responsible Officer with dignity and speaking to them with respect. The Multi-Disciplinary Team 3.1 The Health Board should review the staff training budget, particularly in areas of further professional development and vocational training. Safety 4.1 The Health Board must ensure that there is appropriate visibility in to the Occupational Therapy Room from the adjoining corridor. Food and Nutrition 5.1 The Health Board should monitor the outcome of its audit of the quality of patients food and nutrition, particularly with regards to choices and repetition. Timescales 26