Mental Health Act Annual Statement September 2010 Action plan in response to recommendations and actions Recommendation/action 1. Care Programme Approach, the Commission recommends that efforts are to ensure patients are at the centre of care planning systems. The trust is requested to carry out a review of systems of recording, some forms used do not have a section to record patients own view points and where it appears this is left blank. Recording of patients own views in in-patient care plans has been audited as part of the CPA audit. Ensuring that patients own views are routinely recorded in in-patient care plans will be an action for each service directorate within the CPA audit report action plan A section for recording patients views will be included in all nursing care plan templates. An audit of recording patients views in nursing care plans will be undertaken Associate Director of Social Care/Operational Heads Deputy Director of Nursing Deputy Director of Nursing March 2011 March 2011 A further audit of in-patient CPA will be undertaken Associate Director of Social Care November 2011 1
2. Responsible Clinicians to specify the exact amount of leave patients should be taking for their recovery. The trust is to ensure that patients are receiving their full quota of leave entitlement. Further to the 2010 audit of section 17 leave, a standardised section 17 leave electronic recording system has been designed, incorporated into ICIS and brought into operation across the Trust. An audit of cancellations of planned escorted leave due to non-availability of staff to provide and escort will be undertaken. 3. The CQC recommends that there are more briefings to ward staff and managers on the role of advocacy. All in-patient mental health services have been briefed on IMHA provision with contact details for the commissioned IMHA provider for each service. IMHA and general advocacy service providers will be invited to participate in advocacy awareness sessions for ward staff and managers. April 2011 and on-going 2
4. The CQC would welcome information on how patients in longer term detention have their physical health care needs assessed and met. In accordance with the Physical Healthcare Policy, patients who are detained for longer than six months are given physical healthcare checks at a minimum of every six months. The checks are carried out and recorded using the physical healthcare check proforma which is available on ICIS. In-patients within the Adult Forensic Service have access to a GP service and access to a visiting podiatrist and dietician on a weekly basis. The physical healthcare department has a central database for tracking patients with diabetes and other chronic health conditions such as asthma, bronchiectasis, COPD, arthritis etc. There is also a database for cervical screening which is monitored by the GP service. An audit of physical healthcare has been carried out in November 2010. The physical healthcare audit will be carried out again within the annual audit programme Assistant Director of Nursing/ Chair of Physical Healthcare Group As per audit report recommendations 3
5. The trust is asked to continue the audit of section 132, to remind staff of their responsibilities in terms of section 132 especially for patients when they are transferred within the trust to new clinical teams. The requirement to inform and re-inform detained patients of their rights is set out in the Mental Health Act 1983 Information Policy. On each occasion the patient is informed of their rights, this is recorded on ICIS on the detained patients and SCT patients record of informing patients of their rights proforma which is then used as the basis for the section 132 audits. The section 132 audit will be carried out again as part of the 2010 MHA audit programme. 6. The trust is asked to ensure that ward phone arrangements should offer privacy for patients. Arrangements to enable patients to access a phone in privacy are determined by the needs of the patient group on each ward. This provision includes phone booths, portable phones and, in the case of the John Denmark Unit, mobile phones to enable Deaf patients to text. Further to the observations of the visiting MHA Commissioner, the phones on Ward 21 and Ward 22 at Trafford have been moved from the lounge areas to phone booths in the corridors. Maintenance and reprovision of phones will be carried out as needed Service Managers According to need on each ward 4
7. Staff should be trained in the management of gender separation. A privacy, dignity and respect resource pack and guidance on promoting sexual safety have been developed and training on these launched across service directorates. The training will be further rolled out within the Nursing Strategy, the training elements of which will be taken forward in the new education/learning and development commissioning process. and Organisational Development April 2011 and on-going Richard Backhouse December 2010 5