Mental Health Act 1983 monitoring visit

Mental Health Act 1983 monitoring visit Provider: Nominated Individual: Region: Location name: Location address: Ward(s) visited: Ward type(s): Type of visit: North East London NHS Foundation Trust Stephanie Dawe North Sunflowers Court Goodmayes Hospital, 157 Barley Lane, Goodmayes, Ilford, Essex, IG3 8XJ Ogura Acute admission Unannounced Visit date: 13 January 2014 Visit reference: 30375 Date of issue: 24 January 2014 Date Provider Action Statement to be returned to CQC: 13 February 2014 What is a Mental Health Act monitoring visit? By law, the Care Quality Commission (CQC) is required to monitor the use of the Mental Health Act 1983 (MHA) to provide a safeguard for individual patients whose rights are restricted under the Act. We do this by looking across the whole patient pathway experience from admission to discharge whether patients have their treatment in the community under a supervised treatment order or are detained in hospital. Mental Health Act Commissioners do this on behalf of CQC, by interviewing detained patients or those who have their rights restricted under the Act and discussing their experience. They also talk to relatives, carers, staff, advocates and managers, and they review records and documents. 1

This report sets out the findings from a visit to monitor the use of the Mental Health Act at the location named above. It is not a public report, but you may use it as the basis for an action statement, to set out how you will make any improvements needed to ensure compliance with the Act and its Code of Practice. You should involve patients as appropriate in developing and monitoring the actions that you will take and, in particular, you should inform patients of what you are doing to address any findings that we have raised in light of their experience of being detained. This report and how you act on any identified areas for improvement will feed directly into our public reporting on the use of the Act and to our monitoring of your compliance with the Health and Social Care Act 2008. However, even though we do not publish this report, it would not be exempt under the Freedom of Information Act 2000 and may be made available upon request. Our monitoring framework We looked at the following parts of our monitoring framework for the MHA: Domain 1 Assessment and application for detention Purpose, respect, participation and least restriction Patients admitted from the community (civil powers) Patients subject to criminal proceedings Patients detained when already in hospital People detained using police powers Domain 2 Detention in hospital Purpose, respect, participation and least restriction Admission to the ward Tribunals and hearings Leave of absence Transfers Control and security Consent to treatment General healthcare Domain 3 Supervised community treatment and discharge from detention Purpose, respect, participation and least restriction Discharge from hospital, CTO conditions and info about rights Consent to treatment Review, recall to hospital and discharge 2

Findings and areas for your action statement Overall findings Introduction: Ogura ward is a male acute admissions unit based within Sunflowers Court, a purpose built building providing mental health inpatient services. The ward accepted men between 18 to 65 predominantly from Redbridge and Barking and Dagenham although patients were also admitted from Havering and Waltham Forest if there were no beds in those areas. The ward had 20 beds but on the day of the visit, 27 patients were allocated to the ward, six patients were on leave and one informal patient had left the ward but had not been discharged. All of the patients had individual bedrooms; eight were en-suite. There were four shower rooms and two bathrooms although one shower room and one bathroom were out of order on the day of the visit. Two bedrooms had been adapted for wheelchair users. There were no lockable facilities in the bedrooms for storage of personal items. Patients had access to a courtyard garden area although this was littered with discarded cigarette ends. On the day of the visit (a Monday), there were five staff on duty through the day, two of whom were qualified. As well, the ward manager was present on the ward. We were advised that this was the usual staffing level for a Monday due to the ward round taking place. The staffing level for the rest of the week was five staff in the morning and four staff in the afternoon. We were advised that extra staff would be allocated to the ward if observation levels required this. How we completed this review: We interviewed three patients and reviewed their records. We talked to the ward manager, locum consultant psychiatrist and occupational therapist. We toured the ward and observed lunch being served. What people told us: Patients told us: The staff have been nice and fine with me. I feel safe on the ward and treated with respect. Some staff sit in the office all day. I have a personality clash with some staff. The environment is clean and hygienic. Other patients are noisy. I saw someone punching the floor. I know about the advocacy service. I think I have met the advocate. and I shouldn t be here. I am well enough to be discharged. Staff told us: Covering four boroughs can be challenging in terms of the liaison with community staff. We liaise with eight community recovery teams, three home treatment teams and an assertive outreach team. The multi-disciplinary team works really well; it is 3

one of our strengths as a ward. Discharge planning starts as early as possible although we are finding it is difficult to secure accommodation for patients who need this. We have three people on leave staying with family members who need accommodation of their own. Past actions identified: At the previous inspection, dated 18 October 2012, we identified concerns with the care plans which showed little evidence of patient participation and were not holistic. These concerns were fully addressed. All three care plans reviewed were up to date and showed evidence of patient involvement, quoting patient views and feelings. The care plans were generally consistent with the way the patients had expressed themselves during interview. Only one exception to this was noted. Within one care plan, it was documented, I will get my care coordinator to meet my cultural or spiritual needs. The ward manager agreed that it was unlikely that the patient would have expressed himself in this way and said that he would follow this up. The care plans were holistic. For example, one patient s care plan identified issues with rent arrears, the patient s mental state, medication and getting a travel pass. We also noted that a patient admitted within the last five days, had a comprehensive care plan covering medication, becoming unwell, possible psychology input and explanation of rights. At the previous inspection, it was observed that some of the patients had no wardrobes or chests of drawers. This concern was fully addressed. We were advised that new furniture had been acquired and all patients now had a wardrobe. This was evidenced in the rooms observed. At the previous inspection, it was noted that one patient detained under section 5(2) Mental Health Act (MHA) 1983 and subsequently under section 3, MHA 1983 did not appear to have been advised of his rights. It was also noted that part 1 of the form H1 was dated and signed by the medical practitioner at 4.35pm whereas the form H1 was received on behalf of the managers at 4.20pm. This error had not been picked up on scrutiny of the detention papers. In relation to the detention under section 3, there was no copy of the approved mental health professional (AMHP) report on file. These concerns had been partly addressed but further action is recommended. All three patients had been given information about their rights. However, two of the three patients interviewed did not correctly identify the section they were detained under. On the section 132 form for one patient, it was noted that he had understood his rights but was unsure about whether to appeal. It was unclear what time period would elapse before this was discussed again. Whilst trying to locate detention papers for the patients interviewed, the ward manager found out that detention papers were only uploaded to the WinDIP document management system when the section had expired. The paper copies which had previously been sent to the MHA office and copied to the ward were now stored only at the MHA office. This meant that detention documentation was not readily available to ward staff. One patient did not appear to have a full AMHP report based on a scrutiny of the documentation checklist by the ward manager but this 4

could not be checked with the MHA office as the office had closed at 16.30. Whilst the Code of Practice does not specify that copies of section papers should be available at ward level, the decision to upload documents to WinDIP after the section has expired rather than as soon as they have been scrutinised, means that ward staff do not have ready access to detention documentation. Domain areas Purpose, respect, participation and least restriction: Staff were generally observed to treat the patients with respect and there was a relaxed atmosphere on the ward. We noted one exception to this. One patient became impatient with another patient who was taking his time to choose his food at the meal hatch, in the dining room. This patient commented that the man at the hatch should be given ECT (electroconvulsive therapy) and the female nurse observing the room laughed at this. This incident was discussed with the ward manager and modern matron at the feedback session. We were advised that there had been a serious incident during the previous week when two visitors to the ward had badly assaulted a nurse. Rules regarding visiting times were being applied with less flexibility than prior to this incident although staff were mindful of the need to be as least restrictive as possible. An occupational therapist (OT) was also allocated to the ward and organised the activities programme, facilitating some groups with the psychologist. The nursing staff were solely responsible for the programme at weekends and when the OT was on leave. Activities included current affairs discussion, a recovery group, a healthy living group and gym sessions. The weekend activities were more informal and consisted of games consoles and board games during the afternoon and movie evenings or music appreciation in the evenings. The medical team facilitated a mental health awareness group once per month. Patients had access to the internet via a computer in the information room. Patients did not have any lockable facility in their bedrooms to keep personal possessions with them on the ward. There was a property room for secure central storage of belongings. We were advised that community meetings were scheduled to take place weekly but this had lapsed and minutes were only available for 19 November 2013 and 7 January 2014. The ward manager advised us that weekly meetings were going to be reinstated. Admission to the ward: We noted, as an example of good practice, that there was a multidisciplinary meeting every morning, attended by home treatment team representatives as well as in-patient staff. The care of all the patients allocated to the ward was discussed including those on leave. However, we were concerned that 27 patients were allocated to this 20 bed ward. This bed occupancy rate far exceeded the Royal College of Psychiatrists recommendation that a bed occupancy rate of 85% is 5

optimal (as detailed, for example, in the Royal College of Psychiatrists report: Do the right thing: how to judge a good ward. Ten standards for adult in-patient mental healthcare). We were advised that the independent mental health advocacy (IMHA) service was provided by two providers, Voiceability and POhWER. Staff informed us that both services visited the ward on request of staff or the patient but that there was often a delay of several days before the advocate was able to visit. It was noted that there was no poster advertising the IMHA service for either provider although there were some leaflets about the services in the information room. Patients were advised about advocacy when first informed of their rights. There was no poster advising patients about the role of the CQC and we were advised that this would be remedied. We observed that there was appropriate signage at the entrance door advising informal patients of their right to leave the ward at any time. One patient was admitted to the ward under section 136 on 9 January 2014. He was assessed and placed under section 2, on the same day. The application by the AMHP stated that the nearest relative had not been consulted. The doctor had spoken to the nearest relative on 9 January 2014. The AMHP subsequently tried to phone the nearest relative on 10 January 2014 but it was recorded that her phone was continually engaged. It was therefore not clear whether the nearest relative had been informed about her rights in relation to the patient. During the tour of the ward, we were shown the Dirty Utility room. The ward has been advised that money has been allocated to update and improve this room. All the bags, including laundry bags, black bags and orange clinical waste bags were on the floor as there were no bag holders. Tribunals and hearings: The domain area was not reviewed at this inspection. Leave of absence: The section 17 leave file was checked and out of date leave forms were filed with the current form. There was no box on the form to indicate whether a copy of the leave form had been given to the patient or the carer or any other relevant person although we were advised that patients were given a copy of the leave form if they wanted this. One patient who was detained under section 37/41 had been authorised to take regular five day leave periods since October 2013. We were advised that the locum consultant psychiatrist had informed the Ministry of Justice (MOJ) in October 2013 that the patient was well enough to be discharged. However, despite this being regularly chased up, the MOJ had not yet authorised his discharge. On the day of the visit, this was followed up again and the MOJ had apologised for the delay and said that they would notify the ward within a week of their decision. Whilst we were advised that this patient remained well enough to be discharged, his risk assessment had been changed to high on 18 November 2013 and remained high when risk was assessed again on 12 January 2014 having been previously 6

regarded as low up to 18 November 2013. Therefore, there appeared to be a discrepancy between his risk level and the decision to discharge him. The patient was aware that he could have applied to the Tribunal but had not realised that the MOJ would take three months to reach a decision regarding his discharge. Transfers: The domain area was not reviewed at this inspection. Control and security: We discussed the management of aggression with the ward manager. There was no seclusion room on the ward and de-escalation techniques and distraction were used to support patients. Medication was used as a last resort. We were provided with a copy of the Policy and guidance for the recognition, prevention and therapeutic management of violence and aggression This was dated February 2009 with a review date of April 2012. The policy states, The provision of a homely environment in terms of furnishings and the ongoing maintenance of its decoration is key to creating an atmosphere where violence is discouraged. We noted that there was an absence of pictures and other wall decoration. We were advised that there have been attempts to put up artwork but this is often damaged by patients; the Christmas decorations were destroyed after three days. However, it was acknowledged by staff that maintaining a more homely atmosphere required ongoing effort. Consent to treatment: One patient had not had his capacity to consent to treatment assessed at first administration of Risperidone. One patient had not had his capacity to consent to treatment assessed although he had been prescribed Lorazepam, Promethazine and Zopiclone, on an as required (PRN) basis. None of these drugs had been administered. Both patients had been admitted to the unit within the previous three weeks. One patient had consented to treatment and had T2 certificates dated 31 December 2013 and 1 July 2013. He confirmed that he was still consenting to take his medication. When we discussed the issue of capacity to consent to treatment, the ward manager stated that he had carried out an audit of capacity to consent to treatment within the previous week and within this process, it had become apparent that the locum consultant psychiatrist was not aware of the form for recording capacity used by the ward and had instead been recording capacity within the progress notes. General healthcare: We discussed general healthcare with the ward manager and identified no issues. The medical team attended to patients physical problems. All patients had a routine physical examination on admission along with routine blood tests and an 7

electrocardiogram (ECG) Other areas: The ward manager advised us that three patients were ready to be discharged but were on leave with family and friends as accommodation could not be found for them. We were further advised that local authorities were not willing to pay sufficient housing benefit to cover the high private rents in London boroughs and did not have sufficient council accommodation to provide this. 8

Section 120B of the Act allows CQC to require providers to produce a statement of the actions that they will take as a result of a monitoring visit. Your action statement should include the areas set out below, and reach us by the date specified on page 1 of this report. Domain 2 Admission to the ward CoP Ref: 1.2, Royal College of Psychiatrists, OP79 We found: We noted, as an example of good practice, that there was a multidisciplinary meeting every morning, attended by home treatment team representatives as well as in-patient staff. The care of all the patients allocated to the ward was discussed including those on leave. However, 27 patients were allocated to this 20 bed ward. This bed occupancy rate far exceeded the Royal College of Psychiatrists recommendation that a bed occupancy rate of 85% is optimal. We were concerned that if a patient who was on leave had to return to the ward due to relapse, this could not be facilitated promptly without another patient leaving the ward. Your action statement should address: How the trust (working alongside NHS commissioners) will ensure that bed occupancy rates are reduced to an acceptable level, maximising the safety and wellbeing of patients allocated to the ward. 9

Domain 2 Admission to the ward MHA section: s.132 CoP Ref: 2.44 We found: All three patients had been given information about their rights, according to their documentation. However, only one patient said that he understood his rights. One patient who was detained under section 2 said that he thought he was on a section 136 (which he had been previously). One patient, detained under section 3, asked whether he was detained under a section 19. On the section 132 form for one patient, it was noted that he had understood his rights but was unsure about whether to appeal. It was unclear what time period would elapse before this was discussed again. We were advised that a patient would be informed about their rights on admission and an entry would be made in the diary to repeat this although no time period was specified for this process. It was acknowledged that due to the nature of patients illnesses, information may not be understood or retained. Your action statement should address: How the trust will ensure that there is a robust system of regular checks to confirm that information is given to each patient about their rights and that information regarding rights is understood and retained by the patient. Domain 2 Leave of absence MHA section: 17 CoP Ref: 21.21 We found: The section 17 leave file was checked and out of date leave forms were filed with the current forms for the majority of patients. There was no box on the form to indicate whether a copy of the leave form had been given to the patient or the carer or any other relevant person although we were advised that patients were given a copy of the leave form if they wanted this. Your action statement should address: How the trust will ensure that only the current section 17 leave form is available within the leave file and that copies of the leave form are given to the patient, carer or other professional and appropriately documented. 10

Domain 2 Purpose, Respect, Participation, Least Restriction CoP Ref: 16.8 We found: Patients did not have any lockable facility in their bedrooms to keep personal possessions with them on the ward. There was a property room for secure central storage of belongings. Your action statement should address: How the trust will ensure compliance with the Code of Practice 16.8 by supplying adequate lockable facilities (with staff override) for the storage of clothing and personal possessions which patients may keep with them on the ward. Domain 2 Admission to the ward MHA section: 11 (3) and 133 CoP Ref: 4.57 We found: One patient was admitted to the ward under section 136 on 9 January 2014. He was assessed and placed under section 2, on the same day. The application by the AMHP stated that the nearest relative had not been consulted although the reason for this was not provided. The doctor had spoken to the nearest relative on 9 January 2014. The AMHP subsequently tried to phone the nearest relative on 10 January 2014 but it was recorded that her phone was continually engaged. It was therefore not clear whether the nearest relative had been informed about her rights in relation to the patient. Your action statement should address: How the trust will work with AMHP colleagues to remind them of the need to evidence that practicable steps are taken by each AMHP to inform the nearest relative that an application for detention is going to be made. How the trust will ensure that all nearest relatives receive information about their rights as a nearest relative. 11

Domain 2 Leave of absence MHA section: 42 CoP Ref: 21.13 Ministry of Justice Mental Health Casework Section Guidance - Section 17 leave. November 2012 We found: One patient who was detained under section 37/41 had been authorised to take regular five day leave periods since October 2013. We were advised that the locum consultant psychiatrist had informed the Ministry of Justice (MOJ) in October 2013 that the patient was well enough to be discharged. However, despite this being regularly chased up, the MOJ had not yet authorised his discharge. On the day of the visit, this was followed up again and the MOJ had apologised for the delay and said that they would notify the ward within a week of their decision. Whilst we were advised that this patient remained well enough to be discharged, his risk assessment had been changed to high on 18 November 2013 and remained high when risk was assessed again on 12 January 2014 having been previously regarded as low up to 18 November 2013. Therefore, there appeared to be a discrepancy between his risk level and the decision to continue with leave and the application for discharge. It was unclear whether the change in risk level had been reported to the Secretary of State. The ward manager said that he would not regard the current risk level as high. The patient was aware that he could have applied to the Tribunal but had not realised that the MOJ would take three months to reach a decision regarding his discharge. Your action statement should address: Whether the risk assessment of this detained restricted patient was accurately recorded from October 2013 to the present day and whether changes in the risk level had been appropriately reported to the Secretary of State in line with the Ministry of Justice Mental Health Casework Section Guidance section 17 leave, November 2012. Whether this patient has been advised to seek a legal opinion regarding his continued detention and whether he should be advised of his right to make a formal complaint against the Ministry of Justice in respect of the long delay in considering the recommendation for discharge made by the responsible clinician. 12

Domain 2 Control and security CoP Ref: 15.6 and 15.16 We found: We discussed the management of aggression with the ward manager. There was no seclusion room on the ward and de-escalation techniques and distraction were used to support patients. Medication was used as a last resort. We were provided with a copy of the Policy and guidance for the recognition, prevention and therapeutic management of violence and aggression. This was dated February 2009 with a review date of April 2012. The policy states, The provision of a homely environment in terms of furnishings and the ongoing maintenance of its decoration is key to creating an atmosphere where violence is discouraged. We noted that there was an absence of pictures and other wall decoration. The information on the notice boards was not all current. For example, a You said, we did poster related to work done in 2011. We were advised that there have been attempts to put up artwork but this is often damaged by patients; the Christmas decorations were destroyed after three days. However, it was acknowledged by staff that maintaining a more homely atmosphere required ongoing effort. Your action statement should address: How the trust will demonstrate that there is a valid policy for 2013 to 2014 relating to the prevention and therapeutic management of aggression which all staff are aware of. How the trust will ensure that the environment has a positive impact on the wellbeing of patients. 13

Domain 2 Other areas MHA section: 17 and 117 CoP Ref: 1.3 CQC Monitoring the Mental Health Act in 2011/2012, Jan 2013 We found: The ward manager advised us that three patients were ready to be discharged but were on leave with family and friends as accommodation could not be found for them. We were further advised that local authorities were not willing to pay sufficient housing benefit to cover the high private rents in London boroughs and did not have sufficient council accommodation to house everybody who required housing. The CQC have stated: Delaying discharge past the point at which it is clinically necessary meets neither the expectations of the Code of Practice nor the duties under human rights legislation. Delayed discharges through poor planning or disputes over funding could give rise to legal challenge as a breach of Article 5 of the European Convention on Human Rights. They are also a poor use of expensive and pressurised inpatient services. Your action statement should address: Whether further support, such as legal advice, advocacy support, housing advice can be offered to those people who clinically no longer require inpatient care but who have not been able to access accommodation but are entitled to aftercare under section 117. 14

During our visit, patients raised specific issues regarding their care, treatment and human rights. These issues are noted below for your action, and you should address them in your action statement. Individual issues raised by patients that are not reported above: Patient reference: A Issue: Patient A said that he thought he was detained under Section 136 (he was detained under Section 2) He wanted to be able to go home as soon as possible. Patient reference: A Issue: Patient A was not sure about the contents of his care plan. Patient reference: C Issue: Patient C did not know which section he was detained under. Patient reference: C Issue: Patient C was not sure about the contents of his care plan. He also wanted to be able to go out on leave. 15

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