MENTAL HEALTH CLINICAL PROGRAMME GROUP MENTAL HEALTH ACT 1983 ANNUAL REPORT 1 October 21 31 March 212 MHA Report.Final/1.4.12 1
MENTAL HEALTH CLINICAL PROGRAMME GROUP MENTAL HEALTH ACT 1983 ANNUAL REPORT 1 October 21 31 March 212 CONTENTS Paragraph No Title Page No 1 Introduction 3 2 General 4 3 Changes to the Service 4 4 Healthcare Inspectorate Wales Report 6 5 Data Collection and Exception 7 Reporting 6 HIW Visits 15 7 Age Appropriate Accommodation 16 8 Power of Discharge Committee 16 9 Education/Training 17 1 Future Issues 18 MHA Report.Final/1.4.12 2
MENTAL HEALTH CLINICAL PROGRAMME GROUP MENTAL HEALTH ACT 1983 ANNUAL REPORT 1 October 21 31 March 212 1 Introduction The purpose of this report is to provide assurance to the Health Board on the activities associated with the use of the Mental Health Act 1983 within the Health Board s scope of responsibility between l October 21 and 31 March 212, and to provide assurance to the Board that we are working within the parameters of the MHA 1983 and MHA 1983 Code of Practice for Wales. This report covers an 18 month period so that in future we will coincide with the HIW Report. Future reports will follow the financial year. The Betsi Cadwaladr University Local Health Board has three Mental Health Act Administrators (MHAA) based in the three acute psychiatric units of Hergest (West), Heddfan (East) and Ablett Unit (Central). Each MHAA has an assistant. Hergest also administrates the Mental Health Act for Ty Llywelyn Medium ure Unit in Llanfairfechan and Learning Disability Services in Bryn y Neuadd. Heddfan also administrates the Mental Health Act for Fan Gorau EMI Unit, Newtown. Under a formalised Scheme of Delegation, Associate Managers undertake duties to: Ensure the grounds for admittance under the Mental Health Act are valid and all documentation is in order. Ensure that those formally delegated to receive documents and those who are required to scrutinise them have a thorough understanding of the Act. Review patient s detention. Provide information to patients and their nearest relative. Ensure that any patient who wishes to apply or need to be referred to a Mental Health Review Tribunal and the Hospital Managers are given the necessary assistance. Authorise the transfer of certain patients to the care of another set of managers. Consent to the rectification of certain defined errors which can occur in the documents. Review the grounds for detention and discharge. Withhold mail. Transfer a patient. Discharge a patient. MHA Report.Final/1.4.12 3
2 General The majority of patients detained under the Mental Health Act are admitted to the following units which are the main acute psychiatric admission units (bed numbers in brackets): Hergest Unit, Ysbyty Gwynedd, Bangor - 36 (plus 6 PICU) Ablett Unit, Ysbyty Glan Clwyd, Bodelwyddan 47 (2 AMH, 27 OMPH[17 organic; 1 functional] (plus 8 Intensive Rehab) Heddfan, Ysbyty Maelor, Wrexham 36 (plus 8 PICU) The Health Board also has Ty Llywelyn Medium ure Forensic Unit at Bryn y Neuadd Hospital, Llanfairfechan (25 [1 admission; 1 rehab, 5 intensive care]) where patients are usually detained under Part III of the Act (Patients concerned in criminal proceedings or under sentence), and occasionally under Part II. Additionally, there have been occasions when detained patients have been admitted to the newly opened CAMHS Adolescent Unit in Abergele. Detained patients are also admitted to the following satellite units: Adult Mental Health Services Carreg Fawr Continuing Care Unit, Bryn y Neuadd Hospital (8) Dryll y Car Support Bed Unit, Barmouth (8) Coed Celyn Rehabilitation Unit, Wrexham (1) Tan y Castell Rehabilitation Unit, Ruthin (8) Learning Disability Services Bryn y Neuadd Learning Disability Service Villas (24) Services for the Elderly Mentally Ill Ysbyty Cefni (24) Heddfan EMI Unit, Wrexham (28 [14 functional; 14 organic) Bryn Hesketh EMI Unit, Colwyn Bay (16 [6 respite]) Glan Traeth EMI Unit, Rhyl (15 [6 respite]) Fan Gorau EMI Unit, Newtown (8) 3 Changes to the Service Intensive Rehabilitation/Recovery Ward - Cynnydd The new Intensive Rehabilitation/Recovery ward based at the Ablett Unit, Glan Clwyd Hospital, is now operational. Called Cynnydd, which is welsh for Progress, the unit became operational on Monday 5th September. The Ward Manager is Stuart Mival and Deputy Manager is Tracey Logan. MHA Report.Final/1.4.12 4
Cynnydd is a locked 8 bedded Intensive Rehabilitation unit on the site of Glan Clwyd Hospital catering for North Wales residents who have experienced serious mental health needs, but may also have other complex health and social care needs. The focus of the unit is to involve people fully through assessment and engagement, in order to support people to identify their own future plans, and enable them to attain the things that they would want to achieve within their lives following their discharge from hospital. The average length of stay is expected to be between 3-12 months, with ongoing and intensive support available following discharge in community settings. Patients admitted to Cynnydd are likely to be subject to detention under the Mental Health Act Parts II or III. Heddfan On Thursday 2nd December 21, there was an opportunity for members of the public to visit the new Heddfan Mental Health Unit on the Wrexham Maelor Hospital site. The new unit is part of a 21.3 million project to provide new mental health inpatient facilities for both adults and older persons on the site. The older person s unit opened in the spring of 21; the new adult unit opened in stages towards the end of 21, with the first outpatient services starting on 3 November and the first patients moving into the 44 bed ward areas on 6 December 21. The unit has been designed with a high level of service user involvement and offers much more space and greatly enhanced facilities. These include a café and patient fitness centre, as well as providing a base for the Home Treatment, Occupational Therapy and Psychiatric Liaison Team, helping to increase the integration and coordination of inpatient and community mental health services. This purpose built facility has highlighted the considerable deficits within Ablett and Hergest which will require capital investment in order to upgrade the facilities. Medical On-Call Rota Since October, the psychiatric emergency on-call rota includes 4 Tiers: Tier 1 Band 6 nurses (24 hour cover), 3 rotations across North Wales Tier 2 Junior Doctor cover (generally - Hergest and Heddfan covered up until 1 am, Ablett covered until 5 pm) Tier 3 named weekly Consultant (1 st on-call one rotation across North Wales) Tier 4 2 nd on-call one rotation across North Wales MHA Report.Final/1.4.12 5
4 Healthcare Inspectorate Wales (HIW) Report 29-21 In April HIW presented its first report relating to Mental Health Act issues in Wales and we have been able to make some comparisons between our own data and all Wales data. The report relates to the financial year 29 21. The role of HIW in relation to the Mental Health Act is to review the process for all patients in Wales who are detained, or liable to be detained (eg on CTO s), to investigate complaints, to manage the SOAD reviews and to produce an annual report. Overview 25% of patients receiving secondary care have been subject to the Mental Health Act WALES TOTAL BCUHB Formal Admissions 1,453 (12.8%) 251 (8.53%) tion 136 576 288 (5%) tion 17A(CTO) 261 49 (19%) tion 17A (CTO) Discharge from hospital onto CTO 261 49 Discharges from CTO 52 17 Recall 16 34 Revocations 64 21 In summary 136 assessments are grossly elevated in BCUHB compared to the rest of Wales. However, there are significant fewer admissions to hospital following the tion136 assessment. These concerns have been raised regularly at the Mental Health Act Committee and there are regular discussions with the police regarding this. Talks have been held and are ongoing. Otherwise, we have somewhat fewer formal admissions and CTOs. HIW in year 29-21 undertook a total of 91 Visits. A variety of issues were raised during these visits and include: Mixed sex wards Poor facilities Lack of privacy Risk awareness Risk of children s visits Lack of activity Lack of trained therapists Physical health needs CPA awareness MHA Report.Final/1.4.12 6
Mix of functional and organic Need for police input Inappropriate placement Delayed Length of Stay Problems with Approved Clinician Cover The report, however, does not indicate whether all or only some Health Boards were involved but these are the issues that are likely to be raised at future HIW Visits within BCUHB. 5 Data Collection and Exception Reporting Total tions Total Number of tions in Central, East and West 25 2 15 1 5 135 136 5(4) 5(2) 4 2 3 3 Ren 17A 1 7A Ren CENTRAL 1 93 14 56 12 146 11 25 32 51 2 14 1 1 EAST 5 161 24 55 7 171 123 24 27 41 11 8 2 3 3 WEST 3 23 4 68 14 159 12 28 25 26 17 7 1 5 6 5 4 4 3 1 2 5 17E 17F 37 Rev CENTRAL EAST WEST 37 37 Ren 37/41 35 38 47 47 Ren 47/49 48/49 Explanation of tions at the end of this report. MHA Report.Final/1.4.12 7
Comparison of Percentages of Detained Bed Days Comparison of Percentages of Detained Bed Days in Ablett, Heddfan and Hergest 7 6 5 4 3 2 1 Oct- 1 Nov- 1 Dec- Jan- 1 11 Feb- Mar- Apr- 11 11 11 May- Jun- 11 11 Ablett 45.6 42.7 35.7 45.5 48.4 41.7 35.3 31.8 31.3 3.3 27.5 26.3 41.4 43 36.9 21.2 26.1 26 Heddfan 36 28 36.2 32.5 3.4 42.1 52 46 42.2 44.6 41.2 4 41.1 34.5 35 35 47 47.5 Hergest 53.5 5.8 49.9 52.2 55.7 58.4 26.1 27.3 26.9 48.9 53.1 48.4 5 44.5 44.5 45.3 46.6 4.2 Jul- 11 Aug- 11 Sep- Oct- Nov- 11 11 11 Ablett Heddfan Hergest Dec- Jan- 11 12 Feb-Mar- 12 12 There is a higher percentage of detained beds days in the Hergest Unit, with a 3 month exception. We cannot compare this directly to the rest of Wales, however 12.8% of all admissions in Wales are formal, so indicates that those detained under the Mental Health Act have a greater length of stay, as would be expected. tion 136 Percentage Outcomes of tion 136 Assessments across BCU (Psychiatric Hospital is Place of Safety) Inf Adm, 117, 24% tion 2, 42, 9% tion 3, 9, 2% Discharged, 312, 65% Discharged Inf Adm tion 2 tion 3 MHA Report.Final/1.4.12 8
Central Area Outcome Comparisons of tion 136 Assessments (Psychiatric Hospital is Place of Safety) 15 1 5 21 Discharged 7 3 12 14 8 9 Inf Adm 3 2 8 5 6 6 tion 2 3 1 1 1 1 tion 3 1 Discharged Inf Adm tion 2 tion 3 Jan-Mar 212 East Area Outcome Comparisons of tion 136 Assessments (Psychiatric Hospital is Place of Safety) 35 3 25 2 15 1 5 21 Discharged 19 8 12 3 17 21 Inf Adm 2 4 8 6 8 3 tion 2 1 1 2 5 5 3 tion 3 1 1 2 Discharged Inf Adm tion 2 tion 3 Jan-Mar 212 MHA Report.Final/1.4.12 9
West Area Outcome Comparisons of tion 136 Assessments (Psychiatric Hospital is Place of Safety) 4 3 2 1 21 Discharged 2 23 38 24 29 18 Inf Adm 8 8 11 16 8 5 tion 2 2 2 1 1 4 8 tion 3 1 1 1 1 Discharged Inf Adm tion 2 tion 3 Jan-Mar 212 Exception Reporting of tion 136 (6+ hours) Exception Report of tion 136 Assessments - Over 6 Hours 3.5 3 2.5 2 1.5 1.5 21 Jan-Mar 212 Central 1 2 1 2 East 1 3 2 West 1 1 2 1 Central East West Exceptional reporting remains at low levels. The majority outcome is discharge. This continues to differ significantly from other areas of Wales and from England and these figures are not changing significantly with time. MHA Report.Final/1.4.12 1
tion 5(2) Comparison of Numbers of tion 5(2) 2 15 1 5 21 Central 1 6 13 6 1 11 East 2 9 1 17 11 6 West 1 7 14 13 11 12 Central East West Jan-Mar 212 Exception Reporting of tion 5(2) (6+ hours) Exception Reporting of tion 5(2) - Over 6 Hours 6 5 4 3 2 1 21 Central 1 1 2 East 1 1 4 5 West 2 1 5 1 3 Central East West Jan-Mar 212 No major differences across the areas. MHA Report.Final/1.4.12 11
tion 5(4) Comparison of Numbers of tion 5(4) 1 8 6 4 2 21 Central 1 3 2 2 6 East 1 2 6 9 3 3 West 1 1 1 Central East West Jan-Mar 212 There are significantly higher numbers in Central and East and this may relate to immediate availability of medical staff. tion 4 Comparison of Numbers of tion 4 5 4 3 2 1 21 Central 2 4 1 3 2 East 1 2 1 1 1 1 West 1 4 4 1 4 Central East West Jan-Mar 212 The overall numbers remain low across BCU particularly given the rural nature of the area. MHA Report.Final/1.4.12 12
tion 2 Comparison of Numbers of tion 2 4 3 2 1 21 Central 21 22 31 22 27 23 East 2 33 33 34 27 24 West 23 22 23 28 26 36 No huge variations across all sites. tion 3 Central East West Comparison of Numbers of tion 3 Jan-Mar 212 3 25 2 15 1 5 21 Central 17 15 19 2 19 11 East 17 23 23 2 14 26 West 9 23 14 2 15 2 Central East West Jan-Mar 212 No huge variations across all sites. MHA Report.Final/1.4.12 13
Community Treatment Orders (CTO) Number of CTO's as of last day of each quarter 35 3 25 2 15 1 5 31.12.1 31.3.11 3.6.11 3.9.11 31.12.11 31.3.12 Central 18 24 3 28 3 24 East 24 25 22 27 28 27 West 15 16 17 19 24 26 Central East West The numbers comparing 3 sites appear to becoming more similar and the overall numbers are only increasing slowly. Appeals Data Mental Health Review Tribunals (MHRT) Area Applications and Heard Discharges Pending Referrals Central 132 58 6 6 East 118 52 5 12 West 198 69 16 14 As illustrated in the final t able on this page, on ly 15.1% of a pplications resulted in a successful application. Hospital Managers Area Applications and Renewals Heard Discharged Pending Central 13 86 2 5 East 137 77 5 5 West 12 66 5 2 As illustrated in the final table on this page, only 5.2% of applications resulted in a successful application. MHA Report.Final/1.4.12 14
Comparisons Successful Applications of those heard Withdrawal by patient/ Informal prior to hearing MHRT HOSPITAL MANAGERS 15.1% 5.2% 4.1% 27.2% Whilst the numbers for both MHRT and Hospital Managers for successful applications are small, the numbers for Hospital Managers is almost one third of that of the MHRT. However, the numbers of withdrawals/regrading to informal prior to hearing remain higher for MHRT than the Hospital Managers, although there is not a great deal of difference. 6 Healthcare Inspectorate Wales Mental Health Act Visits Summary of Visits and Action Plans Regular inspection visits are undertaken by Health Inspectorate Wales (formerly known as the Mental Health Act Commission). HIW visit all Health Board premises which are likely to have detained patients on regular basis. These visits can be short notice or unannounced. One of Health Inspectorate Wales functions is to consider legal and statutory matters, including scrutiny of the Mental Health Act documentation, adherence to the Code of Practice, systems that support the operation of the Act and records relating to the care and treatment of detained patients. HIW undertook several visits to the Health Board during the reporting period which were as follows: Date of Visit Venue 25.1.1 All wards, Hergest Unit, Ysbyty Gwynedd 2.11.1 Ysbyty Cefni, Ynys Mon 28.2.11 Dinas Ward, Ablett Unit, Ysbyty Glan Clwyd 22.3.11 Child and Adolescent Unit, Abergele 12.4.11 Taliesin Ward, Hergest Unit, Ysbyty Gwynedd 13.4.11 LDS, Bryn y Neuadd Hospital, Llanfairfechan 16/17.5.11 Clywedog and Tryweryn Wards, Heddfan Unit, Wrexham 29.6.11 Fan Gorau, Montgomery County Hospital 27.7.11 Tan y Castell Rehab Unit, Ruthin awaiting report 28.7.11 Coed Celyn Rehabilitation Unit, Wrexham Following each vis it, formal feedback is obtained in the form of a letter with recommendations which is sent to the Chief Executive. An action plan is developed locally and is reviewed on a regular basis by the CPG Statutory Compliance sub-committee. MHA Report.Final/1.4.12 15
Additionally, regular formal scrutiny is undertaken within the Clinical Programme Group into compliance with the requirements of the Act and the Code of Practice and is co-ordinated by the Mental Health Act Administrators. This includes: Receipt and scrutiny at ward level Administrative scrutiny Medical scrutiny AMHP scrutiny Associate Managers scrutiny Pharmacy Scrutiny The outcome of scrutiny records are considered by the CPG Statutory Compliance sub-committee. 7 Age Appropriate Accommodation tion 31 added a new section 131A to the 1983 Act with effect from April 21. This places hospital managers under a duty to ensure that patients aged under 18 admitted to hospital for mental disorder are accommodated in an environment that is suitable for their age (subject to their needs). In determining whether the environment is suitable, the managers must consult a person whom they consider to be suitable because of their experience in child and adolescent mental health services cases. Occasionally it may still be that the least worst option is for someone under 18 to be admitted to Adult Psychiatric ward but we have already taken the view that these should be regarded as individual serious untoward incidents and investigated accordingly. The numbers of under 18 admitted to an acute adult ward during this period is 13. 8 Power of Discharge Committee The Power of Discharge Mental Health Act sub-committee is well established and is chaired by Reverend Hywel Davies. The sub-committee meets every six months. Its role is to: monitor the exercise of Power under tion 23. monitor activity of Managers Appeals. report annually to the Mental Health Act Committee. administer the Scheme of Delegation as required. keep abreast of national policy, case law and performance indicators. provide feedback on experience in relation to Power of Discharge functions, escalating as appropriate to MHACommittee. ensure MHA scrutiny panels sit on a rotational basis. MHA Report.Final/1.4.12 16
ensure that Hospital Managers are competent to undertake the functions delegated to them by ensuring they are properly informed about the provisions of the Act and receive suitable training. oversee fixed term recruitment of Associate Managers and ensure robust personal and professional development. To date this sub-committee has held two training events on 31.3.11 and 15.12.11 with further events to be held every six months. Feedback from these training sessions has been extremely positive. Annual review meetings were undertaken during March 212 with the existing 19 Associate Managers which was led by Dr Lyndon Miles, supported by Independent Board members. Letters of further tenure are to be sent shortly. It is anticipated there will be a requirement to recruit further Associate Managers during the coming year. 9 Education/Training A training plan has been approved by the Statutory Compliance Committee which will recommend the following to the CPG Board: Category of Staff Level of training Frequency Admin, HCSW, newly General awareness training. Mandatory qualified and new Standardised training programme every 3 starters provided by the Mental Health Act years. Qualified nursing staff, Social Workers, Occupational Therapists, Psychology, medical staff. Associate Managers and Independent Board Members. CPG staff Administrators. Intermediate Level. Standardised training programme provided by the Mental Health Act Administrators, and AMHP/Nursing staff Intermediate Level. Use of outside speaker, possibly specialist MH lawyer. Local associated professionals Mandatory every 3 years. 6 monthly Currently the MHAA are providing two levels of mandatory training across the BCU area General Awareness and Intermediate (incorporating forensic). Training is provided on a monthly rotating basis in central, east and west with the occasional ad hoc sessions being undertaken in North Powys and South Gwynedd. This training will be a rolling programme going and will be updated accordingly as necessary. Numbers currently undertaken training since above programme commenced in October : General Awareness Levels 62 Intermediate Levels 51 MHA Report.Final/1.4.12 17
1 Future Issues i) Mental Health (Wales) Measure Different parts of the Measure are coming into force from January 212 and October 212. The Measure relates to the mental health service as a whole and not directly to the Mental Health Act. The one measure directly relating to the Mental Health Act is that the Independent Mental Health Advocate is now available for some of the shorter term sections. It is not clear whether the measure will have any indirect affect on the Mental Health Act but this will be kept under review. ii) New Health and Social Care Bill We anticipate that with the introduction of the changes to the Health and Social Care Bill, which will mostly affect England. There will be an impact on the Mental Health Act in Wales in relation to ond Opinion Appointed Doctor (SOAD) requests for patients who are on CTOs. It is intended that those patients who are consenting will no longer required a SOAD certificate. But those who are not consenting or lack capacity will still need to be seen and authorisation granted by a SOAD. We anticipate that this will come into effect within the next year. iii) Future Data Collection We intend with the Board s approval to refine the data collection for occupancy as follows: Functional Elderly will be included with Adult Acute Care Heddfan, Ablett, Hergest Organic will be reported separately across named wards/units Rehabilitation will be reported for Coed Celyn, Tan y Castell and Carreg Fawr. Intensive Rehabilitation and Recovery, Cynnydd, will be reported separately. Psychiatric Intensive Care Units Heddfan and Hergest MHA Report.Final/1.4.12 18
Description of tions tion 2 Admission for assessment up to 28 days tion 3 Admission of treatment up to 6 months, renewable for 6 months, 12 monthly thereafter tion 4 Admission for emergency up to 72 hours tion 5(2) Approved Clinician Holding Power up to 72 hours tion 5(4) Nurses Holding Power up to 6 hours tion 17A Supervised Community Treatment, also referred to as CTO (Community Treatment Order) up to 6 months, renewable for 6 months (17A+) 12 monthly thereafter (17A ++) tion 17F/ Revocation of a CTO patient who has been recalled to hospital 37 Rev the section is the re-introduction of the tion 3 or tion 37 (depending on what section they were on previous to the CTO) - up to 6 months, renewable for 6 months, 12 monthly thereafter tion 135 Warrant to search and remove (police section) tion 136 Place of Safety (police section) up to 72 hours tion 35 Remand to hospital for report on accused s mental condition for up to 28 days but can be extended to a maximum of 12 weeks tion 36 Remand of accused person to hospital up to 28 days but duration will be set by the Court maximum of 12 weeks tion 37 Hospital Order or Guardianship Order - up to 6 months, renewable for 6 months, 12 monthly thereafter tion 37/41Hospital Order with Restrictions made with no time limit tion 38 Interim Hospital Order up to 12 weeks, but duration set by the Court maximum 12 months tion 47 } Transfer of sentenced prisoners (including with restrictions) tion 47/49} tion 48 } Transfer of other prisoners (including with restrictions) for urgent tion 48/49}treatment MHA Report.Final/1.4.12 19