Mental Health Act 1983 monitoring visit Provider: Nominated Individual: Region: Location name: Location address: Ward(s) visited: Ward type(s): Type of visit: Birmingham and Solihull Mental Health Foundation Trust Dee Roach Central Dan Mooney House 1 Woodside Crescent, Downing Close, Knowle, Solihull, West Midlands, B93 0QA Dan Mooney House Rehabilitation Unannounced Visit date: 23 May 2013 Visit reference: 28235 Date of issue: 3 June 2013 Date by which you must return your Provider Action Statement to CQC: 1 July 2013 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 tell patients 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 areas we have identified for improvement will feed directly into our public reporting on the use of the Act and 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 However, even though we do not publish this report, it would not be exempt under the Freedom of Information Act 2000 and may be made available on request.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 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 This was an unannounced visit to Dan Mooney House (DMH). During the visit four sets of patient notes were scrutinised and four patients were interviewed. DMH is a high dependency rehabilitation ward providing services to patients from the Birmingham/Solihull area. It is part of the non-acute inpatient service. The ward has seventeen beds, six for females and eleven for males. On the day of the visit sixteen beds were full, and the ward was expecting a patient to transfer into the empty bed. We were told that the ward is never over 100% occupied. Admissions to the ward are planned; patients often visit the ward prior to admission. We were told that recently there has been an increase in the amount of turnover of patients on the ward. We were also told that there was more scrutiny from commissioners in relation to admission to the ward. This was deemed to be both welcome and positive. Advocacy services are available on the ward. User Voice visits the ward once every two weeks. The Independent Mental Health Advocate (IMHA) service attends on request. Patient meetings are held on a monthly basis and are co-facilitated by staff and User Voice. There is an Occupational Therapy (OT) department which serves both DMH and the neighbouring ward; David Bromley. Patients are assessed individually for activities, and a weekly activity plan is drawn up. This was displayed on the ward. All patients have leave of some sort and are encouraged to engage in community activities such as swimming, gym, dog walking and zumba. A mini-bus is available to help to facilitate this. We were told that staff received clinical supervision every six weeks, and management supervision every other month. The ward manager indicated that all staff were up to date with their training. He also said that they had a stable staff group, although occasionally agency staff were used. The ward has one consultant who sees all patients. There are no doctors on site, and in emergencies ambulances are called. The ward does not use rapid tranquilisation. The ward has separate male and female corridors, bathrooms, kitchens and lounges. The female lounge (or quiet room) is small, and located close to communal areas. The male lounge is considerably more spacious. On the day of the visit the female lounge was locked as it was being used to store a patient's possessions. The ward has a number of garden areas, including a large garden Patients have their own key to their bedrooms. In addition there are safes in the wardrobes. 3
There was evidence that patients had been presented with their rights on a regular basis. A number of patients were in the process of appealing their section. All section 17 leave forms were correct. Old forms had been struck through. Patients had received copies of their leave forms. Risk assessments were on file, were up to date, and included a clear risk management plan. Care plans were also on file, and some (but not all of them) showed good patient involvement. There was evidence that patients' physical health was regularly reviewed and checked. There was mixed feedback about the staffing; some patients felt very well supported on the ward, others less so. 4
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.. Admission to the ward MHA section: 2, 3 CoP Ref: 4.94 Approved Mental Health Professional reports for Patients A and B were not on file, and it was therefore difficult to understand the circumstances around their detention. 4.94 of the Code of Practice states that: The AMHP should provide an outline report for the hospital at the time the patient is first admitted or detained, giving reasons for the application and details of any practical matters about the patient s circumstances which the hospital should know. Where possible, the report should include the name and telephone number of the AMHP or a care co-ordinator who can give further information. LSSAs should consider the use of a standard form on which AMHPs can make this outline report. Adherence with paragraph 4.94 of the Code Consent to treatment MHA section: 58 We were unable to find evidence of 'consent discussions' within any of the patient files: Patient A: No evidence of discussions around medication in the notes. When interviewed Patient A reported that she was unaware of her medication and would like to be informed. Patient B: No evidence of discussions around medication in the file. Patient C: No evidence of discussions around medication in the file. Patient D: No evidence of discussions around medication in the file. Patient D has been deemed to have the capacity to make a decision about her medication and a T2 was completed for her on the day of the visit, indicating that she was consenting to her medication. When asked about this however, she said: 'I have not consented to nothing. I have to take these things and that is it.' When asked if she knew what medication she was on she replied 'I haven't a clue.' This is particularly concerning as the T2 stated that she was consenting to receive anti-psychotic 5
medication up to 150% of the BNF limits. Patient E reported that she was not sure what medication she was on, and that she would like to know. The following sections of the Code are relevant to patients who have capacity to give or refuse consent: 23.31 Consent is the voluntary and continuing permission of a patient to be given a particular treatment, based on a sufficient knowledge of the purpose, nature, likely effects and risks of that treatment, including the likelihood of its success and any alternatives to it. Permission given under any unfair or undue pressure is not consent. 23.32 By definition, a person who lacks capacity to consent does not consent to treatment, even if they co-operate with the treatment or actively seek it. 23.33 It is the duty of everyone seeking consent to use reasonable care and skill, not only in giving information prior to seeking consent, but also in meeting the continuing obligation to provide the patient with sufficient information about the proposed treatment and alternatives to it. 23.34 The information which must be given should be related to the particular patient, the particular treatment and relevant clinical knowledge and practice. In every case, sufficient information must be given to the patient to ensure that they understand in broad terms the nature, likely effects and all significant possible adverse outcomes of that treatment, including the likelihood of its success and any alternatives to it. A record should be kept of information provided to patients. 23.35 Patients should be invited to ask questions and professionals should answer fully, frankly and truthfully. There may sometimes be a compelling reason, in the patient s interests, for not disclosing certain information. A professional who chooses not to disclose information must be prepared to justify the decision. A professional who chooses not to answer a patient s question should make this clear to the patient so that the patient knows where they stand. 23.36 Patients should be told that their consent to treatment can be withdrawn at any time. Where patients withdraw their consent (or are considering withdrawing it), they should be given a clear explanation of the likely consequences of not receiving the treatment and (where relevant) the circumstances in which the treatment may be given without their consent under the Mental Health Act. A record should be kept of the information provided to patients. 23.37 Although the Mental Health Act permits some medical treatment for mental disorder to be given without consent, the patient s consent should still be sought before treatment is given, wherever practicable. The patient s 6
consent or refusal should be recorded in their notes, as should the treating clinician s assessment of the patient s capacity to consent. Even when patients lack the capacity to consent or dissent there is still an expectation that they will be provided with information relevant to the decision. The legal authority for this comes from the Mental Capacity Act; Section 1 (principles) and Section 4 (best interests checklist) which clearly specifies that people should be involved as far as possible in decisions relating to their treatment or care. Adherence with paragraphs 23.31-7 of the Code. Specific feedback on actions taken in respect of Patient D and whether she is, in fact, consenting. Consent to treatment MHA section: 62 CoP Ref: 24.35, 24.37 Patient B had a section 62 in his notes dated 31 December 2012 and a further one dated 29 March 12. We were unable to see a record of the justification for urgent treatment in the notes. We were also not able to find evidence that the section 62 had been/was being reviewed. Patient C had a section 62 in his notes dated 18 October 2012. We were unable a record of the justification for urgent treatment in the notes. We were also not able to find evidence that the section 62 had been/was being reviewed. Patient D had a section 62 in her notes dated 17 May 2013. Although there was mention of this in the progress notes we were unable a record of the justification for urgent treatment in the notes. We were also not able to find evidence that the section 62 had been/was being reviewed. The Trust is reminded that section 62 only relates to treatments which are immediately necessary. Given that urgent treatment can only be given in these circumstances it is reasonable to expect the immediate necessity of the treatment to be reviewed on a regular and frequent basis. Paragraph 24.35 of the Code states that Urgent treatment under these sections can continue only for as long as it remains immediately necessary. If it is no longer immediately necessary, the normal requirements for certificates apply. The Code (24.37) also states that: Hospital managers should monitor the use of these exceptions to the certificate requirements to ensure that they are not used inappropriately or 7
excessively. They are advised to provide a form (or other method) by which the clinician in charge of the treatment in question can record details of: -the proposed treatment; -why it is immediately necessary to give the treatment; and - the length of time for which the treatment is given. Adherence with 24.35 and 24.37 of the Code. Tribunals and hearings MHA section: 132 CoP Ref: 2.8 Although there was evidence that most patients were routinely given their rights, we could not find evidence that Patient A had been presented with her rights. She confirmed this to us when we met with her. The trust are reminded of paragraph 2.8 of the code which states that: The Act requires hospital managers to take steps to ensure that patients who are detained in hospital under the Act, or who are on supervised community treatment (SCT), understand important information about how the Act applies to them. This must be done as soon as practicable after the start of the patient s detention or SCT. This information must also be given to SCT patients who are recalled to hospital. Adherence with 2.8 of the Code. Purpose, Respect, Participation, Least Restriction CoP Ref: Chapter 1 Care plans were varied in quality. There were some errors, for example: Patient A's care plan referred to her being at Newbridge House. This needs updating. Care plans did not clearly consider the minimum restrictions on a patient's liberty. Care plans were, however, written in the patient s voice, and they appeared to indicate that patients had been involved in shaping and agreeing them. There was evidence of consideration of diverse needs, and one care plan considered carefully 8
how to manage someone's wish to fast at Ramadan with their diabetes. This is to be commended. Care plans also considered discharge. On interview with the patients, however, it was not clear how much of the care plans had been written with the patients, and how much involvement they had had. Patient A reported that she had not had a copy of her care plan, and that she would like to see it; Patient D was not sure whether she had had a copy; Patient F said that he had not had a copy, that he was unaware of the contents and that he would like a copy. In contrast Patient E reported that she had been involved in writing her care plan, had had a copy and was happy with the contents. The trust is reminded of the guiding principles outlined in chapter 1 of the Code of Practice, in particular the least restriction (para 1.3), respect (para 1.4) and participation principle (para 1.5). Adherence with paragraphs 1.3, 1.4 and 1.5. Specific actions to ensure that patients on the ward are involved in reviewing their care plan and are issued with copies of their plan. Purpose, Respect, Participation, Least Restriction There were a number of concerns about the ward environment. Some of these were raised at the last visit on 10.06.2011. In particular: 1.) 1. There remain large windows in bedroom doors. These are covered by net-curtains on the inside of the door, but afford patients little privacy. This was raised as a concern following our last visit. One Patient reported that other patients had been watching him through his bedroom window. Your response was: 'We are working on a design to convert the existing vision panels into vista matic type. Quotation due 15.7.11; however the prototype unit will have to be approved by the clinical managers.' It is highly disappointing that this has not been resolved. 2.) There remain gaps door and the architrave of many of the bathrooms, again affording patients little privacy. This was raised as a concern following our last visit. Your response was: 'Gap is due to the anti-barricade style doors. Quotation to fit longer brush strips due 4.7.11'. It is highly disappointing that this has not been resolved. 9
3.) One of the toilets in the men's area was particularly smelly. Again this was raised as an issue in our last visit. 4.) Patients complained about the quality of the food, especially the ready meals. Given that patients can be on the ward for many years, and can have a range of physical health difficulties, it is surprising that the trust is providing them with ready meals on a regular basis. This concern was shared by nursing staff who queried the appropriateness of doing this. 5.) Two of the women interviewed complained of not feeling safe on a mixed gender ward. They said that they would prefer a female only ward. Although none of them reported any incidents they felt uncomfortable and outnumbered. This concern was also noted in the records of patient meetings. How to address the above points. Control and security CoP Ref: 1.6 Concerns were expressed by both staff and patients at the lack of staff time available for patients. It is understood that the ward used to run with seven staff on a day time shift, but that number has now been reduced to five. Staffing levels were not increased from five when the ward was re-graded as a high dependency rehabilitation unit. The impact of this was visible in a number of areas: 1. Patients reported that there was little to do on the ward during the day. On the visit, other than television and smoking, there were no activities taking place on the ward. One patient said 'All we do is eat, sleep and wonder around all day.' 2. Patients reported that their leave (especially if escorted) was on occasion cancelled, and they were therefore not able to actively engage with community activities. Staff confirmed that this was the case. 3. Patient D and Patient E reported that they were not receiving 1:1s with their key nurse. 4. Staff reported that if one patient is on observations the amount of time that they have available for other patients is significantly reduced. Patient A, for example, has until recently been on 2:1 observations. 10
The trust is reminded of paragraph 1.6 of the Code which states that: People taking decisions under the Act must seek to use the resources available to them and to patients in the most effective, efficient and equitable way, to meet the needs of patients and achieve the purpose for which the decision was taken. Given that this is a rehabilitation ward, and that patients are largely on the ward for considerable periods, it seems reasonable that they can expect sufficient staffing to allow them to actively engage in therapeutic activities and their recovery. Adherence with 1.6 of the Code. Purpose, Respect, Participation, Least Restriction Patient F is disabled (he has had a leg amputated and uses a wheelchair). He has been on the ward for some months. He reported that although much of the ward is wheelchair accessible he is unable to move from the conservatory to the courtyard, and once in the courtyard he is unable to access the smoking shelter which is up some steps. He therefore has to use crutches should he wish to smoke. This winter, with the snow, this caused particular difficulties and dangers. The trust are reminded of the respect principle in the Code (paragraph 1.4): People taking decisions under the Act must recognise and respect the diverse needs, values and circumstances of each patient, including their race, religion, culture, gender, age, sexual orientation and any disability. They must consider the patient s views, wishes and feelings (whether expressed at the time or in advance), so far as they are reasonably ascertainable, and follow those wishes wherever practicable and consistent with the purpose of the decision. There must be no unlawful discrimination. Actions to address the particular needs of Patient F in line with the respect principle. 11
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: Complained that she had recently been vomiting blood. Is concerned that her bank book (card?) is still at the PICU in Bradford and she therefore has no funds. Is worried about the state of her bedroom and would like her possessions and drawers returned to her room. Is unaware of her medication; she would appreciate some information on this. She would like a copy of her care plan. She has no outdoor shoes (she only has slippers); she would like assistance in obtaining some. She would like to engage in activities in particular jewellery making, art, and pottery and painting. D Is complaining of stiffness in her joints which she associates with side effects from her medication. Is not aware of the medication which she is on; she reports that she thinks they are the wrong tablets. She would like information on her medication in writing. She reported that one hour unescorted leave is not enough time to get to the local shop and back. She would like to be able to see her visitors in privacy. She would like a copy of her care plan. E Would like more activity; especially dancing. Ultimately she would like to drive again. She is particularly worried about her son. F Would like gardening to be an activity on the ward. Would like to see visitors in private. Would like a copy of his care plan. 12
Information for the reader Document purpose Author Audience Copyright Mental Health Act monitoring visit report Care Quality Commission Providers Copyright (2012) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Contact details for the Care Quality Commission Website: www.cqc.org.uk Telephone: 03000 616161 Email: Postal address: enquiries@cqc.org.uk CQC Mental Health Act Citygate Gallowgate Newcastle upon Tyne NE1 4PA 13