Mhareport1516 Web

Monitoring the
Mental Health Act

in 2015/16
Care Quality Commission
Monitoring the
Mental Health Act in
2015/16
Presented to Parliament pursuant to Section 120D(3) of the Mental Health Act 1983
Care Quality Commission 2016
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Contents
Foreword 5
Summary 6
Introduction 10
Part 1: The Mental Health Act in action 12
1.1 Regulation and the Mental Health Act 13
1.2 Implementing the revised Code of Practice 14
1.3 Deaths in detention 15
1.4 The use of the Mental Health Act 17
1.5 Protecting patients rights and autonomy 20
1.6 Assessment, transport and admission to hospital 25
1.7 Additional considerations for children and young people 29
1.8 Care, support and treatment in hospital 31
1.9 Leaving hospital 37
Part 2: CQC and the Mental Health Act 42
2.1 Monitoring visits 43
2.2 The administration of the Second Opinion
Appointed Doctor service 45
2.3 Complaints 47
2.4 Withheld mail and telephone monitoring in high
security hospitals 49
Appendices 50
Glossary 58
References 63
3
1,349 monitoring visits by CQC
6,867 actions from providers to

improve were required by CQC
4 MONITORING THE MENTAL HEALTH ACT IN 2015/16

Foreword
The work of monitoring the Mental Health Act 1983 patients to receive good quality care. Mental health
(MHA) is a distinct but supportive role to CQCs wider care is only likely to be effective and humane when
regulatory task. It is distinct, in part, because our focus patients have their voice heard and their preferences
is on reviewing and understanding the experience and are taken fully into account. In particular, I would
effects of care provided for individual patients, rather highlight the need for care planning to be truly co-
than assessment of systems and processes. This report produced with patients, and individualised to their
sets out our key findings from our work in 2015/16 needs. In many cases, there needs to be better
based on more than 4,000 private meetings with communication between patients and staff, and more
individual patients during our visits to 1,300 wards. It time spent in individual discussion.
acts as both an account of our activity to Parliament What is striking is that some services do get this, and
and an outline of the important issues and concerns we show this in what they do. There is good practice in
heard from patients about their day-to-day experience many different types of mental health inpatient units
when subject to the MHA. and this report provides some examples. If some can
In many respects, mental health inpatient services get it right, others can learn from them and adopt their
are better places now than in past decades. The approach. We have had positive engagement with NHS
expectations of people who use services and England, NHS Improvement and the Department of
professionals around patient involvement, respect for Health during the production of this report, and look
individual rights and the avoidance of unnecessary forward to working with them as they deliver on their
institutional rules are higher than ever. CQC has played priorities for implementing the Five Year Forward View
a significant role in this, but we are aware that there is for Mental Health.
still much to be done to improve. I am grateful to the many patients who have shared
This is a tough environment for mental health services. their experiences with us on visits, and also to our
We know that mental health funding is tight. The Service User Reference Panel for their input into
overall reduction in the numbers of inpatient mental this report.
health beds, necessary to redirect resources into
alternative, less restrictive community provision, may
have created pressures on acute admission wards in
some areas. We have noted the rising use of the MHA
in our previous reports, perhaps in part due to some
areas not yet having the right balance of provision in
place. The process of changing the balance of provision
also requires careful management to make sure wards
continue to provide a safe and therapeutic environment
for all patients. We will be working with other national
partners to look at how this affects the patients behind
the numbers, as part of our monitoring activity in 2017.
Our findings in 2015/16 show that managers and
staff are not receiving the support to understand
and meet the requirements of the MHA and the
recommendations of its Code of Practice. We are
impatient to see change because the end result is for
David Behan
Chief Executive
FOREWORD 5
Summary
The Mental Health Act 1983 (MHA) is the legal of care for some people who are detained under the
framework that provides authority for hospitals to MHA, and changes are needed in response.
detain and treat people who have a serious mental Throughout our monitoring visits and inspections,
disorder and who are putting at risk their health or we saw many examples of good practice, and met
safety, or the safety of other people. The MHA also hundreds of dedicated staff who provide the best
provides more limited community-based powers, support and treatment for their patients. We hope
called community treatment orders and guardianship. that examples of good practice shared in this report
The MHA includes safeguards for peoples rights will support and encourage other providers to
when they are being detained or treated by improve quality of care. Further examples can be
professionals. It does this by providing rules and found in State of Care 2015/16.
requirements for professionals to follow. It also However, good practice is not consistent across the
provides statutory guidance to mental health country. Our concerns are supported by our findings
professionals and services in the MHA Code of in State of Care 2015/16, which found that inpatient
Practice. Managers and staff in provider services mental health services performed less well in general
should have a detailed knowledge of the Code and than community-based services. Some services
follow its guidance, or document the justification for are not meeting the expectations of the Code of
not doing so in any individual case. Practice, leading to variation in the quality of care
Our job is to check that patients human rights are for people detained under the MHA. These are not
being protected, and look at how services in England technical issues of legal process, but failings that may
are applying the MHA safeguards. We carry out visits disempower patients, prevent people from exercising
to see how mental health services are supporting legal rights, and ultimately impede recovery or even
patients, make sure providers have effective systems amount to unlawful and unethical practice.
and processes to meet the MHA, and check that In 2015/16, we have found little or no improvement
staff are being supported to understand and meet in some areas that directly affect patients, their
the standards set out in the Code. families and carers and that we have raised as
There are 57 NHS trusts and 161 independent concerns in previous years. This includes:
hospitals that provide mental health care for people For 12% (515 out of 4,344) of patients
under the MHA in England. During 2015/16, we interviewed on our visits in 2015/16, there was
carried out 1,349 monitoring visits, and met with no evidence that they were informed of their
4,282 patients. right to an Independent Mental Health Advocate
Detention rates have continued to rise in recent (IMHA). Advocates are an important safeguard,
years, and 2014/15 saw the highest ever year offering support to patients and enabling
on-year rise (10%) to 58,400 detentions. It is a them to be involved in decisions about their
challenging time for all health services, including care. Many services have adopted the Code of
mental health care: resources are tight and as Practices recommendation that IMHAs should
outlined in our State of Care 2015/16 report automatically be asked to visit patients who may
lack the capacity to ask for help. We expect all
our annual overview of the quality of health and
services to do this. We have seen some examples
adult social care in England the sector is under
of innovative practice enhancing the support
significant financial pressure. But over the last few
provided by IMHA services at key points of
years, reports such as the Winterbourne View Time
treatment and care, such as during care planning
for Change have highlighted inequalities and failings or when interventions such as seclusion are used.

There was no evidence of patient involvement It is clear from our visits that, one year on from its
in care planning in 29% (1,214 out of 4,226) of introduction, that some providers are not doing
records that we examined. Similarly, 10% (452 enough to implement the revised Code of Practice
out of 4,407) of care plans showed that patients or inform patients of their rights. The revised Code
needs had not been considered. Research came into force in April 2015. We asked providers
suggests that co-production of care plans and to update their policies and practices by October
developing advance statements with patients can 2015, to make sure they supported delivery of the
be an effective way for services to address the new standards. We also expected services to make
rising number of detentions.1 Some services have sure that staff with statutory MHA roles are trained
shown good practice in involving patients from with the right skills and knowledge to meet the
the moment they are admitted, including staff Codes standards to support the delivery of high-
taking time to explain everything as often as the
quality care.
patients needed to help them feel informed and
reassured about their care and treatment. However, fewer than half of the wards we looked at
from September 2015 to April 2016 had provided
We expect all services to consistently make it
staff with any form of training on the revised Code,
possible for patients to be fully involved in their care
or updated their policies and procedures to reflect
and treatment, understand their rights and exercise
the new guidance. All staff in statutory MHA roles
their autonomy. Only through such an approach
must be provided with training staff need to be
can services ensure that those powers are used
better supported in looking after people with mental
proportionately and fairly, and that they help the
health issues, and they need stronger leadership to
recovery process.
make this happen.
Overall, we required more than 6,800 actions from
Where we have found failures to comply with the
providers to improve practice as a result of our
recommendations of the Code due to lack of staff
monitoring visits. Although we do not rate how well
training or policies, we have made sure, and will
services apply the MHA, if we find poor practice we
continue to make sure, that our teams use our
limit a providers rating for the question are services
enforcement powers to improve the support for staff
effective?.
and patients.
Priorities for change
In this, our seventh report on the MHA, we find too influence the improvement work taking place across
many repetitions of our previous findings. There is mental health services, for example delivering the
an urgency for change, with more needing to be aims and ambitions set out in the Five Year Forward
done by all stakeholders providers, commissioners, View for Mental Health.
national bodies and regulators to ensure people
receive high-quality and effective care and
treatment under the MHA. The priorities we have
set are intended to offer greater help, support and
involvement of patients, their families and carers
when detention under the MHA is necessary. We are
committed to making sure our findings inform and
SUMMARY 7
1. Providers
Providers need to do more to ensure that the MHA is properly applied, and that this supports
better care of people detained under the Act. In particular, they must demonstrate stronger
leadership, making sure they train and support their staff to have a thorough understanding and
knowledge of the Code of Practice and how patients should be involved in their care from the
moment they are admitted, to aid their recovery.
Services should also focus on improving their oversight of the MHA safeguards for patients. This
is an important part of ensuring good outcomes for patients and failure to have good oversight
will always affect the providers well-led rating.
2. Commissioners
Commissioners should work together to deliver services informed by national guidance and best
practice. They should review commissioning contracts to make sure they commission services
where they have evidence on how the Act is being applied and that the Code is being met. They
should consider how to ensure a model for commissioning, procuring and delivering services
locally that is based on co-production and collaboration with people who use services, and how
they are ensuring inequalities are monitored and addressed.
The experiences and views of detained patients should be a routine part of local MHA
monitoring, including actively seeking the involvement of local user and advocacy groups.
3. The Department of Health and national agencies

The Department of Health and national agencies should work together on solutions to the issues
we identify, and focus particularly on early intervention to reduce the rates of detention. NHS
England and NHS Improvement need to ensure that the use of the MHA is closely monitored at
both local and national level, and focus on providing earlier interventions, and care planning for
people repeatedly detained, to reduce rates of detention by 2020/21. This includes targeted
work to reduce the over-representation of Black and minority ethnic and other disadvantaged
groups.
All agencies must work with NHS Digital to improve intelligence available via the Mental Health
Services Dataset (MHSDS), to have better personalised data, across pathways, about the way
the MHA is working for people and how different groups are experiencing detention. We expect
that provider Boards should be robustly assured that their organisations' monthly returns are
complete and accurate.
National agencies should ensure that solutions are identified and implemented in partnership
with organisations representing people with mental health problems.

CQC will use its regulatory approach and powers Review the way we present MHA information
to further encourage improvement in the use of in our provider inspection reports, with a focus
the MHA to ensure better experiences for detained on how providers monitor the application of the
patients. We will: MHA and its safeguards for patients.
Work closely with NHS Digital, NHS England, Work with our external advisory group to
NHS Improvement and the Department of Health strengthen how we review equalities information
to publish more detailed reports on areas of our during regular and focused monitoring visits.
monitoring during 2017. This will include carrying
out focused visits to look at rising detentions
and a review of the way Approved Mental Health
Professional services are being delivered.
Create additional guidance for inspection teams
and MHA reviewers on how to assess the way
providers continually review the way the MHA
operates.
There is an urgency for change, with more needing to be done by

all stakeholders providers, commissioners, national bodies and
regulators to ensure people receive high-quality and effective care
and treatment under the MHA.
58,400
detentions in 2014/15 the highest ever
year-on-year rise in recent years
SUMMARY 9
Introduction
The Mental Health Act 1983 (MHA) is the legal professionals. It does this by providing rules and
framework that provides authority to admit, detain requirements for professionals to follow. It also
and treat patients in mental health hospitals. This provides for statutory guidance for mental health
can only be done to people who have, or appear to professionals and services in the Code of Practice
have, a mental disorder, and who are putting their and expects doctors, clinicians, managers and staff
own health or safety, or other peoples safety at risk. in provider services to have a detailed knowledge
The MHA also provides more limited community- of the Code and follow the standards it sets out,
based powers in the form of community treatment or document reasons why the Code has not been
orders (CTOs) and guardianship. followed.
The MHA includes safeguards for peoples rights CQC has a duty under the MHA to monitor how
when they are being detained or treated by services exercise their powers and discharge their
duties when patients are detained in hospital or
are subject to community treatment orders or
guardianship. We visit and interview people whose
rights are restricted by the MHA, and we require
actions from providers when we become aware of
matters of concern. We also have duties to provide
a Second Opinion Appointed Doctor service (see
page 45), review MHA complaints (see page 47) and
Part 1 make recommendations for changes to the Code.
THE MENTAL HEALTH Our role is to check that patients human rights are
being protected, and look at how mental health
ACT IN ACTION services in England are applying the safeguards of
the MHA and the Code of Practice. We are required
to carry out visits and activities to see how providers
The main picture of our findings on
are supporting patients, making sure they have
the Mental Health Act in action.
effective systems and processes in place to meet the
requirements of the MHA, and that staff are being
Part 2 supported to understand and meet the standards
set out in the Code. Part 2 of this report sets out
CQC AND THE MENTAL the activities that inform our work and this report in
more detail.
HEALTH ACT In addition to our MHA duties, we also work to
highlight and seek action when we find practices
An outline of CQCs statutory duties in that may breach human rights standards during our
monitoring the Mental Health Act. MHA visits. This is part of our work as one of several
bodies that form the UKs National Preventive
Mechanism (NPM) against torture, inhuman or
degrading treatment. More information about this
important role and our activities can be found in the
full UK NPM annual reports that are published in
Autumn each year.a
Footnote:
a www.nationalpreventivemechanism.org.uk/

The context of the MHA in 2015/16 There are notable examples of services that have
As outlined in our State of Care 2015/16 report, successfully reduced out-of-area placements of
our work over the year took place in the context acute patients, such as Sheffield Health and Social
of a number of developments and emerging Care Foundation Trust, which announced in March
concerns for mental health and learning disability 2016 that it had eliminated the need to send
services. Several reports highlighted implications adult acute patients out of area for treatment due
for the Mental Health Act and inequalities in to lack of local capacity. This has been achieved
care for people with mental health problems, by redirecting resources to strengthen community
which are putting lives at risk. These included services and develop alternatives to admission.8
the Five Year Forward View for Mental Health; This is an impressive result as the trust previously
Winterbourne View Time for Change (Sir had large numbers of people who use services
Stephen Bubbs final report); The Commission sent out of area for acute care.
on Acute Adult Psychiatric Care; and the NHS Focus for 2015/16 report
England commissioned report on the investigation
of deaths at Southern Health NHS Foundation Following feedback from our external advisory
Trust.2-5 group and service user reference panel, this years
report will form one of a suite of products relating
The Independent Mental Health Taskforce to our findings on the MHA. This report focuses
set out key concerns and issues for inpatient on our monitoring activities and the way services
psychiatric provision, echoing those of our are meeting the MHA and its Code of Practice.
previous annual MHA reports, and made Future products will look in depth at specific
commitments to identifying solutions that will topics and their impact on patients subject to the
improve the experience for people subject to Act, such as the rising numbers of detentions. By
the MHA. This includes reducing the uses of taking this approach, we will be able to provide
the MHA by 2020/21, increasing the focus on more detail on the topics that people who use
the over-representation of Black and minority services and providers have told us they would
ethnic (BME) groups in compulsory detention, find helpful.
and evaluating the way the MHA is working for
patients.
Tackling the issue of reducing the number of
people being moved away from their home has
also been high on the agenda this year. Available
experimental data suggests that, in March 2016,
up to 10% of patients in adult mental health
beds (569 patients) may have been sent out of
area for treatment.6 Lack of local bed availability
appeared to be the main reason for acute out-of
area placements in March 2016.4 This is a serious
10%
concern, and patients' understandable reluctance of patients in mental
health beds sent out of
to be admitted to distant hospital beds may be area for treatment
one cause of rising rates of detention. We will be

working with NHS England, NHS Improvement
Some services have successfully reduced
and the Department of Health to support the out-of-area placements of acute patients
development of new commissioning tools and new by redirecting resources to strengthen
metrics to help reduce this practice, following on community services and develop
from initial guidance issued by the Department of alternatives to admission.
Health at the end of September 2016.7
INTRODUCTION 11
Part 1
THE MENTAL HEALTH
ACT IN ACTION

Key points
We have seen examples of good practice and innovative approaches to overcoming areas
of concern highlighted in our previous reports. We have met thousands of staff who are
compassionate and dedicated to providing the best support and treatment they possibly can for
their patients.
Staff had received training on the changes in the Code, or the revised policies and procedures
to reflect its guidance, on less than half of wards we sampled. From 2016, we have taken these
failings into account and use them to inform the ratings we issue to providers.
Overall, the figures for care planning, patient involvement and discharge planning subject areas
show unacceptable variation in meeting the Codes expectations, similar to those recorded in
the 2014/15 report. Some services need to address the quality of care in these areas for people
detained under the MHA.
One in 10 records do not show evidence that patients have had their rights explained to them at
the point of detention. This leads to patients not knowing what to expect, or understanding their
rights under the MHA.
We were notified of 201 deaths of detained patients by natural causes, 46 deaths by unnatural
causes and 19 yet to be determined verdicts.
1.1 Regulation and the Mental centred care, staff not fully respecting peoples rights,
and people not being fully involved in decisions about
Health Act their treatment and support.
We monitor how the MHA and its Code of Practice Another concern is that inpatient care is often
are applied through our MHA reviewer visits and provided in outdated buildings that do not meet
our comprehensive inspections. Our comprehensive modern standards. This can affect patient safety and
inspection teams of NHS mental health services their experience of the service, and create additional
always include an MHA reviewer and findings from our problems for services already under significant
previous MHA monitoring visits are used to inform the pressure. Problems include a lack of clear lines of
inspection. Although we do not rate how well services sight (making unobtrusive observation difficult),
are applying the MHA, our findings do influence ligature points and other hazards that need attention,
the overall rating for the key questions are services and the layouts of wards compromising same-sex
effective? and are services well-led?. If we find accommodation rules.
significant issues with the way the MHA is working
for patients, core services will only be able achieve a Our strategy for 2016 to 2021 builds on what we have
maximum rating of requires improvement. learnt from our comprehensive inspection programme
and aims to create a more targeted, responsive and
Through our MHA visits and comprehensive collaborative approach to regulation.9 This will include
inspections, we have seen some good care and have making greater use of focused and unannounced
met thousands of staff who are compassionate and inspections, to target areas where our monitoring of
dedicated to providing the best support and treatment services suggests patients are at the greatest risk.
for their patients. However, there are many mental Underpinning this will be continued, regular MHA
health provider organisations that need to improve. reviewer visits to all mental health services that are
Particular concerns include staff not providing patient registered to provide care and treatment to people
THE MENTAL HEALTH ACT IN ACTION 13

Figure 1 Implementation of the Code of Practice, September 2015 to April 2016
Are all policies updated in line 93 113

with the new Code?
Is a copy of the new Code

available on the ward? 169 43
Has training been provided on the

new Code?
104 109
0% 20% 40% 60% 80% 100%
Yes No
Source: CQC
subject to the MHA. Although the majority of our professionals) should have detailed knowledge
MHA visits are currently unannounced (over 95% of the Code, including its purpose, function and
of visits), we are reviewing how we identify and scope (page 12).
carry out visits, and how our MHA focused activity From September 2015 to April 2016, we asked
can be completed in alignment with the inspections MHA reviewers to answer a questionnaire on 214
planned. visits to hospitals. In this sample, staff had been
provided with training on the changes in the Code,
1.2 Implementing the revised or with revised policies and procedures to reflect its
Code of Practice guidance, on less than half of wards (figure 1).
The revised Code of Practice came into effect from Where we found that staff did not have support
April 2015 and is designed to promote and support from managers to implement the revised Codes
the best possible care, ensure patients rights are recommendations, through a lack of training,
protected, and must be considered by health and outdated policies, or other governance failings that
social care professionals. The MHA Reference
Guide was also updated at the same time, and
provides an explanation of the provisions of
the Act.10 One of the most common themes has
been the issue of practitioner training. We
In last years report, we were clear that we
expected providers to have revised their policies
know that best practice, throughout all the
and practices and to make sure staff are trained so different scenarios in mental health care, is
that they have the right skills and understanding to detailed in the Code. These guidelines now
support patients (paragraph 4.61 and 4.62). This is need to be enforced, without exception,
a clear requirement in the Code of Practice, where and for this to happen, training has to be
it states that professionals (including managers, consistent and robust across the board.
staff, doctors and approved mental health
Code of Practice expert advisory group member

affect the safeguards offered to detained patients, we Compliance with the Code
raised this with the provider. On our comprehensive of Practice as a regulation
inspections, issues around complying with the Code
have contributed to lower ratings and been subject to issue
enforcement actions. On a comprehensive inspection of an NHS mental
Our overall findings suggest that providers and staff health trust we found that, although the trust had
need to do more work to promote the importance a governance structure for monitoring the MHA,
of the standards in the revised Code, but national the senior management we spoke with did not
agencies also need to understand the reasons for the have a good understanding of the operation of
lack of implementation. The Five Year Forward View the MHA throughout the trust. The governance
for Mental Health recommended that the MHA and structure was not effective to oversee and
relevant Code of Practice are reviewed to see if they monitor the implementation of the MHA.
require attention or further updates.2 We understand We saw compliance with some aspects of the
that the Department of Health will be carrying out an Code of Practice; this was only in relation to
evaluation of the effect of the latest changes to the the aspects of the Code that had not changed
revised Code, and we will look at ways we can support since its 2015 revision. There was no consistent
their review through our review and findings from training in the trust that included the 2015
provider visits. Code of Practice and its implications for staff
delivering care. The trust did not have an
1.3 Deaths in detention overall implementation plan for the 2015 Code
In our previous reports we have highlighted the of Practice. The trust was rated as requires
importance of investigating, reporting and learning improvement for effectiveness.
from any death of a person detained under the On an inspection of another NHS mental health
Mental Health Act, particularly when they are in trust, we were concerned that the policies and
state detention and receiving care and treatment in procedures reviewed had not been updated
hospital at the time of their death. Over the last year, following the implementation of the revised Code
there has been an increased focus on how the NHS of Practice. For example, we were shown a copy
learns from all deaths, following the avoidable death of the prevention and management of violence
of Connor Sparrowhawk in 2013 and the subsequent and aggression policy on a ward that had been
reports into Southern Health NHS Foundation Trust updated in October 2015, and we accessed
which was found to have a lack of oversight and the absent without leave policy that had been
monitoring in place to learn from deaths in its services. updated in November 2015 but both continued
Following the publication of the NHS commissioned to refer to the previous Code of Practice. Both
report into the deaths at Southern Health NHS policies had been reviewed and approved by the
Foundation Trust, the Secretary of State asked us to MHA scrutiny committee. We found a trust to be
look at how NHS trusts across the country investigate in breach of Regulation 9 (person-centred care)
deaths to find out whether similar problems can be and a requirement notice was issued.
found elsewhere. The review, which is currently taking
place, will look particularly closely at how trusts
investigate and learn from deaths of people using patients. This includes working with stakeholders, our
learning disability or mental health services, including expert advisory group and NHS Improvement to review
deaths in detention. relevant information relating to deaths in detention.
As part of this review, we have included a more We will look at the implementation of previous
detailed enquiry into the way services are responding recommendations, including those from the Equality
to, reviewing and reporting the deaths of detained and Human Rights Commission inquiry into non-natural

deaths; the National Confidential Inquiry into Coroners establish how the person died either by
Suicide and Homicide of mental health patients; carrying out an investigation or a jury inquest. When
and the Five Year Forward View for Mental Health. notifying CQC about a death we ask providers to tell
We will be published the findings from our review in us when the coroner was informed of the death and
December 2016. provide the details of the coroners office.
All providers registered under the Health and Social Following the publication of the annual bulletin
Care Act 2008 must notify us about the deaths of of coroner statistics by the Ministry of Justice, we
people who are detained,b or liable to be detained were alerted to a discrepancy between the number
under the MHA. In 2015/16, providers notified of detained patient deaths reported by coroners
us of 266 deaths of detained inpatients (figure and those reported by our notifications system
2). There were 201 deaths attributed to natural between 2011 and 2014.11 The coroner fulfils the
causes in 2015/16 (figure 3). Full details of the requirements of the Human Rights Act, making
notifications we received are in appendix C. sure anyone who dies under the MHA has an
independent investigation, and any failure to inform
Reporting deaths to the coroner the coroner would be considered a significant issue
Last year we reported our concern of the lack of an for detained patients and their families. We carried
independent system for investigating the deaths of out a review of the 2015/16 data and found that
detained patients in health care settings, and our in two of the 266 cases from the 2015/16 data,
belief that there is much greater opportunity for providers had not reported the death to the coroner,
learning and improvements to take place when deaths probably due in part to an incorrect assumption that
occur. In the absence of such a system, the role of the the coroner did not need to be informed of deaths
coroner is typically the only independent review of a that appear to be clearly from natural causes. We
detained patient death. Section 1 of the coroners and have raised this with the providers concerned but
Justice Act 2009 states that coroners must conduct also made changes to our notifications process to
an investigation into all deaths in state detention, reinforce that all deaths, irrespective of whether or
including people subject to the MHA in hospital and not the provider believes them to be from natural
those subject to a Deprivation of Liberty Safeguards causes, must be reported immediately to the coroner
authorisation at the time of death. as expected by the Coroners and Justice Act 2009.
Footnote: Physical health and mortality for
b Patients liable to be detained include detained patients on people aged 40 and under
leave of absence, or absent without leave, from hospital,
and conditionally discharged patients. For the purposes of It is well known that people with mental health
deaths notifications, detained patients include patients problems are at a higher risk of dying prematurely
subject to holding powers such as sections 4, 5,135 or because of physical health problems. Looking at
136, and patients recalled to hospital from CTO.
Figure 2 Cause of death of detained patients, 2011/12 to 2015/16
2011/12 2012/13 2013/14 2014/15 2015/16

Natural causes 191 200 126 182 201
Unnatural causes 36 48 36 34 46
Unknown 9 27 36 11 19
Total 236 275 198 227 266
Source: CQC

data over the last five years, the number of natural Deaths where restraint had been
cause deaths has fluctuated, with a continuous used within seven days of death
rise since 2013/14, but the underlying trend is We were told about 16 deaths that occurred within
broadly flat. That the number of deaths from natural seven days of restraint being used. Coroners verdicts
causes has not reduced has been highlighted for are not yet available for all 16 deaths to confirm
discussion and review with leads, in both CQC and the causes of deaths within seven days of restraint,
NHS England, for improving and integrating physical although all had been reported to coroners. For the 13
health and mental health as part of implementing the where coroners verdicts are now available, none were
recommendations in the Five Year Forward View for found to be related to restraint.
Mental Health.
This year, we were told of 20 deaths from natural 1.4 The use of the Mental
causes of people aged under 40 years old, 16 Health Act
of whom were detained in hospital and four on
community treatment orders. Twelve deaths were In recent years, the number of uses of the MHA
from circulatory events. Circulatory diseases are the has been rising, with the highest ever year-on-year
third most common form of death in the comparable rise (10%) to 58,400 detentions (excluding holding
general population under 40, with external causes powers) in 2014/15.c At the time of writing this
(including road traffic accidents) being the most report, the 2015/16 data is not available. The effect
common, followed by cancer. of rising detention rates on patients and services
needs to be reviewed at a local level. Following the
Our sample is too small to provide meaningful release of 2015/16 data, we will be working with
conclusions. However, circulatory diseases are made NHS England, NHS Improvement, NHS Digital and
worse by some types of psychiatric medication, as well our inspection teams and MHA reviewers to carry out
as obesity, lack of exercise or smoking. NHS England
has also highlighted the potential benefits to mortality
Footnote:
if people with mental health conditions receive
c As recorded in the NHS Digital data collection
interventions of the same quality as the general
using KP90 returns. The 2015/16 dataset from
population, underlining the importance of detained these returns will be the final collation, as the
patients receiving good quality physical health care.12 system is retired to be replaced with MHSDS.
Figure 3 Natural cause deaths of detained patients, 2011/12 to 2015/16
250
200 201
191
200
150 182
100 126
50
0
2011/12 2012/13 2013/14 2014/15 2015/16
Source: CQC

a programme of focused activities with individual test for deprivation of liberty, to encompass any
providers. We will look at the reasons for changes patient who is under continuous supervision and
in activity in their areas, what this has meant for control and not free to leave a place of care. It
patients and any actions local health economies is likely that this has reduced the proportion of
have taken in response to rising detention rates. patients admitted to mental health beds on an
The reasons why increasing numbers of mental informal basis, as services become more sensitive to
health patients are being detained are likely to be issues of unauthorised deprivation of liberty (also
complex and may differ from area to area. Focused referred to as de facto detention) and seek to avoid
work is needed to investigate this. For example, it. Allowing for some caution as the dataset is not
data on community-based services for the same complete, the number of beds occupied by patients
period show a decline in patient contact. This could detained under the MHA at any one time may
suggest that reductions in the support that would now be surpassing the number of beds occupied
keep patients out of acute crisis and reduce hospital by informal patients (figure 4). This would be an
admissions are a factor in the rising numbers of important change in the profile of resident patients:
detentions.13 It may also be that rising detention before 2014/15, there were always more informal
rates are related to repeated admissions of the same than detained patients in mental health beds.
patient on a rapid cycle, or that the threshold for From April 2016 the Mental Health Services Dataset
accessing one of the reduced number of beds is now (MHSDSd) is the only official collation of statistics
that a patient meets the criteria for detention under on the use of the MHA. In contrast to the previous
the MHA. These uncertainties highlight that they annual collections, MHSDS is collected monthly
need to continue to develop our methodology for and offers person-level data, which will provide
assessing MHA information during our assessments more timely information about the people who
of inpatient and community services, ensuring this is Footnote:
highlighted clearly in our provider reports. d Previously called the Mental Health and Learning
Another potential cause is the Cheshire West court Disabilities Data Set (MHLDDS). This dataset was renamed
the Mental Health Services Dataset (MHSDS) in 2016
ruling in 2014. This redefined and broadened the and is referred to by its new title throughout this report.
Figure 4 Mental health patients at year end, March 2008/09 to 2014/15
120,000
100,000
80,000 68,906 62,113 59,076 57,845 51,196

71,278
75,843
60,000
40,000
48,663 50,964 54,225
20,000 40,146 43,262 45,797
30,913
0
2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15
Detained Informal
Source: Mental Health Minimum Data Set / Mental Health and Learning Disabilities Data
set and Hospital Episode Statistics, NHS Digital; Office for National Statistics

are experiencing detention. It also offers previously under the MHA when compared with White British
unavailable detail about patient pathways through men (56.9 detentions per 100 people who spent
detention and the different groups who experience time in hospital compared with 37.5). However, the
detention, including equalities information that will be reasons why the MHA is used more in some Black and
vital to understanding and improving inequalities in minority ethnic (BME) groups are complex and not
the use of the MHA. well understood.
However, in last years report we highlighted The Five Year Forward View for Mental Health called
significant concerns about considerable under for NHS England and NHS Improvement to ensure
reporting to the monthly data collections, with at that use of the MHA is closely monitored at both local
least 29% less uses of the MHA being reported by and national level, and for rates of detention to be
providers to the MHSDS (41,592) compared with reduced by 2020/21 through the provision of earlier
the annual KP90 collection (58,399). Similarly, intervention, with targeted work to reduce the current
the number of people reported by the KP90 to be over-representation in acute care of people from BME
subject to the MHA at the end of March 2015 was groups, and other groups of people that experience
25,117, compared with the most recent published inequality. We will be discussing how we can support
monthly MHSDS figure of only 16,769 at the end of this work with NHS England, NHS Improvement
June 2016.14 The coverage of MHSDS is improving and others, ensuring we are collectively working on
each month, but this highlights the importance of all improving the MHSDS data that will be critical to
service providers returning complete data to make informing the programme of work needed to deliver
sure we can realise the benefits of having a single this recommendation.
data collection, improving the consistency of data As highlighted in our 2014/15 report, practical
for use by providers and national bodies. We expect guidance for commissioners of mental health services
that provider Boards should be robustly assured that has been available since April 2014 to ensure there
their organisations' monthly returns are complete and is a greater transparency about how areas are
accurate. NHS Digital is placing particular emphasis monitoring and addressing inequalities.15 The guidance
on providers across secure and non-secure care in promotes a co-production, values-based model for
the independent sector. We will be carrying out joint commissioning, procuring, and delivering services, and
activities to look at individual provider issues in the its suggestions include that:
year ahead, taking any action necessary to make sure
we support the delivery of high-quality data and Commissioners should expand community
transparency in the way the MHA is being used. residential alternatives to hospital admissions,
and increase community services that support
We encourage commissioners to monitor the psychosocial rehabilitation of people from BME
MHSDS data, and all national NHS bodies should groups.
continue to work with NHS Digital to review and
Procurement and delivery of such services through
improve compliance with the requirement to submit
third sector organisations from BME communities
information about uses of the MHA.
should be prioritised.
Equalities and the use of the Mental Health Act Peer support services and advocacy services
It has long been recognised that there is inequality in specific to the needs of BME communities should
the use of the MHA between population groups. The be an integral part of mental health service
provision in diverse communities.
Five Year Forward View for Mental Health sets out
the need for greater priority to be given to tackling We continue to encourage providers to work with
these inequalities. For example, men of Black or Black their local commissioners to consider how to apply
British ethnicity are much more likely to be detained these suggestions in practice. We will also be looking

at equalities when we carry out focused reviews, Information for patients
and how the areas we visit have implemented the Under the MHA, providers need to give patients
guidance or alternative improvements, and the information about their rights, verbally and in
effect this has on patients. writing, as soon as possible after the start of their
detention or community treatment order. This
1.5 Protecting patients rights and allows patients to understand how the MHA will
autonomy affect them, be involved in their care and treatment
and discuss any issues or concerns with staff. It also
This section looks at our findings on the way
gives them the opportunity to exercise their rights
services support the empowerment of patients
if they wish to do so, for example by requesting
to be involved in their care and treatment,
their discharge through an appeal to the tribunal or
understand their rights and exercise their autonomy
hospital managers.
while detained. The MHA and Code require
services to provide patients (as well as carers and During our inspections and MHA monitoring
relatives where appropriate) with information and visits, we check that hospital managers have given
opportunities to be consulted and involved in patients this information. We also look at what
treatment. information is available for patients, families and
carers on how to raise a complaint, and if they
In May 2016, we published our report Better care
have access to the Code, so they are aware of the
in my hands, a review of how people are involved
standards of care they can expect to receive.
in their care.16 This report looked at the extent and
quality of peoples involvement in their care and While the majority of records showed that patients
how services are meeting their statutory duties had received information about their rights, there
to offer person-centred care as a fundamental was no evidence that staff had discussed rights
standard. The report made recommendations for with the patient on admission in 10% (421) of the
providers and commissioners, and we will be using patient records. In 12% (512) of records, there was
these to inform our MHA visits and how this has no evidence that patients received the information
affected patients subject to the MHA. in an accessible format. The Code requires staff to
remind patients of their rights and of the effects of
Figure 5 Evidence of discussions of rights in examined records, 2015/16
Evidence of discussions about

rights (on detention) and an
assessment of the patients level of
3,907 421
understanding
Evidence of further attempts to

explain rights where necessary
3,397 750
Evidence that information was

provided in an appropriate and 3,753 512
accessible format
0% 20% 40% 60% 80% 100%

Yes No
Source: CQC

the Act from time to time, to ensure that the hospital temporary halt or a significant reversal of the trend
is meeting its legal duties. However, there was no towards continuous improvement in the figures from
evidence of this happening in 18% (750) of records 2010/11 to 2014/15, but providers should reflect
that we checked (figure 5). on this in relation to their own practice and feedback
These national-level findings on the proportion of from our visits.
services that we judge to be meeting their duties Some services have taken effective action to improve
under the MHA show no improvement from the practice after we raised concerns over the way
previous year. We cannot tell whether this is a information was provided. For example, some learning
Good practice: providing information to patients

and carers
It should be part of the duty of the named nurse to ensure that patients
are supported to understand their rights in a number of different ways:
it should be done individually according to need, and documented.
Service User Reference Panel member, September 2016
What good looks like

Chapter 4 of the Code of Practice states that staff should receive adequate and appropriate support and
training to understand the importance of providing patients with their rights and, where necessary, have
specialist skills so that rights can be given in a number of different ways, tailored to individual patient and
carer needs. Individual records should be kept by staff with a policy to support this and regular checks
made by the hospital managers that information has been properly given and understood by patients.
Examples from practice

We found good use of notice boards on an acute Another acute ward had the direct number for the
ward. A wide range of information was displayed, modern matron available for patients and carers in
including a comprehensive explanation of the MHA the reception area, notice boards and on individual
and the meaning of each section. There was also notice boards in the patients bedrooms. We spoke
creative use of notice boards to give appropriate with the modern matron who confirmed that patients
personal information about staff, such as who they and carers were encouraged to contact her directly.
were, what they liked and so on. There was a notice 5 Boroughs Partnership NHS Foundation Trust,
board on support available to carers, from which Coniston Ward, May 2016
we noted that the trust had set up a secure social
networking site for carers containing posts from On a learning disability ward, staff made sure that
doctors, relatives and carers and contact details to all information for patients was written in a format
obtain advice from pharmacists and therapists. they could understand. This included all signs on
the ward, psychology reports, records of one-
Berkshire Healthcare NHS Foundation Trust, to-one meetings between nurses and patients,
Prospect Park Hospital, Snowdrop Ward, information about patients rights, activity plans
April 2016 and care plans.
Black Country Partnership NHS Foundation Trust,
Orchard Hills, June 2016

disability services have ensured that a wide range
of legal and clinical information is available in The initial shock of being taken forcibly
accessible formats, and some services have been from your home and put in a ward that
able to use ward notice boards to provide accessible you know you hate makes you worse: you
legal information alongside information about are not in a fit state to take in your rights
staffing on the day and activities available. at that time, and theyre written in a sort
It is important that the duties under the MHA to of jargon anyway. So you need to have
provide information to detained patients are not your rights explained to you when you are
read too narrowly by services. We sometimes hear at the right moment, by someone willing
these duties referred to as reading the patient to let you question them. Its no good just
their rights, which has unhelpful echoes of police
reading it to you, thats a waste of time.
procedure. It is not enough to focus on rights to
appeal detention. The duty under the MHA should Theres no substitute for talking to people.
enable patients to understand and engage with The most important thing a psychiatric
staff and others in exercising agency over their nurse can do is talk to a patient.
immediate and longer-term involvement with
Service User Reference Panel member
services.
Independent Mental Health Advocacy patients to make contact with an advocate,

Under the MHA, providers are required to take particularly where patients may lack capacity to
practicable steps to make sure that patients subject decide whether to ask for help from an IMHA.
to the MHA are aware of the help that is available The Code of Practice recommends that hospital
from Independent Mental Health Advocates managers should arrange for an IMHA to visit any
(IMHAs). In our last report, we highlighted that patient who lacks capacity to decide whether or
many providers did not have effective systems in not to request help from an advocate, to explain
place, or were not supporting staff well enough to directly what the IMHA service can offer (paragraph
meet the expectations of the Code or their duties 4.23 and 6.16). We are looking at whether services
under the Act regarding IMHA services. are following this guidance on our MHA visits,
and have already seen many services using this
We continue to look at the availability of advocacy. approach.
In 2015/16, for 12% (515) of patients interviewed
on our visits there was no evidence that the We welcome the governments proposals to
patient was informed of their right to an IMHA. consider changing regulations to make sure that
In most cases, services have taken action on this advocacy services are more formally provided on an
as a result of MHA reviewers reports. A small opt-out (rather than opt-in) basis for patients who
number of our comprehensive inspections of mental lack such mental capacity.17
health services have found difficulties in providing
patients with information about, or access to, MHA
services. We have used our enforcement powers, I think advocacy is very hit and miss.
issuing requirement or warning notices, to require
Some trusts use them to their full
providers to take actions to improve this, and it has
also contributed to services being rated requires advantage, but others dont. Ive not
improvement. seen one and Ive been detained
10 times.
Services should make sure that staff tell patients
about their right to access advocacy and support Service User Reference Panel member

Good practice:
Its not the willingness of services
that is the problem, it is the advocacy
implementing the
resources available.
Codes guidance on

advocacy referrals
In MHA monitoring visits to a dementia unit

champions take the lead on identifying restrictive
in May 2015 and June 2015, we noted that
practices, make plans to appropriately reduce them,
automatic referrals to the IMHA service were
and involve patients individually and in group meetings
not being consistently completed. However,
when discussing their concerns. It is a welcome shift in
by the time of our comprehensive inspection
culture for many services, which empowers patients and
in May 2016, staff were completing timely
staff to challenge long-standing practices.
and regular referrals to the IMHA service
on behalf of their patients. IMHAs also As we visit wards that are both places of psychiatric
visited the wards regularly to offer patients treatment and detention, we expect to see some
independent support and advice. The IMHA tensions between individualised care and treatment and
service told us that the hospital provided maintaining control and safety. We do not expect there
appropriate support to patients who were to be a time when all issues of blanket restrictions
detained under the MHA. are resolved, but instead, look to see that services are
regularly monitoring how their reduction strategies are
Abbey Court Independent Hospital,
being delivered and reviewing their practices to remove

May 2016
unnecessary restrictions.
There is a role for NHS commissioning to encourage
We have also seen some excellent and innovative the development and use of least restrictive practices
practice, demonstrating how advocacy can help to through service contracts. For example, in a unit that
empower patients. We have also noted advocacy otherwise had a strong rehabilitation focus, with many
services developing tools to enable them to intervene of the patients having unescorted leave, we found
and support patients at key points of their treatment staff reluctantly working through a timetable of patient
and care, and a service expecting and appreciating room searches. Staff told us that they did not think
advocacy involvement at these points. such routine searching was necessary, but that it was
specified in their service contract. It is likely that service
Blanket restrictions
contracts may be more flexible than some services
Chapter 8 of the Code of Practice emphasises that presume, and we encourage secure services and NHS
services should avoid the use of blanket restrictions, England to talk about these matters. If contractual
which it defines as rules that restrict patients liberty conditions set between NHS commissioners and
or other rights, and that are routinely applied to all providers are not in tune with the application of the
patients without individual risk assessment (paragraph Code of Practice principles, they should be revised.
8.5). We now see many examples of services reflecting
on their practices to ensure that unnecessary blanket Locked wards
restrictions are identified and challenged. Many services In 2015/16, 91% of the 1,234 wards we visited were
have established governance around this that appoints locked. The proportion of locked wards has risen
specific members of staff to be champions of the slightly every year over the last decade or more.18
process. All services are expected to have a restrictive Any informal patient who is admitted to a ward that
practices reduction programme that can demonstrate is permanently locked is at risk of unlawful de facto
a year-on-year reduction on restrictive practices. Local detention. We often raise concerns about this on our

Good practice: Independent Mental Health
Advocacy
I think advocates have a great role, and theres not enough
money invested in them. In our service theres only two of
them and theyre both overworked. Especially when youre
on a Psychiatric Intensive Care Unit, its really nice to have an
advocate whos based in the building and who comes to see you
and have a chat. Theyre so different from the nurses, and so
non-medical.

Staff should promote, encourage and support patients to access advocates. This includes their
ability to support preparations for meeting, enabling and empowering patients to take part
and understanding the outcomes of meetings or hearings that are taking place.
Chapter 6 of the Code of Practice states that local services and commissioners should work
together to maintain the effectiveness and provision of advocacy services and how they are
working for patients, discuss any improvements needed and promote awareness for patients
of the statutory support available to them.
Example from practice

In a medium secure unit, we observed The IMHA was notified when a patient
the Independent Mental Health Advocate was admitted to seclusion and would
(IMHA) engage with a number of patients. conduct an independent review within
The IMHA supported patients to complete 24 hours. The IMHA completed the
the questionnaire we used on our visit. We seclusion form, presented as a checklist,
observed the IMHA meet with a patient with the patient and cross-referenced
before their Care Programme Approach (CPA) with staff and records. We observed this
meeting, following which she attended the process on the day of our visit, and noted
CPA meeting at the request of the patient, that concerns were raised and addressed
and fed back to the patient afterwards. immediately.
The IMHA service had also developed two The ward staff said that these interventions
forms that it used to support patients: were helpful and supported them to improve
practice.
A CPA form helped the IMHA guide the
patient through the care planning process, Mersey Care NHS Foundation Trust, Scott
and the CPA meeting and document issues Clinic, June 2016
to be addressed and actions agreed.

visits and ask services to make sure that informal we found these issues, we identified them as areas that
patients are aware that they are allowed to leave wards providers must improve on.
with locked doors. There were a number of other occasions when female
There are many possible reasons why the number patients reported feeling threatened by, or receiving
of locked wards is increasing, but few are based on unwanted attention from, male patients. Nobody
evidence. There is often the assumption that the should experience this as a hospital inpatient, but it
door has to be locked to prevent patients leaving or may be particularly traumatising for someone who
to prevent strangers or items that are banned, such is detained under the MHA. Some female patients
as drugs and alcohol from coming onto the ward. raised concerns over being observed by male staff
Research into locked doors in acute wards suggests when they felt vulnerable, such as when sleeping,
that they do significantly reduce the number of bathing or undergoing seclusion or restraint. All staff
people absconding. However, they do not eliminate and managers need to be constantly alert to the
it altogether and have no effect on the rate of use vulnerabilities of women in detention, some of whom
of alcohol or illicit drugs by inpatients.19 There is may have previously experienced sexual abuse, and pay
also evidence that locked doors are associated with special attention to upholding privacy and dignity.
increased patient agitation and treatment refusal,
because patients feel trapped and confined: The 1.6 Assessment, transport and
emotional burdens of the locked door fall on patients
(anger and depression) whereas those of the open door
admission to hospital
fall on staff (anxiety).20 Approved Mental Health Practitioners (AMHPs)
play an important role under the MHA. A key aspect
The Code of Practice recommends that services should
of this role is to decide whether to apply to have
consider how to reduce the negative psychological
someone detained in hospital when two medical
and behavioural effects of having locked doors, and
recommendations for this have been made.
we expect to see services following this approach
(paragraph 8.15). Research suggests that this Local authorities are responsible for providing AMHPs,
should lead to a focus on high-quality ward physical as well as their approval systems and standards.
environments, involving patients in planning engaging However, there are no nationally set governance
activities, and patients having access to garden areas.20 processes for local authorities over AMHP services. As
there is no national oversight and reporting, knowledge
In some wards, we have seen examples of good
about the way AMHP services and individual AMHPs
practice in enabling patients to engage with planning
are supported across England is limited.
life on the ward and being involved with activities.
Some services have found good ways to engage In 2016, we carried out a review with the Department
patients in daily planning meetings that are a part of of Health to evaluate the effectiveness of the way
ward life in most units. AMHP services are currently monitored nationally.
Stakeholders told us that:
Separate facilities for men and women
There are continuing concerns about the low
We have found issues with gender separation on many of
numbers of AMHPs and the ability of services
our visits during 2015/16. The Code of Practice is clear to provide a 24-hour service that can respond
that all sleeping and bathroom areas should be separate, effectively to patient needs.
and that patients should not have to walk through an
area occupied by a person of another sex to reach toilets There is wide variation in the way AMHP services
or bathrooms (paragraph 8.25). However, on many of our are running across the country and local oversight,
reporting and data captured is poor in many areas
visits we have found the layout of wards did not allow for
and variable across the country.
this, for example where female patients can only access
toilets by walking past male patients bedrooms. Where AMHP services continue to be affected by

Good practice: challenging blanket restrictions
The way round blanket restrictions is to write down what should be
done and what shouldnt be done in individual care plans. So that
does away with blanket restrictions. Everybody has a right to an
individualised care plan to say what is and is not required. And that
makes ward staff justify and reflect on what they do.
What good looks like On one ward, we also had concerns over staff
Managers, staff and clinicians must have an attitudes and interaction with patients.
awareness of the Codes guidance and expectations After receiving our visit report, senior managers in
for avoiding practice that may amount to a blanket the trust visited the ward in question, interviewed
restriction. This includes impact assessments for all staff and made some staff changes. A new
changes to policies and procedures that may result ward manager abolished nearly all of the blanket
in unnecessary restrictions being placed on patient rules and addressed all of the concerns raised. We
settings or groups of patients using the service. revisited in June 2014 and saw that facilities on
Clear guidance should be available to all staff and the ward were open for use by patients, routine
patients that promotes independence and recovery, searching had ended, internet equipment was
offering clear instructions on how to challenge ordered, and visits were no longer supervised.
practice that may amount to blanket restrictions. Since then, MHA reviewers have acknowledged
Chapter 8 of the Code of Practice states that that the trust is making ongoing progress in
provider Boards and governance processes should challenging restrictions across all its secure
be clear about the Codes requirement for any services. In September 2015, we visited a ward
restrictions that apply across patient settings, that had changed to medium secure status
necessary for patient safety or others, to be from a low secure environment. Despite this
supported by a clear rationale, agreed only by change, staff described how most of the blanket
hospital managers and subject to governance restrictions previously in place had been replaced
procedures. with restrictions only being imposed as a result of
individual risk assessments.
Example from practice For example, on this and other wards there had
In 2014, MHA reviewers raised serious concerns been blanket requirements for staff to search
about blanket restrictions that we considered every patients bedroom routinely and to search
unnecessary in some secure wards managed by every patient who returned from unescorted leave
Tees, Esk and Wear Valleys NHS Foundation Trust. outside of the hospital. Some wards had blanket

problems in accessing Section 12 approved doctors,
ambulances for transporting patients and local and
specialist beds.
In March 2016 we presented our findings in a briefing
to the Mental Health Crisis Care Concordat, a collection
of 27 services and agencies involved in the care and
support of people undergoing a mental health crisis:e
We recommended that CQC will use its focused visits
to build an evidence base for the future development
and monitoring of AMHP services.
The Department of Health should work with the
AMHP Leads Network to set national standards
rules that patients visits and telephone for AMHP services, identifying best practice and
calls were supervised, and that they must supporting a high-quality service.
open their post in front of staff. These The Department of Health and the Department
restrictions were now only put in place for Education should seek to produce legislation to
following an individual risk assessment. establish a new social work body that will introduce a
new system of registration for individual AMHPs.
The trust is continuing to address
blanket restrictions, the result of which CQC and the Department of Health should work with
has included better staff morale and NHS Digital to establish a new national dataset that
interaction with patients. In our visit of allows monitoring of AMHP services and outcomes.
June 2014, staff said "from receiving We are continuing to work with the Department of
your report we dropped a lot of the Health and others to implement our recommendations
restrictions"; "I am happy with the way and improve oversight of AMHP services. We are
things are going and the patients are planning to complete focused activities in 2016/17 and
happier in themselves"; "we are looking publish national findings.
to make even more changes, and these
will continue to be based on individual 1.7 Additional considerations for
patients assessments"; and "this is the
best ward ever, there is less restriction and
children and young people
its better for patients." In our last report we noted that NHS England had
acknowledged gaps in provision of child and adolescent
In 2015/16, the trust was rated
mental health services (CAMHS).21
outstanding for the key question are
services well-led?. The use of the MHA for children
Tees, Esk and Wear Valleys NHS and young people
Foundation Trust, January 2014 to There are no age-related criteria for use of the MHA. In
February 2016 October 2016, there were more than 400 children and
young people (those aged under 18 years) detained in
hospital under the MHA (figure 6).
The age of people detained under the MHA has not
Footnote:
e See www.crisiscareconcordat.org.uk/
THE MENTAL HEALTH ACT IN ACTION

27
Good practice: engaging patients in life on the ward
We had a morning meeting, and you can sit around talking,
and generally is there anything have we got any visitors
coming in and sometimes wed have the newspaper and just
talk about the newspaper, talk about things that are going on.
All just sitting around, talking, with the staff was lovely. You felt
more engaged with them and with everybody else...

Commissioners, providers and professionals should consider the broad range of interventions
and services needed to promote recovery not only in hospital but also after a patient
leaves hospital, including maintaining relationships, housing, opportunities for meaningful
daytime activity and employment opportunities. Staff should ensure that patients have
the opportunity to be involved in planning and discussing life on the ward while they are
inpatients, acting on feedback given and seeking ways to improve the activities available
based on the needs of individuals and their recovery plans.

We attended the daily morning meeting In addition to a daily planning meeting
with patients and staff. We found this to where practical matters such as leave
be a good example of empowerment and requirements were addressed, all patients
involvement, with all patients playing an and staff attended an additional evening
active part in planning their activities for debriefing session. This focused on a
the day. All of those present at the meeting, review of the day to talk about what had
including staff, gave an account of their plans gone well, and any issues, with a view to
for the day, and detailed who they would be resolving difficulties quickly. The session
spending time with in or at various activities. also encouraged attendees to recognise
Oak Lodge Rehabilitation Centre (Alternative and acknowledge positive outcomes and
Futures Group Ltd), June 2016 their own strengths and abilities. This was
an effective method of ensuring open and
meaningful communication between patients
and the care team on a regular basis, showing
that they were meeting the guiding principles
of the MHA Code of Practice.
Cygnet Hospital Beckton, Bewick Ward,
April 2016

previously been collated. As a result, we do not know patients (and also because it takes the burden of being
whether the above snapshot is typical of children and the primary legal authority for an intervention away
young people inpatient numbers in mental health from parents, who may not want to take on a role that
services.f If it is, this suggests a different pattern to can lead to conflict with the patient).
adult services, where we have seen that there may NHS England acknowledges that inpatient care
now be more inpatients subject to the MHA than can lead to adverse care pathways, even when it is
informal patients. The 2016 snapshot shows a third based on concerns that children or adolescents are
of children and young people inpatients detained a risk to themselves. This could include a spiralling
under the MHA, with most of the remainder treated of worsening symptoms and increased suicidality,
on an informal basis. For some patients, this will be
simply because they have capacity or competence to
consent to admission and treatment, and do so. For
others, parental consent may be the legal authority for Carers can object to out-of-area
admission and treatment. placements; some AMHPs are very
It seems possible that there is a greater proportionate good at explaining this, but some
use of the MHA today for children and young people dont. Other AMHPs are very good at
than in the past, because of recent changes in saying as in the case of my husband,
emphasis on the "scope of parental responsibility" who said that youre not taking
in the Code of Practice (paragraph 19.40 to 19.43). her out of area the AMHP said I
We understand that many clinicians are less willing completely support you, and turned
to rely on parental consent as the legal authority for
round to the psychiatrist and said you
admission or treatment. This may be a positive thing,
due to the safeguards that the MHA provides for
will not get an application. I know
carers all over the country who didnt
Footnote: know you could do that werent
f From January 2016, the MHSDS monthly release has aware that they could step in and stop
included experimental data from children's and young
people's mental health services, including CAMHS, and
that section.
so in future data will become available for comparison.
g For example, MHA sections 37, 47 and 48 with or
without restrictions.
Figure 6 Inpatients aged under 18 years of age, October 2016
Legal status Number of patients

Informal 870
MHA, s.2 159
MHA, s.3 242
MHA, part 3g 10
MHA holding powers 7
Other acts (ie Children Act) 2
Not known 30
Source: NHS England

leading to increased levels of security and delayed the reporting requirement.
discharge.22 As well as understanding which legal Some services have refused to allow children or
authority is used for inpatient care, local areas will adolescents access to places of safety that are
want to examine patterns of hospital admissions based in adult facilities in the mistaken concern
to determine whether sufficient community-based that to do otherwise would breach age-appropriate
interventions are available to avoid inpatient care in accommodation guidelines. We have suggested
the first place. that such an approach is a misunderstanding of the
Second opinions for children guidelines, and of the nature of a place of safety,
and young people which should be relatively self-contained and not
a part of the ward that shares some facilities or
In 2015/16, CQC arranged 371 second opinions staffing. While we understand that health-based
for patients under 18 years of age (figure 7). places of safety may not be ideal accommodation
Roughly two-thirds of these were for female for children or young people, they are generally the
patients. Only two of the visits were to consider best facility available, and refusing to allow a child
treatment with electroconvulsive therapy (ECT), or adolescent to enter could lead to the use of
both for 17-year-old patients. All other visits were police cells as the only alternative.
to consider treatment with medication for mental
disorder. Eight visits were to consider medication CQC monitoring and inspection
for patients subject to CTO. Very few visits of CAMHS units
(14 overall) resulted in no certificate being issued When visiting CAMHS units in 2015/16, our MHA
to authorise some form of treatment without reviewers and inspectors found issues that were
consent. In most of these cases this was because not markedly different from those raised in adult
the patient had begun to give consent, or was services. Matters raised on our visits included:
discharged from being subject to the MHA.
lack of patient involvement in care planning
Notification of placement of children lack of recording of consent and decisions
and young people on adult wards about capacity/competence to give consent
Services are required to notify CQC after any child failures to provide information about legal
or young person under 18 years of age spends rights, both for patients who were detained
more than 48 hours on an adult mental health under the MHA and for those who were not
ward. We are not notified about whether the child
is detained or not. The numbers of notifications lack of information about advocacy, and some
advocacy services that did not appear to have
have increased by 2% (from 235 to 240) from
specialist training in dealing with children and
2014/15 to 2015/16. This contrasts with a jump of
adolescents
22% from 2013/14 to 2014/15 (from 193 to 235).
We do not know whether this reflects changes in patients complaining of boredom and lack of
practice, or changes in the level of compliance with activities, or lack of access to fresh air.
Figure 7 Second opinion requests for patients aged under 18, 2015/16
Detained CTO
Under 16 108 1
16 or 17 255 7
Source: CQC

On many units we engage staff over issues of blanket Convention on Human Rights requires providers to
restrictions. We accept that many CAMHS units will adhere closely to the requirements of legislation and
have more rules than roughly comparative adult good clinical practice (paragraph 2.44).
services, either because of their specialist nature (such Where the MHA allows treatment to be given
as eating disorder units) or because of the vulnerability without consent, the Code of Practice is clear that
or young age of patients. However, on a number the patients consent should still be sought wherever
of wards we have challenged policies that imposed practicable. Consent, refusal to consent, or a lack of
restrictions, not based on individual risk assessment, capacity to consent need to be recorded. Providers
that limited bedroom access during the day; kept should consider carefully whether to go ahead with
toilets and other facilities locked to patients; banned treatment if the patient refuses or is unable to give
many personal items (including mobile phones); and consent (paragraph 24.41). During visits we check
restricted access to sanitary products and items of to see whether clinicians have recorded evidence of
underwear. Where we have raised these, services have their conversations with detained patients over the
agreed to revise their practices to make sure that proposed treatment, and recorded the patients views
restrictions are based on individual risk assessment and on that treatment, as well as whether the patient
not placed unnecessarily on any patient. consents, refuses consent, or is incapable of consent.
If a patient is recorded to be incapable of consent, we
1.8 Care, support and treatment expect to see a capacity assessment to support this
in hospital view and, unless it would clearly be inappropriate to
expect this, evidence that ways in which the patient
In the Code of Practice, chapters 23 and 24 on
might be helped to gain or regain capacity have been
medical treatment and care in hospital emphasise
considered.
the importance of detained patients being offered
appropriate treatment. To determine if treatment is Discussions about consent to give psychiatric
appropriate, staff need to consider whether the patient medication should always happen before treatment
has consented to or refused treatment, whether begins, as the first three months of treatment comes
the patient has the capacity to consent, and if they to an end, and when ongoing treatment is reviewed,
need to use the powers given under the MHA to unless there are clear reasons recorded why this was
impose treatment without consent. The Code also not possible for that individual patient.
expects services to promote good physical health However, on many visits we have found that these
care and healthy living for detained patients, assess discussions are not taking place. The impact of failing
individual needs and have clear processes for managing to engage with patients could be to deny them the
behavioural disturbance in a safe and therapeutic way. chance to contribute towards their care planning,
Consent to treatment or give valid consent. This could lead to unlawful
treatment, or to less than good care for people that
Under the MHA, services have legal powers to give would hinder quick or sustainable recovery. During
psychiatric care and treatment without consent to
some detained patients.h For the first three months Footnote:
of treatment with psychiatric medication, and for the h The treatment provisions of the MHA (and therefore
range of nursing and other interventions that can fall the authority to treat without consent discussed above)
apply to patients detained under sections 2, 3, 17A, 36,
within the broad category of treatment for mental 37, 38, 44, 45A, 46, 47, 48 and 49 of the MHA. They
disorder, the statute simply states that the consent do not apply to patients held under short-term holding
of a patient is not required (section 63). These are powers such as sections 5, 1345 or 136, or conditionally
sweeping powers, and the Code of Practice emphasises discharged or CTO patients who have not been recalled
to hospital, who are in the same position as informal
that exercising them in ways that comply with the patients in relation to treatment without consent.
rights and freedoms guaranteed under the European

2015/16, we have revised the methodology for our looked at the care records of 3,031 patients who
visits, which has given us a greater focus on this had been detained for less than a year in hospital.
area. Not holding discussions about consent will Of these, there was no evidence in 5% (163) of
limit the rating that we give for the key question records that a health assessment was carried out at
are services effective?. admission. This is similar to our findings in 2014/15
To help patients understand the nature, purpose where 5% (137 records) did not have this evidence.
and likely effects of their medication, some In addition, 10% (76) of the records we looked
services have helped patients to speak to hospital at in 2015/16 reported having problems with
pharmacists. This helps patients to understand the arranging GP services for detained patients. Again,
treatment they are being given, and ensures that this is the same proportion as in 2014/15.
the consent given is valid. In addition, by providing However, we have also seen some good examples
a partially independent source of information of services addressing the physical healthcare needs
and advice it may help services gain the trust and of patients. A number of services have addressed
consent of patients. issues with accessing GP services by arranging
regular GP clinics on the ward. Some services have
Promoting good physical health told us that their primary concern is addressing high
In our 2012/13 report, we showed that a worrying levels of smoking and obesity in patients with a
proportion of wards did not have ready access to severe mental illness. We recognise that these are
GP services, and gave examples of undiagnosed or major health issues for many patients subject to the
untreated physical conditions in detained patients MHA, and encourage services to have a primary
that were compromising both their physical and focus on physical healthcare advice and support,
psychological wellbeing (page 32/33). In our last rather than simply restricting access to tobacco or
two reports, we have highlighted the importance food. We recognise that NHS standard contracts
of improving the physical health care and healthy will require mental health services to ensure that
living of mental health patients (page 25). Our their premises are smoke-free by no later than
State of Care report for 2015/16 expressed 31 December 2018. Services should ensure that
our concern that some long-stay units are not they make full use of available resources to help
sufficiently focused on the assessment and promote smoking cessation in mental health
treatment of physical health problems (page 97). settings, including secure settings, in line with the
Patients detained under the MHA are at particular National Institute for Health and Care Excellence
risk of co-morbidity, where physical health
conditions are overshadowed by mental health
conditions and remain undiagnosed or untreated.
Patients using antipsychotic medication may also Good practice requires that doctors
be at increased risk of cardiometabolic disorders.23 listen to the patients preference
As a result, hospitals must routinely assess the because they may know that certain
physical health needs of patients alongside their medications affect them in a bad way
psychological needs (paragraph 24.57). The and others they get on well with that
Working Group for Improving the Physical Health
should be listened to. And psychotropic
of People with Serious Mental Illness has provided
detailed recommendations on this, which we wholly drugs should only be part of the
support, for service providers, commissioners and holistic treatment of a patient; talking
regulators.24 therapies should go along with this.
We continue to review how well the physical health Service User Reference Panel member
of detained patients is monitored. In 2015/16, we
32
MONITORING THE MENTAL HEALTH ACT IN 2015/16
(NICE) guidance to support smokefree policies.25 NHS that will need to be considered when services do not
England is also (at the time of writing) engaging on a have a dedicated seclusion facility in place. However,
new set of draft national Commissioning for Quality all services will be expected to be able to demonstrate
and Innovation (CQUINs) for 2017 to 2019, including what approach would be taken if the need for
the continuation of a CQUIN for improving physical seclusion arose for individual patients.27
health care to reduce premature mortality for people
with severe mental illness.26
Throughout 2016/17, we are looking at how we Good practice: information
can use our powers to encourage better integration
between mental and physical health care. We are
about treatment
working to improve how we assess how well the I did see one example of good
physical healthcare needs of people with a mental
health problem are monitored and addressed. We are
practice on a visit a room with
also looking at how we assess the provision of mental a sign on the door saying come
health care in primary care and acute hospitals. MHA in and discuss your medication
reviewers will be a part of this work, and are taking
part in pilot visits to acute hospitals in 2016.
people could come in and talk
about their individual medication
The safe and effective management
of behavioural disturbance
and I thought that was excellent.
The Code of Practice places a helpful emphasis that
the best form of managing behavioural disturbance What good looks like
is prevention, with a focus on a positive and
therapeutic culture over restrictive interventions Staff and services have a duty to consider the
such as seclusion or restraint (paragraph 26.4). This different ways in which patients understanding,
emphasises the importance of the care environment, level of involvement and opportunity for discussion
staff communication and engagement with individuals can be increased when making decisions about their
and their families, and the involvement of patients in medication. This should include inviting patients
decisions about their care and support as preventive to ask questions, explaining their right to withdraw
measures against behavioural disturbance. or withhold consent, providing access to other
professionals, such as pharmacists or advocates,
Seclusion and, with the support of the patient, involving
family and carers in discussions (paragraph 24.34 to
The Code of Practice recommends that seclusion
24.53).
should only be undertaken in a room or suite of
rooms that have been specifically designed for the Examples from practice
purposes of seclusion and serves no other function
on the ward (paragraph 26.105). As with all of the A rehabilitation unit for men ran a monthly drop-in
Codes recommendations using the terminology session with one of the trusts pharmacists where
should, services may depart from it where they patients could raise issues, request information and
have documented and recorded a reason to do so discuss medication. These issues were also discussed
(paragraph ix). We have seen a variety of services in ward rounds and in one-to-one sessions with
that can demonstrate valid reasons why dedicated named nurses, and the unit gave patients the
seclusion facilities may not be routinely needed, for opportunity to discuss this area with a professional
example children's units. We have issued a brief guide outside of their treatment team.
for inspectors that informs assessments and factors Manchester Mental Health and Social Care Trust,
Anson Road, April 2016

Staff may not expect to use seclusion at all on many pending their transfer to a facility appropriate to
wards where patients are detained, for example their changed circumstances. By their nature such
because the patients on the ward are elderly, or improvisations are rarely perfect, but it seems more
the ward is for rehabilitation before discharge. We reasonable to focus on services ability to arrange
have seen examples where such wards have had timely appropriate transfers, than to expect all units
to improvise safe containment of patients who to be equipped for any eventuality.
suddenly exhibit extremely challenging behaviour, In some services that do not have dedicated
Good practice: physical health checks for

detained patients
I put on all my weight when I went into hospital, all I could do
was comfort eating and I had no way to exercise. It happens to
a lot of people side effects of psychiatric medication can
really harm your general health. Ive got friends who are young
people, in their 30s, really overweight, heart disease, thyroid
trouble, all sorts.
Service User Reference Panel members
Services should consider how to help patients engagement with physical health care, including
healthy living promotion, and steps taken to reduce any potential side effects associated with
treatments. Commissioners and services should work together to ensure the physical needs of
patients are assessed routinely alongside their psychological needs and long-term physical health
conditions are not undiagnosed or untreated, and that patients receive regular oral health and
sensory assessments and, as required, referral (paragraph 24.57 to 24.62).

Our comprehensive inspection of a mixed low On a visit to an acute ward we saw the piloting
and medium secure unit in June 2015 found of a physical health check programme to
good standards of meeting patients physical improve physical health care in people with
healthcare needs. On a subsequent MHA visit long-term mental health needs. A comprehensive
to the womens medium secure unit In April physical and mental health assessment form
2016, we saw that the service was working on a was completed for all patients on admission to
female health project to improve access to breast the ward. This was designed to lead to tailored
screening, smear tests and sexual health through lifestyle advice and signposting, and appropriate
an external service provider. referrals and follow-up. On discharge from the
Brockfield House, South Essex Partnership ward, all patients were given a health passport
University NHS Foundation Trust, April 2016 to take to their GP or to an alternative ward if
transferred.
Central and North West London NHS Foundation
Trust, St Charles Centre, April 2016
34
Weve got a garden in our Psychiatric episodes in their hospital, and indicate whether prone
Intensive Care Unit. Its just a tract of (face-down) restraint was used. If prone restraint
grass that is never used because you is used, we expect the provider to be able to state
need two staff for one patient to go out, the circumstances that justified this, and what
and they go we havent got anybody, arrangements they have in place to get immediate
and the door stays locked How can medical attention. This needs to be clearly recorded
in individual care plans, and regularly monitored and
you be healthy if youre cooped up all
reviewed.
the time? Everyone needs some fresh air
every day. Prisoners get that. In line with the Department of Health's policy Positive
and Proactive Care, providers should have a policy on
Service User Reference Panel members the use of restraint and a programme for reducing the
use of restrictive interventions, for which the board is
accountable.28 Use of all restraint, including any use of
seclusion facilities, occasionally staff will take a mechanical restraint, should always be in line with this
patient to their own room or a quiet part of the ward policy, and any staff need to be appropriately trained.
for additional support. Where this can be achieved
safely, the patient may view it as a less restrictive or Mechanical restraint
less upsetting option than being taken to a dedicated
We expect services to follow the recommendations of
seclusion room. As long as staff recognise that
the Code of Practice in the way they govern the use of
preventing a patient from leaving an area they have
mechanical restraints. However, the Codes approach
been taken to falls within the definition of seclusion,
conflicts with NICE guidance, which suggests that
and they are applying the appropriate safeguards, we
mechanical restraint should only be used in, or in
accept that this is a rational reason to depart from the
transit to, one of the three high security hospitals.29
Codes guidance over only using dedicated seclusion
facilities.
It is encouraging to see initiatives, such as the example
given below, to provide alternatives to seclusion in
some psychiatric intensive care units (PICUs), which Good practice: personalised
are services that will often have an expectation of arrangements to manage
frequent use of this intervention.
patient distress
Where services are trying alternative approaches to
seclusion, or using a non-dedicated seclusion room to Special arrangements had been
isolate patients on occasion, they should periodically made for a patient who found it
review practice to ensure that all interventions falling
within the broad definition of seclusion are recognised difficult to manage his behaviour.
as such, and that the seclusion episodes are reviewed The ward had converted the
as required by the Code. Services must also make sure neighbouring bedroom into a
that patients comfort or safety is not disadvantaged
by the physical environment of the spaces used, which de-escalation room to remove
is unlikely to meet all the recommendations relating to the need for him to have to be
seclusion rooms in the Code. taken off the ward when he was
Physical restraint distressed.
In comprehensive inspections, we ask services to Cheswold Park Hospital (Riverside Health care Ltd),
provide audit data on the number of physical restraint Gill Ward, May 2016

35
Empowerment the providers need
to listen to what the patients want.
That is empowerment so the service
provider is driven by what the patients Good practice:
require. Listening to what the patients a non-seclusion policy in a
want and doing what the patients psychiatric intensive care
want...
unit (PICU)
We visited a PICU ward that had
been rated outstanding in our
A number of services and clinicians have approached
us with concerns over the NICE guidance. We have
comprehensive inspection six
taken the view that all local policies on restraint should months earlier. The ward was
be clear that the least restrictive option for patients is at the forefront of developing
the priority. Monitoring by local teams should include
all uses of restraint and specifically identify mechanical
national standards within PICUs,
restraint use, ensuring there is a clear reason recorded and has been the recipient of
that this has been done in the best interests of several national and international
individual patient, irrespective of the security level
of the service.30 We believe the issue of this conflict
awards. The trust had a non-
between the NICE guidance and the Code of Practice seclusion policy and did not have
should be considered by the Department of Health any dedicated seclusion rooms.
and further guidance should be issued to providers to
clarify the position for services and regulators.
We found that the ward had
We continue to see wards following good practice in
developed innovative ways of
considering whether to use mechanical restraint. The treating patients with challenging
type of intervention used (for example, soft hand behaviour. This included using
restraints that impede but do not immobilise the
patient) needs to be based on the best interests of
verbal de-escalation techniques
the individual patient, rather than whether it is a low, and intensive staff support to
medium or high secure hospital. Whenever mechanical reduce the need for seclusion and
restraint is used, this should be reported to the
managing board of the service.
other restrictive interventions.
Staff told us that when patients
We have found that mechanical restraints are
sometimes being used as a blanket measure when became upset or agitated they
transporting patients off-site (for example to court or would be taken initially to their
other appointments, or when given leave of absence rooms. Staff would stay with
for leisure). Some uses of handcuffs or soft cuffs will
be a Ministry of Justice requirement for granting patients until they became calmer
leave to a restricted patient. However, services need and could re-join the ward.
to ensure that they are not using these measures
2gether NHS Foundation Trust, Wooton Lawn
unnecessarily. Some forensic units have told us that
Hospital, Greyfriars Ward, June 2016
they audit the use of handcuffs. This helped one
service to recognise its use was too high, and led

to the service ensuring that a risk assessment to fully explain and document reasons why they
was completed for each patient. We encourage take any decision that is contrary to the patients
other services to adopt this approach and ensure preferences.
that Ministry of Justice caseworkers know when During our visits in 2015/16, MHA reviewers
patients have been assessed as not requiring found no evidence of patient involvement or
handcuffs so that any requirement established by patient views in 29% (1,214) of the care plans
its caseworkers can be reconsidered. they reviewed (figure 8). There was no evidence
that the patients views about treatment were
1.9 Leaving hospital considered in 26% (1,118) of care plans examined.
In its chapters on leaving hospital, the Code of We recognise that for some people, the nature
Practice provides guidance on care planning in or degree of their mental disorder may make it
the context of the Care Programme Approach, difficult for them to engage with the care planning
including aftercare planning and individualised process. However, it is clear in some of our visit
risk-assessment. reports that staff had failed to make adequate
attempts to make such engagement happen. We
We check the quality of care plans, including
expect all services to carry out and document
whether they are detailed, comprehensive and
measures to support patients engagement with
developed with the involvement of patients and
the care planning process, including building
carers. While some services are doing this well, and
patients capacity to engage where there is an
using innovative practices, overall we continue to
issue.
find issues with a worrying proportion of care plans
and we urge services to look at this closely. There has been a drop in the overall proportion
of care plans that we judged to be meeting Code
Patient involvement in care planning of Practice expectations in 2015/16, compared
Although the MHA provides authority for with the previous year.i We cannot tell whether
treatment without consent, the principles that this is a temporary halt or a significant reversal of
should underpin its use require patients to be Footnote:
involved in decision-making and that clinicians
i In 2014/15, we found no evidence of patient
should consider and fully document patients involvement or patient views in 25% of records
views on proposed treatment. Guiding principles examined, and no evidence of the patients views
of the Code of Practice also requires providers about treatment in 24% of records examined.
Good practice: mechanical restraint in a medium

secure unit
Staff on a womens medium secure unit demonstrated being
open, transparent and looking at all possible least restrictive
ways of supporting a patient being nursed in long-term
segregation with mechanical restraint. Staff also sought feedback
on their intervention through the Royal College of Psychiatrists
Quality Network for Forensic Mental Health Services.
Nottinghamshire Healthcare NHS Foundation Trust, Arnold Lodge, Coniston Ward, April 2016

37
the trend towards continuous improvement in the
figures from 2010/11 to 2014/15, but providers
should reflect on this in relation to their own When we talk about patient
practice and feedback from our visits. involvement, Id like to use the word
In 2015/16 we found 10% of care plans that co-production. So care plans should
showed that patients needs had not been be co-produced, so its less something
considered, or that staff had not considered the done to people When you change
minimum restrictions required for the individual. the language, you can change the
This is the same proportion as for the previous year. practice When youre not cutting
However, some services have addressed this issue and pasting from another care plan,
very well, and we have commended a number of
but co-producing care plans.
services for the levels of patient involvement in
their care. Its very important that you write your
Many services accept the principle of patient own care plan its your chance to
involvement in care planning, but can struggle say how you want to change your life.
to turn this into practice. Effective involvement People should be encouraged to make
requires a person-centred approach, and an advance decisions and planning in
openness towards co-production of care plans.
advance for any future relapse.
There is much user-led research and support for
services on such implementation, including the Service User Reference Panel members
narrative for person-centred care produced by
National Voices, which we commend to services.31
Figure 8 Evidence of patient involvement in care planning in examined records,

2015/16
Care plans show evidence of

consideration of the minimum 3,929 419
restrictions on a patients liberty

consideration of the persons 3,955 452
diverse needs

consideration of the persons view 3,222 1,118
about their treatment
Care plans show evidence of the

patients involvement
3,012 1,214
0% 20% 40% 60% 80% 100%

Yes No
Source: CQC

Good practice: patient involvement in
care planning
What else I hate is them having a meeting before youre invited
in, and then another after youve been in and gone. I want to
see no decisions about me without me, and no discussions
about me without me: I want to be in on every discussion.

Services should have clear strategies in place to actively involve and engage patients as fully
as possible in the co-production of care plans. This should include the allocation of named
individuals responsible for coordinating and regularly reviewing care plans in close partnership
with patients and others involved in implementing the care plan.
Commissioners and providers should have processes in place to monitor how effectively
aftercare needs are being planned and whether these are started as soon as possible following
hospital admissions, ensuring steps are taken to jointly identify appropriate aftercare services
for patients in good time for their eventual discharge from hospital (paragraph 34.10 and
33.10 to 33.15).

We found that each patient had a On an unannounced visit to a learning
comprehensive integrated care plan that disability assessment and treatment unit, we
included a positive behavioural support plan. found comprehensive evidence of full patient
Each patients care plan was tailored to their involvement in all aspects of care planning.
needs and contained the patients own views All documents were in easy read format
and wishes throughout, even when these and demonstrated patient input from their
contradicted the views of the staff. Both admission onwards. Staff took great care at
the care plan and the risk assessment (my all stages and took time to explain everything
shared risk) were provided in an easy read as often as needed to involve and reassure
format. In addition to an active advocacy patients.
service, Women in Secure Hospitals (WISH), Humber NHS Foundation Trust, Townend
a national user-led charitable organisation Court, June 2016
working with women with mental health
needs in prisons and hospitals, held a
monthly surgery to provide additional
advocacy, peer support, supervision and
practical guidance to both staff and patients
on the unit.
Calderstones Partnership NHS Foundation
Trust, Coniston & Grasmere wards,
April and June 2016

Recent research analysing random-controlled as soon as the patient is admitted. Services also
trials also shows that the use of advance need to ensure that patients are clear about
statements may lead to a statistically significant plans and goals for their recovery and discharge.
and clinically relevant reduction in compulsory We see some excellent practice in such care
admissions of adult psychiatric patients, whereas planning, showing that patients are listened to
community treatment orders, compliance and their views are recorded, even when these do
enhancement, and integrated treatment showed not match the clinicians views. Other examples
no evidence of such a reduction.1 Advance of good practice include a particular focus on
statements are a form of care-planning: they engaging with and supporting carers and family
can state preferences for actions to be taken members, both in understanding the patients
or not taken in a crisis. It is possible that such care and treatment in hospital, and in developing
agreements, if made in co-production with clinical skills to help them after the patients discharge.
teams so that they are realisable in practice, Commissioners and all services involved should
could prevent some patients from ending up in give particular attention to the Code of Practices
a position where they refuse consent to hospital chapter on mental health aftercare, that states
admission they do not want, for example, by that they should interpret the definition of
stating a preference for certain hospitals or wards aftercare services broadly. This should include
over others, or other details to do with admission, health care, social care, employment services,
or could ensure that interventions are carried out supported accommodation and services to meet
and accepted before hospital admission becomes the patients wider social, cultural and spiritual
necessary. As such, co-production of care plans needs, to the extent that they meet a need
could be the most effective way in which services arising from or related to that persons mental
might address the rising number of detentions disorder and could help recovery.
under the MHA and seek to reverse this trend.
However, 32% (1,324 out of 4,086) of care plans
Discharge planning we reviewed during 2015/16 showed no evidence
The Code and Care Programme Approach expect of discharge planning. This is a slightly larger
service providers to begin discharge planning proportion than 2014/15, when the equivalent
Figure 9 Evidence of risk assessments in examined records, 2015/16
Care plans are re-evaluated and

updated following changes to care 3,583 562
needs
Care plans/health records show

evidence of risk assessments 4,185 182
being carried out
Identified risks are matched by

an appropriate care plan (risk 3,787 409
management plan)
0% 20% 40% 60% 80% 100%

Yes No
Source: CQC

measure showed 29% of records had no evidence than the previous year. The majority of services do
of discharge planning. As with other such findings have appropriate processes for managing risk. In
discussed in this report, we cannot tell whether this is these services risk assessments are completed with
a temporary halt or a significant reversal of the trend patients; updated in response to significant events,
towards continuous improvement in the figures from such as taking leave from hospital; and actively used
2010/11 to 2014/15, but providers should reflect by staff in the day-to-day care on the ward. Providers
on this in relation to their own practice and feedback whose feedback from our visits raises concerns over
from our visits. Where we find issues, we ask providers individualised risk assessment should reflect on this in
to review their procedures to make sure that aftercare relation to their own practice.
planning is regularly reviewed from the point of
admission, and fully documented in care plans.
We have seen a number of examples where services
have been particularly supportive to carers. Many of
Good practice: involvement
these services are using guidance from the Triangle of of carers
Care initiative.32
We were particularly impressed
Involving carers in hospital care and aftercare planning
can be complicated for patients in out-of-area with the way that one learning
placements, despite guidance in chapter 14.85 of the disability assessment and
Code of Practice. Some families have to pay their own treatment unit involved both
travel costs and are struggling to sustain this. Nearest
relatives may claim travel expenses from the Tribunal patients and carers in developing
service to attend Tribunals. However, there do not and implementing individualised
appear to be any other agreed sources of funding programmes of care. We spoke with
for them to visit hospitals for other purposes. With
current financial restrictions, local authorities may the parents of a patient who was
be less willing to cover such costs through their local resident on the unit and had been
welfare provision. Many hospitals provide financial admitted following a breakdown
assistance to relatives but this is not universal. To
make sure that carers are fully involved, specialist in care arrangements elsewhere.
service providers and commissioners of out-of-area They described how times for
placements should consider how they may offer multidisciplinary meetings were
support and guidance for families and carers visits.
changed to accommodate their
Individualised risk assessments travel arrangements, how visiting
MHA reviewers check care plans for individualised times had been flexible (they lived
risk-assessments, which should be updated as
patients circumstances change. In 2015/16, our MHA some distance away) and how there
reviewers found that 14% (562) of care plans had not was regular contact when anything
been re-evaluated and updated following a change in changed or there was an issue that
circumstances (figure 9).j This is a larger proportion
the staff felt they needed to be
Footnote:
informed or consulted about.
j In 2014/15 we found that 11% (425) care
plans examined had not been re-evaluated and Cheshire and Wirral Partnership NHS Foundation
updated following a change in circumstances. Trust, Greenways, June 2016

41
Part 2
CQC AND THE MENTAL
HEALTH ACT

Key points
In 2015/16:
We carried out 1,349 visits, met with 4,282 patients and required 6,867 actions from
providers.
Our Second Opinion Appointed Doctor service carried out 14,601 visits to review patient
treatment plans, and changed treatment plans in 27% of their visits.
We received 1,422 complaints and enquiries about the way the MHA was applied to
patients. Issues identified included medication, care provided by doctors and nurses, leave
arrangements and safeguarding concerns.
2.1 Monitoring visits treatment and medication (691 instances)
In 2015/16, our MHA reviewers conducted 1,349 section 17 leave from hospital (698 instances)
MHA monitoring visits to 1,309 wards and met patient information and rights (506 instances)
with 4,282 detained patients.k We aim to visit all personal needs, such as care planning, raised by
providers on a regular basis, and during 2015/16 we individual patients (568 instances).
visited 95% of NHS mental health trusts registered
to treat people under the MHA. The influence of MHA monitoring
The central focus of our monitoring visits remains on inspection ratings
the experience and concerns of detained patients. We use the findings from our MHA reviewer visits
Our private meetings with detained patients are the to inform our regulatory inspections of specialist
core of our visits. MHA reviewers also speak with mental health services and, in some cases, use of
patients and staff, and produce a report for the our enforcement powers to require change. On our
provider setting out areas that providers need to act inspections, we check that people subject to the
on to improve the quality of care for patients subject MHA are assessed, cared for and treated in line
to MHA powers. with the Act and its Code of Practice, under the
key question are services effective? This includes
Impacts and improvements whether hospital managers routinely monitor and
At the end of our visits, we meet with local teams manage information about how they are meeting
and explain what we have seen during the day and their duties under the MHA, and take action when
heard about during our interviews with patients. issues are identified.33
This can include general observations about how the Although we have not introduced a specific
MHA is being applied, examples of good practice, regulatory rating for the way providers operate the
and areas where we think that the provider needs to MHA, our MHA reviewers work closely with our
take action to improve care. After the visit, we write inspection teams and use information from the MHA
to the provider to set out our findings, and request
Footnote:
an action plan to address matters of concern.
In 2015/16, we raised 6,867 individual matters k This is 97 more visits than we reported in our 2015/16
Annual Report and Accounts (published July 2016), due
following our visits. The themes of these were similar to late entry of visit data into our records. This means
to those raised in our previous years visits: that we were one visit short of our target number of
visits in 2015/16, and met the target by 100% (as a
choice and access, including food options and
rounded figure) rather than by 93% as reported in July.
ward activities (1,101 instances)
CQC AND THE MENTAL HEALTH ACT 43

to inform the final rating for mental health and relevant to the standards in the Code, which
learning disability services that are registered to amounted to a significant risk and led to the
detain patients. We issue enforcement actions provider service being deregistered.
if we find matters that breach regulations,
proportionate to the impact that the breach
has on the people who use the service and how
serious it is. For example, during our inspection of
the provider below, we found a number of issues
Inspection example of enforcement powers

In February 2016 we inspected a brain-injury unit in London. It had eight patients, three detained
under the MHA, four subject to Deprivation of Liberty safeguards, and one informal. We had
inspected the unit five times since 2010. On our previous visit, in July 2015, we had issued a
requirement notice over the lack of effective systems to assess, monitor and improve the quality
and safety of the services provided, but we continued to find systemic failure to address this,
alongside other serious concerns including:
That one patient, who was not formally The service was not clean and was neglected.
detained, had been locked in their room for Redecoration and maintenance were
several weeks. This had not been recognised required. One patients bedroom had a
as long-term segregation. We took the stained floor and an overwhelming smell of
view that the situation was a breach of the urine. The environment was institutional.
patients human rights and amounted to Patients said they were bored and there were
mistreatment. very few activities. There was no activity
Physical interventions not being recognised programme in the service.
or recorded as restraint, with inadequate There was no effective system for ensuring
physical monitoring during or after restraint that best practice and legal requirements
or rapid tranquilisation. were met regarding the Mental Health Act
Patients risk assessments did not include all and the Mental Capacity Act. There was a
potential patient risks. Risk assessments and lack of clinical audit. Important standards for
management plans were not updated after the care, treatment and safety of patients
incidents, including serious incidents. were not monitored.
Patients care plans did not include their Patients reported they did not feel listened
psychological, spiritual and cultural needs. to by staff.
Patients were not involved in developing Patients were unable to access an advocate
their care plans. Patients did not receive easily.
psychological treatment appropriate to their
needs. Following the February 2015 visit we rated the
unit as inadequate and decided to cancel its
registration. The provider closed the service two
weeks after we conducted the inspection.
44
2.2 The administration of the 2007 amendments, enabling responsible clinicians to
certify patients agreement to treatment.
Second Opinion Appointed Doctor
In last years report, we highlighted a rise in the
service number of visits requested to approve ECT. This
The Second Opinion Appointed Doctor (SOAD) year, there have been a similar number of ECT visits
service is an additional safeguard for patients to 2014/15, with 1,627 visits taking place compared
detained under the MHA, providing an independent with 1,631 visits the previous year.
medical opinion to state whether certain treatments
are appropriate. Outcome of SOAD visits in 2015/16
The law requires this for authority to provide the This year, SOAD reviews resulted in 27% of all
following treatments in the absence of consent, treatment plans considered being changed (figure
except in an emergency: 10). This is similar to the previous years figure of
28%.m
medication for mental disorder after three months
from first administration when a patient is Changes to a treatment plan range from minor
detained under the MHA adjustments to dosages or numbers of drugs
prescribed, to major changes to the proposed
medication for mental disorder after the first
treatment. The most common changes result in
month of a patient being subject to a community
the patient receiving lower medication doses or
treatment order (CTO)l
Electroconvulsive therapy (ECT), at any point Footnote:
during the patients detention. l Or the expiry of the original three month period applicable
The administrative functions for this service are from the start of treatment under detention, if the CTO
was instigated when this still had more than a month
provided by CQC, but SOADs are independent of to run. See Code of Practice, paragraph 25.31.
CQC and reach their own conclusions using their
m In 2014/15, 21% of ECT and CTO second opinions,
clinical judgment. When we receive a request and 30% of medication second opinions, resulted
from the provider caring for the patient, we will in some change to the treatment plan.
appoint a SOAD to make arrangements to visit,
assess the proposed treatment plan, and discuss
it with a minimum of two professionals involved in
the patients care. SOADs can issue certificates to Equalities monitoring of
approve treatment plans in whole, in part, or not at
all depending on their assessment of the treatment
second opinion referrals
plan in any individual case. We have reviewed the equalities data on
In 2015/16, SOADs carried out 14,601 visits. Eighty- the age, gender and ethnicity of patients
two per cent (11,991) of these visits were to look at referred for a second opinion. We found
proposed medication treatment plans for patients that SOAD visits for women are three
who were subject to the Act in hospital. This is the times more likely to be for ECT than is the
highest number of medication visits we have ever case for men, and SOAD visits for white
recorded since starting the visits in 1985. However, people are more than twice as likely to
the number of visits to consider treatment plans for
be for ECT than is the case for people
patients on CTOs continued to decline, with 12%
fewer visits taking place than last year. We believe
from Black and minority ethnic groups,
this is likely to be a consequence of continued although these differences could be due to
uptake of the MHA provision, introduced in the differences in referrals for ECT treatment.

fewer multiple preparations than first proposed. why fewer qualified psychiatrists are putting
Feedback collected from patients suggests that themselves forward to become a SOAD.34 These
they value such intervention. are restrictions on the fees that we are able to
SOADs may certify that treatment with pay SOADS, and the new consultant contract
medication is appropriate and can be given which gives employers more control over the
to detained patients who have capacity but activities of their consultants. Employers are
refuse to agree to the treatment (there are no more reluctant to allow their consultants to
equivalent legal provisions in relation to ECT, perform duties that do not seem to contribute to
or to patients subject to community treatment local targets and organisational performance.
orders). Of the 11,991 SOAD visits in 2015/16 Providers need to recognise the value of SOAD
to consider medication for detained patients, work, not only to help protect patients, but
2,179 (18%) were to consider authorising the also to the overall sectors ability to meet the
treatment of patients refusing to consent. SOADs expectations of the MHA. We are talking to
are more likely to make changes to the proposed the Department of Health and Royal College
treatment plan in these circumstances where, of Psychiatrists about the current situation and
arguably, the treatment is more contested, with looking at future developments that may affect
34% (735 of 2,179) being changed compared the demand for SOAD work. We recommend that
with 28% (2,695 of 9,745) when patients are the government works with us to consider how
found to be incapable of consenting. to influence service providers to take a wider
view of meeting the requirements of the Act and
Meeting the demand for second opinions of contributing more evenly to the service to
Although the number of requests for a second increase SOAD availability.
opinion visit continue to rise, the number of
doctors on our SOAD panel has been reducing. Neurosurgery for mental disorder
This means that it is taking longer for a SOAD to Before any patient can undergo neurosurgery
see the patient, which can lead to services using for mental disorder (NMD), a CQC-appointed
urgent or emergency powers. Many providers panel must approve the treatment. NMD is a
have expressed concern at these delays. surgical operation that destroys brain tissue, or
In addition to the general shortage of the function of brain tissue, for the treatment of
psychiatrists, there are two specific reasons a mental disorder.
Figure 10 Outcomes of second opinion visits, 2015/16
Medication Community
Outcome ECT (detained)
(detained) treatment orders
Number of visits 1,627 100% 11,991 100% 1,226 100%

Plan not changed 1,257 77% 8,494 71% 964 79%
Plan changed 357 22% 3,430 29% 250 20%
Missing data 13 1% 67 1% 12 1%
Source: CQC

In 2015/16, the CQC panel considered and agreed We review all contacts from people who have
four proposals for NMD. The operations proposed to concerns about the MHA, either directly from
treat severe and debilitating depression or obsessive patients or others, such as family, carers or
compulsive disorder. In two cases, these were second advocates, and try to resolve, redirect or investigate
operations, with earlier interventions having given complaints. Some contacts will be general enquiries
limited or short-lived improvements that were likely about the MHA, or from people subject to the
to be enhanced with larger lesions. MHA and looking for information about their
care. Enquiries are usually dealt with by providing
2.3 Complaints information or explaining where to go to find out
more. For complaints or concerns, we can speak
We review all complaints made to us about the way
to the provider to see if it can be resolved locally
providers exercise their powers and duties under the
through the providers complaints procedures before
MHA, and investigate if appropriate. All providers
investigating further. We may also pass a complaint
must inform patients of our complaints role and
that is about general health or social care to the
enable them to contact us as part of the information
Parliamentary and Health Service Ombudsman or the
on patients rights. We received 1,422 complaints
Local Government Ombudsman.
and enquiries in 2015/16 (figure 11). This is an
increase of 121% from 2014/15, and continues the Only a very small percentage of contacts received
overall rise we have seen since 2009. become investigations. In many cases, our MHA
complaints team and inspection teams are able to
The sharp rise in complaints and enquiries received
work with the complainant and provider to resolve
in 2015/16 could reflect better recording of
complaints and enquiries without needing an
complaints and enquiries made by telephone,
investigation. However, it is also important to note
with 76% of complaints being made through our
that not all contacts made amount to a discernible
call centre in 2015/16, compared with 63% the
complaint, and not all complaints fall within our legal
previous year (figure 12). We have recently reviewed
powers, which are limited to investigating matters
and improved our handling systems for MHA
relating to the care and treatment of patients subject
complaints so that telephone calls from detained
to the MHA.
patients are now directed to a dedicated team, with
a 100% quality check on records made and regular During 2015/16, we escalated 26 complaints (less
engagement with inspection staff. than 2% of all contacts made that year) to our MHA
reviewers to investigate further. Eighteen of these
Figure 11 Complaints and enquiries received, 2009/10 to 2015/16
1,500 1,422
884 1,016
1,000
745 664
628 601
500
0
2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Source: CQC

Figure 12 Complaints and enquiries received as per method, 2009/10 to 2015/16
Number (%) of contacts Number (%) of contacts

Method
2014/15 2015/16
Telephone call 421 (63%) 1,086 (76%)

Letter 153 (23%) 181 (13%)
Email 71 (11%) 123 (9%)
Website 8 (1%) 17 (1%)
Share Your Experience 4 (1%) 12 (1%)
Unknown/other 5 (1%) 3 (0%)
Total 664 (100%) 1,422 (100%)
Source: CQC
Figure 13 Withheld mail and telephone monitoring in the high security

hospitals, 2015/16
Withheld items of mail Telephone monitoring

Ashworth Hospital 159 (42%) 125 (60%)
Broadmoor Hospital 33 (9%) 9 (4%)
Rampton Hospital 188 (49%) 75 (36%)
Total 380 (100%) 209 (100%)
Source: CQC

were completed at the time of this report. In the The MHA states that if an item of mail is withheld
concluded cases, two were withdrawn by the by any of the high security hospitals, the patient
complainant, three were decided to be outside (or the sender of any incoming mail) may appeal
of our remit, seven were not upheld and six were to CQC, who will review the decision and can
partially upheld. require the hospital to release the item (section
Where we uphold or partially uphold complaints, 134A). In 2015/16, we dealt with seven appeals
we can make recommendations to the service relating to withheld mail, and for one patient
provider. This year, recommendations to specific we instructed the hospital to release the item
services included issues of care planning, the use concerned.
of emergency holding powers, and apologies and
explanations of actions taken offered by services
to complainants.
2.4 Withheld mail and telephone

monitoring in high security
hospitals
Under the MHA, most hospitals have very limited Example of an MHA
powers to withhold detained patients mail.
Outgoing mail can only be withheld from the post complaint
at the written request of the intended recipient.n In November 2015 we concluded an
In the three high security hospitals outgoing or investigation into a complaint from
incoming mail may be withheld if it is likely to
a patient who had been detained at
cause distress to the intended recipient, or could
be considered a danger to any person. These an NHS mental health hospital after
hospitals also have powers to monitor telephone initially agreeing to informal admission.
calls (figure 13). It is notable that Broadmoor We upheld complaints that paperwork
Hospital uses the powers much more rarely than relevant to the clinical record had been
the other two hospitals, despite it being similar in lost, that the patient had been subject
size to Ashworth Hospital. to de facto detention as an informal
patient when staff refused to allow
her to leave the ward without invoking
holding powers under the MHA, and
that the hospital had failed in its duty
to provide information to the patient
once she had been lawfully detained.
The hospital accepted our findings,
apologised to the patient and provided
Footnote: us with an action plan to address these
n National data on the extent to which this power issues for future care, through staff
under section134 of the MHA is used does training and audit of practice.
not exist for us to review because providers
are not required to tell CQC directly.

Appendix A: Involving people
Involving people who have experience of We are grateful for the time, support, advice and
the MHA expertise given to the report by the group.
We expect mental health services to give the The members are:
people who use their services a central voice in Association of Directors of Social Services
the planning and delivery of care and treatment.
Birmingham MH NHS Trust
We involve people in our own work in the
following ways. Black Mental Health UK
British Association and College of
Service User Reference Panel Occupational Therapists
The Service User Reference Panel gives us British Institute of Human Rights
helpful information on conducting visits and
helps to steer different projects in the right Burke Niazi Solicitors
direction. The panel is made up of people who Central and North West London NHS
are, or have been, detained under the Mental Foundation Trust
Health Act 1983 (MHA). Each member is Department of Health
encouraged to share their views on our work
and advise us about how we can involve more East London NHS Trust
members of the public. Human Rights Implementation Centre
Some of the members of Service User Reference Mental Health Alliance
Panel also attend our MHA monitoring visits and National Survivor User Network for mental
inspections of health and social care services as health
Experts by Experience. Their main role is to talk
Mental Health Provider Forum
to people who use services and tell us what they
say. They can also talk to carers and staff, and NHS Confederation
can observe the care being delivered. NHS Digital
We have found many people find it easier to NHS Providers (Foundation Trust Network)
talk to an Expert by Experience rather than an
Royal College of Nursing
inspector. This is just one of the benefits of
including them in our visiting and inspection Royal College of Psychiatrists
programme, and we include an Expert by Service User Reference Panel representative
Experience on all of our regulatory inspections. (CQC)
Mental Health Act Expert The terms of reference for the advisory group
advisory group can be found by visiting:
An expert advisory group provided experience www.cqc.org.uk/advisorygroups
and expertise on the approach and scope of this
Mental Health Act annual report. The group met
three times in 2016 and offered comment and
advice on the themes and issues covered by the
report, and reviewed draft copies.

Appendix B: First-tier
Tribunal (Mental Health)
The First-tier Tribunal (Mental Health) does not publish a separate report of their MHA activity.
We have reproduced the tables provided to us by the Tribunal Secretariat for information.
Figure 14 Outcomes of applications against detention to the First-tier Tribunal

(Mental Health), 2015/16
Other All detained

Section 2 Restricted
unrestricted patients
Applications 10,093 16,298 3,417 29,808
Applications Withdrawn applications 850 3,955 1,246 6,051
and Discharges by clinician
hearings 3,206 4,617 64 7,887
prior to hearing
Hearingso 6,957 8,259 2,628 17,844
Absolute discharge 430 394 71 895
Delayed discharge 211 158 0 369
Conditional discharge 1 0 405 406
Decision of Deferred conditional
Tribunal 0 0 193 193
discharge
Total discharge by
642 552 669 1,863
Tribunal
No discharge 5,097 6,631 1,477 13,205
Source: Tribunal Secretariat Footnote:
o The number of hearings and the number of applications
will not match as hearings will be outstanding at the end of
each financial year.
Figure 15 Applications against CTOs to the First-tier Tribunal (Mental Health),

2015/16
Applications 4,317
Withdrawn applications 873
Full hearings (with patient present) 3,942
Paper hearings (without patient present) 528
Discharges by Tribunal 132
No discharge by Tribunal 3,196
Source: Tribunal Secretariat
APPENDICES 51
Appendix C: Deaths of detained
patients and people subject to
community treatment orders
CQC data from notifications 2011/12 to 2015/16.
Figure 16 Causes of death of detained patients, 2011/12 to 2015/16
2011/12 2012/13 2013/14 2014/15 2015/16

Natural causes 191 200 126 182 201
Unknown cause 9 27 36 11 19
Total 236 275 198 227 266
Figure 17 Cause of death of detained patients (natural causes),

2011/12 to 2015/16
2011/12 2012/13 2013/14 2014/15 2015/16

Pneumonia 34 33 24 35 34
Pulmonary
18 16 13 21 19
embolism
Myocardial
6 11 7 19 14
infarction
Cancer 18 12 4 13 14
Heart disease 27 17 21 24 49
Aspiration
5 11 5 13 6
pneumonia
Respiratory
4 2 5 6 7
problems
Chronic obstructive
6 3 4 8 9
pulmonary disease
Other 28 51 34 38 49
Unknown 45 44 9 5 0
Total 191 200 126 182 201

Figure 18 Age at death of detained patients (natural causes), 2013/14 to 2015/16
Data for previous years is unavailable for the same age categories so has not been included in the table.
2013/14 2014/15 2015/16
20 and under 0 0 0
21 to 30 3 3 7
31 to 40 6 5 9
41 to 50 15 8 14
51 to 60 21 19 29
61 to 70 29 36 38
71 to 80 27 49 46
81 to 90 20 52 48
91 and over 5 8 8
Unknown date of birth - 2 2
Total 126 182 201
Figure 19 Cause of death of detained patients (unnatural causes),

2011/12 to 2015/16
2011/12 2012/13 2013/14 2014/15 2015/16

Hanging 10 14 16 9 6
Jumped in front of
3 6 1 1 3
vehicle/train
Jumped from
3 5 4 3 5
building
Self-poisoning 3 0 2 5 7
Drowning 2 4 2 4 0
Self-strangulation/
8 10 4 2 12
suffocation
Method unclear 2 3 0 0 1
Unsure suicide/
0 2 4 5 8
accident
Accidental 2 0 3 3 4
Another person 3 3 0 0 0
Iatrogenic 0 1 0 1 0
Fire 0 0 0 1 0
Total 36 48 36 34 46
APPENDICES 53
Figure 20 Age at death of detained patients (unnatural causes),
2013/14 to 2015/16
Data for previous years is unavailable for the same age categories so has not been included in the table.
2013/14 2014/15 2015/16
20 and under 3 2 1
21 to 30 7 9 16
31 to 40 11 9 13
41 to 50 5 5 11
51 to 60 5 6 1
61 to 70 0 0 2
71 to 80 3 1 1
81 to 90 2 0 0
91 and over 0 0 0
No date of birth supplied 0 2 1
Total 36 34 46
Figure 21 Deaths of detained patients by region, 2015/16
Number of deaths
Region Unnatural causes &
Natural causes All deaths
unknown/awaiting
London 34 12 46
South East 32 13 45
Yorkshire & Humber 23 9 32
North West 20 12 32
East Midlands 22 6 28
North East 25 0 25
East of England 16 5 21
South West 14 5 19
West Midlands 15 3 18
Total 201 65 266

Community treatment order (CTO) patients 2011/12 to 2015/16
Figure 22 Deaths of CTO patients by cause, 2011/12 to 2015/16
2011/12 2012/13 2013/14 2014/15 2015/16

Natural causes 27 26 21 29 27
Unknown or
2 10 6 2 2
undetermined
Total 39 45 34 46 40
Figure 23 Cause of death of CTO patients (natural causes), 2011/12 to 2015/16
2011/12 2012/13 2013/14 2014/15 2015/16

Pneumonia 5 3 6 5 3
Pulmonary
1 2 0 3 1
embolism
Myocardial
0 2 2 3 2
infarction
Cancer 4 1 2 1 5
Heart disease 4 1 3 4 5
Aspiration
1 0 0 0 2
pneumonia
Respiratory
0 1 1 2 2
problems
Chronic obstructive
1 0 1 4 2
pulmonary disease
Other 5 7 3 6 5
Unknown 6 9 3 1 0
Total 27 26 21 29 27
APPENDICES 55
Figure 24 Cause of death of CTO patients (unnatural causes), 2011/12 to 2015/16
2011/12 2012/13 2013/14 2014/15 2015/16

Hanging 3 2 1 5 3
Jumped in front of
1 1 1 2 1
vehicle/train
Jumped from
2 1 1 1 2
building
Self-poisoning 1 1 1 1 1
Drowning 1 2 1 2 0
Self-strangulation/
0 1 1 1 0
suffocation
Method unclear 2 0 0 1 0
Accidental 0 1 1 1 0
Another person 0 0 0 0 1
Unsure suicide/
0 0 0 1 3
accident
Total 10 9 7 15 11
Figure 25 Deaths of CTO patients by region, 2015/16
Number of deaths
Region Unnatural causes &
unknown/awaiting
London 8 4 12
South East 5 1 6
East of England 2 3 5
West Midlands 2 3 5
North West 4 1 5
North East 2 1 3
East Midlands 2 0 2
Yorkshire & Humber 2 0 2
South West 0 0 0
Total 27 13 40

Figure 26 Age at death of CTO patients, 2015/16
Unnatural causes &

unknown/awaiting
20 and under 0 1 1
21 to 30 3 4 7
31 to 40 1 2 3
41 to 50 4 3 7
51 to 60 4 2 6
61 to 70 7 1 8
71 to 80 4 0 4
81 to 90 4 0 4
Total 27 13 40
APPENDICES 57
Glossary
The following are definitions of some of the key terms used in our report, taken where possible from the
glossary of Mental Health Act terms in Annex A to the Code of Practice.p
A statement made by a person, when they have capacity, setting out the
persons wishes about medical treatment. The statement must be taken into
Advance account at a future time when that person lacks capacity to be involved in
statement discussions about their care and treatment. Advance statements are not
legally binding although health professionals should take them into account
when making decisions about care and treatment.
Health, care and support services in the community following discharge from
hospital; especially the duty of the responsible health services and local
Aftercare (also authority to provide aftercare under section 117 of the Act, following the
known as section discharge of a patient from detention for treatment under the Act. The duty
117 aftercare) applies to community patients, transferred prisoners returned to prison from
hospital and conditionally discharged restricted patients, as well as those who
have been fully discharged.
Approved
mental health A social worker or other professional approved by a local authority to carry out
professional a variety of functions under the Act.
(AMHP)
A blanket restriction or a blanket restrictive practice is any practice that
Blanket restricts the freedom (including freedom of movement and communication
restriction with others) of all patients on a ward or in a hospital, which is not applied on
the basis of an analysis of the risk to the individual or others.
The ability to take a decision about a particular matter at the time the decision
needs to be made. Some people may lack capacity to take a particular decision
(for example to consent to treatment) because they cannot understand, retain,
Capacity
use or weigh the information relevant to the decision. A legal definition of lack
of capacity for people aged 16 or over is set out in section 2 of the Mental
Capacity Act 2005.
An adult who provides or intends to provide care for another adult, except
Carer
where this is their professional role.
The legal authority for the discharge of a patient from detention in hospital,
Community
subject to the possibility of recall to hospital for further medical treatment if
treatment order
necessary. Community patients are expected to comply with the conditions
(CTO)
specified in the community treatment order.
Footnote:
p www.gov.uk/government/publications/code-of-practice-mental-health-act-1983.

When people who use services are involved as an equal partner in designing
services. Co-production recognises that people who use social care services
Co-production (and their families) have knowledge and experience that can be used to help
make services better, not only for themselves but for other people who need
social care.35
De facto Any situation where a patient is deprived of liberty without legal authority,
detention often in ways unrecognised by the treating authority.
The framework of safeguards under the Mental Capacity Act 2005, as
Deprivation
amended by the Mental Health Act 2007, for people who need to be deprived
of Liberty
of their liberty in their best interests for care or treatment to which they lack
Safeguards
the capacity to consent themselves.
Unless otherwise stated, being held compulsorily in hospital under the Mental
Detention Health Act for a period of assessment or medical treatment. Sometimes
referred to colloquially as sectioning.
A form of medical treatment for mental disorder in which a small, carefully
Electroconvulsive controlled electric current is introduced into the brain. It is administered in
therapy (ECT) conjunction with a general anaesthetic and muscle relaxant medications and is
occasionally used to treat very severe depression.
European
The European Convention for the Protection of Human Rights and
Convention on
Fundamental Freedoms. The substantive rights it guarantees are largely
Human Rights
incorporated into UK law by the Human Rights Act 1998.
(ECHR)
First-tier tribunal
See Tribunal
(mental health)
The appointment of a guardian to help and supervise patients (aged 16 or
over) in the community for their own welfare or to protect other people. The
Guardianship
guardian may be either a local authority or someone else approved by a local
authority (a private guardian).
The powers in section 5 of the Act that allow hospital inpatients to be
detained temporarily so that a decision can be made about whether an
Holding powers application for detention should be made. There are two holding powers.
(section 5) Under section 5(2) doctors and approved clinicians can detain patients for up
to 72 hours. Under section 5(4), certain nurses can detain patients for up to 6
hours.
The organisation (or individual) responsible for the operation of the Act in
a particular hospital. Hospital managers have various functions under the
Act, which include the power to discharge a patient. In practice, most of
Hospital
the hospital managers decisions are taken on their behalf by individuals (or
managers
groups of individuals) authorised by the hospital managers to do so. This
can include clinical staff. Hospital managers decisions about discharge are
normally delegated to a managers panel of three or more people.
GLOSSARY 59
Independent
An advocate available to offer help to patients under arrangements that are
mental health
specifically required to be made under the Act.
advocate (IMHA)
Someone who is being treated for a mental disorder and who is not detained
Informal patient
under the Act.
Permission for a patient who is detained in hospital to be absent from the
Leave of absence hospital for short periods, for example to go to the shops or spend a weekend
(also known as at home, or for much longer periods. Patients remain under the powers of the
section 17 leave) Act when they are on leave and can be recalled to hospital if necessary in the
interest of the patients health or safety or for the protection of other people.
Mechanical restraint is a form of restrictive intervention that involves the use
Mechanical
of a device to prevent, restrict or subdue movement of a persons body, or
restraint
part of the body, for the primary purpose of behavioural control.
An Act of Parliament that governs decision-making on behalf of people, aged
Mental Capacity 16 years and over, who lack capacity, both where they lose capacity at some
Act 2005 point in their lives, for example as a result of dementia or brain injury, and
where the incapacitating condition has been present since birth.
National A body appointed by a state signatory to the optional protocol to the United
Preventive Nations convention against torture and inhuman or degrading treatment. CQC
Mechanism is one of several UK bodies that form the UKs NPM, and its visits to detained
(NPM) patients are a key element of its role as such an NPM.
A person defined by section 26 of the Act (and in relation to children and
Nearest relative young people, sections 27 and 28) who has certain rights and powers under
the Act in respect of a patient for whom they are the nearest relative.
Neurosurgery for A form of medical treatment (sometimes called psychosurgery) that destroys
mental disorder brain tissue, or the function of brain tissue, for the treatment of mental
(NMD) disorder. Must be approved by a specially constituted panel appointed by CQC.
A place in which people may be temporarily detained under section 135 or
Place of safety
136 of the Act, as defined in section 135(6).
Prone restraint Restraint where a person is forcibly laid face down.
Provider Either an NHS or an independent sector hospital.
The approved clinician with overall responsibility for a patients case. Certain
Responsible
decisions (such as renewing a patients detention or placing a patient on a
clinician
community treatment order) can only be taken by the responsible clinician.
Seclusion refers to the supervised confinement and isolation of a patient,
away from other patients, in an area from which the patient is prevented from
Seclusion
leaving, where it is of immediate necessity for the purpose of the containment
of severe behavioural disturbance that is likely to cause harm to others.

Second Opinion An independent doctor appointed by CQC who gives a second opinion on
Appointed Doctor whether certain types of medical treatment for mental disorder should be
(SOAD) given without the patients consent.
The First-tier Tribunal (Mental Health) called in the Code the Tribunal was
established under the Tribunals, Courts and Enforcement Act 2007. This
Tribunal
is a judicial body that has the power to discharge patients from detention,
community treatment orders, guardianship and conditional discharge.
Commissioning decisions have traditionally been guided by the idea that
policy making and practice will be more effective if based on particular forms
of scientific and objective research (evidence-based practice). Critics of this
model have suggested that this has the potential to overlook the thoughts,
feelings and opinions of people who use services and carers.36
Values-based To address some of these issues, the concept of values-based practice has
commissioning been developed as the values counterpart of the evidence-based approach.37
It does not seek to replace evidence-based practice, but instead aims to make
clinical decisions on the basis of values as well as facts. It aims to empower
people who use services and carers to have more direct control over decisions
relating to treatment, access to services and choice about care. It also aims
to identify and make explicit the diverse values of all those involved in the
process of clinical decision-making.
GLOSSARY 61
References
1. De Jong M H, Kamperman A M, Oorshot 12. NHS England, Reducing mortality for people
M, Priebe S and others, Interventions to with serious mental illness (SMI), 2016
Reduce Compulsory Psychiatric Admissions; A
13. Lintern S, Fewer mental health patients seen
Systematic Review and Meta-analysis, JAMA
in community despite rising demand, Health
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Service Journal, 2015
2. NHS England, The Five Year Forward View for
14. NHS Digital, Inpatients Formally Detained in
Mental Health, 2016
Hospitals Under the Mental Health Act 1983
3. NHS England, Winterbourne View Time for and Patients Subject to Supervised Community
Change: Transforming the commissioning of Treatment Annual figures, 2014/15, 2015,
services for people with learning disabilities Table 5
and/or autism, 2014
15. Joint Commissioning Panel for Mental Health,
4. Crisp N, Smith G and Nicholson K (Eds.), Old Guidance for commissioners of mental health
Problems, New Solutions: Improving Acute services for people from black and minority
Psychiatric Care for Adults in England, The ethnic communities, 2014
Commission on Acute Adult Psychiatric Care,
16. Care Quality Commission, Better care in my
2016
hands: A review of how people are involved in
5. NHS England, Independent review of deaths their care, 2016
of people with a Learning Disability or Mental
17. Department of Health, Government response
Health problem in contact with Southern Health
to No voice unheard, no right ignored: A
NHS Foundation Trust April 2011 to March
consultation for people with learning disabilities,
2015 (Mazars report), 2015
autism and mental health conditions, 2015
6. NHS Digital, Mental Health Services Monthly
18. Kinton M,Is it Time to Close the Doors?,
Statistics: Final April, 2016
Mental Health Review Journal, 2006, volume
7. Department of Health, Guidance: Out of area 11, issue 3, pages 19-22
placements in mental health services for adults
19. Nijman H, Bowers L, Haglund K, Muir-Cochrane
in acute inpatient care, 2016
E, Simpson A and van der Merwe M, Door
8. Sheffield Health and Social Care Foundation locking and exit security measures on acute
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Psychiatric Patients, 2016 Psychiatric and Mental Health Nursing, 2011,
volume 18, issue 7, pages 614-621
9. Care Quality Commission, Shaping the Future:
CQC's Strategy for 2016 to 2021, 2016 20. Nijman H, Bowers L, Haglund K, Muir-Cochrane
E, Simpson A and van der Merwe M, The
10. Department of Health, Reference Guide to the
City 128 extension: Locked doors in acute
Mental Health Act 1983, 2015
psychiatry, outcome and acceptability, 2008
11. Ministry of Justice, Coroners Statistics Annual
2015 England and Wales Ministry of Justice
Statistics bulletin, 2016

21. NHS England, Child and adolescent Tier 4 31. Think local, act personal and National Voices, A
Report, 2014 and Childrens Commissioner, Narrative for person-centred, Coordinated Care,
Lightening Review: Access to Child and 2013
Adolescent Mental Health Services, 2016
32. The Princess Royal Trust for Carers and the
22. NHS England, Child and adolescent Tier 4 National Mental Health Development Unit,
Report, 2014, paragraph 3.26 The Triangle of Care. Carers Included: A Guide
to Best Practice in Acute Mental Health Care,
23. Royal College of Psychiatrists, Positive
2010
Cardiometabolic Health Resource: an
intervention framework for patients with 33. Care Quality Commission, How CQC regulates
psychosis and schizophrenia, 2014 Specialist Mental health Services Appendices
to the provider handbook, 2015
24. Working Group for Improving the Physical
Health of People with SMI, Improving the 34. The Centre for Workforce Intelligence, In-depth
physical health of adults with severe mental review of the psychiatrist workforce: Main
illness: essential actions (OP100), Royal College report, 2014
of Psychiatrists, 2016
35. Clark M, Co-production in mental health care,
25. Public Health England, Guidance: Smoking Mental Health Review Journal, volume 20,
cessation in secondary care, mental health issue 4, 2015
settings, 2015 and NICE, Smoking: acute,
36. Hewitt J, Redressing the balance in mental
maternity and mental health services, public
health nursing education: Arguments for a
health guideline, 2013
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26. NHS England, Commissioning for Quality and of Mental Health Nursing, 2009, volume
Innovation (CQUIN): Guidance for 2015/16, 18, pages 368-379 and Rose P, Gidman J,
2015 Evidence-Based Practice within Values-
Based Care, in J. McCarthy and P. Rose (eds),
27. Care Quality Commission, Brief guide: seclusion
Values-Based Health and Social Care: Beyond
rooms, 2015
Evidence-Based Practice, Sage, 2010
28. Department of Health, Positive and Proactive
37. Fulford KW M, "Ten Principles of Values-based
Care: reducing the need for restrictive
Medicine", in J. Radden (ed) The Philosophy
interventions, 2014
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management in mental health, health and
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30. Care Quality Commission, Brief guide: restraint
(physical and mechanical), 2016
REFERENCES 63
See our other
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reports
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Look at our website www.cqc.org.uk
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Care Quality Commission
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The Care Quality Commission is
a member of the UKs National
Preventive Mechanism, a group of
organisations that independently
monitor all places of detention
to meet the requirements of
CQC-354-400-112016 international human rights law.

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Monitoring the

Mental Health Act

6,867 actions from providers to

4 MONITORING THE MENTAL HEALTH ACT IN 2015/16

6 MONITORING THE MENTAL HEALTH ACT IN 2015/16

Priorities for change

3. The Department of Health and national agencies

8 MONITORING THE MENTAL HEALTH ACT IN 2015/16

There is an urgency for change, with more needing to be done by

10 MONITORING THE MENTAL HEALTH ACT IN 2015/16

health beds sent out of

to be admitted to distant hospital beds may be area for treatment

one cause of rising rates of detention. We will be

12 MONITORING THE MENTAL HEALTH ACT IN 2015/16

THE MENTAL HEALTH ACT IN ACTION 13

Are all policies updated in line 93 113

Is a copy of the new Code

Has training been provided on the

0% 20% 40% 60% 80% 100%

14 MONITORING THE MENTAL HEALTH ACT IN 2015/16

THE MENTAL HEALTH ACT IN ACTION 15

Figure 2 Cause of death of detained patients, 2011/12 to 2015/16

2011/12 2012/13 2013/14 2014/15 2015/16

16 MONITORING THE MENTAL HEALTH ACT IN 2015/16

Figure 3 Natural cause deaths of detained patients, 2011/12 to 2015/16

THE MENTAL HEALTH ACT IN ACTION 17

Figure 4 Mental health patients at year end, March 2008/09 to 2014/15

80,000 68,906 62,113 59,076 57,845 51,196

18 MONITORING THE MENTAL HEALTH ACT IN 2015/16

THE MENTAL HEALTH ACT IN ACTION 19

Figure 5 Evidence of discussions of rights in examined records, 2015/16

Evidence of discussions about

Evidence of further attempts to

Evidence that information was

0% 20% 40% 60% 80% 100%

20 MONITORING THE MENTAL HEALTH ACT IN 2015/16

Good practice: providing information to patients

What good looks like

Examples from practice

THE MENTAL HEALTH ACT IN ACTION 21

Independent Mental Health Advocacy patients to make contact with an advocate,

22 MONITORING THE MENTAL HEALTH ACT IN 2015/16

Service User Reference Panel member

In MHA monitoring visits to a dementia unit

being delivered and reviewing their practices to remove

THE MENTAL HEALTH ACT IN ACTION 23

What good looks like

Example from practice

24 MONITORING THE MENTAL HEALTH ACT IN 2015/16

THE MENTAL HEALTH ACT IN ACTION 25

26 MONITORING THE MENTAL HEALTH ACT IN 2015/16

THE MENTAL HEALTH ACT IN ACTION

What good looks like

Examples from practice

28 MONITORING THE MENTAL HEALTH ACT IN 2015/16

Figure 6 Inpatients aged under 18 years of age, October 2016

Legal status Number of patients

Source: NHS England

THE MENTAL HEALTH ACT IN ACTION 29