CQC report — Monitoring the Mental Health Act

On 1 December 2022, the CQC published its annual report “Monitoring the Mental Health Act in 2021 to 2022”. As with previous reports, it is based on the findings from the CQC’s monitoring reviews which involved conversations with 2667 patients and 726 carers, along with discussions with advocates and ward staff, engagement with stakeholders, contact with patients and others with experience in the field (both personal and professional) and family members. The report is split into five sections as summarised below.

Staff shortages and the impact on patients

Unsurprisingly, this remains the area described as “the greatest challenge” for the sector, made worse by the ongoing effects of the pandemic. This has led to a negative impact on patients accessing therapeutic care, a reduction in ward activities, the cancellation of leave and marginalisation of patients who were previously involved in care planning. This in turn is increasing the risk of violence and aggression on wards in circumstances where staffing levels are down, threatening patient and staff safety and increasing the risk of staff burn-out, feeding into the cycle by reducing staffing levels yet further.

The cumulative effect of this is acknowledged by the CQC, who accept that the staffing problems are systemic and that existing staff are working under significant and sustained pressure.

The CQC also identify that units with stable staffing and a motivated workforce get good feedback from patients and are most likely to be valued by both staff and patients as providing a positive environment.

Pressure on services and patient pathways 

Basically, the CQC concludes that there are too many patients and not enough beds, with gaps in community care serving to make things worse in a number of ways:

• Patients are being cared for in inappropriate environments
• There are long waits for beds in some places
• Out of area placements continue, due to a lack of local provision
• A lack of community services is delaying discharge in some areas, having a predictable knock-on effect on bed availability

The CQC considers the effects on children and young people’s mental health services to be particularly acute, leading to overspill onto general children’s wards in acute hospitals, rather than specialist (and appropriate) mental health provision.

Those patients who are admitted tend to be more acute in their presentation, with longer stays being required, which has a knock-on effect within the system. Occupancy levels are at an historic high with some wards having more patients than beds, leading to some patients “sleeping over” on other wards – negatively affecting the continuity of their care.

Time limits under sections 135 and 136 of the Mental Health Act are, in some areas, being routinely breached due to a shortage of available beds, with patients being sent to A&E or PICU as an alternative, leading to increased pressure elsewhere in the system.

Delays in discharge are also highlighted as an area of concern, in some cases meaning that patients remain in unsuitable environments and subject to unnecessary restrictions.

The report deals specifically with the pressures on children and young people’s mental health services, people with a learning disability and autistic people, highlighting that the care provided is still not good enough and highlights that continued reliance on out of area placements is detrimental in the long term.

Once more, lack of training for staff on the Deprivation of Liberty Safeguards is identified as a potential problem.

Addressing inequalities and cultural needs

The CQC has concluded that little headway has been made in tackling the over-representation of people from some ethnic groups who are subject to MHA powers, and in particular the over-representation of Black people on community treatment orders (CTOs).

Whilst the CQC restates its commitment to supporting the work being done at a national level, it is clear that providers and integrated care systems need to take responsibility at a local level for addressing and resolving these inequalities – understanding why there is over-representation and what is preventing real change from happening. The CQC is clear that simply stating that wards are safe spaces for particular groups is not sufficient – work needs to be done to ensure that what is being said is translated into practical application (taking care not to misgender a patient, for example).

Various examples of good practice are identified in respect of various minority groups – this section of the report appears quite positive.

Ward environments

The CQC is critical of the general state and condition of wards, as many are in urgent need of update and repair, adequate Wi-Fi coverage, the suitable provision of private, lockable spaces for patient belongings, space, ventilation and adaptions to be accessible to those with physical disabilities.

They also highlight that noise, echoes and harsh lighting are limiting the therapeutic experience that some patients have on the ward, particularly those who may have sensory disorders or accessibility needs. The continued use of dormitories is criticised (again).

Lack of access to green, therapeutic outdoor space is also identified as having a detrimental impact on both staff and patient morale and welfare, and there are examples given of modernisation and innovation in some units which appear to have reduced violent incidents by 60%, which is attributable to the improved inpatient environment.

Patient centred care

Whilst the CQC identifies some examples of good practice of advance care planning, putting the patient and their family at the centre of the process, there is a level of general concern that things aren’t moving far enough, fast enough.

Poor quality care plans with little patient involvement are a recurring theme and have been identified as an area for improvement in many services, as has communication with families, with the CQC noting that proactive steps that could have been taken to keep relatives up to date with a patient’s progress were not considered in some units. Lack of access to Independent Mental Health Advocates is also flagged up as an area of concern, with a lack of culturally appropriate advocacy services noted in both this section and the section on inequalities.

The report is full of examples of good practice (and not so good) and gives an indication of areas where the CQC is likely to concentrate their attention over the next 12 months. There is acknowledgement of the significant pressures that staff are working under, but a clear drive towards modernisation and improvement of services having a beneficial impact on patients.