29 March 2019
In the mental health chapter of last year’s State of Care Report, CQC stated that ‘our greatest concern is about the quality and safety of care provided on mental health wards’. I am writing to let you know how CQC is strengthening its assessment of these vital services.
In his foreword to the report of the independent review of the Mental Health Act, Simon Wessely says that ‘we must acknowledge that the environment in which we look after those detained under the Act is now often anything but therapeutic’. He suggests that this issue has ‘slipped below the radar because of low expectations of what constitutes good care’ and that ‘the CQC inspection criteria should ‘be strengthened, for example to have a greater focus on therapeutic environments and person-centred care’.
The NHS long term plan also acknowledges the ‘wide variation in the quality and capability of these acute mental health units across the country’ and states that ‘capital investment from the forthcoming Spending Review will be needed to upgrade the physical environment for inpatient psychiatric care’.
What are the concerns about mental health wards?
CQC has highlighted the high use of restrictive interventions on mental health wards (and the great variation in use between wards), the high number of assaults on patients and staff and the frequent incidents of sexual assault and harassment. Underpinning these are problems with:
- The physical fabric of wards. Many wards were not designed to provide safe care for the group of patients that are admitted today. Staff find it difficult to observe all areas easily, many wards have fixtures and fittings that can endanger people who are at risk of suicide and staff who work on wards that admit both men and women find it difficult to comply with guidance on the elimination of mixed sex accommodation.
- Providing patients with access to the full range of treatment and care interventions recommended by NICE.
- Staffing to ensure that there are both a sufficient number of staff who know the ward routine and the patients to maintain safety, and that staff have the skills required to minimise the use of restrictive interventions.
- The quality of leadership and the extent to which this fosters a culture of engagement, co-production and ‘no force first’.
What CQC plans to do
The report of the independent review of the Mental Health Act acknowledges CQC’s concerns about the quality and safety of mental health wards and calls on us to take action. The report recommends that the requirements for the physical design of wards are revised and asks that ‘the prompts and guidelines currently used for inspections in the assessment frameworks specific to mental health inpatient care are reviewed. It also recommends that ‘CQC should develop new criteria for monitoring the social environments of wards. These criteria should be the yardstick against which wards are registered and inspected and this should be reflected in ratings and enforcement decisions’.
CQC will work with stakeholders, including people with lived experience, to explore and coproduce our proposed actions to address the concerns:
- Review, and where necessary, revise the brief guides that direct our inspectors; to ensure that they set an appropriate level of expectation for the quality of care experienced by people admitted to a mental health ward;
- Strengthen our assessment of the actions taken by providers to minimise the use of restrictive interventions — drawing on learning from the thematic review of restraint, seclusion and segregation;
- Assess the steps taken by providers to minimise the impact, on dignity and safety, of wards with shared sleeping arrangements (‘dormitories’) and review providers’ plans to eliminate dormitories by a stated date;
- Give greater weight to whether patients have access to the range of treatment and care interventions, other than medication, that would benefit people admitted to a mental health ward;
- Fully implement the actions set out in CQC’s recent report on sexual safety on mental health wards;
- Ensure that CQC’s findings about the quality and safety of mental health wards are a prominent part of the improvement plan agreed with NHS trusts that participate in the mental health safety improvement programme led by NHSI;
- For NHS trusts, as part of the well led review, assess the extent to which Boards are aware of the quality of the inpatient estate and how active are the steps taken to obtain capital investment — if that is required.
Opportunities to get involved in this coproduction will be shared in our provider newsletter.
Dr Paul Lelliott is Deputy Chief Inspector of Hospitals (lead for Mental Health) at the Care Quality Commission.