The findings from CQC’s programme of comprehensive inspections of specialist mental health services.
The Care Quality Commission (CQC) is the independent regulator of health and social care in England. In 2014 it started a programme of comprehensive inspections of specialist mental care services in England during which it rated services provided by 54 NHS Trusts and 218 independent NHS services. State of Care presents the findings of this programme.
First the good. The report concluded that, both in the NHS and the private sector, staff "are genuinely mental health services’ greatest asset". The inspections highlighted many instances of caring staff who genuinely cared about the people who used their services and found that with a few exceptions staff formed relationships with patients that were respectful and compassionate.
Certain types of services performed particularly well such as community mental health services for people with a learning disability or autism (80% rated as good and 9% as outstanding) and community-based mental health services for older people (76% rated as good and 10% as outstanding).
Individual providers were held out as outstanding examples of high-quality care. Northumberland, Tyne and Wear NHS Foundation Trust, for example, is well-led and has a clear vision and strategy for delivering high standards of care placing the patient at the centre of everything they do.
The report praised the efforts to improve made by services that had been rated as inadequate or requiring improvement in previous inspections. 73% of these services had improved their rating when the CQC re-inspected them.
However, there were a number of areas of concern for the CQC.
Safety is the CQC’s biggest concern. 36% of NHS services and 34% of independent core services were rated as requires improvement for safety of services, and a further 4% of NHS core service and 5% of independent services were rated as inadequate. There were various reasons for these finding:
- The poor physical environment of many mental health wards. Many wards do not allow staff to observe all areas and can contain fixtures and fittings that can be used as ligature points and a substantial number of wards admitted both men and women.
- Inadequate staffing levels. This was in part due to a 12% decline in the number of mental health nurses since 2010. Use of bank staff to fill these shortages could, in worse cases, affect patient safety when the nurses filling in did not know patients or ward routines.
- Some staff not managing medicines safely.
Persistence of restrictive practices.
- Inspections revealed that there are around 3,500 beds in locked mental health rehabilitation wards, many of which situated a long way from patients’ homes isolating them from friends and family. Inspectors were concerned that these services were in effect long stay wards that risked institutionalising patients rather than helping them take steps towards independent life in their home communities. Many of the patients in these wards have the capacity to live in a setting of lower dependency and with fewer restrictions provided there was suitable accommodation and intensive community support available in their local area to meet their needs. The CQC were clear that the locked ward model of care does not have any place in today’s mental health care system.
- Inspectors notes wide variations between wards in how frequently staff used restricted practices and physical restraint to manage challenging behaviour.
Access and waiting times
Inspectors identified a common theme across core services that people had difficulty in accessing the service that is best equipped to meet their needs. Delays were not always the responsibility of the unit that was being inspected, but with other parts of the system. Certain service such as eating disorder services fared particularly poorly, with 27% of patients having to wait 11 weeks or more for appointments.
Physical health of people with mental health problems
The CQC found a mixed picture in this regard. There were some excellent examples in some wards of staff enabling patients to access GPs, dentists and healthcare clinics and promoting exercise and healthy eating. On the other hand they found some services where there was a lack of integration of physical and mental health care.
Poor clinical information systems
Many staff voiced frustration about having to work with a confusing combination of paper and electronic systems, or different systems that “do not talk to each other”. Sometimes staff have been unable to access records for a patient and it has had a real impact on patient care, such as reducing the time spent in face-to-face contact and increasing the likelihood that essential information about risk was not communicated to staff who needed to know. It was observed that this lead to sub-optimal care plans being produced.