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This report sets out the Care Quality Commission (CQC) activity and findings during 2023/24 from their engagement with people who are subject to the Mental Health Act 1983 (MHA) as well as a review of services registered to assess, treat and care for people detained using the MHA. The MHA is the legal framework that provides authority for hospitals to detain and treat people who have a mental illness and need protection for their own health or safety, or the safety of other people. What the report found: Systems We remain concerned that the high demand for mental health services, without the capacity to meet it, means people cannot always get the right care at the right time. Not being able to access care in a timely way can lead to people’s mental health deteriorating while they wait for support. Through our monitoring activity, we have seen how system pressures mean people are detained far from home or in environments that do not meet their needs. Many services told us that patients seem to be more unwell on admission than in the past. Services need to balance the increase in demand for inpatient beds with ensuring existing patients are not discharged too soon. Workforce In 2023/24 there were continuing problems with workforce retention and staffing shortages, as well as concerns around training and support for staff. Although the mental health workforce has grown by nearly 35% since 2019, shortages in both medical and support roles continue to have a negative impact on patient care. Shortages of doctors also continue to affect the delivery of our second opinion appointed doctor (SOAD) service. We remain concerned about the long-term sustainability of the service, with proposals in the Mental Health Bill due to increase the numbers of second opinions required while reducing the timeframes for delivery of some second opinions. Inequalities We are concerned that some of the key issues we raise in this report, including access to mental health support, are particularly challenging for certain groups of people, such as people from ethnic minority groups and those living in areas of deprivation. We identified several issues around people not understanding their rights, despite services having a legal duty to provide this information. There was variation in how well services met people’s needs. While many provided access to spiritual leaders, we remain concerned about gaps in the knowledge of staff around caring for autistic people. Children and young people Children and young people continue to face challenges in accessing mental health care. Increasing demand is leading to long waits for beds, and increases the risk of being placed in inappropriate environments and/or being sent to a hospital miles away from home. Once in hospital, we are concerned that access to specialist staff is being affected by low staffing levels, leading to patients’ needs not being met. In addition, the quality of physical environments for children and young people varies; access to food and drink, and food preparation facilities were key issues for many children and young people. Challenges in transitions of care between children and young people’s mental health services and adult mental health services remain, with many young people still falling through the gaps and not getting the care and support they need. Environment Through our MHA monitoring visits, we found that the quality of inpatient environments continues to vary. We are concerned about the impact of poor-quality environments on patients and have seen examples of how ageing and poorly-designed facilities affect people’s care. Being able to go outside brings therapeutic benefits for patients, but access to outdoor facilities varied across services. Gardens were usually well maintained, and in some services, patients were encouraged to grow plants and vegetables. However, we also found examples of unwelcoming gardens and at some services, patients’ access to outdoor spaces was limited. This issue was also raised by members of our Service User Reference Panel.

It has long been known that a focus on early intervention and prevention in the early years can prevent ill health in the future. With the mental and physical health outcomes of children in England on a downward spiral, the new government’s commitment to raising ‘the healthiest generation of children ever’ has been warmly welcomed by the children’s sector. This blog by Jessica Holden, Policy Adviser at the King's Fund, looks at whether this sentiment will be met with the action needed to address the scale of the challenge.

This report by NHS Digital presents findings from the third in a series of follow up reports to the 2017 Mental Health of Children and Young People (MHCYP) survey, conducted in 2022. The sample includes 2,866 of the children and young people who took part in the MHCYP 2017 survey. It looks at the mental health of children and young people aged 7 to 24 years living in England in 2022, as well as examining their household circumstances, and their experiences of education, employment and services and of life in their families and communities. Key findings In 2022, 18.0% of children aged 7 to 16 years and 22.0% of young people aged 17 to 24 years had a probable mental disorder. In children aged 7 to 16 years, rates rose from 1 in 9 (12.1%) in 2017 to 1 in 6 (16.7%) in 2020. Rates of probable mental disorder then remained stable between 2020, 2021 and 2022. In young people aged 17 to 19 years, rates of a probable mental disorder rose from 1 in 10 (10.1%) in 2017 to 1 in 6 (17.7%) in 2020. Rates were stable between 2020 and 2021, but then increased from 1 in 6 (17.4%) in 2021 to 1 in 4 (25.7%) in 2022. 11 to 16 year olds with a probable mental disorder were less likely to feel safe at school (61.2%) than those unlikely to have a mental disorder (89.2%). They were also less likely to report enjoyment of learning or having a friend they could turn to for support. 1 in 8 (12.6%) 11 to 16 year old social media users reported that they had been bullied online. This was more than 1 in 4 (29.4%) among those with a probable mental disorder. 11 to 16 year old social media users with a probable mental disorder were less likely to report feeling safe online (48.4%) than those unlikely to have a disorder (66.5%). 1 in 5 (19.9%) 7 to 16 year olds lived in households that experienced a reduction in household income in the past year. This was more than 1 in 4 (28.6%) among children with a probable mental disorder. Among 17 to 22 year olds with a probable mental disorder, 14.8% reported living in a household that had experienced not being able to buy enough food or using a food bank in the past year, compared with 2.1% of young people unlikely to have a mental disorder.

Core20PLUS5 is NHS England's approach to reducing health inequalities at both national and system level. The approach defines a target population cohort and identifies five focus clinical areas that require accelerated improvement. This infographic outlines the specific Core20PLUS5 approach to reducing health inequalities for children and young people.

In this Guardian article, parents reveal their heart-wrenching struggles to access NHS services, which have sometimes been too late to help their children.

Restrictive practices are things that limit the rights of a person, like being able to move around freely. Restrictive Practice is used to stop a person from doing behaviours of concern. These Specialised Services Quality Dashboards (SSQD) are designed to provide assurance on the quality of care by collecting information about outcomes from healthcare providers. SSQDs are a key tool in monitoring the quality of services, enabling comparison between service providers and supporting improvements over time in the outcomes of services commissioned by NHS England. Dashboards include: Restrictive Practice - CAMHS Low Secure Restrictive Practice - CAMHS Medium Secure Restrictive Practice - CAMHS PICU Restrictive Practice - CAMHS T4 Restrictive Practice - D/deaf (Adults) Restrictive Practice - D/deaf CAMHS Restrictive Practice - Eating Disorders (Adults) Restrictive Practice - High Secure (Adults) Restrictive Practice - Low Secure (Adults) Restrictive Practice - Medium Secure (Adults) Restrictive Practice - Obsessive Compulsive Disorder and Body Dysmorphic Disorder Service Restrictive Practice - Perinatal Restrictive Practice - Tier 4 Personality Disorder

Young people and expert mental healthcare staff say patients are unlikely to receive in-patient mental health care unless they “have attempted suicide multiple times”, according to a new report published by Look Ahead Care and Support. Launched in the House of Lords, the report – funded by Wates Family Enterprise Trust and produced by experts Care Research – argues Accident and Emergency departments have become an ‘accidental hub’ for children and young people experiencing crisis but are ill-equipped to offer the treatment required.   Based on in-depth interviews with service users, parents and carers, and NHS and social care staff from across England, the findings from the Look Ahead Care and Support report draws on experience of treating depression, anxiety, self-harm, suicidal thoughts and suicide attempts, eating disorders, addiction and psychosis.   Key findings Report commissioned by Look Ahead Care and Support finds increasing demand for children and young people’s crisis mental health services amidst challenges with existing services. Yet researchers heard from professionals, service users and their families and carers found that you “had to have attempted suicide multiple times to be offered inpatient support". Interviewees say A&E departments have become an ‘accidental hub’ for children and young people experiencing crisis but are ill equipped to offer the treatment required. Private sector providers now deliver the majority of support for hospitalised young people with mental health difficulties at “exceptionally high” cost. Report recommends alternative community crisis services, including supported housing away from hospital settings to reduce pressure on A&E and reduce costs by more than 50%

Samuel Howes was 17 when he died by suicide in September 2020. Samuel had ongoing mental health issues including anxiety and depression. This led to his use of drugs and dependency on alcohol, which in turn further worsened his mental health. This blog by his mother Suzanne details her experience of the final day of the inquest into her son's death, which found multiple failings on the part of Child and Adolescent Mental Health Services (CAMHS), social services and the police.

Niche Health and Social Care Consulting (Niche) were commissioned by NHS England in November 2019 to undertake an independent investigation into the governance at West Lane Hospital (WLH), Middlesbrough between 2017 up to the hospital closure in 2019. WLH was provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and delivered Tier 4 child and adolescent mental health services (CAMHS) inpatient services. This review initially incorporated the care and treatment review findings of two index case events for Christie and Nadia who both died following catastrophic self-ligature at the unit. The Trust subsequently agreed to include the findings of the care and treatment review of Emily which related directly to her time at West Lane Hospital, even though Emily did not die at this site. This is to ensure that optimal learning could be achieved from this review.  Summary of recommendations Recommendation 1 (TEWV): It is clear from the research that patients and their families (and some staff) were ignored and that their concerns and complaints are now found to be, on the whole, justified. The Trust must seek assurance that complaints, concerns and feedback are taken seriously and managed in line with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 particularly in relation to recording receipt of a formal complaint. Additionally, feedback and concerns on a service must be comprehensively reported and reviewed on a frequent basis, and importantly, that feedback is acted upon. Recommendation 2 (TEWV): Formal corporate decision-making processes and outcomes were difficult to trace and evidence. The Trust should seek assurance that there is a ratified minute of key organisational decisions. Recommendation 3 (TEWV): Action plans relating to West Lane Hospital were not connected to improvement programmes or risk registers. The Trust should ensure that there is strategic oversight of actions through the Board, Committee or working group where multiple interventions are involved. This will ensure that actions are not duplicated with other activities or overlooked. Using a programme approach around improvement plans and risk registers increases the accountability and enforceability around actions. Recommendation 4 (TEWV): There were issues with the consistent application of Duty of Candour at the Trust. The Trust should seek assurance that there are now mechanisms in place to assess that the Duty of Candour Policy is effectively implemented. Additionally, where there has been a death in a service, whether through self-harm/suicide or homicide, that families are given appropriate, meaningful, timely and compassionate family liaison and support through personal contact with a nominated officer of the Trust. Recommendation 5 (TEWV, CNTW, North East & North Cumbria ICB, Middlesborough Council, NHSE and provider collaborative, and CQC): TEWV, CNTW and System Partners need to seek assurance that they have resolved the problems associated with the clinical transitions phase (between services and child to adult). A compound recommendation is required to address this deficit: a) TEWV must provide assurance that a full gap analysis between the 2018 Healthcare Safety Investigation Branch (HSIB) investigation and its own position has been completed. As the Trust still delivers Tier 3 CAMHS services they should expedite a review of processes and procedures in relation to transitions. b) CNTW need to expedite a review of processes and procedures in relation to transition of CNTW young person inpatient to adult services. c) Patient as well as stakeholder feedback associated with transitions between CAMHS and other services (such as AMHT) should be sought and incorporated into service redesign by all parties. d) Effective governance surrounding transitions was not always in place. The good practice relating to transitions which is described within NICE Guidance should be translated into practice and delivered by all parties. e) Where a young person is in receipt of T4 care and transferring back to T3, there must be a joint response between health and the relevant local authority children’s services (in this case Middlesborough Council) so that the young person is prepared for life in the community and can be properly supported and their risks appropriately managed. f) ICBs, NHSE and provider collaboratives must ensure that providers with a PICU have a written protocol that details the pathway for discharge, including timescales for involving in arrangements, the families and the young person. This will ensure that, wherever possible, a young person is not suddenly transferred without adequate preparation. Recommendation 6 (TEWV): There was a gap between the development and successful implementation of important care initiatives (such as least restrictive practice), plans and evidence-based changes to practice. The Trust must seek assurance that there are implementation plans for new initiatives, policies or procedures and that these are evidence-based, being implemented correctly within services and monitored appropriately. Recommendation 7: There was a lack of systematisation in relation to the identification, mitigation and actioning of known risks at a ward, service and corporate level. A compound recommendation is required to address this deficit: a. TEWV must ensure that risk assessments for young people in CAMHS are based on a psychological formulation and are developed by a multidisciplinary team in conjunction with the young person and their family. b. TEWV must ensure that proper training is provided to staff around clinical risk management and how to ensure that action is taken consistently. c. TEWV must provide assurance that it meets the requirements of the new Patient Safety Incident Response Framework by 2023. d. The North East & North Cumbria Integrated Care Board (ICB), NHSE, and provider collaborative must seek assurance that TEWV has a robust environmental and ligature risk assessment process and the ability to respond effectively and urgently to mitigate risks identified through this process (including risks identified on Tunstall Ward). e. North East & North Cumbria Integrated Care Board must assure themselves that CNTW are following the NHS Child and Adolescent Mental Health Services Tier 4 (CAMHS T4): General Adolescent Services including specialist eating disorder service specification and the QNIC standards for use of mobile phones and social media access in inpatient environments. f. The application of robust risk assessment forms part of the CQC regulatory framework. The CQC should routinely examine the quality and consistent application of TEWV’s clinical risk assessment, clinical risk training and the relationships to local and corporate risk registers. Recommendation 8 (TEWV): The function of Executive team meetings in terms of operational involvement lacked clarity. The Executive team meetings must clearly define and record actions which they are directly responsible for, or, where actions have been delegated. The ET should recognise that it has the mandate to form task and finish groups. Recommendation 9: Safeguarding between mental health providers and system partnerships was insufficient to protect young people in West Lane Hospital. Despite the availability of Working Together Guidance, responsibilities and obligations internally and externally between agencies (providers and system colleagues) were confused, interpreted differently by individuals and consequently gaps developed. A compound recommendation is required to address this deficit: a. NHS England Specialised Commissioning, the North East & North Cumbria ICB and provider collaborative and the South Tees Safeguarding Children Partnership Board and LADO should now all reflect upon matters raised within this report and determine whether further internal review is required to ensure proper learning occurs within each respective agency. All relevant Safeguarding Children’s partnerships need to ensure that there are sufficient mechanisms in place to prevent a recurrence of the same. b. The North East & North Cumbria ICB and provider collaboratives should obtain assurance that provider organisations have sound systems and processes to safeguard young people in mental health facilities, and these provide regular robust assurance to NHS England Specialised Commissioning of effective working. c. Middlesbrough Council and Health providers/ key partners must ensure that there is clarity about the roles and responsibilities of each agency in the planning and delivery of care to young people in Tier 4 CAMHS provision to ensure that support is holistic and meets the educational; social; physical health and emotional needs of children and young people as well as their mental health needs. d. Local Authorities and Health providers must provide appropriate challenge where there are concerns about unsafe discharge arrangements from Tier 4 inpatient care, including appropriate escalation up to chief officers where concerns for children’s safety are high. e. Durham County Council must ensure that responses to referrals are completed within expected time frames, and subsequent assessments always incorporate the views of the family and young person. f. North East and North Cumbria Integrated Care Board and the Provider Collaborative must consider the impact and risks on Tier 4 CAMHS if a local Safeguarding Board is found to be weak or inadequate, or a local provider is found to have a major staffing issue. g. Where Safeguarding concerns are raised about a child, these must include a formal consideration of other vulnerable family members for the lifespan of care. h. Middlesbrough Council must respond formally to serious concerns raised about the care and treatment of a young person under their care and explore concerns with the family and the young person. Recommendation 10 (TEWV): Reporting structures were disconnected between various tiers of governance, and this prevented the ‘drill-down’ required for effective oversight and effective learning. The Trust must ensure rounded reporting arrangements to support proper Board assurance consisting of both hard evidence and soft intelligence. This should include a ‘trigger tool’ when a ward or department is experiencing ‘stress’, such as failing to complete training, debriefs, high sickness absence, low staff morale and this should be viewed alongside patterns of incidents, harms and complaints. Recommendation 11: There were gaps in relation to both the commissioning of effective services and in relation to the regulatory oversight in relation to West Lane Hospital. Assurance seeking activity was weak with a lack of sufficient scrutiny of both hard and soft intelligence. A compound recommendation is required to address this deficit: a. NHS England Specialised Commissioning and the Care Quality Commission (CQC) must ensure that when there is enhanced surveillance of services following quality concerns, the themes and patterns of all incidents are rigorously scrutinised and analysed. b. NHS England Specialised Commissioning, the provider collaborative and the North East & North Cumbria ICB, should work together with the Directors of Children's Services in the North East region. This is to ensure that services are commissioned which will meet the needs of the growing number of young people with complex needs and challenging behaviours that require integrated health and social care responses. c. A demand and capacity review (under the provider collaboratives programme and in association with each local authority) should be undertaken to ensure services have the appropriate capacity locally to minimise placing children out of area and to ensure the availability of suitable specialist care. d. TEWV/NHS England, the provider collaborative and Middlesbrough Council must provide assurance that all looked after children specifically with a diagnosis of autism have care provided that is in line with the NICE guidance on autism spectrum disorder in under 19s: support and management, recognising the challenges in the system. Recommendation 12: (NHS England) A full assurance review of progress against the recommendations contained within this report must be completed in 6-12 TEWS response to the report TEWV-assurance-statement-20-March-2023.pdf

This blog by the Centre for Mental Health looks at data about young people's mental health in 2022 from NHS Digital, highlighting the urgent need for effective mental health services and support for young people. It looks at what needs to change to improve the picture for young people's mental health including addressing child poverty, implementing whole school and college approaches and investing in early intervention support. Key findings One in four teenagers aged 17-19 have a mental health difficulty, an increase from one in six in 2021. Poverty continues to have a strong link to young people’s poor mental health. Reversed patterns of probable mental health difficulty for boys/young men and girls/young women highlights the need for specific gender-specific approaches. Young people with a mental health difficulty are more likely to have negative experience of social media. Young people with a mental health difficulty are more likely to miss school and feel unsafe while at school.

Last week, one of the country’s largest child and adolescent mental health services, Forward Thinking Birmingham, run by Birmingham Women’s and Children’s Foundation Trust, was rated “inadequate” by the Care Quality Commission. The inspection report makes for concerning reading — not least because it speaks to a range of issues being experienced by other providers of CAMHS services across the country. CQC inspectors warned there were not enough nursing and support staff to keep people using community services from avoidable harm. Nurses told the CQC that vacancies in the service impacted on people being allocated a care coordinator — and staff were leaving largely due to handling caseloads they felt were unsafe. Part of HSJ’s Mental Health Matters fortnightly briefing, covering safety, quality, performance and finances in the mental health sector.