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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.

This investigation by the Healthcare Service Safety Investigation Body (HSSIB) is one of a series on the theme of patient safety in mental health inpatient settings. This investigation focused specifically on the conditions that contribute to safe and therapeutic care for adults who are staying in mental health wards or units. The demand on mental health inpatient services in England is high and has been increasing. It is reported that the quality of care received by patients admitted to these services varies, meaning patients may not receive the therapeutic care they need. Issues include limited shared decision making and a lack of consideration of recovery-focused goals. Patients may also be placed in situations that create safety risks associated with mental, physical or sexual harm. This investigation examines the impact of workforce challenges on the delivery of safe and therapeutic care to adult patients in acute mental health inpatient settings (settings for people who need urgent care and are experiencing a severe mental health problem). It also looks at the wider workplace conditions and the organisation of care to see how these factors affect care. The investigation’s scope included adults, older-adults and secure (adults who pose a risk to the public) inpatient settings. The investigation's findings and recommendations offer opportunities to make improvements to systems, practices and future plans to support the delivery of therapeutic care, and therefore safety, in mental health inpatient settings. Findings Mental health inpatient workforce Patients in mental health inpatient settings did not always feel safe and staff were not always able to develop therapeutic relationships with patients in support of their care and safety. Best practice standards for care were not embedded across inpatient settings. Some inpatient models of safety continued to focus on restrictive approaches, rather than relational approaches. Approaches were influenced by the ability of the workforce to form therapeutic relationships with patients. Workforce challenges across the multidisciplinary workforce had negatively influenced the ability of staff to develop therapeutic relationships with patients and therefore patient safety had been affected. Workforce challenges included difficulties recruiting staff and retaining experienced staff, and concerns around the knowledge and skills available to support therapeutic relationship formation and trauma-informed care. The mental and physical health care needs of patients cared for in acute inpatient settings may have changed and acuity may now be greater than in the past. Staff were not always equipped with the required knowledge and skills to understand and meet the mental and physical needs of patients. Wards were not always staffed to ensure patients could access the knowledge and skills of a multidisciplinary team. Some patients had no or limited access to professionals such as dietitians or speech and language therapists. Workforce challenges varied across regions. Barriers to region-wide coordinated workforce planning included unclear national expectations, difficulties predicting workforce needs, limited provider engagement, and a lack of available staff. The goals of the NHS Long Term Workforce Plan may be unattainable if barriers to implementation are not recognised and addressed. Barriers found included education capacity to build the workforce and poor working conditions affecting retention. There were conflicting views about how best to educate pre-registration nursing (mental health) students and where responsibility should lie to support their development of mental and physical health care skills. Registered nurses (mental health) may be being promoted to supervisory roles with limited experience. Inexperience influenced the supervision and development of new staff, and leaders may be reluctant to challenge attitudes that undermine the quality of care. Built mental health inpatient environments The built environments (estates and physical environments) of inpatient settings varied. Some environments were not therapeutic, did not contribute to formation of therapeutic relationships, and had created situations where patients and staff could and had been harmed. The short-, medium- and long-term investment requirements for safe and therapeutic built environments across mental health inpatient settings were not always known at regional and national levels. Capital funding for the NHS to maintain, improve and create new built environments was finite and unable to meet the needs of mental health inpatient settings. Hazards in built environments could not always be removed or mitigated, and environments could not be improved to be therapeutic. There were concerns about the long-term ability of some high-secure built environments to maintain patient, staff and public safety. There was no specific process for high-secure services to access the capital funds they required for long-term estate planning. There was limited evidence around how best to design therapeutic built environments to meet potential changes in patients’ needs and acuity. Providers wanted clarity on design standards and on the role of technology to support the safety of patients experiencing mental health problems. Social and organisational factors influencing mental health inpatient care The development of psychologically safe and therapeutic social environments was not always possible because of demands on services, workforce constraints, workforce knowledge and skill development, and cultural influences. Providers of mental health inpatient care were not always able to accommodate patients in single-sex spaces. Best practice standards in relation to ensuring sexual safety were not always embedded. Approaches to accommodating patients who were transgender and non-binary varied in mental health inpatient settings. Staff wanted to meet the needs and preferences of all patients but this was not always possible. Digital systems had contributed to incidents where patients had been harmed. Clinical information was not always easily accessible in electronic patient records or had not been shared across different care providers’ systems. Availability and access to physical healthcare services for mental health inpatients varied. Access was influenced by how providers designed and set up their services, the knowledge and skills of staff, and collaboration between acute and mental health care providers. In some locations, care pathways between different care providers were limited. This reduced continuity of care and made it more difficult to access physical health services, which increased the need for patients to be transferred to acute physical health hospitals. Inequalities continued to exist in the care of patients experiencing mental health problems. Availability and access to services for different patient groups further influenced the ability of inpatient providers to deliver safe and therapeutic care. Some organisational cultures and individual beliefs surrounding people experiencing mental health problems continued to negatively influence attitudes towards their care, including access to physical healthcare. Safety recommendations HSSIB makes the following safety recommendations Mental health inpatient workforce HSSIB recommends that The Shelford Group reviews and updates the Mental Health Optimal Staffing Tool on a regular basis following collection of recent data from mental health inpatient settings. This is to ensure the tool remains valid for potential changes in patients’ needs and the level of care they require, and to support providers to make decisions about workforce requirements that support therapeutic and therefore safe care. HSSIB recommends that NHS England works collaboratively with relevant national bodies and stakeholders including professional regulators, the Department of Health and Social Care, and relevant royal colleges to: Identify and clarify the goals of acute mental health inpatient care and the roles, required skills and ongoing professional development needs of the multidisciplinary workforce team. Review and update the NHS Long Term Workforce Plan with consideration of the concerns around changes in patients’ needs and the need for a multidisciplinary approach to ensure therapeutic care is provided. Develop a strategic implementation plan to address workforce issues in mental health inpatient settings that identifies the social and technical barriers to implementation and sets out actions to address them. This is to develop, enable, support and retain a future multidisciplinary mental health inpatient workforce that is able to deliver therapeutic and safe care to patients. Built mental health inpatient environments HSSIB recommends that the Department of Health and Social Care, with input from stakeholders including NHS England, identifies the short-, medium- and long-term requirements of NHS mental health built environments to ensure they enable delivery of safe and therapeutic care to patients, and create a supportive working environment for staff. This is to support the development of a strategic and long-term approach to capital investment and prioritisation for NHS built environments. HSSIB recommends that the Department of Health and Social Care undertakes assessment of the capital requirements of the built environments across high-secure services in England and develops plans to ensure the long-term safety of patients, staff and the public. Social and organisational factors influencing mental health inpatient care HSSIB recommends that NHS England, working with relevant stakeholders, develops guiding principles for providers of mental health inpatient care to support local decision making when accommodating patients, including patients who are transgender and non-binary. This is to ensure a provider’s equality and human rights obligations are considered, and all patients are cared for in environments where they feel safe and that are therapeutic. Safety observations HSSIB makes the following safety observations Providers of mental health inpatient care can improve patient safety by ensuring that where professional judgement is used to help make workforce decisions, this accounts for ward physical environments, changes in patient acuity, and the individual mental and physical health care needs of patients that require support from a multidisciplinary workforce. Those involved in the provision of undergraduate and pre-registration education (educational institutions and placement providers) and preceptorship/induction programmes can improve patient safety by collaboratively ensuring that staff entering mental health related professions are developing the required knowledge and skills, including in trauma-informed care, to care for patients with mental and physical health care needs. Those involved in healthcare research can improve patient safety by seeking to understand the design principles for mental health inpatient settings that underpin safe and therapeutic care. Research should include consideration of sensory environments, the role of technology, and the changing needs of patients. Those involved in the design of new and upgraded built environments for mental health inpatient settings can improve patient safety and the delivery of therapeutic care by involving relevant stakeholders in design processes. Stakeholders include people with lived experience (patients and staff) and experts in human factors and ergonomics. Any design should also consider the changing needs of patients. Providers of mental health inpatient care can support patient safety by evaluating and addressing local barriers to the effective use of technology to support patient care, including through gaining insights from people with lived experience (patients and staff) and ensuring the digital infrastructure is available, usable and reliable. Safety responses HSSIB proposes the following safety responses for integrated care boards HSSIB suggests that integrated care boards work collaboratively with the NHS and independent sector to review their system-level workforce plans to ensure they recognise and mitigate the safety challenges in mental health inpatient settings and agree how variation across a geographical area can be mitigated. HSSIB suggests that integrated care boards: 1) ensure system-level infrastructure strategies clearly reflect the risks across their mental health inpatient built environments, and 2) ensure prioritisation of capital funding is equitable across different healthcare settings in a geographical area. HSSIB suggests that integrated care boards: 1) work with mental health inpatient providers to identify patient needs that require input from other providers and agencies, and 2) facilitate cross-provider working arrangements between mental health, acute and primary care providers to minimise the need for transfers of care unless clinically necessary.

This National Institute for Health and Care Excellence (NICE) guideline covers the components of a good experience of service use. It aims to make sure that all adults using NHS mental health services have the best possible experience of care. It includes recommendations on: access to care assessment community care assessment and referral in crisis hospital care discharge and transfer of care assessment and treatment under the Mental Health Act

Serious incident management and organisational learning are international patient safety priorities. However, little is known about the quality of suicide investigations and the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time. This study reviewed research in this area and found that recent literature proposes a Safety-II approach in response to the limitations of RCA.

In this study, 156 participants were recruited and randomised to placebo (n=83) or ketamine (n=73), stratified by centre and diagnosis: bipolar, depressive, or other disorders. Two 40-minute intravenous infusions of ketamine (0.5 mg/kg) or placebo (saline) were administered at baseline and 24 hours, in addition to usual treatment. The primary outcome was the rate of patients in full suicidal remission at day 3, according to the scale for suicidal ideation total score ≤3. Analyses were conducted on an intention-to-treat basis. The findings indicate that ketamine is rapid, safe in the short term, and has persistent benefits for acute care in suicidal patients. Comorbid mental disorders appear to be important moderators. An analgesic effect on mental pain might explain the anti-suicidal effects of ketamine. There are also some useful and thought-provoking comments on this research, and a helpful visual aid. Results More participants receiving ketamine reached full remission of suicidal ideas at day three than those receiving placebo: 46 (63.0%) of 83 participants in the ketamine arm and 25 (31.6%) of 73 in the placebo arm (odds ratio 3.7 (95% confidence interval 1.9 to 7.3), P<0.001). This effect differed according to the diagnosis (treatment: P<0.001; interaction: P=0.02): bipolar (odds ratio 14.1 (95% confidence interval 3.0 to 92.2), P<0.001), depressive (1.3 (0.3 to 5.2), P=0.6), or other disorders (3.7 (0.9 to 17.3, P=0.07)). Side effects were limited and no manic or psychotic symptom was seen. Moreover, a mediating effect of mental pain was found. At week six, remission in the ketamine arm remained high, although non-significantly versus placebo (69.5% v 56.3%; odds ratio 0.8 (95% confidence interval 0.3 to 2.5), P=0.7).

Improving and widening access to care for children and adults needing mental health support is a key priority for the NHS, as outlined in the Long Term Plan. Tthe West of England AHSN are working with NHS commissioners and providers, industry partners, other AHSNs, local trusts, Child and Adolescent Mental Health Services (CAMHS) and community providers on a wide range of initiatives to support their work to improve mental healthcare and wellbeing. Mental Health Safety Improvement Programme Early Intervention Eating Disorder (FREED) Focus ADHD Supporting high impact users in Emergency Departments (SHarED) Future Challenges: Young People and Mental Health Resilience S12 Solutions

The Quality Network for Inpatient Working Age Mental Health Services (QNWA) based within the Royal College of Psychiatrists' Centre for Quality Improvement are pleased to announce the publication of their 8th edition standards. Since the publication of the first edition standards in 2006, the Network has grown to include over 140 members from the NHS and private sector. This new edition of standards aims to reflect the changes in working practices and legislation over the last two years in addition to placing greater emphasis on equality, diversity and inclusion as well as sustainability in inpatient mental health services. The eighth edition standards have been drawn from key documents and expert consensus and have been subject to extensive consultation with professional groups involved in the provision of inpatient mental health services, and with people and carers who have used services in the past.

This report published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) looked to identify and explore remediable factors in the clinical and organisation of the physical healthcare provided to adult patients admitted to a mental health inpatient setting.  The report suggests that a physical healthcare plan should be developed when patients are admitted to a mental health inpatient setting. Other key messages aimed at improving care include calls to: formalise clinical networks/pathways between mental health and physical health care; involve patients and their carers in their physical health care, and use admission as an opportunity to assess and involve patients in their general health, and include mental health and physical health conditions on electronic patient records.

The UK Government has opened a consultation on changes to the Mental Capacity Act (MCA) 2005 Code of Practice, and implementation of Liberty Protection Safeguards (LPS). This consultation is also seeking views on the LPS regulations, which will underpin the new system. This consultation applies to England and Wales and is open until 7 July 2022. This is a joint consultation published by the Department of Health and Social Care and the Ministry of Justice. The Mental Capacity Act applies in England and Wales, but some aspects of its application are devolved in Wales. The Welsh Government has therefore informed this consultation. The LPS will apply to people over the age of 16, and the Department for Education has been involved in the development of this new system. This briefing paper from the Social Care Institute for Excellence (SCIE) provides a summary of the Deprivation of Liberty Safeguards, an amendment to the Mental Capacity Act 2005.

Responding to online patient feedback is considered integral to patient safety and quality improvement. However, guidance on how to respond effectively is limited, with limited attention paid to patient perceptions and reactions. The objectives of this paper, published by Health Expectations, were to identify factors considered potentially helpful in enhancing response quality; coproduce a best‐practice response framework; and quality‐appraise existing responses.

Prisoners should have the same access to healthcare as everyone else. This page looks at what healthcare you should get if you are in prison and what to do if you are not getting the help you need.

Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? My much loved daughter-in-law, Mariana Pinto, died on 16 October 2016. She was 32. Her tragic and unexpected death raised many questions for us about standard practice by psychiatric services and about patient safety. The evening before she died, Mariana was taken by ambulance to her local A&E department, escorted by four police officers, and handcuffed for her own safety. She was psychotic – delusional, paranoid, violent and very distressed. She had attacked her husband (my son) who had visible bite marks, scratches and bruises. It was a first episode and totally out of character. She had not eaten or slept for several days. In A&E she was brought food and drink but spat it out, believing it to be poisoned. She kept trying to escape from the cubicle. The police stayed, stating that she was extremely vulnerable. Eventually she agreed to take a sedative – but not before she had held it under her tongue for some time, and only after we, her family, were able to persuade her that she should take it. Once she was finally sedated, she was given various tests to rule out any physical cause, and a mental health act assessment. This was done with her and her husband together. There was no attempt to see him separately. She was deemed competent to make decisions about her care, and as she wanted to go home, was discharged, with a referral to the local Crisis Team, who we were told would receive the referral at 8 am the following morning and would arrange to visit. The psychiatric team operate within A&E but for a separate mental health trust. This same trust runs the Crisis Team. It is deemed outstanding by the Care Quality Commission (CQC). The following morning, there was no contact from the Crisis Team. My son rang them at midday to ask when they would visit. They said normally between 5 and 7 pm on Sundays and to ring back if he needed to. He rang back at 3.30 pm stating that she had deteriorated rapidly and asking for the visit to be brought forward. He was told that it could not be. At 4.00 pm Mari ran out of the open door to the roof terrace and jumped off it. She did not survive her injuries. The Coroner gave a narrative verdict, making it clear that Mariana did not know what she was doing, though her actions were deliberate. She also gave a Prevention of Future Deaths Report. Whilst the trust is obliged to reply, there is no statutory obligation to demonstrate that the actions they have promised have actually been taken. There was no attempt at any risk assessment. There was no attempt to check that my son could speak freely (he could not – it was a studio apartment). There was no attempt to call the emergency services on his behalf, and no attempt to check he had been able to do so. None of this is regarded as negligent or especially problematic. Since her death the Crisis Team do visit on Sunday mornings. We also found out that the number we were given to call was for service users already allocated a key worker, rather than a more general number – but as my son spoke to senior staff on each call, this should not have made a difference. After her death we raised the following questions: Surely given the bite marks and bruising, her husband should have been allowed to give his information to the psychiatric team separately? No, it turns out that while this would have been good practice, it was not negligent. Surely, given that her family knew and loved her, we should have been asked post sedation if she seemed like herself (she did not). No, it turns out that this is not seen as necessary. It’s not even regarded as good practice. Surely, given that she was paranoid and had told the police that she did not trust her husband, her husband should have been given private space to discuss the discharge and rehearse what to do if things went wrong once the sedative wore off? And surely we should have been told that the Crisis Team is not instead of calling 999 in an emergency. And efforts made to help us to decide if the situation was an emergency. No, it turns out that while this would have been good practice, it was not negligent. The mental health trust has now introduced a written discharge template for care and contingency planning. We have been told that the circumstances of Mariana’s death were unusual and could not have been foretold. That may be. But there are still lessons to be learnt. To improve patient safety in mental health crisis and to learn from deaths, we need to change standard practice. It should become standard to: See family and friends separately if someone is paranoid, to understand the family’s concerns, learn more about the patient and work together to consider how best the patient can be kept safe and helped. Provide written care and contingency plans to patients and their family Use one number for a Crisis Team helpline, with clear policies to offer help and support to service users and to their carers, and proper protocols in place to assess risk and intervene if someone is at immediate risk of harm. Make it very clear to patients that a referral to a Crisis Team is not a substitute for calling 999 in an emergency (where there is an immediate risk of harm to the patient or others) and to distinguish between a crisis and an emergency. Other professionals have a role in this too: On discharge, the A&E staff (who were very kind and very concerned) could invite the family to come back if the situation deteriorates, making it clear that it was an emergency, was a legitimate use of 999 and of A&E, and that the Crisis Teams are not for emergencies. The police could do the same, if they are trusted by the family (in many cases they are not).

The following blog was shared by a patient who wished to remain anonymous. In this account, they explain why they felt they were treated differently when they presented with symptoms of Covid-19 due to their mental health difficulties. They also describe how receiving a false negative test result caused further harm to their mental health. I was experiencing symptoms of Covid-19 and when I became unable to complete a sentence or walk to the bathroom, my GP advised me to go to hospital. I have mental health difficulties and one of the staff recognised me from when I had been admitted previously, following a suicide attempt. I felt that I was treated like a 'frequent flyer' of A&E and that my symptoms were taken less seriously than they would have been otherwise. I was sent home after my tests for Covid came back negative and was told that it was just anxiety. I got much worse over the coming days. If I had tested negative, why was I feeling desperately unwell with all the published symptoms of Covid? I thought that I should be physically active if I didn't have Covid-19, so I pushed myself and berated myself when I repeatedly became unable to breath with a pounding heart upon any exertion. I couldn't cope caring for my four children and was in a 'critical' dangerous mental state many times. I self-harmed to try and cut off from feeling so awful. My physical health deteriorated. The ambulance was called by the GP who had sent a nurse to assess my oxygen levels and the paramedic said I should be in a coma according to my obs. This made me feel less like I was making it up, but it was still in my head despite my husband telling me repeatedly that the results of the test are 30% wrong. The paramedic gave me oxygen and I protested strongly against going to hospital a second time. The paramedic insisted I went, put me on oxygen and reassured me he would ask the hospital staff to relate to me as a patient who was showing clear signs of Covid and that I did struggle with my mental health but that I was doing my best to recover. I also asked the paramedics to inform the hospital staff about my eating disorder so they could gently help me to manage my low blood sugar without judgements and causing me further shame. In the hospital I saw a Dr who confirmed that I did have Covid-19 and that my test must have been a 'false negative'. I had felt judged, dismissed and had doubted myself. The first thing anyone I spoke to asked was whether or not I had had a test and whether it was positive. The negative test result isolated me from calling family and greeting neighbours as I didn't have the energy to go into the false negative answer. I found that saying my test was 'negative' sparked a surge of invalidation of everything I was experiencing. The isolation caused me further significant harm to my mental health. Among other fleeting symptoms I have had overwhelming fatigue, breathlessness, sweats or chills, no smell or taste, a rash, headaches and low mood. After nearly four weeks I am slowly recovering. I am lucky to have a social worker, family support worker and psychologist available over the phone through this period, so I do feel my family and I are supported. But I am interested to know if anyone else has found their symptoms are being quickly dismissed as anxiety when they are sure they have the virus? Or if anyone else feels like they haven't had their symptoms taken as seriously because of their mental health difficulties?

This action plan was produced by the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group following a treatment delay for a patient in intensive care.

The Mental Capacity Act (MCA) is designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over. The NHS provides a summary of the Act. The NHS web page summarises: How capacity is assessed What is 'best interests' Deprivation of liberty Advanced statements and decisions Lasting powers of attorney The court of protection Professionals duties

Powerful bog written by Alison Cameron about her experiences as a patient on a mental health unit. This powerful, honest, blog by Alison Cameron describes what its like to be a patient in a mental health unit. She calls for mixed sex wards to be eradicated within mental health units, better staffing and increased trauma training for staff. Her recount reinforces the importance of patient dignity, respect and humanising patient care within the mental health setting.

CQC's completed programme, which started in 2014, of comprehensive inspections of all specialist mental health services in England.