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The Care Quality Commission yesterday highlighted areas of poor practice in mental health services for patients who are subject to the Mental Health Act, and pledged to use its regulatory powers to lever improvement.

Publishing its first annual report on the use of the Act, CQC said its findings raised important concerns about how some care providers, in both the NHS and private sector, were adhering to the principles of the Act and its Code of Practice.

The commission identified three priority areas where services needed to do much better:

• involving patients in decisions about their care and treatment;
• assessing and recording patients’ consent to treatment;
• minimising restrictions on patients and avoiding ‘blanket’ security measures.

Cynthia Bower, CQC’s Chief Executive, said: “Staff and managers who work in mental health services don’t always get the recognition they deserve. Many of the men, women and children who come under their care may owe their very survival to their dedication and compassion, both on the hospital ward and out in the community.

“But we have found too much poor and unacceptable practice and this must be tackled. Our top priority is to protect the interests of patients, and we will use our powers to ensure that care providers address these issues and make real improvements.”

Ms Bower said the former Mental Health Act Commission, whose responsibilities were inherited by CQC in April 2009, helped to drive significant improvements in mental health services but it did not have the regulatory powers available to its successor.

She gave the example that when NHS trusts had to apply for a licence to run services from April this year, CQC placed conditions on four trusts providing mental health services – three of them because patients were not being cared for in accordance with their rights. Improvements have subsequently been made by these trusts and CQC will continue to monitor them.

CQC’s Mental Health Act Commissioners visited more than 1,700 hospital wards and talked to more than 5,000 detained patients during the year that ended on 31 March 2010. Thirty per cent of the visits were unannounced and 9% took place at the weekend.

Of the three priority areas that CQC has identified for improvement in its report, Ms Bower said: “Firstly, involving people in the decisions that are made about their care is a key factor in helping their recovery. 

“We see excellent examples of patients being actively involved and participating at each stage of their treatment, such as care planning meetings and reviews. Their care is tailored to their individual needs. This is the gold standard, but we have found many services that could do so much more to improve in this respect.

“Secondly, we will be looking for improvement in the assessment and recording of patients’ capacity to consent to their treatment. When our Mental Health Act Commissioners visit patients on the wards, they often find that what patients tell them doesn’t match up to what the records say. It may be recorded that they have given their consent, but either they apparently lack the capacity to do so or they say they have refused to do so, and this is a concern.

“And thirdly, we are urging hospitals to minimise the restrictions they place on patients. We recognise the importance of ensuring people’s safety, but more hospitals are keeping psychiatric wards locked at all times, even though they often accommodate voluntary as well as detained patients. In some places there are blanket bans on mobile phones and internet access. These sorts of measures could compromise patients’ privacy or dignity, hold back their progress and even breach their human rights.”

In its report CQC also features an analysis that it has carried out on how Community Treatment Orders (CTOs) are working.

CTOs were introduced in November 2008 and were particularly intended for patients who, on being discharged from hospital, may refuse to take their medication or co-operate with community mental health services. The order is meant to ensure they receive effective care outside hospital, while allowing for them to be recalled if necessary.

In 2009-10, more than 4,000 people were made subject to a CTO when they left hospital. This is at least 10 times more than the numbers predicted by the Department of Health at the time the orders were introduced. One in five patients was recalled to hospital.

CQC studied a sample of 200 reports about people on CTOs compiled by its Second Opinion Appointed Doctors (SOADs), who have to authorise the medication prescribed for patients on CTOs.

Most of the patients in the sample (81%) had a diagnosis of schizophrenia or other psychotic disorders, while 12% suffered from mood disorders. Almost all were prescribed some form of antipsychotic medication.

Thirty per cent of the patients in the sample did not have a history of refusing to take their medication or co-operating with community services. CQC said this suggests that some hospitals are playing safe by putting patients on a CTO as a preventative measure, and it could be one of the reasons for the higher-than-expected number of orders.

CQC is concerned that there are more patients from some of the black and minority ethnic (BME) groups placed on a CTO compared to the proportions among detained patients, where there is already BME over-representation in relation to the wider community. It said more research was needed to try to understand this and other issues raised by its study.

Notes to editor:

The full report and a summary can be found (from Wednesday 27^th October) at: /mha

CQC is responsible for protecting the interests of people who are subject to the Mental Health Act, by monitoring how mental health services across England are using their powers and fulfilling their duties for patients who are detained in hospital or subject to community treatment orders or guardianship.

Each year more than 45,000 people are detained in hospital under the Mental Health Act for assessment and treatment for mental disorder. At any one time, about 16,000 patients are detained (including those on short-term holding powers). Of these, around 12,500 are in NHS hospitals and 3,500 are in independent (private) sector hospitals. Around 900 people are subject to guardianship by a local social services authority (council).

About 4,100 community treatment orders were made in 2009-10, the first full year since CTOs were implemented in November 2008. A total of 6,240 were made between November 2008 and the end of March 2010.

For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of all health and adult social care in England. Our aim is to make sure that better care is provided for everyone, whether it is in hospital, in care homes, in people’s own homes, or anywhere else that care is provided. We also seek to protect the interests of people whose rights are restricted under the Mental Health Act. We promote the rights and interests of people who use services and we have a wide range of enforcement powers to take action on their behalf if services are unacceptably poor.

We are introducing a new regulatory system that brings the NHS, independent healthcare and adult social care under a single set of essential standards of quality and safety for the first time. We register health and adult social care services if they meet essential standards, we monitor them to make sure that they continue to do so and we respond quickly if there are concerns that standards are not being maintained.  We rely on people who use services and those who care for and treat them to tell us about the quality and safety of services. This feedback is a vital part of our dynamic system of regulation which places the views, experiences, health and wellbeing of people who use services at its centre.