Annual Statement - August 2010 - Care Quality Commission

Mental Health Act Annual Statement August 2010
Arbury Court Psychiatric Secure Services
Partnerships in Care
Executive Summary
This statement reflects the findings of visiting Mental Health Act (MHA)
Commissioners in the period between March 2010 and August 2010. Where
appropriate this statement includes consideration of the responses given by the
provider to those visits. During the reporting period the Care Quality Commission
(CQC) has visited Arbury Court Psychiatric Secure Services on seven occasions,
visiting six wards, interviewing 28 patients in private and others in informal groups
and scrutinising 17 sets of records. The Commissioner would like to thank the unit
managers and staff for their support and assistance during the visits.
Purpose of the facility
Arbury Court Psychiatric Secure Services, Partnerships in Care is an Independent
Hospital. Its primary function is to provide a range of secure facilities for men and
women who have a diagnosis of mental disorder as defined under the 1983 Mental
Health Act who require continuing care and treatment.
The service comprises of 74 beds, of which there are two 15 bedded medium secure
wards and four 11 bedded female wards of varying security. The clinical
environments are supported by therapeutic facilities including fitness suite, social
club, rehabilitation kitchen and other multi-purpose facilities. In summary:
• 2x15 bedded Male Medium Secure Wards.
• 1x11 Medium Secure Women’s Wards.
• 1x11 bedded Enhanced Low Secure Women’s Wards.
• 2x11 bedded Low Secure Women’s Wards.
Giving in total:
• 44 female beds of varying security
• 30 Medium Secure Male beds
The service provides gender specific services and is only considered appropriate at
18 years or above.
Main Findings
The following points highlight those Mental Health Act issues raised by
Commissioners on visits and is drawn from the data presented in annex A. The
detailed evidence to support them has already been shared with the provider through
the feedback summaries and is not repeated here. For further discussion about the

findings of this Annual Statement please contact the author via the Care Quality
Commission’s Mental Health Operations Office located at The Belgrave Centre,
Nottingham.
Relationships with the provider in the reporting period
The previous Annual Statement was received positively by the managers and an
action plan published. This has been monitored by visiting Mental Health Act
Commissioners on their visits during the reporting period and considerable progress
noted in a number of areas. There are currently no feedback summaries awaiting a
response.
There have been two constructive meetings with the hospital managers together with
informal meetings at each visit with Responsible Clinicians (RCs), nurse managers,
MHA administrator, social workers, occupational therapists, activity organisers and
catering managers.
Progress on recommendations in the 2009 Annual Statement
The team at Arbury Court has always been keen to receive feedback about the
quality and nature of services provided and have endeavoured to respond to findings
in a timely manner. Previous Annual Statements have been well received by
managers and staff. During visits the Commissioner has undertaken assessments of
progress against those issues highlighted previously. There has been much good
progress. However, there are some concerns that remain live issues during this year
that require attention. These will be highlighted.
Mental Health Act and Code of Practice Issues
Consent to Treatment
Concerns in this area may contribute to an understanding of the CQC’s evaluation of the Provider’s compliance with Regulatory
Outcome 2c and 9E
Section 58 Statutory Consultees: This remains an ongoing concern. The
Commission would remind managers of their responsibility to ensure by audit that
the role of the statutory consultee is carried out as per the Code of Practice.
Part IV compliance: There were two instances noted during the reviews where the
Responsible Clinician had not recorded the assessment of the patients’ capacity to
consent and discussion surrounding the treatment.
Legal documentation
It should be noted that the maintenance of legal documents both in Mental Health
Act administration office and at ward level were kept in an exemplary way in a
separate folder, easy to access and in date order. Good liaison was evidenced
between the mental health act administrators, clinicians and ward managers.
Clinical notes: There was evidence that RC’s met regularly with each patient both
individually and with a multidisciplinary team. Assessments, treatment plans and

eviews were timely and there was good evidence that the requirements of the Code
of Practice relating to assessment of capacity prior to treatment were carried out and
recorded. The care pathway and regular reviews and audits relating to the use of the
Mental Health Act were available and showed high level compliance.
Section 132 – Information to Patients
the Essential Standards of Safety and Quality Concerns in this area may contribute to an understanding of the CQC’s
evaluation of the Provider’s compliance with Regulatory Outcome 1a
Information to patients was clear, regularly and appropriately reviewed both in writing
and supported in discussion by the ward staff, evidenced in notes and Mental Health
Act files. Additional evidence was found in the patients’ appeals to the Tribunal
Service.
Section 130A – Independent Mental Health Advocacy (IMHA)
Concerns in this area may contribute to an understanding of the CQC’s evaluation of the Provider’s compliance with the
Essential Standards of Safety and Quality Regulatory Outcome 1a
Patients were informed of their rights to the use of advocacy and an IMHA. These
were provided by Rethink, who provide the ongoing advocacy services. To ensure
the service meets the needs of the patients there are regular review meetings with
the Social Work Department at Arbury Court and attendance at the wards is
monitored via the electronic entry system, which logs all staff entering and exiting the
service.
Seclusion and the management of Violence
the Essential Standards of Safety and Quality Concerns in this area may contribute to an understanding of the CQC’s
evaluation of the Provider’s compliance with Regulatory Outcome 4Q [Seclusion] Restraint [Regulation 11]
A seclusion facility is available. A suitable policy is in place and training regarding
management of violence is part of the training requirements for all staff.
Observational policies and regular review by the RC was evidenced in notes.
Violence does occur and the Commissioner noted that staff were skilled in deescalation
techniques and in reducing violence.
Other issues
Safeguarding patients
Bullying: This was complained of by patients during the visit. A problem that is clear
from the notes and policies that the manager, clinicians and staff take seriously and
use observational skills to minimise these incidents. Staff management of bullying
and educational input by staff was observed. It was noted that there had been
safeguarding meetings within the wards, with both managers and Commissioners.
Patients’ complaints: There was one active complaint during the period under review,
which has now been investigated and resulted in the relevant staff being the subject
of a disciplinary hearing, being demoted and to have further development and
training. Complaints are rigorously looked into. In general, patients spoke highly of
staff and care.

Staffing levels: Staffing is said to be near establishment. However, it is noted that
there is a high use of bank and agency staff. Patients speak of the insecurity that
they feel with new staff, particularly the females. There are apparently an over
abundance of male staff both contracted and in the bank and agency. One patient
spoke of having one to one observation by a male agency staff at night. This is
unacceptable. Managers have since agreed to robustly monitor the use of bank and
agency staff.
Obesity: This is clearly a problem within the male and female wards. The hospital
has taken a multidisciplinary approach to this problem and is well represented at the
regional meetings. Menus have been reviewed. The hospital shop now stocks
healthier options. Medical assessments highlight issues.
Health lifestyles: The hospital is well represented at the regional lifestyle groups,
where good practice is shared. A staff team has been identified to drive forward the
work. A practice nurse has been appointed to focus on physical health working with
a GP, RC and the patients. Metabolic syndrome assessments were carried out.
Temperature, pulse and respiration, blood pressure, blood reviews and levels were
all part of the push forward to improve and encourage healthy lifestyles.
Activity levels/care plans: There have been positive and pleasing efforts to increase
the levels of activity for each patient, though uptake has been poor. New attempts to
motivate patients with regard to an increase of activity is being approached and
supported by the whole multidisciplinary team; some promising improvements have
already been noted. Access to the gym has been a problem and is to be reviewed.
Deaths whilst detained under the Mental Health Act: During the reporting period
there has been one patient’s death. The CQC are awaiting reports of any internal or
external investigations and the outcome of the Coroner’s inquest is expected. Action
plans and any lessons learnt should be shared with the CQC.
Recommendations and Actions Required
1. Patient Activity: The hospital should continue its work in increasing activity plans
for each patient and monitor patient activity levels and in promoting healthy
lifestyles.
2. Dining arrangements: The hospital should ensure appropriate dining
arrangements are available both in dining rooms and ward areas so that the
patient experience is improved.
3. Use of gym: The hospital should continue its work in reviewing the current gym
facility and ensure that appropriately trained staff are available to support patients
in using the equipment. The provider is requested to inform theCQC of the
outcome of review.
4. Staffing arrangements: The hospital should continue to monitor use of bank and
agency staff, ensuring that gender appropriate staff are available for each ward.

5. Safeguarding patients: The hospital should continue to meet the safeguarding
requirements to ensure that all appropriate observation and management of
aggression and violence can limit bullying and safeguard patients.
6. Statutory consultees: The hospital should ensure that the discussion between the
Second Opinion Appointed Doctor (SOAD) and the statutory consultee regarding
the care plan should be recorded as per the Code of Practice.
Forward Plan
The CQC will continue to visit Arbury Court in the coming year to monitor the
operation of the Mental Health Act and to meet with detained patients in private.
Progress will be actively followed up by the Commissioner in the forthcoming 12
months against issues raised in this statement. They will work with other colleagues
in the CQC to further develop an integrated approach to the service provision.

Annex A
The quantitative data will only apply to visits completed from 1 April 2010
which is the time that the new data started to be captured uniformly.
Visits to Arbury Court Psychiatric Secure Services
Date Ward
Patients
seen
Patients
in groups
Records
checked
8 March 2010 Oakmere Ward
12 April 2010 Appleton Ward 5 0 3
13 April 2010 Heathfield Ward 6 0 3
19 April 2010 Cinnamon Ward 4 0 3
20 April 2010 Oakmere Ward 3 0 3
29 April 2010 Rosewood Ward 5 0 2
30 April 2010 Delamere Ward 5 11 3
Totals for the trust: 28 11 17
Findings from Visits – Environment and Culture YES NO N\A
If the door is locked is there evidence that informal patients are informed of their right to leave the
ward and given the means to do so?
Are you satisfied that there is evidence that informal patients are free to leave the ward in line with
legal requirements?
Do patients have the ability to lock their rooms securely and the means to do so? [answer no if in
dormitories]
0 2 4
0 1 5
6 0 0
Do patients have lockable space which they can control? 6 0 0
Are arrangements to cover viewing panels in bedroom doors adequate to protect patient privacy? 6 0 0
Are curtains or other window coverings in patient bedrooms adequate to protect privacy from people
outside the ward?
6 0 0
Does the ward provide single gender sleeping areas, toilets, bathrooms and lounges? 5 0 1
Is there a ward phone for patients’ use? 6 0 0
Is it placed in a location which provides privacy? 5 1 0
Are there any circumstances under which patients may have their mobile phones? [answer N/A if
HSH]
Do patients have an opportunity to participate in influencing the ward they are on via such
mechanisms as community meetings, patients’ councils etc?
4 2 0
3 0 3

Findings from Document Checks YES NO N\A
Were the detention papers available for inspection? Did the detention appear lawful 16 0 1
Was there either an interim or a full AMHP report on file? 16 0 1
If the NR was identified was s/he consulted, If there was no consultation, were reasons given? 4 5 8
Where appropriate was all psychotropic medication covered by a T2 and/or T3? 16 0 1
Was there evidence a capacity assessment at the time of first administration of medication following
detention?
16 1 0
Was there evidence a discussion about consent at the time of first administration of medication
following detention?
16 1 0
Was there a record of the patient’s capacity to consent at 3 months? 16 0 1
Was there a record of a meaningful discussion about consent between the AC and the patient at 3
months?
16 0 1
Was there evidence that the RC had advised the patient of the outcome of the SOAD visit or an
explanation why not?
Was there evidence of discussions about rights on first detention and an assessment of the patient’s
level of understanding?
5 0 12
16 0 1
Was there evidence of further attempts to explain rights where necessary? 17 0 0
Was there evidence of continuing explanations for longer stay patients? 16 0 1
Is there evidence that the patient was informed of his/her right to an IMHA? 9 8 0
Are the patient’s own views recorded on a range of care planning tools? 16 0 1
Was there evidence that the patient was given a copy of their care plan? 16 0 1
Is there evidence that the patient signed / refused to sign their care plan 10 0 7
Was there evidence of care plans being individualised, holistic, regularly reviewed and evaluated? 17 0 0
Is there evidence of an up to date risk assessment and risk management plan? 17 0 0
Is there evidence that discharge planning is included in the care plan? 15 1 1
Were all superseded Section 17 leave forms struck through or removed? 15 2 0
Was there evidence that the patient had been given a copy of the section 17 leave form? 15 1 1
Are the timescales, frequency and conditions for the use of leave unambiguously specified? 16 0 1
For patients in hospital less than a year, is there evidence of a physical health check on admission? 15 0 2
For patients in hospital over than a year, is there evidence of a physical health check within the last
12 months?
If the patient’s medication was authorised on a T3, was there a record of the discussion
between the SOAD and the statutory consultees [enter 0 for none, 1 for one consultee, 2
for both consultees, and n/a if no T3]?
15 0 2
0 1 2 N\A
0 3 3 11

Annex B – CQC Methodology
The Care Quality Commission visits all places where patients are detained under the
Mental Health Act 1983. Mental Health Act Commissioners meet and talk with
detained patients in private and also talk with staff and managers about how services
are provided. Since November 2008, Commissioners have also been meeting with
patients who are subject to Community Treatment Orders. As part of the routine visit
programme information is recorded relating to:
• Basic factual details for each ward visited, including function, bed occupancy,
staffing, and the age range, ethnicity and gender of detained patients.
• Ward environment and culture, including physical environment, rights to leave,
patient privacy and dignity, gender separation, choice/access to
services/therapies, communication facilities, physical health checks, food, and
staff/patient ratios, smoking facilities, staff patient engagement, diversity and
cultural sensitivity, cleanliness and upkeep of the ward, fresh air and exercise,
physical safety and environmental risks.
• Issues raised by patients and patient views of the service provided, from both
private conversations with detained patients and any other patient contacts
made during the course of the visit.
• Legal and other statutory matters, including assessing the providers
compliance with the Mental Health Act 1983 and the Code of Practice including
scrutinising the supporting documentation, records, policies and systems. The
Commissioner reviews the basis and evidence of detention, including
compliance with Sections 132, 132a (information to the detained patient about
their rights), Section 58 and 58A (consent to treatment), the provision of the
Independent Mental Health Advocacy (IMHA) service, the use of the Mental
Capacity Act Deprivation of Liberty safeguards, Section 17 and 17A (leave and
Community Treatment Orders) and reviews the evidence of the patient’s
participation in their treatment by reference to the Care Programme Approach
documentation. The patient’s access to physical care and treatment is also
assessed.
At the end of each visit a “feedback summary” is issued to the provider identifying
any areas requiring attention. The summary may also include observations about
service developments and / or good practice. Areas requiring attention are listed
and the provider is asked to respond stating what action has been taken. The
response is assessed and followed up if further information is required. The
information is used by the CQC to inform the process of registration and ongoing
compliance with the outcomes and essential standards of safety and quality in
accordance with the Health and Social Care Act 2008.