Agenda item 11 Enclosure Paper E. Mental Health Act Scrutiny Committee Annual Board Report. Yes

Transcription

1 Agenda item 11 Enclosure Paper E Report to: Trust Board 31 March 2014 Author: Richard Butt-Evans Presented by: Colin Merker, Director of Service Delivery SUBJECT: Mental Health Act Scrutiny Committee Annual Board Report Can this report be discussed at a public Board meeting? If not, explain why Yes This Report is provided for: Decision Endorsement Assurance To Note EXECUTIVE SUMMARY In line with the CQC s statutory duties, the Mental Health Act Commissioner has made a number of unannounced visits to the Trust s Inpatient Units and Community Services to meet with detained patients and review MHA Statutory Paperwork and Processes. The Lead MHA Commissioner for the Trust and the CQC Operations Manager (Mental Health) attended the MHA Scrutiny Committee meeting in May 2013 to comment on their visit reports and the Trust s responses. The Area manager commented that 2 gether was very good at ensuring smart and timely responses were returned to the CQC and the Commissioner expressed her thanks to staff noting that she was always made to feel welcomed when arriving to conduct a visit. The MHA Scrutiny Committee continues to monitor and request detailed action plans for those areas of the MHA Code of Practice, highlighted by either the MHA Commissioner or by internal audit, that remain a challenge for the Trust. Mental Health Act Commissioners visited Herefordshire during the year to carry out an Assessment and Application for Detention Review. The Trust was required to facilitate the visit - the commissioners met with representatives from Herefordshire Council, the police and ambulance service, the Mental Health Advocacy Service, Trust staff, patients and carers. A Non-Executive Deputy Chair has been appointed to the MHA Managers Forum as it is taking on a more formal role within the overall Trust committee and subcommittee structure. 1

2 The MHA Scrutiny Committee has reviewed and discussed the use of the Deprivation of Liberty Safeguards and reviewed the Mental Capacity Act key findings audit. The Mental Capacity Multi Agency Policy for Gloucestershire is currently being reviewed and will be presented to the MHA Scrutiny Committee once completed. RECOMMENDATIONS The Board is asked to receive this report which has been approved by the MHA Scrutiny Committee as part of their assurance around our appropriate management of the powers entrusted to us in the use of the Mental Health Act. Corporate Considerations Quality implications: Resource implications: Equalities implications: Risk implications: The Trust is required to be compliant with the MHA Code of Practice it is essential therefore that the Mental Health Scrutiny Committee is able to assure the Trust Board of the Trust s overall compliance with the Code of Practice. None Identified None Identified Covered by statement under Quality Implications. WHICH TRUST STRATEGIC OBJECTIVE(S) DOES THIS PAPER PROGRESS OR CHALLENGE? Continuously Improving Quality P Increasing Engagement P Ensuring Sustainability WHICH TRUST VALUE(S) DOES THIS PAPER PROGRESS OR CHALLENGE? Seeing from a service user perspective P Excelling and improving P Inclusive open and honest P Responsive P Can do P Valuing and respectful P Efficient P Reviewed by: Colin Merker, Director of Service Delivery Date January 2014 Where in the Trust has this been discussed before? Mental Health Scrutiny Committee Date January

3 What consultation has there been? Date Explanation of acronyms used: MHA Mental Health Act CQC Care Quality Commission KPI s Key Performance Indicators MCA Mental Capacity Act DoLS Deprivation of Liberty Safeguards CTO Community Treatment Order 1.0 CONTEXT 1.1 The purpose of the Mental Health Act Scrutiny Committee is to ensure on behalf of the Trust Board that the Trust establishes monitors and maintains appropriate integrated systems, processes and reporting arrangements to ensure it continues to operate with compliance of the Mental Health Act, Mental Capacity Act and Human Rights Acts and associated codes of practice. 1.2 The main duties of the MHA Scrutiny Committee as detailed within its terms of reference are as follows: To ensure that the Trust complies with the Mental Health and Human Rights Acts and any associated codes of practice in relation to patients detained under the MHA or subject to supervised community treatment. To ensure that the Trust complies with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS) requirements and monitor their interface with the Mental Health Act. To establish a performance and compliance framework and arrangements for the ongoing review and monitoring of statistical information on MHA activity. To ensure that all Trust staff acting on the Hospital Managers behalf under the Scheme of Delegation are competent to undertake their delegated tasks and that appropriate systems are in place and reviewed to monitor their performance. To ensure that appropriate arrangements are in place and are operating satisfactorily for the completion and review of relevant legal documentation relating to the compulsory admission and detention of patients and automatic referrals to the Mental Health Review Tribunal. To ensure that procedures are in place and operating satisfactorily to inform detained patients and their nearest relatives about the applicable provisions of the Mental Health Act and of their rights. 3

4 To review and ratify policies and procedures relating to the Mental Health Act and Mental Capacity Act. To consider and action as appropriate any matters referred from the Mental Health Act Managers Forum To review issues raised through Care Quality Commission visits and Annual Reports and to receive reports on any recommendations and action plans resulting from them. To review issues arising from Managers Hearings, ensuring that any lessons learned are identified and disseminated throughout the Trust To ensure that appropriate training programmes are in place for Trust staff and MHA Managers. To raise issues for action and review by the Executive Team. To produce an Annual Report for the Trust Board. 1.3 The MHA Scrutiny Committee s current Terms of Reference are being reviewed to ensure that they reflect all of the Committees responsibilities as delegated by the Trust Board. 2.0 REVIEW OF VISITS BY THE CQC MENTAL HEALTH ACT COMMISSIONER 2.1 Unannounced Visits the Commissioner visits the Trust s in-patient units to meet with and talk to detained patients and review the associated Mental Health Act paperwork and records on an annual basis. The process forms part of the Care Quality Commission monitoring system. During the course of 2103 the commissioner has visited: Oak House, Hereford Mortimer, Jenny Lind & Cantilupe Wards, Stonebow Unit, Hereford Laurel House, Gloucester Honeybourne, Cheltenham Willow Ward, Charlton Lane Hospital, Cheltenham Review of CTO s Gloucestershire and Herefordshire The subsequent Commissioner visit reports were responded to with appropriate action plans, approved by the MHA Lead Executive and subsequently presented to the MHA Scrutiny Committee or are currently in the process of being completed. 4

5 2.2 Announced Visits - In addition to the unannounced visits the Commissioner has made the following announced visits: Review of s17 paperwork for those patients on leave for in excess of seven days this was to ensure that the Trust was not using extended s17 inappropriately and that where appropriate patients were being transferred to CTO s in line with the MHA Code of Practice guidance. Seclusion Review of the Hollybrooke & Westridge Units Assessment and Application for Detention Review for Herefordshire it should be noted that this was a review of not only Trust procedures and policies but also those of our partner agencies within Herefordshire. e.g. Herefordshire Council, West Midlands Ambulance Trust and the Police Force. The Trust was expected to facilitate the visit as the commissioned providers for Mental Health Services within Herefordshire. The Trust provided detailed action plans to the CQC on receipt of the Commissioners reports which were approved by the Executive Lead and presented to the MHA Scrutiny Committee. 2.3 As has been reported in previous years, the CQC no longer issue Mental Health Trust s with annual overall assessments as a consequence the Trust invited the MHA Commissioner (Mary Nettle) and the CQC MHA Area Manager Phil Wales to attend the May MHA Scrutiny Committee. During the meeting the CQC Area Manager said that 2 gether was very good at ensuring smart and timely responses were returned to the CQC and the Commissioner expressed her thanks to staff noting that she was always made to feel welcomed when arriving to conduct a visit. 2.4 During the meeting Mary Nettle made specific comments regarding Capacity & Consent Care Planning S132 Understanding of Rights Renewal of S17 Leave The use of Community Treatment Orders (CTO s) The MHA Scrutiny Committee regularly receives reports and audit outcomes regarding these points as they had been previously identified by the Committee while reviewing the Trust s responses to the Commissioner s review visits. Action plans are in place with regard to these particular points to ensure compliance with the MHA Code of Practice. 5

6 3.0 KEY PERFORMANCE INDICATORS 3.1 The Head of Health Records has continued to develop the Key Performance Indicators (KPIs) report during the year. In response to the comments made during the MHA Commissioner s visits with regard to the use of extended s17 leave the KPI report has been extended to include a rolling comparison of the number of patients on extended s17 leave by time versus the number of patients on Community Treatment Orders. 3.2 The report now provides a normalisation of some of the KPI s against the respective populations we serve in Herefordshire and Gloucestershire to support a comparative analysis of performance between the two localities. 4.0 AUDITS 4.1 The MHA Scrutiny Committee has received audit outcomes in relation to - Paperwork with regard to Second Opinion Appointed Doctors (SOADs) Section 17 leave paperwork The recording of Patients Capacity to Consent The audits have been led and presented by the Medical Lead for the Mental Health Act for Gloucestershire. 4.2 To ensure that the Trust is compliant with the MHA Code of Practice with regard the Second Opinion Appointed Doctor (SOAD) visits all requests for a SOAD are completed using the CQC online process and a Pathway has been developed and circulated to all clinical teams which details the actions that have to be completed by the Secondary Consultees following the SOAD s visit. 4.3 An analysis of the use of extended S17 leave versus the use of Community Treatment Orders (CTO s) has been added to the KPI s to monitor the transfer of patients from s17 leave to Community Treatment Orders. The analysis has indicated that in the one or two instances where the use of extended s17 is preferred to CTO s there are robust, recorded and audited clinical reasons. 4.4 The results of the recent Patients Capacity to Consent recording audit indicates that this particular requirement remains a challenge the Medical Lead for the MHA is currently working with colleagues to ensure that compliance with this particular requirement improves. 6

7 5.0 MENTAL CAPACITY ACT & DEPRIVATION of LIBERTY SAFEGUARDS 5.1 The MHA Scrutiny Committee has reviewed and discussed the use of the Deprivation of Liberty Safeguards - this continues to be an ongoing area of debate for the MHA Scrutiny Committee particularly in relation to those patients with Learning Difficulties. 5.2 The Mental Capacity Act (MCA) Multi Agency Policy for Gloucestershire is currently out for review the MHA Scrutiny Committee will review the new policy when complete. Several members of the MHSA Scrutiny Committee in conjunction with the Trust s MCA professional leads are involved in the review. 5.3 The MHA Scrutiny Committee has recently reviewed the key findings from the joint Gloucestershire County Council and 2 gether Mental Capacity Act audit. The key findings from the audit will be incorporated into the revised MCA Multi Agency Policy for Gloucestershire. A further audit is scheduled for 2015 which will be presented to the MHA Scrutiny Committee. 6.0 ISSUES RAISED FOLLOWING MHA MANAGER REVIEW HEARINGS 6.1 The MHA Scrutiny Committee has reviewed a number of issues raised by the MHA Managers and approved the associated action plans - where the same issue has been raised on a number of occasions the MHA Scrutiny Committee has requested that appropriate procedural guidance be identified. 7.0 MENTAL HEALTH ACT MANAGERS 7.1 The MHA Managers Forum, which is chaired by Trust Non-Executive Director (Charlotte Hitchings), has met on a quarterly basis during the course of the year. As part of the meeting the MHA Managers have received the following training: Fire awareness Safeguarding Personal Safety Awareness (specifically with regard to when visiting wards). 7.2 At the suggestion of the Trust Chair a Non-Executive Director has been appointed as deputy chair to support the MHA Manager s Forum Chair as it was felt that the Forum should take on a more formal role within the Trust s committee structure. 7

8 7.3 The Chair and Deputy Chair (Charlotte Hitchings & Martin Freeman) of the MHA Managers Forum have carried out a number of Manager s Appraisals in line with the policy over the course of the year. 7.4 During the course of the year two MHA managers have either resigned for personal reasons, or as they have served the maximum number of years. One new MHA manager has been appointed and a second is currently awaiting final approval before taking up their role. 8.0 TRAINING 8.1 Members of the Committee are currently working with the Training Department to identify any additional training needs that are required to support those clinicians involved in the application of the MHA Code of Practice. 9.0 SCRUTINY COMMITTEE CHAIR 9.1 Due to the retirement of the MHA Scrutiny Committee s non-executive Chair (Roger Brimblecombe) the Trust Chair has recently appointed a new chair (Martin Freeman) to the MHA Scrutiny Committee CONCLUSION 10.1 The MHA Scrutiny Committee continues to take very seriously its delegated responsibilities by maintaining a very proactive approach to the manner in which it ensures the Trust s compliance with the MHA Code of Practice by Reviewing the MHA Commissioner s visit reports and the Trust s responses so ensuring that the responses are both robust and returned in a timely manner. Reviewing issues raised following MHA Manager Review Hearings Reviewing those Audits identified within the annual work plan. Reviewing a wide range of KPI s relating to the mental Health Act Code of Practice The MHA Scrutiny Committee continues to monitor and request detailed action plans for those areas of the MHA Code of Practice, highlighted by either the MHA Commissioner or by internal audit, that remain a challenge for the Trust. 8

9 10.3 The Trust continues to develop and build on its relationship with the CQC Mental Health Act department. The CQC MHA Area Manager advised the MHA Scrutiny Committee when he visited that the Trust was very good at ensuring smart and timely responses were returned to the CQC and the Commissioner expressed her thanks to staff noting that she was always made to feel welcomed when arriving to conduct a visit The MHA Scrutiny Committee maintains an overview of those areas where the Trust shares its responsibilities with other agencies the Mental Capacity Act and Deprivation of Liberty Safeguards for example The MHA Scrutiny Committee regularly reviews both its Terms of Reference and Annual Work Plan to ensure that it is receiving the appropriate level of assurances so enabling it to provide assurance to the Trust Board that it is fulfilling its delegated powers. 9