Agenda item 12 Enclosure Paper F
Report to: gether NHS Foundation Trust Board
Author: Colin Merker – Acting Chief Operating Officer
Presented by: Colin Merker – Acting Chief Operating Officer
SUBJECT: Care Quality Commission Mental Health Act Commissioner
Visit Analysis for 2011
This Report is provided for:
Decision Endorsement Assurance Information
We have been informed that there will be no specific Mental Health Act annual statement
issued by the CQC for the visits made by the MHA Commissioner during 2011
Our CQC Mental Health Act Commissioner and Mental Health Act Commissioner
Operations Manager attended the January Mental Health Act Scrutiny Committee meeting.
In conjunction with the MHA Commissioner the MHA Scrutiny Committee reviewed the
Trust’s 2010 Action Plan and the Commissioner visit reports for 2011.
In the absence of a MHA Annual Statement for 2011 the Trust has identified an “actions
matrix” in line with the questions raised during the Commissioner’s visits.
It is recommended that the Board:
Notes the content of this paper and specifically the points regarding the Annual CQC
Statement for 2011.
Notes the Action Plan and the proposal and that it’s completion is monitored by the
MHA Scrutiny Committee.
Supports the proposal that the Trust assist’s the CQC in its “on line SOAD request”
Resource implications: Non identified
Equalities implications: Non identified
Risk implications: The Trust is required to ensure that it adheres to the MHA Code
of Practice with regard to detained patients.
WHICH TRUST KEY STRATEGIC OBJECTIVES DOES THIS PAPER PROGRESS OR
Quality and Safety P Skilled workforce P
Getting the basics right P Using better information
Social inclusion P Growth and financial efficiency
Seeking involvement Legislation and governance P
WHICH TRUST VALUES DOES THIS PAPER PROGRESS OR CHALLENGE?
Seeing from a service user perspective
Excelling and improving P Inclusive open and honest
Responsive Can do
Valuing and respectful P Efficient
Acting Chief Operating Officer – Colin Merker Date 20 February 2012
Where in the Trust has this been discussed before?
Mental Health Act Scrutiny Committee Date January 2012
What consultation has there been?
Explanation of acronyms CQC – Care Quality Commission
used: IMHA – Independent Mental Health Advocacy
MHA – Mental Health Act
SOAD – Second Opinion Appointed Doctor
1.1 In previous years it has been the practice of the CQC Mental Health Act Commissioner
to submit to the Trust an annual statement which reflected the findings of the visits
which they had made to the organisations inpatient units during the course of the year.
The Trust has then been required to submit to the CQC an appropriate action plan
covering any points specifically identified by the Commissioner as needing action.
The last annual report that the Trust received covered the CQC visits made during
1.2 The Commissioner and colleagues from the CQC attended the February 2011 Board to
present their 2010 Annual Statement and to discuss the Trust’s response to the report.
1.3 In November 2011 the Chief Executive received a letter from the CQC Chief Executive
advising that that they would not be compiling retrospective Annual Statements
regarding the Commissioners visits. The letter advised that the CQC would now be
including broad conclusions from the visits on their website as part of the information
published about the provider.
1.4 In line with the Mental Health Act the CQC did report to parliament on their work in
monitoring the use of the act in England. It subsequently published an overview of the
findings and recommendations based on the findings of the visits to services made by
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Commissioners and Second opinion appointed doctors (SOADs). A copy of this is
included at Appendix One for reference.
1.5 Our CQC MHA Commissioner and the Mental Health Act Commissioner Operations
Manager requested to attend the January 2012 MHA Scrutiny Committee to receive an
update of the Trust’s Action Plan as a result of the 2010 Annual Statement and to
discuss issues arising from the feedback reports following visits made during the year
2. REVIEW OF 2010 ANNUAL STATEMENT ACTION PLAN
2.1 The Committee and the Commissioner reviewed the Trust’s 2010 Action Plan – a copy
is included at Appendix Two for reference. They noted that a significant amount of work
had been completed during 2010 ahead of the statement ensuring that the
recommendations associated with Section 17 leave, consent to treatment and the
IMHA service had been completed.
2.2 A member of the Service Experience department commented during the discussion
that, as a consequence of the changes introduced in line with the Project Improvement
Plan highlighted in the Action Plan, the Trust was better able to understand the nature
of complaints as the process was now managed by clinicians. As clinicians the Service
Experience team were then able to ensure that the lessons learnt were embedded
within the Trust’s policies and procedures.
3. REVIEW OF VISIT FEEDBACK RESPONSES FOR 2011
3.1 A review of the 2011 visit responses had been completed and had been categorised
under the following headings:
Independent Mental Health Advocacy
S132 Understanding of rights
Consent to Treatment
3.2 The CQC Commissioner commented that whilst our responses always answered the
question asked in terms of our policies and scrutiny of the issue, she would like to see
more information as to how any specific patient issue had been resolved from the
4. ACTION PLAN
4.1 As the CQC will not be issuing an Annual Statement for 2011 it is proposed that the
Trust reviews, as a whole, the general themes raised by the questions identified.
4.2 Appendix three details an actions matrix relating to the points detailed in 3.1 which
represent the general themes from the questions asked by the CQC Commissioner
following their visits.
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5. SECOND OPINION APPOINTED DOCTOR (SOAD) REQUEST PILOT
5.1 The Mental Health Act Commissioner Operations Manager (Phil Wales) outlined a new
“on line” SOAD request process that the CQC were about to pilot and asked if the Trust
would be prepared to be involved. The CQC stated that they believed that the new
process would result in a more efficient system that would both assist Trusts and better
5.2 The Scrutiny Committee supported the request and agreed that the Operations
Manager would contact the Head of Health Records to finalise arrangements.
6.1 The Mental Health Act Commissioner reported that she was “comfortable” with the
actions that the Trust were taking to ensure compliance with the Code of Practice and
wished to thank the staff for facilitating her visits.
6.2 It is proposed to establish an “action plan” to address the points raised by the
Commissioner during her visits.
6.3 The plan will be monitored by the MHA Scrutiny Committee.
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