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Inspection report

Date of Inspection: 11 January 2011
Date of Publication: 9 February 2011
Inspection Report published 9 February 2011 PDF

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Before people are given any examination, care, treatment or support, they should be asked if they agree to it (outcome 2)

Not met this standard

We checked that people who use this service

  • Where they are able, give valid consent to the examination, care, treatment and support they receive.
  • Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed.
  • Can be confident that their human rights are respected and taken into account.

How this check was done

Our judgement

We found that the location is not meeting this outcome in full. We are concerned that there was no systematic and clear recording of assessments of a person’s capacity to make decisions for people who was either detained or informally admitted. We were concerned that medical staff did not always record explanations of the risks, benefits and alternative options of treatment in patient records.

User experience

The provider gave an example of how a person using the service had not agreed with taking prescribed medication and would not consent to receiving medical treatment in the community. The patient, advice and liaison service (PALS) liaised with the person’s doctor to arrange a meeting to ensure they had clear and relevant information. Once the person using the service was better informed, consent was given to care and treatment and they were able to be discharged into the community.

Though not relating directly to the consent process itself explanations about medications and involvements in decision making are key parts of the overall consent processes. In the mental health acute inpatient survey 2009 the trust was rated in the best performing 20% of NHS trusts nationally regarding two questions relating to the explanation of the purpose and possible side effects of medications. Also , in relation to the question ‘were you involved as you wanted to be in decisions about care and treatment’ the provider scored just below the threshold for the highest 20% of NHS trusts nationally.

As part of our site visit conducted 11 January 2011 we sought the views of patients who were admitted about this outcome in relation to side effects and benefits of medication, which is part of the consent to treatment processes for persons detained under the MHA. Of the seven patients we spoke to three did say that the doctor had explained the side effects of treatments.

Other evidence

The provider declared compliance with this outcome at this location at registration with CQC in April 2010. The current provider level QRP was not currently risk rated as it contained insufficient information. None of the external stakeholders referred to within outcome one who responded raised any areas of concern specifically relating to this location or outcome.

The last MHA Commissioner reports were obtained for Pinecroft ward (27/10/2009), Intensive Treatment Centre (27/10/2009), Maple ward and Rowan Ward (19/07/2010). Both the Maple and Rowan wards received positive commentary concerning statutory (MHA) documentation from the commissioner. However the commissioner feedback reports also found some areas where there was gaps in assurance. On Rowan ward found one patient without a valid consent to treatment form as required by the Mental Health Act. On Maple ward the commissioner was not able to find clear entries in patient notes in respect of discussions regarding capacity with their clinician. Action plans were included by the respective managers.

As part of the assessment of this location the provider submitted a provider compliance assessment for this outcome. We found the provider had a range of policies, procedures and guidance relating to consent to treatment. The consent policy and mental capacity act guidance set out the processes whereby staff members enable people who use services to make informed decisions. Where individuals lack capacity the provider has best interest guidance to inform staff on the most appropriate methods in supporting the person using the service. Informed decision making in relation to treatments are supported by a range of information leaflets relating to the treatment itself. The CPA process requires documentation that shows consent has been given by people who use services. The deprivation of liberty safeguards guidance complimented the Mental Capacity Act in its requirements for consent and is supported by a range of “useful and well used prompt cards” (provider compliance assessment outcome 2).

A specific section on consent and capacity for people aged 16 and 17 years was found in the policy Admission of 16 – 17 year old young people to an adult mental health ward. Guidance in relation to advance decisions/statements made using the provisions of the Mental Capacity Act 2005 was included in the CPA process. The Resuscitation policy was found to include procedure and form for do not resuscitate decisions.

We found that the provider had processes and measures in place to monitor the effectiveness of its various policies relating to consent. These measures were found to include groups such as the provider ‘consent and confidentiality group’, which had identified where improvements could be made in relation to the annual care records audit. The application of the Mental Health Act (MHA) requires staff to ensure recording of consent is documented and audited through a quarterly “MHA Audit” this was conducted through the “clinical effectiveness” department. The use of relevant forms of persons who are non-consenting are monitored by the ‘mental health act group’.

Clinical staff members were found to have access to traditional and electronic training in the implementation of the Mental Capacity Act which included guidance on consent. Through a completed training needs analysis the provider has piloted plans to widen training to include consent in the induction and mandatory training.

We found gaps in assurance that this location may not be fully meeting this outcome based on the findings of the MHA commissioner visits to Rowan and Maple wards which gave an assessment of a minor concern. As we had identified areas of concern in relation to outcome four that required a site visit to gain additional evidence we decided to include this outcome to review consent to treatment practices made via the Mental Health Act along with practices relating to assessing and recording a persons capacity t