• Organisation
  • SERVICE PROVIDER

Bradford District Care NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

22-23 June 2022

During an inspection of Community health services for children, young people and families

We carried out this unannounced inspection of the community health service for children, young people and families, provided by this trust as we had concerns about the quality of the service provided.

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not have enough staff, there were several unfilled vacancies and staff were holding caseloads much larger than recommended by national guidance. Staff sickness and turnover levels were high.
  • The service was unable to meet mandated contacts for children and young people. Aspects of the service were in business continuity which meant that not all services were being provided. There were waiting lists in place in the looked after children’s team which meant that children waited for individual health assessments longer than they should, and this was not in line with national guidance.
  • We reviewed 29 records during the inspection. Whilst the majority of records were detailed and consistent, we had concerns that five of the records did not meet the trust's standard in evidencing what action had been taken to address concerns in relation to risks such as domestic violence or mental health concerns. Managers were aware that this was an area of improvement for the service and were undertaking a records audit at the time of the inspection.
  • The service worked on a risk-based approach whereby children were placed into four tiers dependent on need. We were concerned that in some cases late identification of health conditions and disabilities could occur for those children in lower tiers of need due to lower levels of oversight for these families.

However:

  • Staff teams worked collaboratively and were encouraged to share ideas and give feedback on service development. Staff supported people to live healthier lives and thought of different ways to engage harder to reach service users.
  • Staff treated children, young people and their families with compassion and kindness. Staff were passionate about the roles they performed and wanted to provide high quality care. Service users were encouraged to give feedback, which was largely positive. Staff recognised the importance of mental and emotional health as well as physical health and offered appropriate support and information to families.
  • The service was beginning to consider and introduce some innovative ways of working to meet the needs of the local population.
  • Leaders at all levels of the service were knowledgeable and passionate and sought to drive improvement. Strategies and development plans reflected the needs and challenges of the service and there were clear action plans in place detailing how improvement would be made. Staff were satisfied with their roles in the service and felt valued and supported.

How we carried out the inspection

During the inspection visit, the inspection team:

• visited six locations

• carried out six home visits and one school visit

• spoke with the general manager and assistant general manager for the service

• spoke with 55 other members of staff including, service managers, school nurses, health visitors, staff nurses and nursery nurses

• spoke with nine service users including one young person

• observed the running of one baby clinic and one immunisation session

• looked at 29 care and treatment records of service users

•looked at a range of policies, procedures and other documents relating to the running of the service.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

During the inspection we spoke with nine service users, including one young person. We also observed interactions between staff, young people and their families during 10 appointments including at an immunisation clinic, school nurse clinic, baby clinics and home visits.

Service users told us that staff were friendly, helpful and approachable and would always give advice and respond to queries. They also told us staff were accommodating at rearranging appointments to support service users. We observed staff providing reassurance and support to those with concerns or worries. The majority of those using the service told us that staff were helpful, approachable and available to give advice and support. Staff took time to explain about the service and ensure service users knew what support was available to them. Service users were regularly requested to give feedback about the service to aid improvement, but staff were clear that they needed to do more to gain feedback from children and young people.

10 December 2020 - 11 December 2020

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

Bradford District Care NHS Foundation Trust provides five inpatient wards for adults of a working age and one psychiatric intensive care unit. Services are provided from wards located at two sites; the Airedale Centre for Mental Health and Lynfield Mount Hospital.

The trust is registered to provide two regulated activities in relation to this core service:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983
  • Treatment of disease, disorder of injury.

We carried out this unannounced focused inspection because we were made aware of some serious incidents which had taken place on the wards, and this gave us concerns about the safety and quality of the services provided. We also followed up on the provider’s progress with areas of improvements we identified during our last inspection of the service in March 2020.

This inspection was a focused inspection. We reviewed the safe key question and specific key lines of enquiry within the effective, caring and well-led domains.

As part of our inspection we visited four mental health wards for adults of a working age. The wards we visited were:

  • Ashbrook ward – a 25 bed female acute ward with a one bed child and adolescent mental health service annex, located at Lynfield Mount hospital
  • Maplebeck ward – a 21 bed male acute ward located at Lynfield Mount hospital
  • Fern ward – a 15 bed male acute ward located at the Airedale Centre for Mental Health
  • Oakburn ward – a 21 bed male acute ward with a one bed child and adolescent mental health service annex, located at Lynfield Mount hospital

We did not rate the service at this inspection. The previous rating of good remains. We found:

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They involved patients and families and carers in care decisions.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

  • Staff on Fern ward did not always complete regular daily environmental reviews of the ward. On Fern ward the ward manager's office space was located within the clinic room.
  • Staff compliance with some mandatory training courses on Oakburn ward (management of violence and aggression) and Ashbrook and Maplebeck wards (immediate life support) was below 75%. This was due to an initial pause on training delivery until Covid19 safe lesson plans and environments were identified in line with Government guidance. At the time of our inspection face to face training had resumed with restricted numbers. A prioritisation process to target staff for training was in place.
  • Care plans were not always personalised. The recording of discharge planning was inconsistent. Patients and carers we spoke with were not all aware of independent mental health advocacy services.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

During the inspection we visited four wards, looked at the quality of the environment and observed how staff were caring for patients. We spoke to the ward managers of the four wards we visited, and 16 other staff members including registered nurses, healthcare assistants, doctors, psychologists and occupational therapists. We spoke to eight patients using the service and to nine carers and family members of patients using the service. We reviewed 17 care records including observation and seclusion records and 40 medication charts. We attended four clinical meetings and reviewed a range of policies and procedures relating to the running of the service.

What people who use the service say

We received mostly positive feedback from patients using the service. Patients told us they felt safe in the service. Patients described staff as supportive and caring. Patients generally felt involved in their care and decisions around their care and treatment.

10 to 12 March 2020

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

Our overall rating of this service improved. We rated it as good because:

  • The service provided safe care. The trust had taken significant action to improve the safety on the wards. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers supported staff with appraisals and opportunities to update and further develop their skills. Eighty seven per cent of staff within the service had received regular supervision at the time of our inspection. However, on Fern ward this was lower with 59% of staff receiving regular supervision. The ward staff worked well together as a multidisciplinary team and with those outside the ward.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They involved patients, families and carers in care decisions.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
  • The service was well led, and the governance processes ensured that ward procedures ran smoothly.

10-12 September 2019

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We did not re-rate the service following this inspection:

  • Whilst there had been significant improvements in ensuring that patients were safe, systems and processes were still embedding and there remained some areas of concern including staff not always completing environmental checks, ligature risk assessments not always identifying all the ligature risks or being updated, risk management plans were not always personalised or specific to the risks identified in the risk assessment, controlled drugs were not always managed appropriately, and patient leave documentation and the allocation of a risk rating for incidents was not always completed in line with the trust’s policies.

However:

  • The safety of the service had improved.
  • Wards were safer, clean, well equipped, well furnished, mostly well-maintained and fit for purpose.
  • Most staff had completed and kept up to date with their mandatory training, which was comprehensive and met the needs of patients and staff.
  • Staff assessed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour.
  • Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.
  • The governance framework and processes had improved and ensured that ward procedures ran more smoothly and ensured that senior leaders within the service had better oversight.
  • Staff spoke of a change in the culture of the organisation and that there was a collective responsibility. Senior leaders within the organisation were accessible and managers and staff felt supported.
  • Most patients reported they had a positive experience and that most staff were nice. They told us staff kept them safe and they rarely used physical restraint.

28 Feb to 10 Apr 2019

During a routine inspection

Our rating of the trust stayed the same. We rated it as requires improvement because:

  • We rated the trust as requires improvement overall in safe, effective and well led. We rated caring and responsive as good. Our rating for the trust took into account the current ratings of the services not inspected this time.
  • We rated well-led for the trust overall as requires improvement.
  • Of the 14 core services, one is rated as inadequate and five as requires improvement, taking into account the current ratings of the services not inspected at this time. Of the eight core services inspected during this most recent inspection, one was rated as inadequate and three were rated as requires improvement.
  • Overall ratings went down for the acute inpatient mental health services for adults of working age and the psychiatric intensive care unit to inadequate, and for the community health services for children and young people to requires improvement. The forensic low secure services were rated as requires improvement. The rating stayed requires improvement for the wards for older people with a mental health problem.
  • Due to the concerns we found during our inspection of the trust’s acute inpatient mental health wards for adults of working age and psychiatric intensive care unit, we used our powers to take immediate enforcement action. We issued the trust with a Section 29A warning notice. This advised the trust that our findings indicated a need for significant improvement in the quality of healthcare. We will revisit these services to check that appropriate action has been taken and that quality of care has improved. However, by the time of the well-led review the trust had already taken significant action to address the issues identified in the warning notice.
  • The trust was not providing consistently safe care, particularly on the inpatient mental health wards. Issues identified included ligature and environmental risks not being identified and managed, the maintenance of premises and equipment, medicines management, blanket restrictions that were not individually risk assessed, no alarms for patients to call staff in an emergency.
  • The trust did not have effective systems in place to investigate incidents within appropriate timescales to identify learning from incidents and make improvements.
  • The trust was not consistently providing effective care. The trust had failed to address concerns identified in the 2017 inspection in relation to staff supervision and audit of the Mental Capacity Act. Staff understanding and adherence to the Act was inconsistent.
  • The arrangements for governance and performance management did not always operate effectively. Whilst there had been a recent review of governance arrangements the plans to change these were in the early stages and were not embedded at the time of the inspection.
  • The trust did not always deal with risk issues and poor performance appropriately. Senior leaders were not aware of all the concerns found during the inspection. Areas for improvement identified at the last inspection in 2017 had not been addressed at the time of this inspection.

However:

  • We rated community health services as outstanding overall for caring. We rated community end of life care services as outstanding overall. Three of the six mental health core services we inspected were rated as good. There were improvements in the overall ratings for the trust’s wards for people with a learning disability or autism and mental health crisis services and health-based places of safety. The community mental health services for older people with a mental health problem were also rated as good.
  • Two of the trust’s services were rated as outstanding for caring, and 11 were rated as good. (This took into account the current ratings of the six services not inspected this time.)
  • Staff interactions with patients we observed were kind, respectful and compassionate. Feedback from patients and those close to them was continually positive in almost all the services we inspected about the care provided. Feedback from patient and carer surveys was positive.
  • Staff found innovative ways to enable people to manage their own health and care, particularly in those services rated as outstanding.
  • Most of the trust’s core services were providing care in a way that was responsive to patients’ individual needs. The community end of life care services were rated as outstanding in the responsive key question.
  • The directors of the trust had completed all the checks needed to work at that level. They all had disclosure and barring service certificates and met the fit and proper person requirements.
  • The trust had implemented a new vision and strategy and had plans to improve services. Staff knew and understood the provider’s vision and values.
  • The trust actively engaged in collaborative work with regional and place-based external partners to agree joint health and care priorities to support the delivery of high-quality, sustainable care and treatment, and to meet the needs of the local population.

October 4th - November 8th

During a routine inspection

Our rating of the trust went down. We rated it as requires improvement because:

  • We rated six of the 14 core services provided by the trust as requires improvement overall. This takes account of the ratings of core services that we did not inspect this time.
  • We rated safe, eff ective and well-led as requires improvement for the trust overall. Our rating for the trust took into account the current ratings of services not inspected this time.
  • We rated well-led at the trust level as requires improvement. The trust’s senior leadership team did not have eff ective oversight of staff training, staff supervision and of restrictive interventions in inpatient services. The trust had not ensured that all staff had checks with the disclosure and barring service in line with trust policy. The trust had not ensured that documentation was maintained in line with the fit and proper persons requirements. There was an inconsistent approach to audits in relation to the use of the Mental Health Act and Mental Capacity Act. The trust had not updated all active policies to reflect the changes to the Mental Health Act Code of Practice in 2015. The trust had not ensured that all serious incidents were reviewed in line with the requirements of the duty of candour and that serious incidents were investigated appropriately and eff ectively.
  • Services were not consistently managing risks safely. Risk assessments were not always completed or reviewed regularly. Staff were not consistently trained in line with the trust’s requirements. Services had high sickness, vacancy and turnover rates and some relied on agency and bank staff to maintain safe staff ing levels. Staff were not consistently recognising and reporting safeguarding concerns to external agencies. Staff had a mixed understanding of the duty of candour.
  • Services were not consistently providing eff ective care. Care records in some services contained information that was incomplete or had not been reviewed for some time. Not all care plans were holistic and centred on the individual needs of the patient. Not all staff were regularly receiving supervision in line with the trust policy. Staff had a mixed understanding of the Mental Health Act and Mental Capacity Act.

However:

  • The staff showed a caring attitude to those who used the trust services. Feedback from people using services and their relatives and carers was highly positive. Staff in all services were kind, compassionate, respectful and supportive. People who used services were appropriately involved in making decisions about their care.
  • The trust had ensured that services were responsive to meet the needs of people. Services were planned so that local people could access services when they needed them. There was a systematic approach to managing access to services which was based on individual needs. The trust had ensured there was a clear pathway so that people were transferred appropriately between services.

11, 12 and 13 January 2016

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We found that the trust had implemented systems to ensure that on each of the acute wards, consultants had dedicated weekly time slots for when they were available to attend the wards. In addition to this, the acute wards each had dedicated junior doctors and advanced nurse practitioners who were available around these times to assist with all aspects of patient care.

The trust had reduced its use of out of area beds over the last 12 months to zero. This meant patients received the care they needed nearer to their home.

The wards worked towards discharge from the point of admission. The wards had dashboards in place, which allowed them to monitor patient’s progress on a daily basis.

Staff told us comprehensive discharge planning was carried out which included home visits. Care records we reviewed confirmed this.

Ward managers told us patients were discharged from the ward during the daytime only.

17 to 19 June, 1 July and 3 July 2014

During a routine inspection

We found that the trust was providing a good service to the population that it served. Within all the core services inspected we saw evidence of good practice. This was being delivered by caring and professional staff who were working collaboratively.

We saw that the trust was not always providing a safe service for people across some of the services it provided. This included the children and adolescent mental health service, the long stay/forensic/secure mental health service and the health based place of safety. We identified robust systems in place for managing risks within the trust. Clear protocols were established for the identification and investigation of safeguarding concerns. Staff were aware of their role in proactively identifying and reporting risks. However within the children’s and young people’s community service, staff we spoke with were concerned about the low number of new referrals accepted by the local authority, which they felt placed them at risk. The trust told us they will undertake a review of these concerns and talk with the local authority. We also found that in the children and adolescent mental health service and the long stay/forensic/secure services that risks were not always fully assessed or reviewed by staff. We have issued a compliance action in relation to the health based place of safety due to issues with ligature risks and received assurances that these risks would be addressed.  We did not find wider organisational or systemic concerns about safety.

Overall, trust staff adhered to the requirements of the Mental Capacity Act 2005 to assess capacity to consent and work within best interest considerations where people lacked capacity; but in community health and learning disabilities services this could not always be evidenced.  We visited most of the wards at each location where detained patients were being treated. In the majority of the care records we reviewed, which related to the detention, care and treatment of detained patients, the principles of the Mental Health Act (MHA) and the MHA Code of practice had been followed and adhered to. 

We saw that the trust was providing evidence based treatments in line with best practice guidance. We saw that people were being supported to make choices and gave informed consent where possible. Evidence was seen of effective outcome measures being used throughout the trust in most of the services. The exceptions were within learning disability services where outcomes were unclear and assessments of capacity were not detailed and community health services where we found similar issues regarding capacity assessments and supervision of staff was not always occurring.  The trust employed appropriately qualified and trained staff throughout their services. There were good systems to ensure adherence with the Mental Health Act 1983 when people were compulsorily detained. 

We saw that overall the trust was providing a caring service for people across all core locations. Throughout the inspection we saw examples of staff treating people with kindness, dignity and compassion. The feedback received from people who used services and their visitors was generally positive about their experiences of the care and treatment provided by the trust.

We saw that the trust was not always responsive to people’s needs across some of the services it provided but this appeared to be a transient problem due to the development of administrative hubs. Throughout the inspection we noted that the trust had organised services so that they met the needs of the local population based on the resources it had. We saw outstanding care for people receiving end of life care.  Patients were highly complementary of the service and confirmed they had received a coordinated and seamless service with 24 hour access to ‘The Gold Line’ service. We found that mostly people’s individual needs and wishes were met when the trust assessed, planned and delivered care and treatment to people.  However recent changes to services including integrated care, single point of access and a move to administrative hubs meant that people had experienced (and still had to experience) longer than necessary delays in getting the care and treatment they required, particularly on the acute mental health wards and in community health services. Service users reported difficulty accessing crisis mental health services at night.  The crisis team offered only telephone contact at night.  Those who needed immediate assessment were directed to the emergency department at Bradford Royal Infirmary and Airedale General Hospital; where they might have to wait a long time to be assessed by the liaison psychiatry team because these services were not commissioned on a 24 hour basis.

We saw that overall the trust was well led with proactive and responsive trust wide leadership. There was a clear governance arrangements in place that supported the safe delivery of the service and to monitor and improve trust performance. Lines of communication from the board and senior managers to frontline services were mostly effective. Staff felt engaged with the trust and were well supported by local managers. We saw some recent good examples  where board members spent time within services to understand the challenges faced and were actively engaging with front line staff including clinical buddying, walk abouts by the non executive directors and the culture conversations initiated recently by the chief executive officer. Staff felt well supported by their immediate line managers. However the organisations vision and values were not fully embedded across all community health teams.  The recent scale and pace of change within the organisation was continuing to cause difficulties for the front line community mental health team staff. There had not been the appropriate level of engagement from leaders to ensure that this change was managed well.   The scale and pace of change had also caused difficulties for service users in terms of accessing services and communicating with people within teams.  We saw that there had been some recent improvements and a commitment to make these changes work including increasing trust board oversight and ownership of these issues.

17 to 19 June 2014

During an inspection of Adult community-based services

Bradford District Care Trust provides a range of adult community-based mental health services, including the assertive outreach team, community mental health teams and the early intervention service.

Adult community-based services were safe. Staff received appropriate training and they understood safeguarding procedures. Risk was managed effectively and communicated promptly on a daily basis. Although the number of community caseloads had increased overall, good line management and effective caseload management systems meant that they were well managed.

People’s care and treatment was planned and delivered effectively. Care was recovery-focused and people were supported to achieve positive outcomes. Assessments of people’s needs were thorough, and person-centred care plans were developed in partnership with people who used the service. Staff were supported well by their team managers and there was a good mix of professional backgrounds and skills in the teams. Multidisciplinary working was embedded across community services and information about people was shared appropriately. Staff received regular training and supervision.

Staff delivered care and support with kindness and compassion, and treated people with dignity and respect. People felt listened to and involved in decisions about their care, and their cultural needs were included in their care plans. People were also able to influence how the service was managed and developed.

Adult community-based services were responsive. The trust’s follow-up of people after discharge had improved since last year, and people were being provided with the right care at the right time. In addition, we did not find any issues with appointments or waiting times. Services were planned and delivered in a way that took account of the different needs of local communities. The relevant community teams were involved before people were admitted to hospital, during their stay in hospital, and in planning and supporting their discharge back into the community. We also saw evidence of trust-wide learning from complaints and incidents, for example through updates from team managers and trust-wide emails. This information was also included and discussed at monthly team meetings.

We found that teams were well-led by their team managers and that staff were aware of the trust’s vision and strategy.  We found evidence of responsible governance, and that the trust had an oversight of key risk areas, as identified on their risk register.

17-19 June 2014

During an inspection of Community health services for adults

Bradford District Care Trust provides a range of community health services for adults with long-term conditions. These include district nurses, community matrons and community clinics, such as podiatry, speech and language therapy, leg ulcer clinics and continence clinics.

Overall, patients received safe care across all services and teams. Patients and relatives told us that they were treated in a caring and friendly way and were kept informed. In general, we found that there were enough staff for the service to be safe. While there were vacancies in some community teams, the number of staff on duty was monitored to make sure that the service was flexible and met patients’ needs. Recruitment for staff vacancies was on-going. The senior managers and district nurses we spoke with confirmed that they met regularly to discuss the number of staff and what support was required across the different teams.

Arrangements were in place to manage and monitor infection control, medicines and the safeguarding of people from abuse. There were also dedicated teams to make sure that policies and procedures were implemented. For example, the safeguarding lead told us that the safeguarding team undertook record keeping audits to check that policies and procedures and were complied with. In addition, there were measures in place to minimise risks to patients, for example pressure ulcers. These measures included using the NHS safety thermometer tool to monitor and analyse patient data on harm-free care.

Staff knew how to report incidents, near misses and accidents, and were encouraged to do so. However, we found that learning from incidents, and the sharing of learning within teams and across the organisation, was inconsistent.

Services were effective, evidence-based and focused on patients’ needs. There were also examples of staff working well together.

We saw some excellent practice from the district nurse team and in the clinics we visited, where staff provided compassionate and individualised care that promoted independence. Staff were aware of the emotional aspects of caring for people living with long-term health problems, and made sure that specialist support was provided where needed. The patients we spoke with were positive about the services and said that the care they had received was good and met their needs. Patients also told us that staff involved them in decisions about their care and treatment.

The majority of staff were up-to-date with mandatory training and there were systems in place to make sure that they received appraisals. However, we found that the clinical and reflective supervision of staff varied across the community nursing teams.

Patients, their carers and/or families were encouraged to provide feedback about their care and treatment, and we saw examples where feedback had been used to develop the service. There were also complaints procedures available and complaints were handled effectively. Staff across the services told us that they offered patients choices about where they wanted to be treated, and there were, for example, community clinics for wound management.

Managers and staff understood the roles and responsibilities of governance and quality performance. While most staff were aware of the trust’s vision and strategy, this was not embedded across the service. In addition, some staff were unaware of the issues about quality that were affecting their service.

There was a positive culture, where staff were encouraged to raise problems and concerns without fear of being discriminated against. However, some staff told us they did not always get feedback about the problem or concern they had raised.

Community team managers provided good leadership and support, and most staff felt engaged with their line managers. However, some staff told us that they felt disconnected from the trust’s board, although they did acknowledge that this had improved recently.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

Other types of report

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.