The Care Quality Commission
  • Mental Health
  • Independent mental health service

Archived: Huntercombe Hospital - Maidenhead

Overall: Inadequate read more about inspection ratings

Huntercombe Lane South, Taplow, Maidenhead, Berkshire, SL6 0PQ (01628) 667881

Provided and run by:
Huntercombe (No 12) Limited

Important: The provider of this service changed. See new profile
Important: We are carrying out a review of quality at Huntercombe Hospital - Maidenhead. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

19/11/2020, 03/12/2020

During an inspection looking at part of the service

Huntercombe Hospital - Maidenhead provides specialist child and adolescent mental health inpatient service (CAMHS), including psychiatric intensive care for young people.

Following this inspection, we served the provider with a letter of intent under Section 31 of the Health and Social Care Act 2008, to warn them of possible urgent enforcement action. We told the provider that we were considering whether to use our powers to urgently suspend, impose variation or remove their registration. The effect of using Section 31 powers is serious and immediate. The provider was told to submit an action plan within 5 days to address concerns about poor care and treatment on two of the wards.

We also issued a Warning Notice under Section 29 of the Health and Social Care Act 2008, telling the provider they must ensure that a Positive Behaviour Support (PBS) approach is embedded across the hospital, to enable an effective response to young people whose behaviour poses a challenge and risk to themselves, others and service, and that this must be achieved by 31 January 2020.

We have rated the service as inadequate overall and placed it in special measures. This means that the provider must make the required improvements otherwise we will take further enforcement action. The service will be subject to close scrutiny and monitoring.

Our rating of this service went down. We rated it as inadequate because:

  • On two of the three wards we inspected (Severn and Thames), young people did not receive safe care that met their individual needs. We found young people did not receive person centred care. We found minimal evidence of clinical formulations being made, despite some young people experiencing long and highly restrictive admissions. Staff did not appear to be using a Positive Behaviour Support (‘PBS’) informed approach, despite us telling the provider it must use these at the previous inspection in 2019. PBS is an evidence based and person-centred approach to supporting patients who behave in ways which pose risk and challenges to themselves and others.
  • On Severn and Thames wards, staff did not follow safe systems and processes to prescribe, administer, record and store medicines. Prescribing was not always in line with national guidance. Staff did not record the reasons why some medicines were prescribed for some young people outside of licensed or best practice guidance, and the hospital lacked the required peer review process to review these prescribing practices. Young people did not have personalised care plans to support them or staff to manage agitation or distress without the use of medicines. Staff appeared to use medicines to manage young people’s agitation and distress, without ensuring that less restrictive and more therapeutic options were consistently provided. We observed several young people on Seven and Thames ward that appeared over sedated due to effects of prescribed medication.
  • Staff did not robustly assess young people’s mental capacity or Gillick competency which is the legal framework used to decide whether a child, under 16 years of age, is able to consent to their own treatment. We were unable to find evidence that staff routinely reviewed consent during a young person’s admission. We found incomplete or contradictory Mental Health Act 1983 consent to treatment paperwork. We found incidents where staff had administered medicines without young people’s consent or legal authorisation in place. We found young people were not regularly referred to the second opinion appointed doctor (SOAD) service, who safeguard the rights of patients detained under the Mental Health Act who either refuse the treatment prescribed to them or are deemed incapable of consenting.
  • Staff did not effectively monitor young people’s physical health. Staff did not consistently follow the providers policy, or best practice guidance, when monitoring young people’s physical health following giving rapid tranquilisation. paediatric early warning (PEWS) charts used by staff to assess and monitor young people’s physical health had been introduced but had not been used correctly. At the last inspection we told the hospital it must use nationally recognised early warning assessment and monitoring methods (e.g. PEWs) for all young people. Staff reviewed the effects of regular medications on each patient’s physical health but did not always record the effects of rapid tranquilisation for a minimum of two hours as required by national guidance and service policy.
  • On Thames and Seven ward young people and their families were not involved in care planning or risk assessment. Care plans lacked personalisation. Young people did not have copies of their care plans. Parents told us they felt their knowledge of their child’s needs and risks, and their views, were ignored by staff. Parents told us they felt concerned this had led to less effective and potentially harmful care being provided to their child.
  • Risk assessments were not up to date or sufficiently detailed. Patients did not have risk management plans. On Thames and Seven ward records showed staff relied on restrictive interventions such as sedating medications, increased nursing observations, and restricted access to items within the ward environment, without evidence of considering person-centred or less restrictive alternatives.
  • Although a new senior team had been appointed, governance processes had not been operating effectively, which prevented the issues we found in care and treatment from been identified or addressed by the provider organisation. Issues of concern raised at the previous inspection, that we told the provider they must address, had not improved. The hospital lacked robust governance and assurances processes to ensure risk assessments, risk management plans and care plans were consistently completed, sufficiently detailed, and were regularly updated and reviewed across the wards. Issues with the safe storage and management of medication in clinic rooms on the PICU wards had not been identified by the hospital governance systems.
  • There was a lack of robust oversight and assurance by Huntercombe senior leaders. Therefore, they had not picked up poor care at the hospital and acted to make improvements in a timely manner.

However:

  • The provider had recently recruited a new Hospital Director, Head of Nursing, Head of Quality and Quality Manager. The new managers had the skills, knowledge and experience needed to perform their roles, and had identified the need for improvements at ward level. In response to the concerns which were identified during this inspection, the new management team developed a comprehensive action plan with clear timescales to address our concerns about patient safety and wellbeing.
  • The new managers showed a good understanding of the service they managed and were visible in the service and approachable for patients and staff.
  • While a significant number of the registered nursing staff were from agencies, all agency staff received the same induction, training and supervision as permanent employees, and most were on long term agreements.

11-13 June 2019

During a routine inspection

We rated Huntercombe Hospital Maidenhead as Good because:

  • The wards had enough nurses and doctors. Staff assessed and managed risk well, followed good practice with respect to safeguarding, and had a dedicated social work team with a named social worker for each ward.
  • The provider had made substantial progress in the reduction of restrictive practices and blanket restrictions across the hospital.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the young people 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 young people on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
  • Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of young people. They actively involved young people and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised well with services that could provide aftercare, and while delayed discharges did occur due to the lack of available specialist placements, the provider worked closely with commissioners and other providers to seek suitable alternatives.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly. The provider was engaged in a number of initiatives to improve staff wellbeing and morale, and invested well in training and career development.
  • Young people and their carers gave mostly positive feedback about the relationships they had with staff and the impact of their treatment on their lives.

However:

  • Physical health was inconsistently monitored using the paediatric early warning system (PEWS) which meant there was a risk that a young person’s deteriorating health might not be identified early enough.
  • The service was not applying a positive behaviour approach to the management of behaviour that challenged, as staff who had been previously trained had left the organisation. Staff training levels in positive behaviour support were below target at 57%.
  • At the time of our inspection, only 67% of staff had received mandatory training in the Mental Health Act. This had increased to 73% for all staff within two weeks of the visit, which was still below the target of 75%.

7-22 September 2017

During a routine inspection

We did not rate the Huntercombe Group following the well-led review as we only rate individual services for independent providers.

We found the following issues that the service provider needs to improve:

  • The Huntercombe Group had been unable to recruit and retain a sufficient number of nurses with experience in CAMHS across the five services that were open at the time of our inspection. This resulted in services relying heavily on temporary staff to cover shifts. We concluded that this shortage of experienced nursing staff was one of the factors that impacted adversely on the safety of these services. Although the provider had made efforts to recruit, across the five services that were open at the time of the inspection, there were a total of 44 whole time equivalent (WTE) vacancies for registered nurses out of a total required workforce of 109 WTE - a vacancy rate of 40%. Meadow Lodge had the highest vacancy rate (50%); followed by Stafford (48%). The lowest vacancy rate for registered nurses in any of the five services was at Cotswold Spa (29%). These figures did not include long-term contracted nurses and block booked agency staff filling substantive roles as a means to mitigate against high vacancies.
  • The Huntercombe Group had not put in place a programme of specialist training of its workforce to mitigate the low numbers of experienced staff.
  • Although the Huntercombe Group had investigated and identified lessons to learn from the serious problems identified at Huntercombe Hospital Stafford, the system for ensuring that these lessons were put into practice was immature and not embedded across all of the hospital sites.
  • There was no identified member of the senior leadership team accountable for the CAMHS service delivery across The Huntercombe Group. This hindered the organisation’s ability to standardise good practice across the specialism. This was reflected in our findings across the services of inconsistent implementation of policies, sharing of good practice and embedding of lessons learnt across teams.
  • We identified a number of significant lapses in governance. There was no effective corporate oversight of the provision of mandatory and role-specific training for staff and no effective system in place to ensure that staff in all services received consistent and regular supervision and appraisal. We found a lack of detail in the minutes of the various provider level governance meetings including the delivery board and quality assurance group. The minutes did not capture the discussion of data relating to performance or adverse incidents. Although senior management were able to inform us what had been discussed at these meetings, the minutes and papers of the meetings did not record this detail.
  • The staff engagement strategy was not consistently embedded across all CAMHS services. Staff, at some services, reported they did not feel consulted or engaged in changes to practice and service developments. They did not feel the systems and processes in place supported an open culture for whistle blowing.

We found the following areas of good practice:

  • The Huntercombe Group had a clearly stated vision and objectives. Managers worked to ensure all staff at all levels understood them in relation to their daily roles. All staff, including temporary workers, received an induction to their service.
  • There was evidence of some improvements in the governance of services since our inspections of Huntercombe Hospital Stafford and Watcombe Hall. The organisation’s early warning escalation system, quality dashboard, quality assurance framework and quality improvement forums provided a range of data.
  • There was a programme of regular audits intended to identify issues and inform improvements.
  • The provider had a number of initiatives that involved young people. For example, the ‘you said, we did’ initiative encouraged young people to be champions of their peers’ views; and the ‘glamour for your manor’ initiative encouraged young people (and staff) to submit proposals for improvements to their ward environment.
  • Several wards had registered with the Royal College of Psychiatrists’ Quality Network for Inpatient Child and Adolescent Mental Health Services (QNIC), and some wards had already received QNIC accreditation.

11 July- 12 July 2017

During an inspection looking at part of the service

We found the following issues that the service provider needs to improve:

  • Assessments of whether or not a child or young person could consent to medical treatment did not take into account the age of the patient. On Severn ward assessments of young people under the age of 16 were documented as assessments of capacity when the Mental Capacity Act does not apply to young people under the age of 16. Staff had varying degrees of knowledge of the Mental Capacity Act and in particular there was inconsistent staff understanding of Gillick competency. On Thames ward there were no readily accessible copies of patient consent forms, which should include either assessed capacity or Gillick competency. For children under the age of 16, the young person’s decision making ability is governed by Gillick competence. The concept of Gillick competence recognises that some children may have sufficient maturity to make some decisions for themselves. We issued a requirement notice on this issue in 2016 and the requirement notice remains in place.
  • On Thames ward, young people had their own bedroom, however the bedrooms were in a mixed sex corridor and had no access to segregated bathroom and toilet facilities without passing through opposite-sex areas to reach their own facilities.
  • With the exception of Tamar ward, the remaining ward clinic rooms were not clean. On Severn ward staff did not know where the blood spillage kit was kept and the sharps container was not signed for or dated. All of the wards had worn and torn furniture which needed replacing. The monthly environmental audits on the ward had not taken place for six months. With the exception of Tamar ward, the other wards were untidy, disorganised and dirty. On Kennet ward there was a significant amount of graffiti on walls and windows.
  • On Severn ward staff had not adhered to the provider’s policy on controlled medicine.
  • On Severn ward two young people receiving nasogastric feeding did not have a specific care plan relating to this procedure and food and fluid charts on Severn ward were not completed fully and consistently.
  • Discussions with staff on lessons learnt from incidents were not always recorded as having taken place. Not all staff had access to email accounts so they were not receiving up to date information from the provider.

However we found the following areas of good practice:

  • Staff had received training on managing ligature risks and staff were able to tell us where the high-risk ligature anchor points and ligatures were and how these risks were mitigated and managed.
  • All staff told us there were sufficient staff to deliver care to a good standard and the staffing rotas indicated that there were always sufficient staff on duty. Staff were available to offer regular and frequent one-to-one support to their young people. There were enough staff on each shift to facilitate young people’ leave and for activities to be delivered. There was administrative support available in the hospital which included reception staff available during the day. This meant clinical staff could spend more time in direct contact with young people. The staff across the wards came from various professional backgrounds, including medical, psychology, nursing, support work, occupational therapy, family therapy, eating disorder specialists, art therapy, dance and movement therapy, activity co-ordination, dietetics and education.
  • Staff knew how to raise a safeguarding issue or concern. All staff were aware of who the hospital safeguarding lead was and how to contact them. Safeguarding team contact details and flow charts of the safeguarding procedure were placed on all of the wards both in the nurses’ office and also on the young people’ notice boards. Eighty-six per cent of staff had up to date safeguarding children and adults training.
  • Staff knew how to recognise and report incidents on the providers’ electronic recording system. Incidents and lessons learnt from incidents were shared at the hospital’s daily de-brief meeting which was attended by representatives from each ward and the hospital manager.
  • There were detailed and timely assessments for young people, in 24 of the 26 care records we reviewed, across the four wards. Staff had assessed all young people for their current mental state and physical healthcare needs. The care plans were recovery focused. Young people told us that they were included in the planning of their care. All of the wards had implemented the ‘teen outcome star’. This is a holistic tool which measures progress towards safety and well-being for young people. As well as providing outcomes data, the tool encourages patient engagement and a recovery focused model of care. Staff followed the National Institute for Health and Care Excellence guidance and engaged in a mixture of clinical and management audits on a range of topics.
  • The provider’s vision, values and strategies for the service were evident and on display on information boards throughout the hospital. Staff understood the vision and direction of the organisation. Staff at every level felt very much a part of the service and were able to discuss the philosophy of the wards confidently.
  • Staff spoke very highly about the management team and there was evidence of clear leadership at a local level. The ward managers and service manager were visible on the wards during the day-to-day provision of care and treatment, they were accessible to staff and they were proactive in providing support. The culture on the wards was open and encouraged staff to bring forward ideas for improving care.
  • All of the ward staff we spoke with were enthusiastic and engaged with developments on the wards. They told us they felt able to report incidents, raise concerns and make suggestions for improvements. They were confident they would be listened to by their line managers. Some staff gave us examples of when they had spoken out with concerns about the care of young people and said this had been received positively as a constructive challenge to ward practice.
  • A series of clinical quality audits, human resource management data and data on incidents and complaints was available. The information was summarised and presented monthly in a key performance indicator dashboard. This meant that the management team was able to receive assurance and apply clear controls to ensure the effective running of the service

16th – 18th February 2016

During a routine inspection

We rated Huntercombe Hospital Maidenhead as good because:

  • Processes were in place to manage environmental risks and the hospital complied with same-sex accommodation guidelines. Emergency equipment was available and checked regularly. Wards were clean and there were nurse call bells for patients and personal alarms for staff. Each nursing shift throughout the day and night was covered with qualified and unqualified staff and there was appropriate use of agency staff. Staff assessed risks and observed patients according to their risk. There were robust links with the local authority and staff were aware of safeguarding procedures. Following incidents there was good investigation and learning, and changes were made. Staff had processes in place to ensure that physical health needs were met.
  • There was timely assessment of needs on admission. Medicines and therapy were provided as directed in NICE guidance. Staff used a range of evidence based psychometric tests and outcome measures. Staff received induction and training relevant to their roles and had access to a specialist training budget. They received regular supervision from their managers. We found there to be comprehensive, informative shift-to-shift handovers on all wards. Mental Health Act paperwork was in good order.
  • Staff were caring, treated patients with dignity and respect and were knowledgeable of patients’ needs. There was excellent involvement in hospital affairs and patients’ views were sought and implemented regarding changes to the hospital.
  • Transition options were available for patients to step up to a more secure ward or down to a ward with greater freedom dependant on risk. There were a range of facilities inside the wards and in the grounds. Patients were able to personalise their bedrooms. Activities were available throughout the week. Catering was provided and the team were able to cater for individual patients’ ethnic or religious dietary needs. Complaints were dealt with appropriately and the provider fulfilled its duty of candour.
  • The hospital management were visible and supportive to staff. There was oversight of performance through monitoring and review. The hospital responded to staff and patient needs from the results of questionnaires, user involvement groups and a staff forum. Communication from management had been improved with the addition of a newsletter. There had been a recent restructuring of the senior management team which had a positive effect on morale and teamwork.

However:

  • Staff knowledge of the Mental Capacity Act was inconsistent and knowledge of Gillick Competency was poor.
  • A decision had been made to allow staff to use a room for seclusion that did not comply with their own policy or the guidance in the Mental Health Act Code of Practice.
  • We found that there were blanket restrictions on all of the wards rather than patients being individually assessed for restrictions.
  • Staff did not consistently report all lower level incidents on the wards and tended to focus on recording incidents of restraint.
  • Patients gave some negative comments about the night staff.
  • There were mixed reports on the quality of the food.

3 - 4 December 2014

During a routine inspection

Kennet Ward

Service provided: Eating Disorder Service

Male/female/mixed: mixed

Capacity: 20 beds

Tamar Ward

Service provided: Child and adolescent mental health wards

Male/female/mixed: mixed

Capacity: 11 beds

Severn Ward

Service provided:  Psychiatric intensive care unit

Male/female/mixed: mixed

Capacity: 15 beds

Thames Ward

Service provided: Psychiatric intensive care unit

Male/female/mixed: mixed

Capacity: 14 beds

The services provided were safe. Staff knew how to recognise and report potential abuse in order to protect children and young people. The service had an open and transparent reporting culture, incidents were fully investigated to identify learning. Learning was shared with staff to minimise risk of reoccurrence.

There were systems in place to ensure an effective service. Patient satisfaction surveys were carried out twice a year, we saw there was a 75% response rate to the survey carried out in July 2014. The hospital carried out audits to ensure they were following their own polices and procedures; for example the training audit measured staff compliance with mandatory training and we saw they had plans in place to improve this. Despite good access to GP services there were inconsistencies in the monitoring of physical health care and some care plans did not contain evidence of children and young people’s involvement in the planning of their care and treatment.

Staff followed best practice guidelines when providing care and treatment. Staff received the training and supervision they needed to enable them to care for people appropriately. The staff team worked well together to meet the needs of people. Staff applied the Mental Health Act and Code of Practice correctly

The services provided were caring. This was confirmed by observations of the care and treatment being provided and subsequent discussions with staff. Children and young people expressed that they felt safe on the wards and had good care. They said they felt staff listened to them and explained to them reasons for their treatment. Patients and staff told us about methods used to support their involvement and maintain relationships with families and carers. Staff were kind and respectful towards children and young people using the service and were positive when planning their care and support. Care was person-centred and people were involved in developing their own care plans. Staff recognised children and young people’s individual needs and understood how to care for them. Families and friends were involved in care when this was appropriate. Children and young people gave feedback about the service and this was listened to by staff and managers and used to influence the running of the service. Children and young people knew how to access advocacy services and this information was displayed on the ward.

The services provided were responsive. There was evidence that the provider encouraged feedback from children and young people and staff and used this to influence the running of the service. All patients knew how to make a complaint and staff responded appropriately when patients voiced issues. Children and young people had access to outside space and could take part in a range of activities and groups both inside and outside the service, including access to on-site gym facilities. Children and young people were supported to practice their faith and a religious items box was available. Staff focussed on people’s recovery and helped them build on their strengths. Meals were cooked on site and there were choices available.

The services provided were well led. Most staff told us that they felt supported and could approach senior management. Staff across all of the wards inspected told us that there were difficulties with the recruitment and retention of staff. We found that there was widespread use of bank and agency staff on the wards, but staff told us that most of these staff were ‘regulars’ and therefore familiar with the patients routines.

Staff knew the vision and values of the organisation. The manager knew that staff had received the training they needed and conducted checks to see that policies and procedures were being followed. Staff actively learned from incidents, complaints and feedback from people and colleagues, and took action to improve the quality of service.

12 March 2014

During an inspection in response to concerns

We looked at the processes, and records held by the service relating to the use and management of medicines.

We reviewed the supply process, supporting information and administration records. Most medicines were obtained in a timely manner. Staff showed us where and how medicines were stored and the expiry date and temperature records they kept. Therefore we were assured that the medicines were safe to be administered.

We reviewed the prescribing and administration records including additional monitoring records that were required when medicines were administered. Whilst the prescribing and administration records were complete; there was a lack of additional monitoring records.

We spoke to three people who use the service. They explained to us how they were given their medicines. People were given written information about medication. If people had questions about their medication they said staff provided answers.

3 March 2014

During an inspection looking at part of the service

During this inspection we spoke with five patients, seven members of staff and the service manager. We looked at five records of patients who were detained under the Mental Health Act (MHA) 1983 and one record for an informal patient. We undertook this inspection to determine whether concerns we identified during the last inspection had been addressed.

We found arrangements for obtaining consent were appropriate. Patients signed their treatment records and care plans. Patients told us they were involved in decisions about their treatment. The service had the necessary documentation to demonstrate patients detained under the MHA were assessed appropriately and reassessed when necessary. Patients were made aware of their rights.

New systems were in place to assess risk to patients and ensure changes to any risks posed by patients to themselves and others were recorded and managed. Staff told us they had regular handover meetings to share concerns about patients and update each other on the risks associated with patients' care and treatment.

We found section 17 leave (leave for patients detained under the MHA) assessments had been changed. Staff told us the new system for section 17 leave made them more aware of the associated risks.

We found incidents were recorded, investigated and findings were shared with staff to ensure they were aware of any learning from investigations.

Patient records contained up to date information on patient assessments and their care and treatment.

24 October 2013

During a routine inspection

During the inspection we spoke with five patients, eight members of staff and the registered manager. We looked at nine patients' records and other documents related to the management of the service. We observed the care provided to patients, where this was appropriate.

Patients told us they were able to communicate well with staff and that staff responded to their needs. Patients had a high regard for the therapy provided by the service. One patient told us "Therapy is amazing. They talk to you as a whole person." Patients we spoke with felt involved in decisions about their care and treatment. However one patient told us they felt the service did not respond effectively to risks before they became crises.

All the staff we spoke with felt they were involved in decisions about patients and the service. Staff said they received training relevant to the needs of patients they cared for. Staff had training in safeguarding, the Mental Capacity Act and the Mental Health Act.

The service had systems to monitor the quality of its service. However the provider did not effectively analyse and learn from incidents and events in order to reduce the risk of harm to patients. The service did not effectively assess and manage risks in order to protect patients from the risk of harm.

Patient records were not completed appropriately. Legal documentation required to detain patients or seek their consent were not always available.

12 December 2012

During a routine inspection

People told us they felt cared for by trained and experienced staff. They valued their relationships with key workers and participated in organised activities. There were some areas where the people we spoke with felt the hospital could improve. These areas included providing more time with key workers; improving the quality of food; and organising structured activities at the weekend.

We found people using the service were provided with appropriate care to meet their needs. They were involved in making decisions about their care and understood their rights under Mental Health Act 1983. There was information on all the wards about advocacy services and people told us advocates regularly visited the wards. National clinical guidelines and recommendations were understood and implemented by the hospital. Infection prevention and control measures were in place. There were systems in place for monitoring the quality and safety of services provided to people including a system for reviewing complaints.

24 February 2011

During a routine inspection

Patients and their parents were involved in making decision. Staff treated patients with respect and dignity. They said there was a suitable balance and their privacy was respected. We were told that there was good communication between patients and doctors, therapists, social workers and teachers. Patients were encouraged to join in with groups and activities. Patients were informed of their rights and knew how to raise concerns.

A member of staff said that 'it was a nice place to work, they looked after staff well and that training was good'. There also said that there was a good clinical team with good team dynamics.

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.