Key points
- Many parts of the mental health hospital estate need upgrading. Wards are often unsuitable sensory environments, particularly for autistic patients. The use of dormitory wards can also leave patients feeling unsafe.
- In many hospitals patients and staff complained to us about poor internet coverage. Not only does this stop patients contacting their friends and families, but it also interrupts online medical or legal consultations and tribunal hearings.
- Catering still needs serious improvement in some services. Bad food encourages take-away use and obesity, and people detained for health purposes should expect decent, nourishing food.
“The environment is not autism friendly if you are having a meltdown.”
Patient on an eating-disorder ward
Mental health inpatient wards are often noisy and bustling environments. This can be a challenge for all patients, who can feel trapped in a space that is not conducive to recovery. However, these types of environments can be particularly distressing for autistic people who may be at risk of sensory overload.
For example, on our review of a specialist eating disorder ward in January 2021, staff told us that there were a relatively high number of patients with diagnosed or suspected autism in the hospital. The lead nurse for autism had carried out work to help ward staff develop their skills in working with people with autism and had helped develop and refine care plans, but patients and staff told us that the environment was not friendly for autistic people or people with sensory challenges. The service had previously insulated walls and ceilings and fitted sound-reducing panels to walls, but was in consultation with a specialist sound engineer as the problems of noise persisted. They were also developing sensory rooms on wards in consultation with patients and a specialist company.
Steps that other services have taken to reduce noise levels include attaching rubber feet to moveable furniture on hard floor surfaces, and ensuring there are quiet spaces. We also heard that staff needing to stay on the wards during the pandemic had highlighted previously unidentified environmental challenges, such as noisy doors.
During a period of lockdown staff stayed on the ward to support patients and reduce the risk of contamination. This experience helped staff identify several improvements to improve patient care. For example, doors that had banged at night were fixed to ensure they were less disturbing to patients.
Men’s rehabilitation ward, November 2020
Dormitory wards in particular can be noisy environments that can be distressing to patients. Although likely to be a consequence of aging infrastructure, larger wards can add to problems with noise and disturbance, which can also create problems for patient involvement and engagement. For example, at one trust we heard that patients and visiting relatives who used hearing aids struggled with communication because of the level of background noise.
Even when dormitory wards are managed well, and in accordance with the guidance ‘Delivering same-sex accommodation’, we have heard that people do not always feel safe in these environments.
Dormitory rooms were organised depending on the amount of male or female patients admitted to the ward. One patient said he did not like sleeping in a dormitory room as he felt unsafe. This was due to the person in the next bed responding to him in a threatening manner. Staff said they were aware of this and monitored this issue closely.
Older adults’ ward, December 2020
As stated previously, we do not think that dormitory accommodation should be acceptable in any mental health inpatient unit. The government has pledged over £400 million to make progress on replacing dormitories.
A number of larger wards were scaled back at the start of the pandemic, although this of course added to pressures over bed availability and the numbers of beds increased again as local infection rates declined.
The intensive assessment model being used to develop initial formulation and treatment plans was very proactive and facilitated early discharge or transfer from the ward. Staff were very positive about working to this model. We are aware that this creates significant demands on clinical staff time requiring intensive engagement with patients, and to maintain this patient numbers need to be kept at a manageable level. We were informed that this was better managed when bed numbers were 12 but this have now risen to 15 and this has put a strain on staff trying to meet key performance indicator targets and can affect the quality of care.
Acute ward, November 2020
The funding pledge to replace dormitory wards is welcome. However, there are many other improvements required in mental health inpatient environments that will similarly be dependent on adequate capital funding being available.
Sexual safety
The reconfiguration of wards at the start of the pandemic could create challenges for services in meeting the requirements for single-sex accommodation. Positively, the only breaches of guidelines we saw were when single-sex day spaces were temporarily unavailable. In many services these spaces were not in demand anyway.
While gender segregation alone cannot address all concerns around sexual safety, many services aim to group patient rooms so that women do not need to pass men’s rooms to get to their own rooms, and vice-versa. This is not a requirement of guidance on same sex accommodation, and is not always possible due to the infrastructure of the ward. However, where this can be arranged it can add to patients’ sense of sexual safety.
During the pandemic, some service reconfigurations meant that these types of arrangements could not be maintained. In these instances, we found that services had taken steps to maintain patients’ sense of safety, for example having staff allocated to specific areas where people were shielding.
The designation of ‘shielding’ versus ‘non-shielding’ patient areas had meant that there was no longer a ‘male’ and a ‘female’ corridor to the ward. This was mitigated for by allocation of staff to designated areas.
Rehabilitation ward, March 2021
For some services, the reconfigurations offered an opportunity to introduce single-sex wards that may continue post-pandemic.
Reconfiguration of the wards into female and male and reduction from 22 to 19 beds had been necessary to manage COVID-19. This had worked well. Feedback from a female patient was that being on a single gender ward “felt safer and more relaxed”.
Acute ward, March 2021
We also heard about good practice in proactively addressing sexual safety:
The ward was piloting the sexual safety project on the ward. Staff ensured patients were involved in this project. They collected patient views by circulating postcards to patients on a weekly basis. No concerns had been flagged up by patients. The feedback was reviewed by the reduction in restraint lead. Staff showed compassion when speaking about this topic and a good awareness that this piece of work could be retraumatising for some patients. Staff offered support to patients and a safe space to talk, if needed.
Ward 1 (high dependency acute ward), Harplands Hospital, North Staffordshire Combined Healthcare NHS Trust, March 2021
WiFi connectivity issues
In last year’s report, we highlighted our concerns around the availability and quality of WiFi on mental health wards.
Over the last year, we have heard frequent complaints from patients, staff and even the Tribunal service about WiFi signal availability (see section on the First-tier Tribunal). In some hospitals, detained patients have had to use their own mobile phone accounts to speak with families, and even lawyers, at their own expense.
All the patients we spoke with told us that telephone and internet connectivity was poor on the ward. They told us that this regularly affected their conversations with families and on occasions their right to private communication with the advocacy service and solicitors. Most patients told us that could not use the ward WiFi and they paid for access to the internet on their mobile phones but still could only access the internet and calls to telephones in certain parts of the ward and that this regularly disconnected.
Women’s PICU, March 2021
Patients told us the WiFi connection was “really quite terrible”, that the signal was poor and if you were able to get a signal it was constantly breaking up. Patients used their own mobile phones instead. Although the trust had provided a tablet computer for patients to have video calls with friends and family, patients had not been able to use them due to the poor WiFi coverage. Staff told us the only place where the video calls worked was a communal day room with no privacy for the callers.
Acute ward, March 2021
As a consequence, many of our remote reviews have requested that services address their WiFi coverage. In a number of cases, services have replied that they are installing signal boosters or other technological fixes.
“The WiFi issue is currently a high priority piece of work within the organisation. The trust IT operations manager has advised that there are currently issues with WiFi at the unit and the trust was currently carrying out improvements, including adding and relocating wireless access points. All technical specification changes with remote servers with the Mental Health Tribunals have been rectified and a support team is on standby for every Mental Health Tribunal. The trust is also assessing a more significant capital investment to substantially improve WiFi access or a technical solution”.
Response to remote review, acute ward, November 2020
Food and nutrition
The catering arrangements and quality of food available on mental health wards is an area for concern, with patients often telling us that the standards of meals provided is not good enough.
Meals were described as poor in terms of quality and quantity. Patients and staff both reported that portions sizes were often too small and that meals were served on plates that were not appropriate in size or design for an adult.
Patients told us that they were not offered second helpings even if they were still hungry and there was food leftover. One patient said they ate chocolate after a meal as were frequently still hungry. They told us “the food is not enough to feed a chihuahua”. The second patient told us “food is bad and there’s not enough of it. Its rubbish, not much selection and not much protein”.
However, patients had access to hot and cold drinks and fruit including a range of fresh fruit delivered from a local farm, which staff prepared in individual pots for patients to access when they wanted.
Medium secure unit, April 2021
Over 2020/21, as part of the Adult Secure Clinical Reference Group, we have worked with NHS England and NHS Improvement to develop guidance on ‘Managing a healthy weight in adult secure services’. This guidance will be useful for all hospitals that detain patients, including those that are not specifically designed as secure hospitals, as it encourages services to work with patients on improving their diet and lifestyle. We have seen some good practice in services, for example:
Staff encouraged healthy eating and one patient had lost a considerable amount of weight whilst on the ward, which meant that they were now eligible for treatment that would have been dangerous for them before they lost the weight.
Women’s ward, medium secure unit, March 2021
In October 2020, the Independent Review of NHS Hospital Food published its report recommending measures to improve standards for patients’ food, including statutory standards. We welcome the inclusion of this in the Health and Social Care Bill, as improving the standard of meals provided to patients in hospital will help to support implementation of healthy weight strategies.
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Monitoring the Mental Health Act in 2020/21
Contents
- Summary
- Foreword
- Service provision during the pandemic
- Person-centred care during the pandemic
- Ward environments
- Leaving hospital
- Tackling inequalities
- The MHA and our concerns for key groups of people
- The MHA and mentally disordered offenders
- MHA interface with Deprivation of Liberty Safeguards
- First-Tier Tribunal (Mental Health)
- Restraint, seclusion and segregation and the Independent Care (Education) and Treatment Reviews
- Our work in 2020/21
- Appendix A: Monitoring the MHA as a part of the UK’s National Preventive Mechanism