Monitoring the Mental Health Act in 2021 to 2022

The physical environment and condition of mental health inpatient wards is still not good enough, with many wards in need of urgent update and repair. Issues that we have seen include broken windows, holes in walls, dirty wards, and fixtures and fittings in need of repair. In many cases, the condition of wards has been made worse by the additional wear and tear created during lockdowns.

Many inpatient wards are in old and outdated buildings that lack the space and ventilation of newer buildings. This can lead to issues around privacy and dignity for patients, as well as compromise the safety of patients and staff. In addition, outdoor spaces for such wards can be barren, visually impoverished environments dominated by security fencing. Not only can these environments be less pleasant to stay in, but they can affect patient and staff morale and have a detrimental impact on patient recovery.

In its response to the autumn 2021 government spending review, the Royal College of Psychiatrists stated that the mental health estate is some of the oldest and least suitable in the whole NHS. It reported that in 2019/20 there was a backlog of £31 million worth of repairs posing a high risk of catastrophic failure, major disruption to clinical services, or deficiencies in safety liable to cause serious injury and/or prosecution.

Funding issues and backlogs due to the COVID-19 pandemic, mean that patients continue to be cared for in environments that are not suitable for their needs. We have also heard that bed pressures are creating delays as maintenance staff cannot access wards or patients’ rooms.

In some cases, we found that wards had made temporary repairs. Not only could these be unsightly but they could be a visual reminder of past incidents on the wards and lead to patients feeling unsafe.

In our last 2 annual reports, we have also raised concerns about inadequate WiFi access for patients. Lack of WiFi can limit patients’ contact with family and friends, and cause issues with online meetings. We are now seeing examples of wards that have addressed WiFi issues, although many still have inadequate coverage.

Refurbishing services can have a hugely positive effect on patients and staff. Improvements we have seen include entirely new buildings for the new Broadmoor Hospital in West London (opened October 2019) and St Ann's Hospital, Haringey (opened August 2020).

We visited St Ann’s Hospital shortly after it opened. Patients and relatives told us that the new building is “such an improvement”, “amazing”, “superb” and “like a 5-star hotel”. We were impressed with the new environment and by innovations such as touch-screen walls in the seclusion rooms. We saw the effect this had on patients and staff. Patients comments such as “the staff are helpful and friendly”; “the service is excellent”; and “staff are very kind”, with the provider reporting a 60% reduction in violent incidents since the move to the new building.

We have also seen similar improvements in staff and patient relationships in other services that have refurbished existing buildings.

However, services must ensure that buildings are adapted to patient needs when carrying out refurbishment. In some services we visited, while the reception areas of wards were fully accessible, the wards behind them did not cater for people with physical disabilities or impairments.

The current arrangement of many wards continues to create other challenges for patients, for example a lack of space for patients to eat together. On a visit to a low-secure rehabilitation unit in November 2021, we noted that there were only 6 chairs in the dining area for a ward with 11 beds. Although patients rarely chose to eat together or at the same time, they had raised in community meetings that this stopped them from eating together on special occasions, such as Christmas. Following our visit we were assured that more chairs would be in place to allow Christmas lunch together.

In some cases we have seen examples where the number of beds on a ward has been increased, but the service has not been able to accommodate everyone in the lounge or dining areas. This should be a warning sign that the ward configuration needs to be reviewed.

We also continue to see examples where patients are not given a lockable space to keep their belongings in. A particular problem encountered over the last year has been the use of rooms as additional bedrooms that have not been designed or fitted for that purpose. If it is not practicable to provide a lockable space in these types of rooms, staff need to consider alternative ways patients’ belongings can be kept securely.

We do see some improvement in progress. For example, in June 2021, we raised concerns about patient safety at a large mixed sex acute admission ward. This included concerns about the ‘old and dated’ environment, delays in repair works, and a lack of space for all patients to eat in the dining room at the same time. In response the trust told us that there was a capital funding programme in place for refurbishment. The programme included plans for the removal of ligature risks, moving on to a programme of work for reconfiguration.

Poor sensory environments

The very nature of hospital wards, including the lighting, noise levels and general environment, can be non-therapeutic. For example, on a visit to an acute ward for women in August 2021, patients told us about the negative effects that the bright lights and noise of the wards was having on them. When we told the service, they fitted dimmer-switches in bedrooms and corridors, repainted the wards and closed corridor doors at night.

These environments can present a particular sensory challenge for autistic people and cause them distress.

Noise levels can also be a barrier to patients with hearing difficulties. On an eating disorder unit in May 2021, we met a patient who told us she did not wear her hearing aids because the environment was too noisy. Staff needed management support to access a portable hearing aid loop available to the ward, which reduces background noise in loud environments.

We also continue to have concerns around the use of dormitories. As highlighted in last year’s report, dormitory wards, which are often a consequence of aging infrastructure, can be very noisy and nontherapeutic environments. As well as concerns over noise, some patients have raised concerns about their safety and privacy when staying in dormitory wards.

As stated previously, we do not think that dormitory accommodation should be acceptable in any mental health inpatient unit. In our last report we reported that the government has committed over £400 million to make progress on replacing dormitories. We urge the government to continue to make funding available until all dormitory accommodation has been replaced.

Where services are waiting to have dormitories replaced, we continue to check that:

• beds are separated from one another and staff ensure the maximum privacy possible
• patients using these rooms have access to a lockable, personal storage facility
• patients are offered a choice of accommodation
• services ensure that patient flow and ward teams assess and consider each patient based on their diagnosis, clinical presentation and any other risks to determine whether admission to a dormitory would be acceptable or not to that patient and for the needs of the other patients on the ward.