agenda - cwm taf morgannwg university health boardcwmtafmorgannwg.wales/docs/mental health act...

MENTAL HEALTH ACT MONITORING COMMITTEE Thursday 15 June 2017

Taff Meeting Room, Cwm Taf University Health Board,

Ynysmeurig House, Abercynon 2.00pm

AGENDA

Lead / Attachment

PART 1 - PRELIMINARY MATTERS

1.1

Welcome and Introductions

Chair / Oral

1.2 Apologies for Absence

Chair / Oral

1.3

Declarations of Interests Chair / Oral

1.4 Unconfirmed Minutes of the meeting of the Mental Health Act Monitoring Committee held on 16 February

2017

Chair

Attachment

1.5 Matters Arising

Chair / Oral

1.6 Action Log Chair

Attachment

1.7 Chairs Report

Chair

Oral

PART 2 - ITEMS FOR DISCUSSION

2.1 Annual Report on Suicides

Clinical Director MH

Attachment

2.2

Mental Health Act Monitoring Committee Annual Report

and Committee Self Assessment Questionnaire

Board Secretary

Attachment

PART 3 - GOVERNANCE, PERFORMANCE AND ASSURANCE

3.1 Mental Health Act – Quarterly Activity Statistical Report Director of Primary,

Community & Mental Health

Attachment

3.2 Mental Health Crisis Care Concordat

South Wales Police

Attachment

3.3

Mental Health Act Breaches / Analysis of Unlawful

Detention

Assistant Director of

Operations MH

Attachment

Agenda

1 of 115Mental Health Act Monitoring Committee Meeting 15 June 2017 Web-15/06/17

3.4

3.5

Risks related to the Monitoring of the Mental Health Act

National Benchmarking data on Breaches

Assistant Director of

Operations MH

Oral

Ian Wile (C&V UHB)

Attachment

PART 4 – FOR INFORMATION

(These items will only be discussed if related issues are raised with the Chair in advance of the meeting)

4.1 Internal Audit Report on Mental Health Act S117 for

review and monitoring from Audit Committee 3 April 2017

Board Secretary

Attachment

4.2 Internal Audit Report - Royal College of Psychiatrists

Review Follow up

Board Secretary

Attachment

PART 5– OTHER MATTERS

5.1 To review the Forward Look for 2017/18

Chair

Attachment

5.2

Any other urgent business

Chair / Oral

5.3 Date of Next Meeting

Thursday 14 September 2017 2.00pm

Ynysmeurig House, Navigation Park, Abercynon

Agenda

2 of 115 Mental Health Act Monitoring Committee Meeting 15 June 2017 Web-15/06/17

Agenda item 1.4

Unconfirmed Minutes of the Mental Health Act Monitoring

Committee meeting held on 16 February 2017

Page 1 of 7 Mental Health Act Monitoring Committee Meeting

15 June 2017

Mental Health Act Monitoring Committee Meeting

Minutes of the meeting held on 16 February 2017

Cwm Taf UHB, Abercynon Present

Prof Donna Mead (Chair) Vice Chair of the University Health Board Mr Mel Jehu

Mr John Palmer

Independent Board Member

Director of Primary, Community & Mental Health

Dr Paul Davies (PhD) Mr Peter Thomas

DI Karen John Mr Mark Anderton

Assistant Director of Operations (ADO) South Wales Police

South Wales Police Merthyr Tydfil County Borough Council

Ms Gail Hollowman

Ms Samantha Shore

Mr Peter Halford Dr Adarsh Shetty

Rhondda Cynon Taf County Borough Council

Senior Nurse, Adult Mental Health

Consultant Psychiatrist, CAMHS Clinical Director, Mental Health (in part)

In attendance

Miss Gwenan Roberts Miss Kate Bowd

Mr Phil Robson

Head of Corporate Services Secretariat

Vice Chair, Aneurin Bevan UHB

MHAM/17/01 WELCOME AND INTRODUCTIONS

The Chair welcomed everyone to the meeting of the Mental

Health Act Monitoring Committee and Members were invited to introduce themselves.

Mr Phil Robson was in attendance from Aneurin Bevan University Health Board to observe.

MHAM/17/02

APOLOGIES FOR ABSENCE

Apologies for absence were received from Dr Tracy Gardiner; Ms Julie Cude; Mr Phil Lewis; Mrs Pamela Connor; Mr Gregory Lloyd;

and Supt. Jim Dyson.

MHAM/17/03 DECLARATIONS OF INTEREST

There were no additional declarations of interest.

1.4 Unconfirmed minutes of the meeting of the Mental Health Act Committee held on 16 February 2017


Agenda item 1.4




15 June 2017

MHAM/17/04 MINUTES OF THE PREVIOUS MEETING

The minutes of meeting held on the 8 December 2016 were

recorded as a true and accurate record subject to the following addition:

On page 2 – Apology to be recorded for Samantha Shore.

The Chair thanked Mr Mel Jehu for chairing the last meeting.

MHAM/17/05 MATTERS ARISING

MHMAC/16/62 – Mental Health Act Breaches - Category 4 breaches was on the agenda for discussion.

MHAMC/16/65 – Her Majesty’s Inspectorate of Constabulary - Unannounced Inspection (HMIC) – Members NOTED the

partnership data.

MHAM/17/06

ACTION LOG

Members RECEIVED a copy of the action log and AGREED the

following:

1. MHAM/16/44 - Due to Supt Jim Dyson being unable to attend the meeting, this item would be received at the next meeting.

2. MHAM/16/46 – Benchmarking statistical report data – an update would be provided at the meeting.

3. MHAM/16/54 – Completed 4. MHAM/16/61 – Mental Health Crisis Concordat – update report

from SWP was on the agenda. 5. MHAM/16/62 – MHA Breaches – Draft proposal was on agenda

for information. Members were assured that work was in progress and NOTED that the proposal was currently at the

consultation phase which had been shared with operational leads of Health Boards for comment. Members NOTED that a

pilot was underway in Cardiff and Vale UHB and dependent on

the success would be rolled out in June. Members NOTED that it had been formally agreed to review at individual health

board Mental Health Act Monitoring Committee meetings. 6. MHAM/16/65 – No response had yet been received from South

Wales Police. It was AGREED that this would be discussed with Supt Dyson at the next meeting.

(Dr A Shetty joined the meeting).



Agenda item 1.4




15 June 2017

GOVERNANCE, PERFORMANCE AND ASSURANCE

MHAM/17/07 MENTAL HEALTH ACT – QUARTERLY STATISTICAL REPORT

Mr J Palmer presented the Mental Health Act Monitoring Report

for Quarter 3, Members NOTED that the report was evolving to ensure the latest information available and the following key

areas were highlighted: The report contained the reconciled data and had been

validated by the Health Board and South Wales Police. Quarterly reports would be provided to the Committee to

review any variations and to identify any mitigation used in practice.

Inpatient MHA – Members NOTED the decrease within the data of the sub sections as within normal variation

Members AGREED that the trends would be illustrated in a bar chart for ease of reference in the next report.

Tribunals had slightly decreased. The number of patients held using Section 136 had slightly

increased. The information was felt to be consistent and there were no issues for particular discussion. Members

NOTED that page 9 showed the increased numbers of

patients detained under Section 136 were as expected during the winter period.

Deaths while detained – Members NOTED a small increase from previous data

Staff Training – Members AGREED to receive an update on annual staff training in the next report; courses undertaken

to date and the costs associated. Dr P Davies advised that adult detention placements were

based on specialised nature of treatment and not commissioned and provided by the Health Board.

Mental Health Advocates – Mental Health activity for Q2/Q3 indicated that services were working effectively. Dr P

Davies (PhD) advised that the service provided was a non professional advocacy; independent advocates were

working in partnership to act on behalf of the patient (as

the voice of the patient). Dr Shetty advised members that there was also an Older Persons Advocacy service within

the Mental Health services. Dr P Davies (PhD) advised that Ms L Garwood (Clinical Director) would provide an update

to the Mental Health Partnership Board on the advocacy service.

Code of Practice - Members NOTED that hospital managers were aware of the new Code of Practice. Dr Shetty

confirmed that the Health Board was compliant.

Members of the Committee RESOLVED to: DISCUSS and NOTE the report.



Agenda item 1.4




15 June 2017

MHAM/17/08 MENTAL HEALTH CRISIS CONCORDAT

The first written report was received from South Wales Police and was presented by Mr Peter Thomas. The report provided an

update on the progress to date within the South Wales Police

service and provided a précis on the key issues for the Force as a result of the HMIC Unannounced Inspection.

Mr Thomas confirmed that a meeting had taken place on 16

January 2017 with Dr Gaynor Jones as the new Chair and supported by Mr James Thomas at the Caswell Clinic. The Mental

Health Care Concordat was discussed and it had been decided to write to the Health Boards and Local Authorities, as well as to the

Welsh Ambulance Services NHS Trust, the Child and Adolescent Mental Health network service and to MIND to work together to

implement a Crisis Care Forum. Members NOTED that a Task & Finish Group (T&F) had been established to cover key areas of

the business to implement the plan.

The key areas of business were identified as:

Adverse incident reporting – Members NOTED the aim

to link the Health Boards / Local Authorities to improve services.

Training – a training guide had been developed. Members

NOTED that a multiagency steering group had been established and updates would be reported to the T&F

Group bimonthly. A community psychiatric nurse had also been appointed to work in the police control room to offer

advice which was based on work in other force areas which had been supportive to front line staff.

Transport – Members NOTED that the ambulance usage

was low.

Alternative place of safety – Members NOTED that

intervention research was underway to review options between agencies. However, there was an impasse as

additional resourcing issues had been identified. Work was underway in Gwent and a small pilot had been commenced

with a report available of what would be shared. Mr P Thomas explained that costs would be shared and it was

AGREED to discuss with the team from Aneurin Bevan University Health Board regarding progress and potential

invitation to a future meeting. Members NOTED that Cardiff and the Vale UHB had identified a need for a

sanctuary house and were progressing funding options.



Agenda item 1.4




15 June 2017

Dr P Davies (PhD) confirmed that there had been several requests using the Freedom of Information Act and press

enquiries in relation to restrictive physical intervention; Members NOTED that extra training had been provided for staff in adult

mental health and there was a plan for robust audits to take

place when restrictive physical intervention had taken place.

Members NOTED that the Police and Crime Act would take effect from May. Dr E Stephenson (Consultant A&E at Prince Charles

Hospital) was working with Cardiff and Vale UHB on the area business restraint to comply with the Mental Health Act Codes of

Practice. Mr P Thomas confirmed that the Welsh Government had established a working group with the Chief Constable to progress

the work. Members NOTED that a National Project Board had also been established to oversee the work. Mr J Palmer AGREED

to draft a letter to the Welsh Government to clarify the position.

Mr Mel Jehu welcomed the inclusion of the Memorandum of Understanding (MOU) and Mr P Thomas explained that the police

would not be called to attend for restraint purposes; Members NOTED that the next phase would be to monitor the compliance

and provide evidence. Mr J Palmer advised Members that he

would ensure that the Health Board was compliant with the MOU and would ensure that the correct sign off and governance would

take place and an oral update provided at the next meeting.

Members RESOLVED to: Thank Mr P Thomas for the report

Receive additional information on the HMIC Inspection report. MHAM/17/09 MENTAL HEALTH ACT BREACHES / ANALYSIS OF

UNLAWFUL DETENTION

Mr J Palmer presented the report and gave an overview of the

key issues.

Mr Palmer explained that work was continuing within the service

to reduce the number of breaches of the Mental Health Act in the Category 1 & 2 sections; Members also NOTED that the Datix

Risk Management system was now in use to report all breaches in line with patient safety issues.

Members NOTED the 4 breaches on recording personal

information and that the numbers were low against the benchmarked data available; specific training was in place for

staff to prevent further avoidable breaches of the Act. Two incidents were also reported which had the incorrect addresses

which would have resulted in breaches of the Act if they had not been amended within 14 days.



Agenda item 1.4




15 June 2017

Dr A Shetty provided an update on the consent to treatment; Dr

Shetty confirmed that Ms P Wilson had appropriately escalated the issue and had provided feedback to the Consultant. Dr Shetty

explained to the Committee that the care provided to patients

was not adversely affected in terms of the application of the Mental Health Act including administrative errors and advised the

Committee that the model of care was being revised to ensure compliance.

Members discussed exploring ways of better sharing information

prior to the Committee meeting as this report was a ‘closed’ report as it included personal identifiable information in relation

to breaches of the Mental Health Act. Mr J Palmer agreed to seek a different approach to sharing data / information to the

Committee which could be via the secure portal. Further information would be shared prior to the next meeting.

Members RESOLVED to:

NOTE the report.

MHAM/17/10 RISKS RELATED TO THE MONITORING OF THE MENTAL

HEALTH ACT

No risks were identified.

FOR INFORMATION

MHAM/17/11 ADULT MENTAL HEALTH PERFORMANCE REPORT

Mr J Palmer provided an update regarding the improved performance related to the Mental Health Measure and explained

that it was expected that all targets would be met by the end of March 2017. Members were advised that there had been a

significant improvement in the assessment, treatment and care planning. Members NOTED that the Finance, Performance &

Workforce Committee had undertaken a deep dive into the

performance and were assured; ongoing performance would also be scrutinised by that Committee and quarterly updates would be

received at the Mental Health Act Monitoring Committee for information only.

Member RECEIVED and NOTED the report.

MHAM/17/12 CHILD AND ADOLESCENT MENTAL HEALTH PERFORMANCE

REPORT

Mr J Palmer provided an update regarding the performance within the CAMH Services. Members were advised that there had



Agenda item 1.4




15 June 2017

been significant improvement over the year and the Health Board was on target to deliver the planned year end position.


MHAM/17/13 NATIONAL APPROACH TO MENTAL HEALTH ACT BREACHES

REPORT

Mr J Palmer gave an overview regarding the national approach to

Mental Health Act breaches. The proposal has been adopted by other Health Boards and Mr Ian Wile (C&V UHB) had been invited

to attend the next meeting to provide an update. The Chair invited any further comments be sent to Ms P Connor for

collation and onward inclusion in the national report.


OTHER MATTERS

MHAM/17/14 TO REVIEW THE FORWARD LOOK FOR 2016/17

Members RECEIVED and NOTED the Forward Look Plan.

It was AGREED to add:

Receive an update from South Wales Police on the HMIC inspection report

The Committee Annual Report Update on Suicide (Annual Report)

National Approach to Breaches – Ian Wile to attend next meeting

Discuss the pilot on alternative place of safety with the team at Aneurin Bevan UHB.

MHAM/17/15 ANY OTHER URGENT BUSINESS

None

MHAM/17/16 DATE OF NEXT MEETING

The next meeting would take place on Thursday 15 June 2017 at 2.00pm at Cwm Taf UHB, Headquarters, Ynysmeurig House,

Abercynon.

Signed ……………………………………………….

Prof Donna Mead (CHAIR)

Date …………………………………………………..



Agenda item 1.6

Action log Page 1 of 1

Mental Health Act Monitoring Committee

15 June 2017

MENTAL HEALTH MONITORING COMMITTEE ACTION LOG

Date Issue Lead Complete / Ongoing

22 June 2016

MHAM/16/44 Ongoing issue regarding very intoxicated individuals to be discussed at the Community

Safety Partnership meeting (June and September

meeting)

South Wales Police Supt Jim Dyson

Ongoing matter – for update 16 February

2017(now June 2017)

8 December 2016

MHAM/16/62 Invite Ian Wile to present the national approach for

benchmarking MHA breaches

John Palmer Update at June meeting

– Ian Wile attending

MHAM/16/65 &

MHAM 17/08

HMIC unannounced inspection – response from

South Wales Police to the chair of the committee to

confirm compliance with the speed of referrals to Mental Health

Supt Jim Dyson To be confirmed

16 February 2017

MHAM/17/07 Mental Health Act – Quarterly Statistical Report Trends to be demonstrated using bar char

Provide enhanced information on staff training including the numbers trained and the amount

of funding used to date

John Palmer June meeting

MHAM/17/08 Discuss the alternative place of safety pilot with Aneurin Bevan UHB and potentially invite to a

future meeting

John Palmer To be confirmed

1.6 Action log

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6 Year analysis update of reported suicide in Cwm Taf

April 2010 – March 2016


15 June 2017

AGENDA ITEM 2.1

15 June 2017

Mental Health Act Monitoring Committee Report

6 YEAR ANALYSIS UPDATE OF REPORTED SUICIDE IN CWM TAF

REGION: APRIL 2010 – MARCH 2016

Executive Lead: Mr John Palmer, Director of Primary Care, Community and Mental Health

Author: Dr Paul D Davies (PhD), Mr James McMahon

Contact Details for further information: Paul D Davies RGH 3700 /

[email protected]

Purpose of the Mental Health Act Monitoring Committee Report

The purpose of this brief report is to follow previously detailed reports on

the prevalence of suicide in the Cwm Taf region

Governance

Link to Health Board Strategic

Objective(s)

The Board’s overarching role is to ensure its Strategy outlined within ‘Cwm Taf Cares’ 3 Year Integrated

Medium Term Plan 2015-2018 and the related organisational objectives aligned with the Institute of

Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:

To improve quality, safety and patient experience

To protect and improve population health To ensure that the services provided are

accessible and sustainable into the future To provide strong governance and assurance

To ensure good value based care and treatment for our patients in line with the resources made

available to the Health Board.

This report focuses mainly on supporting all of the strategic objectives

Supporting evidence

National Confidential Inquiry (NCI) on Suicide and Homicide for people with mental illness

Engagement – Who has been involved in this work?

The mental health clinical and management team



mailto:[email protected]

http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/2016-report.pdf

http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/2016-report.pdf




15 June 2017

Mental Health Act Monitoring Committee Resolution (insert √) To;

APPROVE ENDORSE DISCUSS √ NOTE √

Recommendation The Mental Health Act Monitoring Committee is

asked to: DISCUSS the higher levels of suicide in the Cwm

Taf region and the actions aimed at reduction

Summarise the Impact of the Mental Health Act Monitoring

Committee Report

Equality and diversity

Potential equality issues relate to access to services and gender differences

Legal implications All suicides and suspected suicides are reviewed at a Coroner’s hearing

Population Health The socio-economic factors of the Cwm Taf region

impact negatively upon the mental health of the population. High unemployment rates are linked to a

higher suicide rate.

Quality, Safety &

Patient Experience

This analysis acts as a quality assurance check on

how the community is responding to suicide rates and scrutiny of such data will reveal areas for

improvement and action.

Resources None highlighted at present. The improvements recently introduced in Primary Care Mental Health

services over time will make a positive difference as people receive earlier assessment and intervention.

Risks and Assurance

Key risks: Increased suicide rates compared to national

benchmark

Increasing gender differences Increase in middle-aged men

Fluctuating increase in patient suicide above the national benchmark

Health and Care Standards

The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes:

Staying Healthy; Safe Care; Effective Care; Dignified Care; Timely Care; Individual Care; Staff &

Resources

http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework_2015

_E1.pdf

Workforce Increasing awareness and skills across a range of

services within health and in other agencies

Freedom of information

status

Open



http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework_2015_E1.pdf






15 June 2017

6 YEAR ANALYSIS UPDATE OF REPORTED SUICIDE IN CWM TAF

REGION: APRIL 2010 – MARCH 2016

1. SITUATION / PURPOSE OF REPORT

The purpose of this report is to provide a sixth year analysis and benchmark of

suicide rates in the Cwm Taf Region. The original intention of these reports was to examine trends in years, not months, as suicide rate does not follow a

natural epidemiological pattern.

This report is presented against a background where Cwm Taf region is one of

the most prevalent areas of socio-economic deprivation, substance misuse and mental health problems in Wales.

Through a 5-year strategic framework Cwm Taf UHB (2011 – 2016) has

redesigned mental health services to provide enhanced community care, responsive primary care and effective hospital care and treatment. There have

also been two significant developments through extra funding in the last three years:

The Valleys Steps initiative; a self-referral programme providing intervention and training for people with emotional disorders

The Primary Care Mental Health Service to deliver part 1 of the Mental Health (Wales) Measure

Whilst our strategy and new funding will respond appropriately to the increasing

demand upon primary, secondary and tertiary services there also needs to be

consideration to the wider community response to reducing suicide rates. Previous reports have been presented to Local Service Boards by the Assistant

Director of Operations for Mental Health to discuss the wider response.

A comprehensive clinical governance report focusing on the clinical review of unexpected death in adult mental health was received by the Health Board in

2013, reporting on individual cases known to health services.

2. BACKGROUND / INTRODUCTION

Since 2010 – 11, the Adult Mental Health Directorate has collated local data on the rates of suicide in the Cwm Taf region from the National Confidential

Inquiry (NCI) on Suicide and Homicide by people with mental illness. This report to the Health Board references large sections of the recent Annual Report

in October 2016 1.

Information on all general population suicides (i.e. deaths by intentional self-

harm and deaths from undetermined intent) by individuals aged 10 and over is collected from the Office for National Statistics (ONS). To identify patients (i.e.

1 The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2016) Making Mental

Health Care Safe: Annual Report 2016. Manchester: University of Manchester






15 June 2017

individuals who died by suicide within 12 months of mental health service contact) national data are submitted to mental health services in each

individual’s district of residence or district of death and adjacent districts. Detailed clinical data are obtained for these individuals via a questionnaire sent

to the consultant psychiatrist.

This report is based on findings reported for the local authority regions of

Rhondda Cynon Taf and Merthyr Tydfil which includes all suicide and open verdicts. This report also included data on deaths within the Cwm Taf region of

people non-resident to the area.

3. ASSESSMENT / GOVERNANCE AND RISK ISSUES

The National Confidential Inquiry (NCI) helpfully produce a national report to

benchmark regions in the United Kingdom every year and there is a focus in Wales within the report.

In October 2016, the NCI produced a report examining the 10 year period

between 2004 and 2014.

For Wales the headlines were: There was a drop in suicide rate from 2012 in males and the overall

numbers Cwm Taf region remains the highest rate in Wales at 13.7 deaths per

100,000 population over 2012 -2014. This rate was 13.6 deaths in 2012






15 June 2017

Compared to the specific rates for other countries, Wales is 11.1 deaths per 100,000 population. Scotland is 14.6 and Northern Ireland 18.0.






15 June 2017

For Crisis Resolution Home Treatment teams (CRHT) in Wales the NCI report that there was an average 5 deaths per year. There was also an overall

increase in the number of suicides under CRHT teams with a rise in 2009 and a substantial fall in 2011.

17 (33%) who committed suicide while under the care of a CRHT died within 3 months of hospital discharge, the majority (11, 65%) within 2

weeks. Eight (14%) had been non-compliant with drug treatment in the month

before suicide and 23 (41%) patients lived alone. There was concern that the rise in suicides of patients under the care of

CRHT between 2008 -2010 was due to premature discharge and paralleled a reduction in inpatient suicides but this has not proved to be

the case over time. More research is required in this area.

Patient suicide: number under Welsh crisis resolution home treatment services

In relation to substance misuse in Wales between 2002 and 2011, the overall

number of patient suicides with a history of alcohol or drug misuse did not change, although numbers have increased since 2008 and the NCI estimate

further rises in 2012.






15 June 2017

Patient suicide: number with a history of alcohol or drug misuse in Wales (2002-12)

For Wales, and the United Kingdom in general the suicide rate peaks in the

middle-age group as below.

In relation to Cwm Taf we have obtained local data from the NCI over the

last 6 years and report these statistics based upon the date of the actual incident as below. Our aim is to develop a rolling statistical analysis to present

to the Health Board annually because the last year of reporting is always subject to review. This is due to some outcomes not received by the NCI in

time for the annual report and for the reasons reported at the introduction

regarding the epidemiological pattern for suicide.






15 June 2017

Suicide and open verdict rates for Cwm Taf region from 2010/11 to 2015/16 2 3

Suicide rates by gender for Cwm Taf region from 2010/11 to 2015/16

2 Source: NCI University of Manchester: requested by P D Davies

3 For general population figures, NCI only have complete data on deaths registered (rather than by date of

death) up until the end of June 2016. For patient figures, there may still be unconfirmed cases for the most recent years. Therefore, these figures may change at a later date.

0

5

10

15

20

25

30

35

40

45

2010 2011 2012 2013 2014 2015

Male

Female

All






15 June 2017

% Total in Contact with services for Cwm Taf region from 2010/11 to 2015/16

Recent male suicides have dropped significantly to 16 in 2014/15 and this has been sustained in 2015/16 although at this stage that may be reviewed as

outcomes of Coroners hearings and checks are made by the NCI. However, on the face of it, there is a significant drop in suicide of men which was previously

demonstrating a worrying trend upwards.

Open verdicts have been reported as nil for 2012-2013; a significant reduction on previous years. However this has now risen to 7 for 2014/15 and 5 for

2015/16.

In relation to the percentage of patient suicides in contact with services, there

has been a reduction in Cwm Taf from 29% in 2010/11 to 19% in 2015/16. This latest % is now 5 percentile points below the 10 year average for Wales as

reported below by the NCI between 2002 and 2012.

Region Year % of patient suicides

Wales 2002-12 24 England 2002-12 28

N. Ireland 2002-12 28 Scotland 2002-12 30

As with suicide rate, this statistic has to be viewed over longer periods of time

as the variance can be large between years. Small changes in the total number

in absolute terms in Cwm Taf will have a disproportionate effect on our percentage rates due to our relatively small total population compared to other

UHBs.

0

5

10

15

20

25

30

35

40

2010 2011 2012 2013 2014 2015

% in contact with services






15 June 2017

Within Cwm Taf our strategies on reducing suicide and self harm has been focused on two areas:

1) Children and Young People

Work to reduce suicide and self harm among Children and Young People up to 25 years of age which is over seen by the ‘Reduction in Suicide and Self Harm

in Children and Young People Steering Group’.

This multi agency and multi disciplinary steering group was established in 2009 following the launch of the first all Wales suicide and self harm reduction

strategy ‘Talk to Me’. The steering group identified local priorities and established a number of sub groups to address the key issues (see below).

Structure

Reduction of Suicide and Self Harm in Young People Steering Group

Management of Self Harm

Training Delivery Group

Information / Data Collection

Immediate Response Group

(IRG) Protocol

Cwm Taf Safeguarding

Children Board

Safeguarding Training Delivery

Group

The development of the Immediate Response Protocol to deal effectively with local suicides and attempted suicides among young people and the

impact on families, friends etc. as well capturing lessons learnt has been nationally recognised as good practice.

The training group has also developed a package of training for all staff working with children and young people and this training has now been

delivered to over 800 workers from across all statutory agencies and voluntary sector organisations within Cwm Taf.






15 June 2017

Training

Level 2 Attendees (2012 – 2015) (826)

2) Adults

Within the Mental Health Directorate the following is provided to reduce suicide among those people our service comes into contact with:

An open access Crisis Resolution Home Treatment service which is open

to self referrals – this is not the standard approach across Wales but we have always felt it important to ensure timely access for people who feel

desperate and may be suicidal The crisis practitioners provide an assessment service into A&E for people

who present with deliberate self harm and offer follow up and signposting as appropriate for people in need.

We have a walk out protocol in our A&E departments to alert agencies to

patients who may leave the department before an assessment can be completed so that we follow this through depending on initial risk

assessment to ensure their safety We have frequent flyer meetings between CRHT and A&E staff to review

patients who may have multiple presentations to A&E in crisis to review their overall care plan with a view to achieving greater stability and

support. Nationally, 1 in 5 admissions via unscheduled care are related to attempted suicide or self harm.

On our admission ward, we have the Citizen’s Advice Bureau (CAB) surgery as debt and the impact of financial reforms is one of the most

significant triggers for desperation within the local communities and can bring people into contact with our services. MIND have employed a PIP

worker to assist patients subject to benefit reform who are vulnerable to having essential benefits stripped away. Gofal are also commissioned to

provide a ‘Hospital to Home’ service to ensure patients tenancies are

maintained well they are in hospital. We have a mandatory 7 day follow up appointment for patients

discharged from in-patient care.






15 June 2017

We are now delivering Dialectical Behaviour Therapy (DBT) for patients with personality disorder who are at significant risk of self harm. This is in

its first year so is yet to be evaluated locally but this treatment approach is evidence based with recognised positive outcomes for this client group

We have established Outreach and Recovery Community Services (7days

a week) to provide care and treatment for those with most complex needs who can difficult to engage.

Primary Care Mental Health services deliver stepped psycho-social interventions with a view to helping people manage mild to moderate

difficulties and building resilience.

It important to remember that only 19% of those adults who commit suicide have been known to Mental Health Services in the year preceding their death as

reported for 2015/16.

As well as the direct work undertaken by the Mental Health Directorate, the Health Board is supporting several initiatives that we anticipate will also support

a reduction in suicides among adults:

The Valleys Steps project will be heavily promoted to the general population and will aim to be non-stigmatising and easily accessible to hard to reach

groups. Several key aspects of the projects are based on ‘Glasgow Steps’

which has demonstrated best practice on engaging hard to reach groups, in particular, middle aged men who are often isolated and may have co-

occurring substance misuse issues. Targeted promotion of the service and the telephone call back service will support local engagement with the

specific groups where suicide appears to be on the increase.

The Samaritans ‘Valleys Project’ - we have also been supporting the development of a local suicide prevention project being undertaken by the

Samaritans. The project manager is now in plan and is undertaking a local scoping exercise with our support. The project aims to extend the

Samaritans presence into Cwm Taf, raise awareness of they involvement in reducing suicide and recruit local volunteers so that they can deliver a

sustainable local service. Areas we are encouraging them to focus the project on include:

– Engaging the ‘hard to reach’ members of our local population – A highly accessible and visible service to support our crisis and A&E

services and particularly ‘frequent flyers and self harmers’ – Outreach to food banks and other community based services

– ‘Feet on the Street’ – this works well in other welsh town centres and could be piloted in Pontypridd and Merthyr Tydfil

– Work to review ‘hot spots’ such as local railways and bridges – the Samaritans have undertaken this type of work with other Local

Authorities and Network Rail in other parts of Wales.






15 June 2017

3) Strategic Developments

The Health Board has also been involved in attempting to establish a regional Suicide and Self Harm Prevention group (as required within the ‘Talk to Me’ and

Talk to Me 2’ action plans) with Cardiff and the Vale UHB. A highly successful

multi agency conference was hosted by Cwm Taf in July 2014 to support this development. The conference was well represented by health, local authority,

emergency services, the third sector and service users with over 70 participants attending. The key themes that were identified as priorities for the regional

group included: – Training and awareness raising

– Data and information sharing – Communication and signposting

– Prevention and intervention – Managing the consequences of suicide and self harm

Following the launch of the ‘Talk to Me 2’ (June 2015) and its accompanying

action plan, leads from the Cwm Taf, Cardiff and Vale and Aneurin Bevan UHB areas met to confirm arrangements for the South East Wales Regional Multi-

Agency Suicide Prevention Forum (SEWRMASPA).

Locally, developments in relation to reducing suicide and self harm among

adults are fed back via the Cwm Taf ‘Together for Mental Health’ Partnership Board.

4. RECOMMENDATION

The Mental Health Act Monitoring Committee is asked to:

DISCUSS the higher levels of suicide in the Cwm Taf region and the actions aimed at reduction

Freedom of information status

Open






15 June 2017



Mental Health Act Monitoring Committee Annual Report 2016-2017


15 June 2017

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AGENDA ITEM 2.2

15 June 2017


MENTAL HEALTH ACT MONITORING COMMITTEE

DRAFT ANNUAL REPORT 2016-17

Executive Lead: Director of Primary, Community and Mental Health

Author: Head of Corporate Services

Contact Details for further information: [email protected] or 01443 744911


To present to the Mental Health Act Monitoring Committee the draft

Annual Report, that provides an overview of the work undertaken by the Committee during the year and sets out how it met its Terms of

Reference.

Governance

Link to Health

Board Strategic Objective(s)

The Board’s overarching role is to ensure its Strategy

outlined within ‘Cwm Taf Cares’ 3 Year Integrated Medium Term Plan 2015-2018 and the related

organisational objectives aligned with the Institute of


To improve quality, safety and patient experience

To protect and improve population health To ensure that the services provided are

accessible and sustainable into the future To provide strong governance and assurance


available to the Health Board. This report aims to support all of the strategic

objectives.

Supporting evidence

Information from the Committee’s work for 2015/16


The Chair of the Committee, Director of Primary Community and Mental

Health, Mental Health Act Monitoring Committee members and secretariat.

2.2 Mental Health Act Monitoring Committee Draft Annual Report





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Mental Health Act Monitoring Committee Resolution To:

APPROVE √ ENDORSE DISCUSS NOTE

Recommendation Members of the Mental Health Act Monitoring

Committee are asked to: DISCUSS and APPROVE the report for

submission to the Health Board. Complete the Self Assessment

Questionnaire for the Committee (Attached as Appendix 2)

Summarise the Impact of the Mental Health Act Monitoring

Committee Report

Equality and

diversity

This report is a summary of the work of the

Committee over the past year. There are no specific equality and diversity issues

Legal implications There are no specific legal implications

Population Health This report does not impact on population health

Quality, Safety & Patient Experience

This report does not impact on the quality, safety and patient experience although the aim of the

Committee’s work to assure the Board that Mental Health services are performing in

accordance with the Mental Health Act which directly impacts on patient care.

Resources This report outlines the work of the Committee

over the past year

Risks and Assurance The risks and assurance forms the key part of

the Committee’s work over the past year

Health & Care

Standards

The 22 Health & Care Standards for NHS Wales

are mapped into the 7 Quality Themes:

Staying Healthy Safe Care

Effective Care Dignified Care

Timely Care Individual Care

Staff & Resources http://www.wales.nhs.uk/sitesplus/documents/1

064/24729_Health%20Standards%20Framework_2015_E1.pdf

The work of the Committee over the past year reported in this summary takes into account

many of the related quality themes.

Workforce There are no workforce issues in this report


Open








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DRAFT ANNUAL REPORT 2016-17


INTRODUCTION

The Mental Health Act Monitoring Committee is chaired by the Vice Chair

of the Health Board and monitors the Health Board’s compliance with the statutory requirements of the Mental Health Act. The work of this

Committee, including its Terms of Reference, has been reviewed and refreshed during the year and related processes and focus has been

strengthened. This has led to changes to the standard format and agenda for the Committee which has evolved to an agreed position over the year.

A key change to the Committee this year coincided with the University

Health Board move towards a paperless solution to increase transparency

and openness for members of the public to be able to access the business of the Committee. Since December 2016, the papers for the meeting are

routinely shared on the website one week before the meeting is due to take place; papers are available using this link:

http://cwmtaf.wales/mental-health-act-monitoring-committee/ .

The Committee meets on a quarterly basis. Issues are also reported on an exception basis to the Integrated Governance Committee by the

Committee Chair. There is also the opportunity to refer key risks back to the Health Board or through reports from the Committee Chair at full

Board meetings. Broader Mental Health issues are discussed and taken forward via other established fora such as the Together for Mental Health

Partnership Board (which is chaired by the Vice Chair of the Health Board).

MEMBERSHIP

The membership of the Mental Health Act Monitoring Committee comprises both Independent and Executive Members, enabling the

Committee to provide appropriate scrutiny and assurance to the Board independently of the management decision-making processes.

Independent membership during 2016-17 was as follows:

Prof Donna Mead, who also Chairs the meeting Mr Trevor Davis, Associate Board Member (in attendance from

December 2015 meeting and his last meeting was the 19 September 2016).

Executive Director member of the Committee was as follows:

Mr John Palmer, Director of Primary, Community and Mental Health.



http://cwmtaf.wales/mental-health-act-monitoring-committee/



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MEETINGS

The Mental Health Act Monitoring Committee met on 4 occasions during 2016-2017:

16 June 2016 15 September 2016

8 December 2016 16 February 2017.

Mental Health Act Monitoring Attendance 2016-2017

16 June

2016

19 Sept

2016

8 Dec

2016

16 Feb

2017

Meeting

/4

Prof Donna Mead Vice Chair, Cwm

Taf UHB (Chair)

√ √ X √ 3/4

Mr Mel Jehu Independent Member

√ 1st meet

√ √ √ 4/4

Mr John Palmer Director of Primary,

Community & Mental Health

√ √ √ √ 4/4

Mr Trevor Davis Associate Board

member

√ √

(Last)

2/2

Dr Paul Davies

(PhD)

Assistant Director

of Operations

√ √ √ √ 4/4

Supt Jim Dyson South Wales Police √ √ √ X 3/4

DI Peter Thomas South Wales Police X √ √ √ 3/4

Dr Adarsh Shetty Clinical Director X √ X √ 2/4

Mr Phil Lewis Head of Nursing AMH

X √ X X 1/4

Ms Sam Shore Senior Nurse √ X X √ 2/4

Mrs Pamela Connor MHA Administrator √ √ √ X 3/4

Ms Gail Holloman Representative

RCT CBC

√ X X √ 2/4

Mr Mark Anderton Merthyr Tydfil CBC X √ X √ 2/4

Mrs Julie Cude Head of Nursing

CAMHS

X √ √ X 2/4

Dr Tracy Gardiner Clinical Director CAMHS

X X X X 0/4

Mr Gregory Lloyd WAST X X X X 0/4

Ms Jane Treharne Davies

Carer representative

X X X X 0/4

Mr Robert Williams Board Secretary X X √ X 1/4

Miss Gwenan Roberts

Head of Corporate Services

√ √ √ √ 4/4

Miss Kate Bowd Secretariat √ √ X √ 3/4

Ms Chrystelle Walters

Senior Nurse CAMHS

√

Mr Colin Hatherley South Wales Police √

Mr Roger John WAST √

Dr Peter Halford CAMHS √





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During 2016-2017 slight amendments were made to the Terms of Reference in relation to staff ‘in attendance’ at the Committee meetings,

including identifying minimum attendance expectations as follows:

In attendance: Representatives from South Wales Police

Representative from Rhondda Cynon Taf County Borough Council Representative from Merthyr Tydfil County Borough Council

Chair of Mental Health Act Monitoring Operational Group Head Administrator - Mental Health Act Administration Team

Carer Representative from the Together for Mental Health Partnership Board

Representative from Welsh Ambulance Services Trust (minimum

twice per annum) Clinical Director for Mental Health (minimum twice per annum)

Head of Nursing for Mental Health (minimum twice per annum) Clinical Director, Child & Adolescent Mental Health Service (CAMHS)

(minimum twice per annum) Head of Nursing CAHMS (minimum twice per annum)

During the review of the Terms of Reference the those required to ensure

that each meeting was quorate was agreed as: one Independent Member

the Director of Primary, Community and Mental Health or the Assistant Director

a representative from the partner organisations either from the South Wales Police, Local Authorities or the Welsh Ambulance

Services NHS Trust and

at least one clinical representative.

2. BACKGROUND / INTRODUCTION

The purpose of Cwm Taf University Health Board’s Mental Health Act

Monitoring Committee is to ensure that all the requirements of the Mental Health Act 1983 (as amended) are met by the Health Board.

The Committee shall consider:

how the delegated functions under the Mental Health Act are being exercised (for example using the Annual Audit) and in line with the

‘Code of Practice’ requirements the multi agency training requirements of those exercising the

functions (including discussing the training report for assurance) the operation of the 1983 Act within the Cwm Taf area

issues arising from the operation of the hospital managers’ power of discharge

a suitable mechanism for reviewing multi agency protocols / policies relating to the 1983 Act

trends and patterns of use of the Mental Health Act 1983

cross-agency audit themes and sponsor appropriate cross-agency audits





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lessons learnt from difficulties in practice and the development of areas of good practice

Develop an annual report for presentation to the Health Board.

MAIN AREAS OF MHAM COMMITTEE ACTIVITY

The agenda for each meeting has followed a standard format in five main

parts: Part 1 - Preliminary Matters

Part 2 - Items for Discussion Part 3 - Governance, Performance and Assurance

Part 4 - For Information Part 5 - Other Matters.

Part 1 - Preliminary Matters

This section of the meeting provides the standard governance approach

within all sub committees of the Board within Cwm Taf University Health Board. This includes the action log which captures all areas for attention

following the meeting. The Chair provides an oral report at every meeting.

Part 2 - Items for Discussion

This section has included receiving the:

Committee Annual Report Operational delivery plan Section 136 Crisis Concordat

Terms of Reference.

Part 3 - Governance, Performance and Assurance

This section has included papers in a standardised format throughout the year which included:

Mental Health Act – Quarterly Activity Statistical Report Mental Health Crisis Care Concordat

Mental Health Act Breaches / Analysis of Unlawful detention - this

report was changed during the year to assist the reader in identifying the levels of breaches in the categories of the Mental

Health Act (including the Annual Report on 8 December 2016) Risks related to the monitoring of the Mental Health Act (Oral)

In December an oral report on the national approach to reporting Mental Health Act Breaches was received.

During the year a change took place to the reporting of the Mental Health

Crisis Care Concordat and the Health Board and South Wales Police worked together to ensure that the data related to the Mental Health Act

Monitoring was aligned. The Committee also agreed to receive a written report from South Wales Police related to Section 136 at each meeting,

which was very well received by Members.





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The Risk Register for risks identified for this Committee would also be presented within this section of the agenda – no organisational risks from

the Cwm Taf Organisational Risk Register were identified during the year.

Part 4 - For Information

The following items have been shared with the Committee for information sharing purposes:

Adult Mental Health Performance Report received at the Finance, Performance & Workforce Committee (June 2016; September 2016;

December 2016 and February 2017) HIW Inspection Reports (oral report in June 2016)

- Community Treatment Orders (September 2016)

- Joint Health Inspectorate Wales / CSSIW inspection of Learning Disabilities in Merthyr Tydfil (September 2016)

- All Wales overview of Joint HIW/CSSIW inspection of learning disabilities (September 2016)

Mental Health Act 1983 – Code of Practice for Wales Her Majesty’s Inspectorate of Constabulary (December 2016)

CAMHS Performance Report received at the Finance, Performance & Workforce Committee (February 2017)

National Approach to Mental Health Breaches (latest draft) (February 2017).

Part 5 - Other Matters

The ‘Forward Look’ plan for the Committee is reviewed at each meeting to

ensure that it is still targeted at the appropriate risk areas.

Links with Other Committees/Boards

Key risk areas from the Mental Health Act Monitoring Committee can also

be highlighted at Integrated Governance and/or full Board by the Chair of the Committee.

During the course of the year, no matters have been referred to other

Committees.

Key elements are also taken into account at the Quality, Safety and Risk Committee; this linkage is made by the Director of Governance and

Corporate Services / Board Secretary.

Action Log

In order to monitor progress and any necessary follow up action, the

Committee has developed an Action Log that captures all agreed actions. This has provided an essential element of assurance both to the

Committee and from the Committee to the Integrated Governance Committee and the Board.





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GOVERNANCE

The Committee provides an essential element of the overall governance

framework for the organisation and intends to develop its function still further in the forthcoming year. The Terms of Reference for the

Committee provide a robust commitment to monitor the application of the Mental Health Act – these were approved by the Cwm Taf University

Health Board on 18 January 2017 (attached as Appendix 1).

ASSURANCE TO THE BOARD

The Mental Health Act Monitoring Committee wishes to assure the Board that on the basis of the work completed by the Committee during

2016/16, there are effective measures in place to monitor the application of the Mental Health Act and to effectively scrutinise and monitor this

important area.

The position over the last year related to the breaches of the Mental

Health Act has highlighted 84 breaches of the Act, the majority identified as administration breaches. The table below summarises the categories

from the Annual Report of the MHA Breaches.

Cat 1 Cat 2 Cat 3 Cat 4 Frequency 75 6 0 3

Category 1 Administration Breaches within 14 days

Category 2 Incorrect applications of the Act but corrected within14 days

Category 3 Incorrect applications of the Act but not corrected within 14 days

Category 4 Incorrect applications of the Act and not corrected

The number of the most serious Category 4 has reduced from 11 in the

previous reporting period to 3.

All incidents are now reported on Datix and these are investigated and lessons learnt taken into the service. Over the year the Committee have

noted that the consistent theme of simple errors made by medical staff on the application forms would be taken forward by the Clinical Director as an

action for improvement with medical professional staff. It was noted that

the breaches were a mix of errors made by all staff involved in the patient pathway including medical staff, social work staff and administration staff.

This will continue to be an area for focus and determination.





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4. RECOMMENDATION

Members of the Mental Health Act Monitoring Committee are asked to:

DISCUSS and APPROVE the report for submission to the Health Board

Complete the Self Assessment Questionnaire for the Committee (Attached as Appendix 2)

Freedom of

information status

Open





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TERMS OF REFERENCE

INTRODUCTION

The Standing Orders provide that “The Board may and, where directed by

the Welsh Government must, appoint Committees of the Health Board either to undertake specific functions on the Board’s behalf or to provide

advice and assurance to the Board in the exercise of its functions. The Board’s commitment to openness and transparency in the conduct of all

its business extends equally to the work carried out on its behalf by committees”.

In accordance with Standing Orders (and the Health Board scheme of delegation), the Board shall nominate a committee to be known as the

Mental Health Act Monitoring Committee - “the Committee”. The detailed terms of reference and operating arrangements set by the Board in

respect of this Committee are set out below.

CONSTITUTION

The Board hereby resolves to establish a Committee of the Board to be

known as the Mental Health Act Monitoring Committee (The Committee).

The Committee is an Independent Member Committee of the Board and has no executive powers, other than those specifically delegated in these

Terms of Reference.

SCOPE AND DUTIES

The Health Board should determine any necessary arrangements to

monitor and review the way functions under the Act are exercised on its behalf, it may authorise a committee, or sub-committee, for this purpose

with a process of reporting on findings. The Committee shall consider:

how the delegated functions under the Mental Health Act are being exercised (for example using the Annual Audit) and in line with the

‘Code of Practice’ requirements

the multi agency training requirements of those exercising the functions (including discussing the training report for assurance)

the operation of the 1983 Act within the Cwm Taf area





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issues arising from the operation of the hospital managers’ power of discharge

a suitable mechanism for reviewing multi agency protocols / policies relating to the 1983 Act

trends and patterns of use of the Mental Health Act 1983 cross-agency audit themes and sponsor appropriate cross-agency

audits lessons learnt from difficulties in practice and the development of

areas of good practice Develop an annual report for presentation to the Health Board.

AUTHORITY

The Committee is authorised by the Board to:

- investigate or have investigated any activity within its Terms of Reference and in performing these duties shall have the right, at all

reasonable times, to inspect any books, records or documents of the

Health Board. It can seek any information it requires from any employee and all employees are directed to co-operate with any

request made by the Committee - obtain outside legal or other independent professional advice and to

secure the attendance of outsiders with relevant experience and expertise if it considers this necessary, subject to the Board’s

budgetary and other requirements - by giving reasonable notice, require the attendance of any of the

officers or employees and auditors of the Board at any meeting of the Committee.

SCHEME OF DELEGATION

Hospital Managers may arrange for their functions under the Mental Health Act to be carried out on a day to day basis by particular Officers on

their behalf. (COP 11.7) The arrangements for authorising decisions has been set out in a scheme of Delegation and this is included at Appendix

1.

MEMBERSHIP

The 1983 Act is operated by health and social care practitioners, in

collaboration with a range of agencies including police and ambulance services, as well as third sector bodies such as advocacy providers.

Membership of the Committee should reflect this, as different agencies

and practitioners have differing responsibilities and duties under the Act.

The Vice Chair of the Health Board shall Chair the Committee given their specific responsibility for overseeing the Health Board performance in

relation to mental health services and the following shall be members:





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Two Independent Board Members (one of which would be the Chair of the Committee)

Director of Primary, Community & Mental Health

In attendance: Representative from South Wales Police

Representative from Rhondda Cynon Taf County Borough Council Representative from Merthyr Tydfil County Borough Council

Chair of Mental Health Act Monitoring Operational Group Head Administrator - Mental Health Act Administration Team

Carer Representative from the Together for Mental Health Partnership Board

Representative from Welsh Ambulance Services Trust (minimum

twice per annum) Clinical Director for Mental Health (minimum twice per annum)

Head of Nursing for Mental Health (minimum twice per annum) Clinical Director, Child & Adolescent Mental Health Service (CAMHS)

(minimum twice per annum) Head of Nursing CAHMS (minimum twice per annum)

If members are unable to attend, a fully briefed and appropriately senior

deputy should be sent, wherever possible.

Support to Committee Members

The Director of Governance and Corporate Services / Board Secretary, on behalf of the Committee Chair, shall:

determine the secretarial and support arrangements for the Committee;

Arrange the provision of advice and support to committee members on any aspect related to the conduct of their role; and

Co-ordinate the provision of a programme of organisational development for committee members.

COMMITTEE MEETINGS

Quorum

This will comprise of one Independent Member, the Director of Primary, Community and Mental Health or the Assistant Director; a representative

from the partner organisations either from the South Wales Police, Local Authorities or the Welsh Ambulance Services NHS Trust and also at least

one clinical representative.

Frequency of Meetings

Meetings shall be held not less than three times a year. The Committee

will arrange meetings to fit in with key statutory requirements during the year consistent with the Health Board’s annual plan of Board Business.





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Circulation of Papers

Papers will be distributed at least 5 working days prior to each meeting.

REPORTING AND ASSURANCE ARRANGEMENTS

The Committee Chair shall:

report formally, regularly and on a timely basis to the Board on the Committee’s activities. This includes oral updates on activity, the

submission of committee minutes and written reports, as well as the presentation of an annual report;

bring specific attention to any significant matters under consideration

by the Committee via the submission of the minutes as part of the Committee Chairs and Champions Report to the Health Board;

ensure appropriate escalation arrangements are in place to alert the Chair, Chief Executive or Chairs of other relevant committees of any

urgent / critical matters that may affect the operation and / or reputation of the Health Board.

The Director of Governance and Corporate Services / Board Secretary, on

behalf of the Board, shall oversee a process of regular and rigorous self assessment and evaluation of the Committee’s performance and

operation.

RELATIONSHIP WITH THE BOARD AND ITS COMMITTEES /

GROUPS

The Chair of the Mental Health Act Monitoring Committee and the Director of Primary, Community and Mental Health will meet with their

counterparts on the Audit Committee, Quality, Safety & Risk Committee as part of the Integrated Governance Committee on at least an annual

basis to plan the agenda and agree what issues are being considered by each Committee and the timescales involved. A meeting will also be held

to review progress mid year.

The Committee, through the Committee Chair and members, shall

maximise cohesion and integration across all aspects of governance and assurance through the:

- joint planning and co-ordination of Board and Committee business; - sharing of information, as appropriate.

The Committee shall embed the Health Board’s corporate standards,

priorities and requirements, e.g. equality and human rights through the conduct of its business.





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Related (but not reporting) Sub Groups Mental Health Act Monitoring Operational Group

Together for Mental Health Partnership Board

APPLICABILITY OF STANDING ORDERS TO COMMITTEE BUSINESS

The requirements for the conduct of business as set out in the Health

Board’s Standing Orders are equally applicable to the operation of the Committee, except in relation to the Quorum.

REVIEW

These Terms of Reference shall be adopted by the Mental Health Act Monitoring Committee at its first meeting and subject to review at least on

an annual basis thereafter.

Approved by the Board on 18 January 2017



Mental Health Act Monitoring

Committee Draft Annual Report 2015 -2016

Page 15 of 16 Mental Health Act Monitoring

Committee Meeting 16 June 2016

Appendix 1 CWM TAF HEALTH BOARD

Mental Health Directorate Hospital Managers’ Scheme of Delegation

COP 11.7 Hospital Managers may arrange for their functions to be

carried out on a day-to-day basis by particular people on their behalf.

COP 11.8 The arrangements for authorising decisions should be set out in a scheme of delegation approved by a resolution of the

body itself.

Sections of

MHA 1983

Issue/Task Delegated to

4, 2, 3 Admission to hospital: Record of

detention in hospital

MHA Administrator /

Nurse in Charge or Senior Nurse

5(2) Report on hospital inpatient MHA Administrator / Nurse in Charge or

Senior Nurse

21B Authority for detention after absence without leave for more than 28 days

(hospital or community patient)

MHA Administrator

20 Renewal of authority to detain

Hospital Managers Committee,

MHA Administrator

COP 11.15

Ensuring appropriate RC for patient

Clinical Governance Committee

19 Transfer between hospitals under

different managers

MHA Administrator /

Nurse in Charge or Senior Nurse.

19 Transfers into/from guardianship MHA Administrator /


MHA 1983

Part 6

Date of reception of a patient into hospital in Wales

MHA Administrator / Nurse in charge or

senior nurse

MHA 1983

Part 6

Transfer of patient subject to compulsion in the community

MHA Administrator / Nurse in charge or

senior nurse

19A Authority for assignment of

responsibility for a community patient

from one hospital to another under

MHA Administrator



Mental Health Act Monitoring

Committee Draft Annual Report 2015 -2016



Sections of

MHA 1983

Issue/Task Delegated to

different managers

17E Record of detention of recalled

community patient

MHA Administrator /


17F Authority for transfer of a recalled

community patient to a hospital under different managers

MHA Administrator /

Nurse in charge or senior nurse

20A Report extending CT period MHA Administrator

132, 132A,

133

Information for patients and nearest relatives refer to chapter 11 COP for

Wales

MHA Administrator/ Nurse in Charge or

Senior Nurse

S20 Renewal of authority for detention MHA Administrator

68 Referral to MHRT for patients subject to

the Mental Health Act 1983

MHA Administrator

COP 26.27

Responsible Clinician acting as the nominated representative of the

responsible authority

Responsible Clinician

COP

11.35

Informing LHBs and LSSAs of MHRT

hearings so they can consider s117 needs

MHA Administrator

67 Referrals by Welsh Ministers to MHRT MHA Administrator

25 Report barring discharge by Nearest Relative

MHA Administrator

S48 / Schedule

6

Domestic Violence Crime and Victims Act 2004

RC, MHA Administrator



1

BOARD-COMMITTEES: SELF ASSESSMENT CHECKLIST 2016/17

The primary purpose of this annual self assessment is to consider the effectiveness of the Committee. It also includes a section on you and your

role on the Committee. Committee Name - MENTAL HEALTH ACT MONITORING COMMITTEE

Yes

(√)

No

(√)

Don’t

Know

(√)

Comments

Part A (The Committee)

Composition and Establishment

1. Does the Committee have written terms of reference that adequately and accurately define

its role, purpose and accountabilities?

2. Have the terms of reference been adopted by the Board?

3. Are the terms of reference reviewed annually to

ensure they remain fit for purpose?

4. Does the Committee have an annual work plan in place?

If yes, is it reviewed regularly?

5. Has the Committee been provided with sufficient

membership, authority and resources to perform its role effectively and objectively?

6. Does the Committee have the requisite number (4) of Non Officer Members?

7. Does the Committee monitor its attendance?

8. Is the Committee membership appropriate, in terms of available skills, expertise? If no, please elaborate within comments section.

Effective Functioning - Committee

9. Is there effective scrutiny and challenge from all Committee Members?

10. Does the board review the progress and outputs

of the Committee?

11. Does the Committee report regularly to the Board verbally and through minutes and make clear recommendations when necessary?

12. Does the Committee periodically assess its own

effectiveness?

13. Can members give appropriate feedback on the effectiveness of the Chair and the Secretary?

14. Has the Committee determined the appropriate

level of detail it wishes to receive from reports?

15. Does the Committee receive the appropriate level of timely and accurate information to allow it to fulfil its role?

16. Does the Committee have sufficient time to cover its business?

17. Does the committee effectively monitor – or ensure monitoring of - agreed actions? e.g. by use of the action grid

18. Are members particularly those new to the Committee, provided with training?

19. Has the Committee formally considered how it integrates with other committees and groups?

20. Where they exist, does the Committee receive timely and appropriate feedback from its sub-groups ?

2.2.1 Appendix 2 Committee Self Assessment Questionnaire


2

Yes

(√)

No

(√)

Don’t

Know

(√)

Comments

21. Does the Committee provide clear direction to its

sub-groups?

22. Does the Committee produce an Annual Report of its work?

23. If yes (to Q 22) - Do all members contribute to and review the committee’s Annual Report?

Compliance with the law and regulations governing the NHS

24. Does the committee have a mechanism to keep it aware of topical issues?

25. Does the committee have a mechanism to keep it aware of any related legal / regulatory

guidance?

Assurance 26. Does the committee receive timely exception

reports about the work of external regulatory and inspection bodies?

27. Does the committee receive timely information on performance concerns?

28. Are all these reports clear, concise, readily understood?

29. Is the Committee able to refer matters outside its own jurisdiction and if yes, is any feedback reviewed on such matters?

30. If considered appropriate, does the Committee escalate matters to the Integrated Governance

Committee?

31. If considered appropriate, does the Committee

know the process to be followed should it need to escalate matters to the Board?

32. In relation to the Board Assurance Framework and the Organisation’s Risk Register, does the Committee appropriately review the risks assigned to it?

Other Issues

33. Does the committee meet the appropriate number of times to deal with planned matters, development and liaison?

34. Are arrangements in place to call ad hoc meetings when necessary?

35. Are committee members notified of urgent matters when appropriate?

36. Does the committee make the organisation aware of issues of staff capacity and skills that impact on the running of the committee?

Administrative arrangements

37. Is the committee aware of the costs of its operation?

38. Are the Committee’s costs appropriate to the perceived risks and benefits?

39. Are papers circulated in good time and are minutes and agreed actions, received as soon as possible after meetings?

Questions for Consideration & Discussion

40. How does the Committee ensure that its work is fully conveyed to the Board and wider organisation?

41. Is the work of the committee duplicated elsewhere in the organisation? if yes, please elaborate.

42. Do you consider the Committee to be effective in



3

Yes

(√)

No

(√)

Don’t

Know

(√)

Comments

discharging its terms of reference?

43. Do you have any suggestions on how the work of the Committee could be improved or strengthened?

PART B - Effective Functioning - individual members

44. What is your role on the Committee? Non officer member Officer member Executive Director

Senior Manager External stakeholder

Other

45. Do I have sufficient understanding and knowledge of the issues covered within the terms

of reference of the Committee?

46. Do I appropriately challenge Executives and management on critical and sensitive matters?

Please return completed self assessment checklist to Robert Williams

[email protected]




MHA Monitoring Report

Quarter 4 Activity Report Jan-Mar 2017



AGENDA ITEM 3.1

16 February 2017


QUARTER 4 ACTIVITY REPORT FOR

JANUARY 2017 TO MARCH 2017

Executive Lead: Director of Primary Care, Community and Mental Health Services

Author: Assistant Director of Operations (Mental Health) and Mental Health Act Administration team

Contact Details for further information: Dr Paul Davies (PhD)

Assistant Director Operations [email protected] 01443 443700


A report of Mental Health Act (MHA) activity to the Mental Health Act

Monitoring Committee regarding Quarter 4 and (January to March 2017).

Governance


Objective(s)




To improve quality, safety and patient experience.

To protect and improve population health. To ensure that the services provided are

accessible and sustainable into the future. To provide strong governance and assurance.



This report focuses mainly on providing strong governance and assurance.

Supporting evidence

Performance data A glossary of terms is attached at Appendix 1.


Staff in the Mental Health Directorate

3.1 Mental Health Act - Quarterly Activity Statistical Report







Mental Health Act Monitoring Committee Resolution To;


Recommendation The Mental Health Act Monitoring Committee is requested to:

DISCUSS and NOTE the report.

Summarise the Impact of the Mental Health Act Committee Report


No specific equality and diversity issues have been identified.

Legal implications This report presents the local implementation trend of the MHA.

Population Health No specific impact.

Quality, Safety &

Patient Experience

It is necessary to ensure there is no adverse use

of the MHA sections with Cwm Taf UHB

Resources The report is produced quarterly for the Adult

Mental Health MHA Operational group

Risks and Assurance The report does not present any overt risks

Health & Care Standards


Staying Healthy

Safe Care Effective Care

Dignified Care Timely Care

Individual Care Staff & Resources

http://www.wales.nhs.uk/sitesplus/documents/1


The work reported in this summary and related

annexes take into account many of the related quality themes

Safe Care

Dignified Care

Workforce Some added work due to the West Cheshire

judgement (increase in administration)

Freedom of

information status

Open










QUARTER 4 ACTIVITY REPORT FOR JANUARY 2017 TO MARCH 2017

1. SITUATION /PURPOSE OF REPORT

The purpose of this report is to present activity data regarding the application of the Mental Health Act (1983) within Cwm Taf University Health Board. A

glossary of terms is attached for ease of reference at Appendix 1. This report presents the Mental Health Act (MHA) activity to the Mental Health Act

Monitoring Committee in respect of Quarter 4 (January to March 2017) for discussion and scrutiny.

2. BACKGROUND

The report covers both Adult Mental Health and Children and Adolescent Mental

Health (CAMHS) services managed by Cwm Taf University Health Board.

Activity is regularly monitored in the operational (adult) Mental Health

Committee chaired by the Senior Nurse Samantha Shore, supported by the Mental Health Act administration office team and information is reported via the

Assistant Director of Operations to the monthly operational Mental Health Clinical Governance Committee.


IN-PATIENT MHA ACTIVITY

Number of Adult compulsory admission under the Mental Health Act

1983 for Quarter 4 (January to March 2017)







Section Q4 Q3

Section 5(4) 2 0

Section 5(2) 26 17

Section 4 1 4

Section 2 37 33

Section 3 22 22

Section 37 1 0

Section 37/41 0 1

TOTAL 89 77

ADULT DETENTION BY AREA

Area Q4 Q3

Merthyr Tydfil 15 12

Cynon 20 18

Taff 19 14

Out of area 6 3

Rhondda 29 30

Number of Older Persons compulsory admission under the Mental Health Act 1983 for Quarter 4 (January to March 2017)

Section Q4 Q3

Section 5(4) 0 1

Section 5(2) 7 7

Section 4 1 0

Section 2 21 20

Section 3 13 9

Section 37 0 0

Section 37/41 0 0

TOTAL 42 37







OLDER PERSONS DETENTION BY AREA

Area Q4 Q3

Merthyr Tydfil 12 5

Cynon 8 12

Taff 13 11

Out of area 0 2

Rhondda 9 7

Number of CAMHS patients compulsory admission under the Mental Health Act 1983 for Quarter 4 (January To March 2017)

Section Q4 Q3

Section 5(4) 0 0

Section 5(2) 6 1

Section 4 0 0

Section 2 7 2

Section 3 1 2

TOTAL 14 5

Number of ALL patients compulsory admission under the Mental Health Act 1983 for Quarter 4(Section 4, 2 and Section 3 only)

There were 103 detentions in quarter 4 compared to 92 in Quarter 3.







DISCHARGES BY RESPONSIBLE CLINICIANS

Section 23 of the Mental Health Act 1983 provides for the Responsible Clinician (RC) to discharge a detained patient from certain detention orders by giving an

order on a statutory form.

Section Q4 Q3

Adult 2 24 25

4 0 1

3 10 9

Older Persons 2 15 9

4 0 0

3 11 8

CAMHS 2 7 2

4 0 0

3 3 0

TOTAL 70 54

SECTION LAPSING

Section Q4 Q3

Adult 2 1 2

4 0 0

3 0 0

Older Persons 2 0 0

4 0 0

3 0 0

CAMHS 2 0 0

4 0 0

3 0 0

TOTAL 1 2

TRANSFER BETWEEN HOSPITALS

Section 19 of The Mental Health Act allows for the transfer of Part 2 (Section 2, 3 and CTO Patients) and some Part 3 (Section 37,37/41, 47, 47/49 and 48/49)

detained patients from a hospital under one set of managers to a hospital under

a different set of managers. For restricted patients transfers are subject to the prior agreement of the Secretary of State.

SECTION Q4 Q3

Part 2 Patients T0 CTUHB 5 0

Part 3 patients to CTUHB 0 0

Part 2 patients from CTUHB 4 5

Part 3 patients from CTUHB 0 0

TOTAL 9 5







MANAGERS HEARING

Under the provisions of the Mental Health Act 1983, detained patients have a right to have their detention reviewed by the Hospital Managers. The Hospital

Managers responsibilities are as follows:

Undertake a review of detention at any time Must review a patient’s detention when Responsible Clinician (RC) submit

a report under Section 20 renewing detention and community treatment orders

Must consider holding a review when a patient requests it Must consider holding a review when the RC makes a report under

Section 25 (1) opposing a nearest relative application for the patient’s discharge

Hospital Managers Hearing Q4 Q3

Number of review requested by Hospital Managers 0 0

Number of renewal of authority to detain considered by Hospital Managers during the period

15 13

Number of Section 2 hearings requested by patient 2 0

Number of Section 3/37 hearings requested by patient

2 1

Number of Section 2 hearings following RC barring of

application by nearest relative to discharge patient.

0 0

Number of Section 3 hearings following RC barring of

application by nearest relative to discharge patient.

0 1

Number of renewals of CTO considered by Hospital

Managers during this period

8 20

Number of CTO hearings requested by patient 0 0

Number of CTO hearings following RC barring of

application by nearest relative to discharge patient

0 0

Total number of hearing arranged in that period 27 35

Total number of hearing heard in that period 25 28

Total number of hearings arranged in period

that were not heard and reasons: Patient discharged by RC prior to hearing

Request for additional info requested by legal rep Adjourned

Postponed Patient discharged subject to CTO therefore no

longer required Communication error

Transferred prior to hearing Other

1

1

7

3

2

1

1







TRIBUNAL HEARINGS

The Mental Health Review Tribunal for Wales is a statutory body which works independently of the Health Board to review appeal made by detained patients

for discharge from their detention and community orders under the Mental

Health Act 1983. Patients are also referred by the Hospital Managers within define period as set in the MHRT Tribunal rules 2008.

Mental Health Review Tribunal Hearings Q4 Q3

Referrals made by Hospital Managers to MHRT 6 6

Tribunal requested by patient (Section 2) 10 20

Tribunal requested by patient (Section 3/37) 8 7

Tribunal requested by patient (Section 7) 0 0

Tribunal request by patient (Section 37/41) 1 2

Tribunal requested by patient (CTO) 0 0

Tribunal requested by nearest relative 0 0

Referrals by Secretary of State to MHRT 0 0

Total number of MHRT arranged 25 35

Total number of hearings heard 17 14

Total number of hearings not heard and

reasons

Discharged by Responsible Clinician Withdrawn by patient

Transferred prior to hearing Adjourned

8

4 1

1 2

21

13 5

0 3

COMMUNITY ACTIVITY

COMMUNITY TREATMENT ORDER (CTO)

Section Power Q4 Q3

17 A Community Treatment Order made in this quarter

6 5

Community Treatment order extended in

this quarter

6 13

Recalled to hospital and not admitted in

this quarter

1 0

Recalled to hospital and revoked in this quarter

2 2

Discharged from CTO this quarter 6 0

Transferred in this quarter 0 1

There are currently 33 patients subject to CTO







CURRENT COMMUNITY TREATMENT ORDER BY AREA

Q4 Q3

Merthyr Tydfil 7 12

Cynon 8 7

Taff 8 8

Out of area 0 1

Rhondda 10 9

Bridgend 0 0

GUARDIANSHIP

Section 7

Power Q4 Q3

Guardianship made in this quarter 0 0

Discharged from Guardianship 0 0

Renewal of Guardianship 1 1

Guardianship lapsed 0 0

There are currently 3 patients subject to Guardianship

USE OF SECTION 135 AND SECTION 136 - REMOVAL TO A PLACE OF SAFETY

Section 135 of the Mental Health Act Q4 Q3

Assessed and admitted informally 0 0

Assessed and detained under Section 2 2 1



TOTAL 2 1







Section 136 of the Mental Health Act Q4 Q3

Assessed and admitted informally 4 5




Discharged no mental disorder 11 10

Discharged referred to community services 8 10

Other (Recall from CTO) 0 1

TOTAL 29 34

Q4 (January to March 2017) Q3 (October to December 2016)

Gender: Out of 29 Section 136 detention 62%

were male and 38% Were female

Gender: Out of 34 Section 136 detentions 65%

were male and 35% were female

Place of safety:

100 % of patients were taken to hospital as first place of safety

Place of safety:

94% of patients were taken to hospital as first place of safety and

6% to Police Station and subsequently to hospital for assessment.

Use of illicit substances:

4 patients were under the influence of alcohol whilst detained and all were

subsequently discharged as no mental disorder

2 patients were under the influence of drugs whilst detained and one was

admitted under Section 2 and the other discharged and referred to

community services.

1 patient was under the influence of both alcohol and drug and was

subsequently admitted voluntarily to hospital

In 8 cases it was not possible to

ascertain whether under the influence as not documented

Use of illicit substances:

11 patients were under the influence of alcohol whilst detained and 1 was

subsequently detained under Section 2, 2 informally,8 discharged.

2 patients were under the influence of drugs and 1 was subsequently recalled

from CTO and the other detained under Section 2

2 patients were under the influence of

both alcohol and drug both were subsequently discharged

Reasons for detention:

Out of 29 Section 136 66% relates to

direct threats of suicide and 34% relate to aggressive/odd behaviour in

a public place.

Reasons for detention:

Out of 34 Section 136 71% relate to

direct threat of suicide, 23% relate to aggressive/odd behaviour in public

places, 6% directly relate to alcohol consumption.







SECTION 136 DETENTION BY AREA

Area Q4 Q3

Merthyr Tydfil 2 3

Cynon 7 9

Taff 9 9

Out of area 2 3

Rhondda 7 8

camhs 2 2

OTHER ACTIVITY

DEATH OF DETAINED PATIENT

The Mental Health Hospital Managers have a duty to report to Healthcare Inspectorates Wales any patients deceased subject to the Mental Health Act

within 72 hours of death. This applies to in-patients as well as community treatment order and guardianship patients. The Coroner must also be informed.

1 patient passed away whilst subject to Section 2 of the Mental Health Act in

this quarter.

REFERRALS TO INDEPENDENT MENTAL HEALTH ADVOCATE (IMHA) SERVICE FROM HEALTH STAFF

Ward / Area Q4 Q3

Seren 10 12

St. David’s 9 6

Enhanced Care Unit (ECU) 5 7

Fernhill 1 1

Cambrian 0 0

Ward 35 0 1

Ward 7 0 2

Admissions 1 4

Ward 21 3 3

Ward 22 5 3

Psychiatric Intensive Care Unit (PICU) 1 2

Supported Recovery Unit (SRU) 0 3

Pinewood 0 2

TOTAL 35 46

STAFF TRAINING

The Health Board training plan is jointly funded by Health and Local Authorities. The joint budget has been an average of £7,000 per year which provides 6

formal training sessions per year.







Training subject areas Q4 Sessions

held

Q3 – sessions

held

Section 117 aftercare 1

Child and Adolescent Training

MHRT Training

Legal Update

Mental Capacity Act/Deprivation of Liberty Safeguards

DoLS

1

Revision of Code of Practice 1

Medication awareness

Community Treatment Orders

Mental Health Act sections

One to one Hospital Managers Training 1

Power of discharge Hospital Managers 1

Total number of sessions 3 2

3 Training Sessions were held in this quarter in relation to Hospital Managers power and discharge, section 117 aftercare and Hospital Managers Training.

Training attendance

Activity Title Date Approved Attended CTUHB RCTCBC MTCBC Other %

attendance

Changes to the

Code of Practice

in Wales

05/10

/16

80 65 35 22 5 3 80%

MHA/MCA Legal

update plus CTO

19/10

/16

81 61 33 26 2 0 75%

Managers

Hearings-Process

and preparation

04/01

/17

36 26 15 9 2 0 72%

Section 117

Ordinary

Residence

29/03

/17

63 62 32 24 5 1 98%

Training costs

The total cost of joint Mental Health Training for 2016/17 was £4502.15.

4. RECOMMENDATION

The Mental Health Act Monitoring Committee is requested to:


Freedom of

information status

Open







Appendix 1 MENTAL HEALTH ACT (1983)

GLOSSARY OF TERMS

SUMMARY OF COMMON SECTIONS OF THE MENTAL HEALTH ACT 1983 Section 5(4)

Nurse holding

power.

This means that if a nurse feels that a patient suffers from a mental

disorder and should not leave hospital s/he can complete this form

allowing detention for 6 hours pending being seen by doctor or Approved

Clinician

Section 5(2)

Doctor’s or

Approved

Clinician’s Holding

power

This means that an inpatient is being detained for up to 72 hours by a

doctor or Approved Clinician if appears to suffer from mental disorder and

patient wishes to leave hospital.

Section 4

Admission for

assessment in

cases of

emergency

Individual in detained for up to 72 hours if Doctor believes person is

suffering from mental disorder and seeking another Doctor will delay

admission in an emergency.

( 1 Medical Recommendation and AMHP assessment required)

Section 2

Admission for

assessment

Individual is detained in hospital for up to 28 days for assessment of

mental health.

Criteria:

Suffering from mental disorder of a nature or degree which

warrants the detention of the patient in hospital for assessment

And it is necessary that patient ought to be detained in the

interests of own health, own safety, protection of other persons

(2 Medical recommendations and AMHP assessment required)

Section 3

Admission for

Treatment

Individual is detained in hospital for up to 6 months for treatment of

mental disorder.

Criteria:

Suffering from mental disorder of a nature or degree which makes

it appropriate for patient to receive medical treatment in hospital

And it is necessary for the patient’s own heath, safety, protection

of other persons that patient receive treatment in hospital


Section 7

Guardianship

Individual who suffers from mental disorder can be given a guardian to

help them in the community. Guardianship run for six months and can be

renewable.

Criteria:

Live in a particular place

Attend for medical treatment, occupational; education or training at

set places and at set times.

Allow a doctor, an approved mental health professional or other

named person to see patient


Section 37

Guardianship by

Court Order

Court can make an order (6 months) that patient be given a guardian if

needed because of mental disorder.

The guardian is someone from social services.

Criteria:

Live in particular place

Attend for medical treatment, occupational education or training at

set places and times

Allow a doctor or an approved mental health professional or other

named person to see you

(Court Order required)







Section 37/4

Admission to

hospital by a

Court Order with

restrictions

Individual admitted to hospital on the order of the Court. This means that

the Court on the advise of two doctors thinks that patient has mental

disorder and need to be in hospital for treatment. Restrictions are made

by the Court and as such patient cannot leave hospital or be transferred

without the Secretary of state for Justice agreement.

(Court Order with restrictions required)

Section 135

Admission of

patients removed

by Police under a

Court Warrant

Individual brought to hospital by a Police Officer on a warrant from Justice

Of Peace which means that an AMHP feels that individual is suffering from

mental disorder for which s/he must be in hospital. Warrant last for 72

hours.

(Section 135 (1){non-detained patient} warrant required or Section

135 (2){ sections and CTO patients} required)

Section 136

Admission of

mentally

disordered

persons found in a

public place

Individual brought to hospital by Police Officer if found in public place and

appears to suffer from mental disorder.

Assessment by Section 12 Approved Doctor and Approved Mental Health

Professional. Section 136 last for 72 hours.

(Police Force Section 136 monitoring form required)

Section 17 A

Community

Treatment Order

(CTO)

CTO allows patients to be treated in the community rather than detention

in hospital. Order last 6 months and is renewable. There are conditions

attached which are:

Be available to be examined by Responsible Clinician for review of

CTO and whether should be extended.

Be available to meet with Second Opinion Doctor or Responsible

Clinician for the purpose of certificate authorising treatment to be

issued.

The Responsible Clinician may also set other conditions if relevant to

individuals, carers and/or family.

(CTO Form to be completed by Responsible Clinician and AMHP)

Section 17 leave Allows Responsible Clinician (RC) to grant day and/or overnight leave of

absence from hospital to patient liable to be detained under the Mental

Health Act 1983.Leave can have set of conditions attached for the

patient’s protection as well as protection of others. Leave can be limited to

specific occasions or longer-term. There is a requirement for RC to

consider CTO if overnight leave will be over 7 days.

(Section 17 leave non-statutory form required)

Section 117

aftercare

This section applies to persons who are detained under Section, 37, 45 A,

transferred direction under section 47 or 48 and who cease to be detained

after leaving hospital. It is the duty of the Health Board and Local

Authorities to provide aftercare under Section 117 free of charge to

patients subject to the above sections. Patients can be discharged from

Section 117 aftercare if they no longer receiving services.



OFFICIAL

CWM TAF UNIVERSITY HEALTH BOARD MENTAL HEALTH ACT MONITORING COMMITTEE MEETING 15 JUNE 2017

OFFICIAL

Page 1 of 2 AUTHOR TO INSERT GPMS CLASSIFICATION

SUBJECT MENTAL HEALTH REVIEW

GPMS CLASSIFICATION OFFICIAL

REPORT BY PETER THOMAS FORCE ADVISOR ON MENTAL HEALTH

CONTACT OFFICER SUPERINTENDENT ALUN MORGAN

SUMMARY AND PURPOSE OF REPORT Briefing Report for The Mental Health for Cwm Taf University Health Board

RECOMMENDATIONS None

Sir,

I refer to the Mental Health Act Monitoring Committee meeting for Cwm Taf University Health Board on 16th February 2017 and report on the following matters-Crisis Care Concordat, Caswell MOU, The Police and Crime Act 2017, Restraint MOU and Mind Blue Light Programme Wales Concordat On the 23rd May 2017 the steering group met for the first time (21 members) under the chair of James Thomas. Helen Bennett accepted the nomination of chair of the triage/liaison group. The first scheduled meetings for the work streams will commence within 4 weeks of the 23rd May 17. The following are the chairs of the work streams:

Training –James Thomas- AMHP and training officer for Swansea City Social

Services.

Adverse Incident Reporting and Transport- Insp Emma Tyler PSC.

HPOS- Phil Lewis –Director of Nursing CTUHB.

Alternative PoS- Lianne Martyinski, Hafal.

Triage- Helen Bennett



OFFICIAL

AUTHOR TO INSERT MEETING TITLE

OFFICIAL

Page 2 of 2

AUTHOR TO INSERT GPMS CLASSIFICATION

Caswell MOU on Murder/Manslaughter or Attempts

On Friday 19th May 2017 members of the task and finish group met to agree the

final draft of the MOU. The draft will be circulated via the members of the Mental

health Criminal Justice Planning Forum for feedback and sent to Chief

Executives and Assistant Chief Constable Drake for sign off.

Police and Crime Act 2017

On the 3rd May 2017 Chis Witt, Head of Health and Policing at the Home Office

indicated that the earliest timeframe for possible commencement of PACT 2017

will be July 17.

Restraint MOU

A standard operating procedure has been developed from the main document

launched on the 26th January 2017.This is with Dr Gaynor Jones, Chair of the

Mental health Criminal Justice Planning Forum for proof reading before

dissemination.

Mind Blue Light Programme Wales for Emergency Services On 4th May 2017 Keith Bowman from the South Wales Police training department met with Penny Cram from MIND Cyrmu to discuss Blue Light training for police officers and police staff. The training is broken down into 4 areas: 1. Managing for supervisors ( ½ day) 2.Champions Speaking Up/Speaking Out 3.Peer Support 4.Mindfulness,Wellbeing & Resilience (long term) (1/2 Day) The authorization for the training has been approved and the training programme is for first and second line supervisors to identify any signs of mental illness in South Wales Police employees. Training is anticipated to commence in July/August 2017. I attach S136 figures for 2016/17. There has been a small reduction of 4% in detentions compared to 2015/16. I ask that this positional briefing paper be forwarded to Donna Mead, the chair of the Mental Health Act Monitoring Committee for Cwm Taf University Health Board.

Peter Thomas Force Advisor on Mental Health



Mental Health Act Breaches / Analysis of unlawful detention


15 June 2017

AGENDA ITEM 3.3

15 June 2017


BREACHES OF THE MENTAL HEALTH ACT

JANUARY 2017 – MARCH 2017

Executive Lead: Mr John Palmer, Director of Primary Care, Community and Mental Health

Author: Dr Paul D Davies, Assistant Director of Operations (Mental Health) and Mental Health Act Administration team

Contact Details for further information: [email protected]

Tel 01443 443700


A report of Mental Health Act breaches to the Mental Health Act Monitoring

Committee from Quarter 4 (January 2017 - March 2017).

Governance


Objective(s)




To improve quality, safety and patient experience.

To protect and improve population health. To ensure that the services provided are

accessible and sustainable into the future. To provide strong governance and assurance.



This report focuses mainly on providing strong governance and assurance.

Supporting evidence

Performance data Glossary of terms of breaches under the Act included

at page 3.


Staff in the Mental Health Directorate

3.3 Mental Health Act Breaches / Analysis of Unlawful Detention





15 June 2017

Mental Health Act Monitoring Committee Resolution To;


Recommendation The Mental Health Act Monitoring Committee is requested to:


Summarise the Impact of the Mental Health Act Committee Report


No specific equality and diversity issues have been identified.

Legal implications This report presents the local implementation trend of the MHA in terms of breaches.

Population Health No specific impact.

Quality, Safety &

Patient Experience

It is necessary to ensure there is no adverse use

of the MHA sections with Cwm Taf UHB

Resources The report is produced quarterly for the Adult

Mental Health MHA Operational group

Risks and Assurance The report does not present any overt risks

Health & Care Standards


Staying Healthy

Safe Care Effective Care

Dignified Care Timely Care

Individual Care Staff & Resources

http://www.wales.nhs.uk/sitesplus/documents/1


The work reported in this summary takes into

account many of the related quality themes Safe Care

Dignified Care

Workforce None


Open








15 June 2017

BREACHES OF THE MENTAL HEALTH ACT JANUARY 2017 – MARCH 2017


The purpose of this report is to present activity data regarding the application of the Mental Health Act (1983) and breaches in procedures. The report covers

both Adult and CAMHS services managed by Cwm Taf University Health Board.

2. BACKGROUND

Activity is regularly monitored in the operational Mental Health Committee

chaired by Senior Nurse Samantha Shore, supported by the Mental Health Act administration office and reporting to the Assistant Director of Operations and

the monthly Mental Health Clinical Governance Committee.


Members will be aware of the Categories of Breaches of the Mental Health Act:

Category 1 Administration Breaches within 14 days

The MHA administration office quality assures all MHA paperwork accompanying applications under the Act. All paperwork must be submitted to the MHA

administration office as soon as conveniently possible following any application of the act; for example, following an admission for assessment Section 2. A

breach could be simply an unsigned box or incorrect date, but nevertheless important for compliance. If these are quality assured and corrected within 14

days, there is no technical breach.

Category 2 Incorrect applications of the Act but corrected within 14 days

Such breaches are where the Act has been incorrectly applied but has been

picked up by the MHA administration office and corrected.

Category 3 Incorrect applications of the Act but not corrected

within 14 days

Such breaches are where the Act has been incorrectly applied and not been picked up by the MHA administration office in time. This can be corrected later

but technically it is an illegal detention or treatment.

Category 4 Incorrect applications of the Act and not corrected

Such breaches are where the Act has been incorrectly applied and has not been picked up by the MHA Administration office in time. Legal advice must be

sought to establish legality and next step forward which may be potential harm to patient and legal challenge.





15 June 2017

SUMMARY TABLE (JANUARY TO MARCH 2017)

ADULT MENTAL HEALTH

Category Q4

(Jan to March 2017)

Q3

(Oct to Dec 2016)

1 17 17

2 3 2

3 0 0

4 0 1

Resolved Amended within the 14 days time

limit

Other

17 17

Unresolved 3 3

CAMHS

Category Q4 (Jan to March 2017)

Q3 (Oct to Dec 2016)

1 1 0

2 0 0

3 0 0

4 0 0

Resolved Amended within the 14 days time

limit

Other

1 0

Unresolved 0

Members will be aware that the MHA Team is liaising with professionals to avoid such minor errors in Category 1 and regularly report to the operational Mental

Health Act Monitoring Meeting and to the Clinical Director.

The MHA Team Leader also shares data with the counterpart within MHA

Administration and also ensure that breaches relating to Cwm Taf patients placed within other Health Board are also cascaded.

Members should note that it is only recently that Category 1 and 2 breaches

have been reported under Datix and thus only serious breaches such as Category 4 normally come to the attention of Senior Management.





15 June 2017

Mitigating Actions

All Datix reported incidents are investigated and lessons learnt taken into

the service

The consistent theme of simple errors made by medical staff on the application forms will be taken forward by the Clinical Director as an

action for improvement with medical professional staff

Category 4 Breaches - Incorrect application of the Act

The majority of errors relate to the recording of patient’s personal details and medical recommendations which are reported to the Clinical Director. Each case

is reviewed in detail. Grade 4 breaches are low, however specific training in areas has been offered to avoid invalid detentions.

4. RECOMMENDATION

The Mental Health Act Monitoring Committee is requested to:


Freedom of

information status

Open



All Wales Mental Health Act Benchmarking Report

April 2017

Executive Lead: Chief Operating Officer

Author: Head of Operations and Delivery – Mental Health

Financial impact - NA

Quality, Safety, Patient Experience impact -

Healthcare Standard Number 1 and 6 CRAF Reference Number – 8.1.2

Equality Impact Assessment Completed: Not Applicable

RECOMMENDATION The Board/Committee is asked to:

Agree the approach taken by the Mental Health Clinical Board

SITUATION The Welsh Health Board’s responsibilities as Hospital Managers are to ensure compliance with the Mental Health Act. This is formally delegated to UHB staff, particularly mental health staff and mental health act administration departments as per the Hospital Managers' Scheme of Delegation. The Hospital Managers must ensure that patients are detained only as the Act allows, that their treatment and care fully comply with it, and that patients are fully informed of, and supported in exercising, their statutory rights. Hospital Managers must also ensure that a patient’s case is dealt with in line with other legislation which may have an impact. Within this responsibility this paper recaps on how Cardiff and Vale MHCB has explored, made recommendations and has now collated benchmark information in relation to additional measures to provide Health Board Mental Health Legislation Committees with assurance in three specific areas:

1. Invalid detentions under the Mental Health Act - With a proposal that they are all:

consistently reported to allow for monitoring, investigation and improvements,

reported to a standardized definition to allow for comparison and performance management,

investigated to a minimal standard with a standard response to repeated breeches to allow for consistency and fairness of approach.

The overall aim is to have zero invalid detentions.

3.5 National Approach to Mental Health Act Breaches


http://www.cardiffandvaleuhb.wales.nhs.uk/sitesplus/documents/1143/3%203%20Hospital%20Managers%27%20Scheme%20of%20Delegation.pdf

2. A Common Data Set of mental health act activity and compliance – With a proposal of an All

Wales agreement for critical mental health act activity relevant to current service changes to inform management decisions with the aim of sharing this information on a regular basis to allow for benchmarking and improvements to be planned.

3. Errors protocol - a proposed protocol for responding to professionals who make repeated mistakes I relation to the application of the Mental Health Act.

BACKGROUND The Cardiff and Vale General Manager led an initial working group of Mental Health Act Administrator Representatives of C&V, Hywel Dda, Aneurin Bevan and Cwm Taf Health Boards. This was followed by attendance at the all-Wales mental health act administrators meeting for October 2016, where this document was presented on behalf of the UHBs at the initial working group. All UHBs in Wales represented at this meeting. At this meeting agreement was established for the rationale for the data collection but not all UHBs were able to commit to the extent of data collection described in this paper. It was further agreed to circulate an electronic copy of the report for individual UHB mental health act administrators offices to assess their ability to contribute to this routine bi annual data collection exercise with the support of their line managers and/or clinical governance leads. It was suggested and agreed that the core mental health act data collected would initially reflect the collation capacity of the majority of UHBs. This information was copied to mental health service leads for information and support. Cardiff and Vale UHB offered to collate this information from January ‘17 on behalf of the Welsh UHBs and circulate to all UHBs regardless of their ability to collect it to allow for information and ideas exchange. Areas of agreement Reached: 1. Agreed Invalid Detentions Definition The experience of the Health Boards consulted with, were that they are reporting a number of invalid detentions on a regular basis whereby patients have been detained without authority for a number of reasons reported to their Legislation Committees. Some of these incidents have resulted in detention for a number of hours to a number of days/weeks due to procedures not being followed mainly in relation to receipt of an application for admission for assessment or treatment. The information gathered from an analysis of these incidents suggests that reporting could be simplified into two categories in relation to a definition and level of seriousness as follows:

Rectifiable Errors – concerned with errors resulting from inaccurate recording – invalid detention which can be retrospectively validated

Fundamentally Defective Errors – concerned with errors other than the above.

Definition - These two categories were chosen with reference to the Code of Practice (Ch10.15) which states any rectification, or correction, is mainly concerned with inaccurate recording, and it cannot be used to enable a fundamentally defective application to be retrospectively validated. Rectifying or correcting cannot be used to cure a defect which arises because an element of the procedural process leading to the detention has simply not taken place at all. Therefore a form may be ‘incorrect‘, for example, if names, dates or places are mis-stated, but which, if corrected, would not make the decision to admit a patient an unjustified one, and it may be ‘defective’ if the signatory has failed to complete all the sections, or delete alternative options. An unsigned form should not be accepted as rectifiable.



In terms of investigation and reporting of invalid detentions, rectifiable or not, the minimum standard suggested by the working group was to ensure an incident report was completed and a summary provided to the local MHLC at each meet containing:

Numbers

Short description of breech identifying cause

Summary of follow up actions taken to mitigate future risk.

The individual UHBs to discuss implementation of these minimum standards with line managers and Q&S departments. 2. Agreed Common Data Set (See Assessment Section) UHB agreement arrived at WAS to collate a minimum data set, easy to collect, currently available for the majority of UHBs, had existing definitions and would be useful to share. The following more specific reasons for collating core data were:

General Mental Health Act Activity – activity data which reflected the volume of use of the act and therefore could support further questions related to acuity, bed availability, community services capacity etc. With 135/6 data to gauge response to the police concordat and collaboration with partners responding to people in crisis. Useful to subdivide into gender age and speciality to monitor demand and equality.

Rectifiable and fundamentally defective errors – see rationale above in this paper

3. Agreed Errors Protocol Standard Agreement reached to adopt a common approach again to support consistency of application, response and ultimately to support the reduction or absence of people detained unlawfully. ASSESSMENT (See Attached)



1

ASSESSMENT

Benchmarking data October - December 2016:

Cardiff and Vale UHB Hywel Dda HB Cwm Taf HB ABMU UHB

For the purposes of the report, until the process can assure greater

confidence and completeness of data, the activity has been anonymised

3.5.1. Appendix 1


2

Part 2 (Inpatient) MHA Activity

During the period a total of 672 patients were subject to the part 2 provisions of the MHA 1983 across

the four HB’s who provided the data to collate this report.

Adult Acute Older People

0

20

40

60

80

100

120

140

160

180

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Adult Acute Older People CAMHS LD General

Section 5(2)

Section 5(4)

Section 4

Section 3

Section 2

0

20

40

60

80

100

120

140

160

180

1 2 3 4

Adult Acute

Section 5(2)

Section 5(4)

Section 4

Section 3

Section 20

5

10

15

20

25

30

35

40

1 2 3 4

Older People

Section 5(2)

Section 5(4)

Section 4

Section 3

Section 2

3.5.1. Appendix 1


3

CAMHS General

LD

Comments

Wide variation in adult services of use of MH Act

Incomplete data for CAMHS

Opportunity for UHBs to review emergency assessment pathways

0

1

2

3

4

5

6

1 2 3 4

CAMHS

Section 5(2)

Section 5(4)

Section 4

Section 3

Section 2

02468

10121416

1 2 3 4

General

Section 5(2)

Section 5(4)

Section 4

Section 3

Section 2

216, 32%

175, 26%

118, 18%

163, 24%

Total (2,3,4,5(4) & 5(2))

1

2

3

4

0

2

4

6

8

10

12

14

1 2 3 4

LD

Section 5(2)

Section 5(4)

Section 4

Section 3

Section 2

3.5.1. Appendix 1


4

Section 135 & 136

The charts below provide data on how section 135/136 is used across the four HB’s broken down into

specialities, HB’s and total activity across the HB’s.

Comments

Police concordat proving effective with only 1 UHB assessing in custody

Learn from UHB 3 to reduce overall 136 numbers – useful to develop bench mark average

0

10

20

30

40

50

60

70

80

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4


Section 136 (Custody)

Section 136(Hospital)

Section 135

0

10

20

30

40

50

60

70

80

1 2 3 4

Section 136(Custody)

Section136(Hospital)

Section 135

4, 45%

3, 33%

1, 11%

1, 11%

Section 135

1

2

3

4

63, 29%

58, 26% 34, 15%

67, 30%

Section 136(Hospital)

1

2

3

4

Section 136 (Custody)

1

2

3

4

3.5.1. Appendix 1


5

Rectifiable Errors

Rectifiable errors by HB and speciality.

Total Number of rectifiable errors per HB.

Total number of rectifiable errors across the four HB’s.

Comments

Possible reporting issue in UHB 4

Wide UHB variation across age groups in all UHBs to help with clinical governace

investigation

Case for consistency with the investigation and approach to rectifiable errors – opportunity for

exchange of training information

Help to support with parameters after further data points collected

0

10

20

30

40

50

60

70

80


1

2

3

4

0

20

40

60

80

100

120

140

1 2 3 4

40, 17%

79, 33% 118, 49%

3, 1%

1

2

3

4

3.5.1. Appendix 1


6

Fundamentally Defective

Number of fundamentally defective applications by speciality and HB.

Total number of fundamentally defective applications per HB

There were a total of 11 fundamentally defective applications across the four HB’s.

0

0.5

1

1.5

2

2.5

3

3.5

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4


Section 5(2)

Section 5(4)

Section 4

Section 3

Section 2

0

1

2

3

4

5

6

7

1 2 3 4

Section 5(2)

Section 5(4)

Section 4

Section 3

Section 2

4, 36%

6, 55%

0%

1, 9%

1

2

3

4

3.5.1. Appendix 1


7

Comments

Incomplete data UHB 3

Issues for training in the DGH

Low numbers across UHBs

Hospital Managers Activity

Hospital managers’ hearings arranged during the period by speciality and HB.

Total number of hearings arranged by HB.

A total of 167 managers hearings were arranged across the four HB’s.

0

10

20

30

40

50

60

70

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4


Discharged by HM's

Review of Papers

Barring Hearings

Renewal Hearings

Application by patient

0

10

20

30

40

50

60

70

1 2 3 4

Review of Papers

Barring Hearings

Renewal Hearings

Application bypatient

3.5.1. Appendix 1


8

Hospital Managers across the all HB’s did not exercise their power of discharge during the period.

MHRT Activity

Total numbers of Tribunals arranged during the period.

A total of 223 tribunal hearings were arranged across the four HB’s.

59, 35%

55, 33%

35, 21%

18, 11%

1

2

3

4

0

10

20

30

40

50

60

70

80

90

1 2 3 4

Referral by Welsh Ministers

Referral by MOJ

Referral on behalf of HM's

Application by patient

81, 36%

61, 27%

35, 16%

46, 21% 1

2

3

4

0

1

2

3

4

5

1 2 3 4

Discharged by MHRT

1

2

3

4

3.5.1. Appendix 1


Mental Health Act (1983) section 117 - Aftercare

Internal Audit Report

2016/17

Cwm Taf University Health Board

Private and Confidential

NHS Wales Shared Services Partnership

Audit and Assurance Service

4.1 Internal Audit Report on Mental Health Act S117 for review and monitoring from Audit Committee


Mental Health Act (1983) section 117- Aftercare Report Contents


NHS Wales Audit & Assurance Services Page | 2

CONTENTS Page

1. Introduction and Background 3

2. Scope and Objectives 3

3. Associated Risks 4

Opinion and key findings

4. Overall Assurance Opinion 5

5. Assurance Summary 6

6. Summary of Audit Findings 7

7. Summary of Recommendations 9

Review reference: CTU1617.12

Report status: Final Fieldwork commencement: 9 January 2017

Fieldwork completion: 8 February 2017

Clearance meeting: 27 February 2017

Draft report issued: Management response received:

28 February 2017 14 March 2017

Final report issued: 16 March 2017

Auditors: Ian Virgill, Lucy Jugessur

Executive sign off: John Palmer, Director of Primary, Community

& Mental Health

Distribution: Paul Davies, Assistant Director of Operations

Pamela Connor, Team Leader

Debra Pennell, Directorate Support Manager

Committee: Audit Committee

ACKNOWLEDGEMENT

NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this review.

Please note:

This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee.

Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance Services, and addressed to Independent Members or officers including those designated as Accountable Officer. They are prepared for the sole use of Cwm Taf University Health Board and no responsibility is taken by the Audit and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third party.

Appendix A Appendix B

Management Action Plan Assurance opinion and action plan risk rating



Mental Health Act (1983) section 117 - Aftercare Internal Audit Report



1. Introduction and Background

Our review of the management of Mental Health Act (1983) section 117 - aftercare procedures was completed in line with the 2016/17 Internal

Audit Plan for Cwm Taf University Health Board (the ‘Health Board’).

The relevant lead Executive Director for the review is the Director of

Primary, Community & Mental Health.

Section 117 of the Mental Health Act (1983) (the ‘Act’) provides a legal

right to aftercare services for anyone who has been detained under the following sections of the Act:

Section 3 – admission to a hospital for treatment;

Section 17A – release of a detained patient, subject to a Supervised

Community Treatment order;

Section 37/41 – power of courts to order hospital admission or

guardianship;

Section 45A – power of higher courts to direct hospital admission;

Section 47 – removal to hospital of persons serving sentences of

imprisonment; and

Section 48 – removal to hospital of other prisoners when they cease to

be detained and leave hospital.

The duty to provide aftercare services under section 117 applies when a

patient ceases to be detained and leaves hospital. The duty also applies to detained patients on periods of Section 17 leave.

The Act places an enforceable joint duty upon the Health Board and the local Social Services Authority, in co-operation with any relevant voluntary

organisation, to provide aftercare services for certain categories of mentally disordered patients who have ceased to be detained in hospital

or prison if they have spent part of their sentence detained in hospital.

Aftercare services under section 117 can include almost anything that

helps the patient to live in the community, such as help with accommodation, social care support, or day centre facilities. The purpose

of providing free aftercare is to try to prevent an individual’s condition

deteriorating to a point where they need to be readmitted to hospital.

2. Scope and Objectives

The objective of our audit was to evaluate and determine the adequacy of the systems and controls in place for the management of section 117

arrangements, in order to provide assurance to the Health Board’s Audit Committee that risks material to the achievement of the system’s

objectives are managed appropriately.

The purpose of this review was to provide assurance to the Audit

Committee that the Health Board has adequate procedures in place to






ensure that all relevant patients are appropriately assessed in order to

establish their eligibility for free aftercare services and all eligible patients receive appropriate services.

The main areas that the review sought to provide assurance on were:

there is a formally documented policy and procedure in place for the

management of section 117 arrangements;

the Health Board maintains an accurate register of all patients who

are subject to section 117 aftercare;

patients subject to section 117 are appropriately assessed before

being discharged from hospital;

a care plan, stating the services to be provided, is produced for

patients who are identified as being eligible for aftercare;

eligible patients actually receive the aftercare services that have been

identified;

on-going regular reviews of patient’s requirements for aftercare are

carried out in conjunction with Social Services;

an appropriate reassessment of need is carried out before section 117 services are removed from any patient and appropriate reasons

for the removal of services are identified and recorded; and

periodic reports on the management of section 117 are produced

and submitted to management and Health Board groups for appropriate review and action.

3. Associated Risks

The potential risks considered in the review were:

patients who are eligible for section 117 aftercare are not identified;

eligible patients do not receive appropriate aftercare; and

patients continue to receive aftercare when it is no longer required.






OPINION AND KEY FINDINGS

4. Overall Assurance Opinion

We are required to provide an opinion as to the adequacy and

effectiveness of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives

within this report. An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the

identified risks associated with the objectives covered in this review.

The level of assurance given as to the effectiveness of the system of

internal control in place to manage the risks associated with the management of the Mental Health Act (1983) section 117 - Aftercare is

Reasonable Assurance

Reason

ab

le

assu

ran

ce

- +

Yellow

The Board can take reasonable assurance that arrangements to secure

governance, risk management and internal control, within those areas under review, are suitably designed and applied

effectively. Some matters require management attention in control design or

compliance with low to moderate impact on residual risk exposure until resolved.

There were a number of issues identified with the management of Mental Health Act (1983) section 117 – Aftercare.

The policy for the implementation of the Act confirms the processes that need to be followed with regards to section 117 patients. However, there

were instances whereby the policy was not being complied with as initial meetings were not held within two – four weeks of the section application.

In addition, the policy confirms the documentation that should be completed for these meetings and the correct paperwork was not always

completed.

‘Termination of Aftercare’ forms are not always being sent to the central mental health office for the Mental Health Act administrator to update the

section 117 register. In addition, one form was not signed by the responsible clinician within the Health Board as authorisation to remove

section 117 aftercare from the patient.

Section 117 meetings are held regarding the administration processes but

the minutes are not being reported to any Health Board Groups.

The overall level of assurance that can be assigned to a review is

dependent on the severity of the findings as applied against the specific review objectives and should therefore be considered in that context.

More detailed findings can be found within section 6 of this report under: Summary of Audit Findings and the Action Plan, at Appendix A.






5. Assurance Summary

The summary of assurance given against the individual objectives is described in the table below:

Assurance Summary

1

There is a formally

documented policy and procedure in place for section 117

2 The Health Board maintains an accurate register of all

section 117 patients

3

Patients subject to section

117 are appropriately assessed before being discharged from hospital

4

A care plan is produced for patients who are identified

as being eligible for aftercare

5

Eligible patients actually receive the aftercare

services that have been identified

6 On-going regular reviews of patient’s requirements for aftercare are carried out

7

An appropriate reassessment of need is

carried out before section 117 services are removed

8

Periodic reports on the management of section

117 are produced and submitted to management and Health Board groups

* The above ratings are not necessarily given equal weighting when generating the audit

opinion.






Design of Systems/Controls

The findings from our review have highlighted one issue that is classified as a weakness in the system control/design for the management of Mental

Health Act section 117 - Aftercare.

Operation of System/Controls

The findings from our review have highlighted six issues that are classified as weakness in the operation of the designed system/control for the

management of Mental Health Act section 117 - Aftercare.

6. Summary of Audit Findings

Objective 1: There is a formally documented policy and procedure in place for the management of section 117 arrangements

We identified the following good practice:

The Health Board has produced a policy for the implementation of

section 117 of the Mental Health Act in collaboration with Merthyr Tydfil County Borough Council and Rhondda Cynon Taf. The policy was

approved in May 2014 and is due to be reviewed in May 2017.

We identified the following significant finding under this objective:

There have been some amendments to the Act and therefore the

policy for the implementation of section 117 of the Mental Health Act is out of date and needs revising.

Objective 2: The Health Board maintains an accurate register of all patients who are subject to section 117 aftercare

We identified the following area of good practice:

The Mental Health Act administrator maintains a database of all

mental health patients which records the section they are subject to and also if they are subject to section 117 aftercare.

We did not identify any significant findings under this objective.

Objective 3: Patients subject to section 117 are appropriately

assessed before being discharged from hospital

We identified the following significant findings under this objective:

4/20 sampled section 117 patients did not have an initial meeting

within two - four weeks of the section application being made, which is not in accordance with the policy for the Implementation of section

117 of the Mental Health Act.

We identified 12 cases where incorrect documentation was used in the

initial meetings.






Objective 4: A care plan, stating the services to be provided, is

produced for patients who are identified as being eligible for aftercare


Our testing confirmed that care plans are produced for the patients

whilst they are in hospital and they are reviewed throughout the patients stay.


From the sample of 20 patients reviewed, two had no documentation

held on the electronic shared drive.

Objective 5: Eligible patients actually receive the aftercare

services that have been identified

We identified the following significant findings under this objective:

Following discharge from hospital, the Swift database is utilised by the Community Mental Health Teams (CMHTs) to record all patients that

are under section 117. From the sample of 12 patients reviewed, there

were 2 that were not recorded on the Swift database as section 117 patients.

We checked the care plans for a sample of patients to confirm that aftercare was being provided as detailed in the care plans. One patient

had passed away on the 5 November 2016 but records had not been updated and the patient was still on the Swift system.

Objective 6: On-going regular reviews of patient’s requirements for aftercare are carried out in conjunction with Social Services


We reviewed the patients that had been discharged into the

community to confirm that regular reviews were undertaken with them. It was evident from the patient’s records that the Care

Coordinators visit the patients more often than stipulated in the policy. Furthermore, the Care and Treatment plan review paperwork

was updated where required and this was evidenced with the copies of

the documentation held on the patient’s files.

We did not identify any significant findings under this objective.






Objective 7: An appropriate reassessment of need is carried out

before section 117 services are removed from any patient and appropriate reasons for the removal of services are identified and

recorded


Patients are only removed from section 117 services if it is considered that they no longer require secondary services. Reassessments are

undertaken prior to the patients being removed from the section 117 database.


Our review of six ‘Termination of Aftercare’ forms identified that one

had not been signed by the responsible clinician on behalf of the Health Board. In addition, two forms had not been sent to the Mental

Health Act administrator to record in the section 117 register.

Objective 8: Periodic reports on the management of section 117

are produced and submitted to management and Health Board

groups for appropriate review and action


A section 117 meeting is held which is an administration meeting where administration processes are reviewed and any queries that

administration team leaders may have are reviewed within this forum.


The section 117 meeting minutes are not reported to any other forum such as the Clinical Governance Board or Board and no other reports

on the management of section 117 requirements are produced.

7. Summary of Recommendations

Our audit findings and recommendations are detailed in Appendix A together with the management action plan and implementation timetable.

A summary of these recommendations by priority is outlined below.

Priority H M L Total

Number of recommendations

1 5 1 7



Mental Health Act (1983) Section 117 - Aftercare Action Plan


NHS Wales Audit & Assurance Services Appendix A

Finding 1 – Initial meeting following section application (Operational) Risk

The policy for the implementation of section 117 of the Mental Health Act

identifies that an initial meeting should be held with the patient within two – four weeks of the section application.

We tested a sample of twenty patients and note that four did not have an initial meeting undertaken within the required two – four weeks of the section

application being made. Of the four patients identified:

Two patients’ initial meetings were undertaken five weeks after the

section application was made.

One patient’s initial meeting was seven weeks after the section application was made.

One patient’s initial meeting was 15 weeks after the section application was made.

For the sample of patients we also checked that the correct Mental Health Measure (MHM) Care and Treatment Planning form was completed for the initial

meeting, in line with the policy for implementation of section 117 of the Mental Health Act. We noted 12/20 instances where the MHM Care and Treatment

Planning form wasn’t completed but a Care and Treatment Plan (CTP) form was completed instead. This is the form that should be utilised to ensure that

regular planned reviews take place.

Eligible patients do not receive

appropriate aftercare.

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Recommendation 1 Priority level

Management should ensure that the policy for the implementation of section

117 of the Mental Health Act is complied with and initial meetings are held

within two - four weeks of the section application.

Management should ensure that the Care Treatment Plan review form should

be completed for the initial meetings as per the Policy for Implementation of Section 117 of the Mental Health Act.

High

Management Response 1 Responsible Officer/ Deadline

Initial Meeting between 2-4 weeks – As per Cwm Taff CTUHB policy should be

implemented into practice.

Reminder to all Consultant and Team Managers to reinforce good practice that

all initial meetings take place within 4 weeks.

Reminder to be sent to all Consultants and Team Managers to reinforce the use

of the CTP/S117 Review form for all S117 reviews that take place. A Copy of the required CTP/S117 Review Form will be attached to e-mail.

Lynne Garwood – 6.3.17 (sent)

Lynne Garwood – 6.3.17 (sent)


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Finding 2 – Policy for Implementation of Section 117 of the Mental Health Act

(Design) Risk

The policy for the implementation of section 117 of the Mental Health Act was agreed and approved on the 21 May 2014 and is due to be reviewed in May

2017.

However, we note that there have been some amendments to the Act,

including the process to be followed upon the death of a section 117 patient,

and therefore the current policy is already out of date and requires revising to be in line with the Mental Health Act.

Eligible patients do not receive appropriate aftercare.


Management should review and update the policy for the implementation of

section 117 of the Mental Health Act in line with the changes with the Mental Health Act.

Medium


S117 Policy is currently under review and has included all amendments under the most recent Mental Health Code of Practice. This Policy will need to be

ratified via the Policies and Procedures Group and then taken through Clinical Governance for final ratification.

Lynne Garwood on behalf of the Mental Health Directorate –

Policy updated within 1 month – 6.4.2017

Ratified within 2 months – 6.5.2017


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Finding 3 – Maintenance of documentation (Operational) Risk

Copies of all section 117 patients’ documentation, including the initial assessment and on-going care plans, should be maintained on the Health

Board’s electronic ‘w’ shared drive.

We tested a sample of twenty patients and note that:

for one of the patients sampled there was no care plan in place and there was no other documentation held on the shared drive for the patient; and

a second patient did not have an initial meeting on file and there was no other documentation on the shared drive for the patient.

Eligible patients do not receive appropriate aftercare.


Management should ensure copies of all paperwork is maintained on the shared drive as evidence that the appropriate meetings are held and that the required

documentation such as care plans are being completed in line with the Policy for Implementation of Section 117 of the Mental Health Act.

Medium


The Mental Health Directorate works with over 3 different IT systems within inpatient and community settings. Local authority does not have direct access

to the health W drive for saving documentation. The number of IT systems in use has already been highlighted as a significant risk on the Directorate’s Risk


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Register.

Reminder to be sent to all health staff ensuring that all patient documentation is uploaded and saved onto the W drive. This is to be done by ensuring admin

team leaders reinforce this within teams and information taken to Community

Mental Health Team Meetings. An e-mail will also be sent to ward managers to ensure that documentation is uploaded and saved onto the W Drive. Local

authority staff will continue to save information to the Swift ESR system.

New Policy will make reference to the new patient information system WCCIS

which will be introduced into community teams over the next 6 months and will be used in the community by health and social services. Inpatient services are

likely to go to WCCIS in 2018.

D Pennell – 17.4.17

Suzanne Claridge – 6.4.17


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Finding 4 – Maintenance of patient records in the Community (Operational) Risk

Following discharge from hospital, section 117 patients should be recorded on

the Swift database within the Community Mental Health Teams (CMHTs). We selected 15 section 117 patients that had been discharged into the community

to check that they were appropriately recorded on the Swift database as section 117 patients. However, our testing identified two patients that were not

recorded on the Swift database as section 117 patients.

In addition, we checked the care plans for the patients and that after care was

being provided as detailed on the care plans. Our testing identified that one

patient had passed away in November 2016 but, at the time of our audit fieldwork in January, CMHT records had not been updated, and as such the

patient was still on the Swift system.

Eligible patients do not receive

appropriate aftercare.


Management should ensure that all section 117 patients are recorded correctly on the Swift database as section 117 patients.

Management within the Community Mental Health Teams should update their records when a patient has passed away including updating the Swift

database. Furthermore, a Termination of Aftercare form should be completed

and sent to the Mental Health Team so that records can be updated.

Medium


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Reminder sent to all Managers and staff reinforcing the need to forward all

relevant information to Business Support with regard to updates on S117

status. Admin Team Leaders to reinforce this in Community Mental Health Team Meetings

D Pennell – 6.4.17


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Finding 5 – Removal of services for patients (Operational) Risk

The policy for the Implementation of section 117 of the Mental Health Act

confirms that a ‘Termination of Aftercare’ form needs to be completed if a

person no longer requires aftercare. A section 117 review meeting should be carried out to assess the patient that includes a representative from the Local

Authority and the Health Board.

We tested 6 patients in the CMHTs that no longer receive section 117 aftercare

to establish if the appropriate assessment had been undertaken and agreed by a representative from the Local Authority and a responsible clinician from the

Health Board.

Whilst ‘Termination of Aftercare’ forms had been completed for all 6 patients,

one form had not been signed by the responsible clinician on behalf of the Health Board. In addition, two forms had not been sent to the Mental Health

Act Administrator to record in the section 117 database that they no longer require aftercare.

Patients continue to receive

aftercare when it is no longer

required.


Management need to ensure that all ‘Termination of Aftercare’ forms are signed by appropriate personnel in line with the policy for the Implementation of

section 117 of the Mental Health Act. In addition, the forms should be sent to the Mental Health Act Administrator so that the section 117 database and the

patient records / Myrddin are updated appropriately.

Medium


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A Termination Form is in place and gives clear direction for discharge from

S117.

A reminder with a copy of the Termination of Aftercare Form is to be

recirculated to all Consultants and Team Leaders.

This will also be reinforced through Clinical Governance.

Lynne Garwood – 6.4.17


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Finding 6 – Section 117 meetings (Operational) Risk

The policy for Implementation of Section 117 states that the section 117

process will be monitored for effectiveness by the section 117 steering group,

but we were not provided with any agendas or minutes of the steering group to confirm that monitoring was being carried out.

However, Team Managers and Consultants are given regular reports showing which patients are on section 117.

Furthermore, an ad hoc section 117 meeting is held which is an administration meeting where processes are reviewed and any queries that the Administration

Team Leaders may have are discussed within this forum. However, this meeting does not report upwards into any other health board groups or

committees and no other reports on compliance with section 117 requirements are produced.

Patients continue to receive

aftercare when it is no longer

required.


The management of section 117 patients should be effectively reported and monitored and the minutes of section 117 meetings should be formally reported

into an appropriate Health Board group or committee for review and action.

Medium


Discussed in Directorate Management Team Meeting on the 28th February 2017. Agreed to reinstate the S117 Steering Group that will report directly back to

the Directorate Management Team Meeting and the Mental Health Act

Lynne Garwood

Debra Pennell – 6.4.17


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Monitoring Group on a quarterly basis. Quarterly reports will also be sent to

Clinical Governance. The Admin S117 meeting will now be incorporated within the S117 Steering Group Meeting.


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Finding 7 – Recording of section 117 patients (Operational) Risk

We selected a sample of 20 patients that were subject to section 117 according

to the database maintained by the Mental Health Act Administrator and reviewed the Myrddin Patient Management System to check that the patients

had been appropriately flagged as being subject to section 117 on Myrddin.

We note that three of the 20 patients reviewed were not recorded as being

subject to section 117 on Myrddin.

Patients who eligible for section 117

aftercare are not identified.


Management should ensure that patient information recorded on the Myrddin

Patient Management System appropriately reflects their section 117 status. Low


Procedure for recording S117 patients on Myrddin to be developed and audits

will be undertaken.

It has also been agreed that a 6 monthly audit of S117 clients will be developed

and undertaken by the Directorate and fed back accordingly through Audit Committee.

D Pennell 6.4.17

Lynne Garwood – 6.4.17


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Mental Health Act (1983) Section 117 - Aftercare


Action Plan

NHS Wales Audit & Assurance Services Appendix B

Audit Assurance Ratings

Substantial assurance - The Board can take substantial assurance that

arrangements to secure governance, risk management and internal control, within those

areas under review, are suitably designed and applied effectively. Few matters require

attention and are compliance or advisory in nature with low impact on residual risk

exposure.

Reasonable assurance - The Board can take reasonable assurance that


areas under review, are suitably designed and applied effectively. Some matters require

management attention in control design or compliance with low to moderate impact on

residual risk exposure until resolved.

Limited assurance - The Board can take limited assurance that arrangements

to secure governance, risk management and internal control, within those areas under

review, are suitably designed and applied effectively. More significant matters require

management attention with moderate impact on residual risk exposure until resolved.

No Assurance - The Board has no assurance that arrangements to secure

governance, risk management and internal control, within those areas under review, are

suitably designed and applied effectively. Action is required to address the whole control

framework in this area with high impact on residual risk exposure until resolved

Prioritisation of Recommendations

In order to assist management in using our reports, we categorise our recommendations

according to their level of priority as follows.

* Unless a more appropriate timescale is identified/agreed at the assignment.

Priority

Level

Explanation

Management

action

High

Poor key control design OR widespread non-compliance

with key controls.

PLUS

Significant risk to achievement of a system objective OR

evidence present of material loss, error or misstatement.

Immediate*

Medium

Minor weakness in control design OR limited non-

compliance with established controls.

PLUS

Some risk to achievement of a system objective.

Within One

Month*

Low

Potential to enhance system design to improve efficiency or

effectiveness of controls.

These are generally issues of good practice for

management consideration.

Within

Three

Months*



Royal College of Psychiatrists Review Follow up

Final Internal Audit Report

2016/17


Private and Confidential

NHS Wales Shared Services Partnership

Audit and Assurance Service

4.2 Internal Audit Report - Royal College of Psychiatrists Review Follow up


Royal College of Psychiatrists Review Follow up Report Contents



CONTENTS Page

1. Introduction and Background 3

2. Scope and Objectives 3

3. Associated Risks 3

Opinion and key findings

4. Overall Assurance Opinion 4

5. Assurance Summary 5

6. Summary of Audit Findings 6

7. Summary of Recommendations 7

Review reference: CTU1617.13

Report status: Final Fieldwork commencement: 23 November 2016

Fieldwork completion: 10 January 2017

Draft report issued: Draft report clearance meeting:

Management response received:

24 January 2017 30 January 2017

3 February 2017 Final report issued: 3 February 2017

Auditors: Ian Virgill, Liz Vincent

Executive sign off: John Palmer, Director of Primary, Community

& Mental Health

Paul Davies, Assistant Director of Operations

Distribution: Adarsh Shetty, Clinical Director

Philip Lewis, Head of Mental Health Nursing

Committee: Audit Committee

ACKNOWLEDGEMENT

NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation given by management and staff during the course of this review.

Please note:

This audit report has been prepared for internal use only. Audit & Assurance Services reports are prepared, in accordance with the Service Strategy and Terms of Reference, approved by the Audit Committee.

Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit and Assurance Services, and addressed to Independent Members or officers including those designated as Accountable Officer. They are prepared for the sole use of Cwm Taf University Health Board and no responsibility is taken by the Audit and Assurance Services Internal Auditors to any director or officer in their individual capacity, or to any third party.

Appendix A Appendix B

Management Action Plan Assurance opinion and action plan risk rating



Royal College of Psychiatrists Review Follow up Final Internal Audit Report



1. Introduction and Background

Our review of progress against the Royal College of Psychiatrists (RCP)

report was completed in line with the 2016/17 Internal Audit plan for

Cwm Taf University Health Board (the ‘Health Board’).

In December 2014 the Health Board invited the RCP Invited Review

Service (IRS) to carry out a review of the current model of acute mental health services for adults of working age. The particular matters on which

guidance was sought were:

gate-keeping for the admission of emergency adult patients;

management of sub-specialty patients; and

overall clinical responsibility for patients on an assessment ward.

The IRS’s fieldwork was carried out in April 2015 with a formal report to the Health Board in June 2015. The report included a total of eight specific

recommendations for implementation by the Health Board, and three more general recommendations around the effective operation of the

Admission Unit.

2. Scope and Objectives

The overall objective of our review was to provide the Health Board with

assurance over the actions that have been taken to address the recommendations made in the IRS report.

The scope of our review did not aim to provide assurance against the full scope and objectives of the original IRS review. Our follow up review

opinion provides an assurance level against the implementation of the agreed recommendations only.

The main areas that our review sought to provide assurance on were:

that an appropriate action plan was developed to address the

recommendations from the IRS review;

the action plan was subject to appropriate communication and

approval;

appropriate progress has been made with the implementation of the

agreed actions identified to address the recommendations;

adequate evidence is available to support the level of progress; and

the actions implemented have effectively addressed the

recommendations identified in the IRS report.

3. Associated Risks

The potential risk considered in our review was:

the risks identified in the IRS review that resulted in the agreed

recommendations are not effectively addressed.






OPINION AND KEY FINDINGS

4. Overall Assurance Opinion

We are required to provide an opinion as to the adequacy and

effectiveness of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives

within this report. An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the

identified risks associated with the objectives covered in this review.

The level of assurance given as to the effectiveness of the system of

internal control in place to manage the risks associated with the findings from the IRS review is Reasonable Assurance.

Reaso

nab

le

assu

ran

ce

- +

yellow

The Board can take reasonable

assurance that arrangements to secure governance, risk management

and internal control, within those areas under review, are suitably

designed and applied effectively. Some matters require management

attention in control design or compliance with low to moderate

impact on residual risk exposure until resolved.

An appropriate action plan was developed by the Directorate to focus on

the recommendations identified in the original IRS Review. The plan included details of the actions required to address the 8 recommendations

and 3 commentaries that were included in the IRS report. Details of the delegated leads and target dates for completion of the actions were also

included on the plan.

The action plan was subject to appropriate approval by the Mental Health Clinical Governance Committee and was communicated to the September

2015 meeting of the Cwm Taf Clinical Governance Committee.

The latest version of the action plan, updated in November 2016 states

that all the agreed actions have been completed and through our discussions with management we were assured that sufficient progress

has been made in addressing the original report findings. However we were unable to obtain evidence to fully verify the stated progress for 4 of

the 8 recommendations.

Our review has confirmed that the completed actions have effectively

addressed the majority of the recommendations from the original IRS report. However there is one action, relating to the consideration of the

staffing levels within the unit, that we are unable to confirm has fully addressed the IRS recommendation.






The overall level of assurance that can be assigned to a review is dependent on the severity of the findings as applied against the specific

review objectives and should therefore be considered in that context.

Our detailed findings can be found within section 6 of this report and the Action Plan, at Appendix A.

5. Assurance Summary

The summary of assurance given against the individual objectives is

described in the table below.

Assurance Summary

1

An appropriate action plan was developed to address the recommendations from

the IRS review

2

The action plan was subject

to appropriate communication and

approval

3

Appropriate progress has

been made with the implementation of the agreed actions identified to

address the recommendations

4 Adequate evidence is available to support the

level of progress

5

The actions implemented

have effectively addressed the recommendations identified in the IRS report

* The above ratings are not necessarily given equal weighting when generating the audit

opinion.

Design of Systems/Controls

The findings from our review have highlighted no issues that are classified

as a weakness in the system control/design for the IRS review follow-up.

Operation of System/Controls

The findings from our review have highlighted 3 issues that are classified as a weakness in the operation of the designed system/control for the IRS

review follow-up.






6. Summary of Audit Findings

In this section we highlight areas of good practice that we identified

during our review. We also summarise the findings made during our audit

fieldwork.

Objective 1: An appropriate action plan was developed to address

the recommendations from the IRS review

We identified the following areas of good practice:

a sufficient action plan has been developed to focus on the recommendations from the IRS Review; and

the Health Board’s plan contains details of the actions identified to address all 8 recommendations and the 3 commentaries that were

made within the report. Actions within the plan have identified lead officers and implementation target dates.

We did not identify any findings under this objective.

Objective 2: The action plan was subject to appropriate

communication and approval

We identified the following areas of good practice:

the action plan was formally approved by the Mental Health Clinical

Governance Committee; and

the action plan was included in the July – September 2015 quarterly

Mental Health Directorate exception report that was presented to the Health Board’s Clinical Governance Committee.

We did not identify any findings under this objective.

Objective 3: Appropriate progress has been made with the

implementation of the agreed actions identified to address the recommendations

We identified the following good practice:

the Health Board’s November 2016 action plan identified that 7 of the

8 recommendations had been completed. Our discussions with management have confirmed that the recorded status is accurate and

the agreed 7 management actions have been appropriately implemented.

We identified the following finding under this objective:

the agreed action identified to address recommendation 10.6 (relating to re-visiting the Assessment Unit operational policy) from the original

IRS report has not been fully completed.






Objective 4: Adequate evidence is available to support the level of progress


we were unable to obtain documented evidence to fully verify and support the stated level of progress for 3 out of 8 recommendations.

Objective 5: The actions implemented have effectively addressed the recommendations identified in the IRS report


we are unable to confirm that the action implemented in relation to

recommendation 10.8 (relating to consideration of the Medical staffing of the treatment Units) from the original IRS report has fully addressed

the finding. There is currently no evidence to confirm the outcome of the implemented action.

7. Summary of Recommendations

Our audit findings and recommendations are detailed in Appendix A

together with the management action plan and implementation timetable.

A summary of these recommendations by priority is outlined below:

Priority H M L Total

Number of recommendations

0 3 0 0



Royal College of Psychiatrists Review Follow up Action Plan



Finding 1 – Documented evidence to support actions (Operational) Risk

The Health Board developed an action plan to address the recommendations raised in the IRS report. The action plan was approved by the Mental Health

Clinical Governance committee, and progress against the actions has been monitored by the Head of Nursing and the Assistant Director of Operations.

Our review of the Health Board’s action plan and our discussions with management has identified that 7 of the 8 agreed actions have been

completed. However, the action relating to recommendation 10.6 has not been fully completed and there was limited documented evidence to support the

Health Board’s assessment of ‘completed’ for 3 out of the 8 actions.

Our findings for the 4 actions where there was limited documented evidence

are set out below:

Recommendation 10.2

The numbers of medical staff in the Assessment Unit (AU) should not fall below three at any time.

Agreed action

Introduce a system of escalation if the number of medical staff in the AU falls below 3 in working office hours.

Internal Audit follow up

The system of escalation is for management to consider either using locum

cover or moving other staff into the AU to address any shortfall.

While the Head of Nursing confirmed that staff members have been verbally

The risks identified in the IRS review that resulted in the agreed



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advised of the system there is currently no documented procedure or flowchart

supporting this new process.

Recommendation 10.4

The quality and timeliness of the information received by the Assessment Unit

when patients are admitted should be regularly reviewed by the Ward Manager and the Assessment Unit consultant. Deficiencies in either quality or timeliness

of this information should be reported as an untoward event.

Agreed action

Ward Manager to include the recommendation to the 'trigger list' with trends reported to the Health Board’s Clinical Governance meeting.


The ‘trigger list’ identified within the agreed action has not been developed.

However, we note that incident trends are reported to the Mental Health Clinical Governance Committee, and we understand that staff members have

been told to ‘incident report’ any issues around information not getting to the Assessment unit. However, there is no documented evidence to confirm that

this has been discussed with staff members.

Recommendation 10.6

The numbers of admissions from CAMHS, learning disability services and older

adults’ services should be regularly monitored. Clear written care pathways for the management of sub-specialty patients admitted to the Assessment Unit

should be developed.

Agreed action

To revisit the Assessment Unit Operational policy to include more narrative and


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clarity regarding the pathways for CAMHS, learning disability and Older Adults.


We were unable to find any reference to learning disability in the Assessment

Unit’s updated Operational policy.

Recommendation 10.8

The Board may wish to consider the medical staffing of the treatment units:

provision of a more consistent or permanent presence of medical staff on those units (at consultant and specialty doctor level) may improve the throughput of

those wards. These doctors would also be available on site to cope with surges in demand from the AU, which, as has been previously noted, occurs at

unpredictable intervals.

Agreed action

The Clinical Director would discuss and advice if necessary.


The Head of Nursing confirmed that the recommendation was considered by the Assistant Director of Operations (ADO) and discussed with the Clinical Director.

However, there is no documented evidence to show that this occurred or the outcome of the discussion.


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Management should ensure that appropriate procedures and / or other

documented evidence are in place to fully support the level of progress against these recommendations.

Management must also ensure that action 10.6 is completed as soon as possible and consider formally reporting completion of the action plan back to

the Mental Health Clinical Governance Committee.

Medium


The issues of escalating concerns regarding medical staffing levels; recognising the trigger to incident report untimely or poor quality documentation and

reference to Learning difficulties will be added to the Admission Ward

Operational Policy and ratified through Clinical Governance.

The Directorate management Team will agenda a discussion regarding Consultant cover on the Treatment Wards and if felt that this is the direction of

travel will make recommendation to the Board.

Assistant Dir of Operations / Clinical Director / Head of MH Nursing

31st March 2017

Assistant Dir of Operations / Clinical

Director / Head of MH Nursing

28th February 2017


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Finding 2 – Discrepancy in reported figures (Operational) Risk

Evidence to support the agreed actions relating to IRS recommendations 10.1 (audit of admissions), 10.3 (review of non-face to face assessments), and 10.5

(data definitions when reporting to Welsh Government) is recorded within the Crisis Resolution Home Treatment (CRHT) data template that is submitted to

Welsh Government. The figures recorded should be the same as those within the Health Board’s dashboard that is reported to the Clinical Board Meeting

(CBM).

We compared a sample of 5 figures relating to referrals for crisis assessment

from the North and South from the data submitted to Welsh Government in April, June and September 2016 to the corresponding CBM dashboards to

establish if the information was consistent.

While the majority of the sampled figures were consistent, we identified a

difference between the June figures for the South relating to:

face-to-face admissions which were out by 1 (12/13); and

telephone admissions and follow-up assessments which were out by 10

(18/8).

We were unable to confirm why the differences had occurred.

However, our testing has confirmed that the requirement of the Health Board to complete the follow-up assessments for all telephone admissions within 24

hours was complied with in all cases.

The risks identified in the IRS review that resulted in the agreed



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Management should ensure that there is a system in place to cross check the

figures before submitting to Welsh Government and the Clinical Board Meeting.

Management should review the June figures and make the necessary

adjustments to the crisis assessment data if appropriate.

Medium


June figures will be reviewed and appropriate steps taken to remedy difference.

To explore possibility of using QLIK sense to manage the data in order to

reduce opportunity for human error when moving data from one template to

another.

Head of MH Nursing

28.02.17

Head of MH Nursing

31.03.17


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Finding 3 – Actions not addressing the recommendations (Operational) Risk

Recommendation 10.8 from the original report stated that ‘The Board may wish

to consider the medical staffing of the treatment units: provision of a more

consistent or permanent presence of medical staff on those units (at consultant and specialty doctor level) may improve the throughput of those wards.’

The November 2016 action plan records the required action as ‘Clinical Director to discuss and advice if necessary’. This action is recorded as ‘complete’ and, as

highlighted in finding 1 above, the Head of Nursing has confirmed that discussions took place.

However, while we acknowledge that the recommendation is of a ‘light touch’, it appears that the completed action does not address the ‘spirit’ of the

recommendation and may not therefore fully address the original report finding.

In addition, we were unable to confirm the outcome of the discussion to understand if any further actions were identified.

The risks identified in the IRS review

that resulted in the agreed



Management must review the appropriateness of the agreed action to ensure that the original finding from the RCP report has been addressed.

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The Directorate management Team will agenda a discussion regarding

Consultant cover on the Treatment Wards and if felt that this is the direction of

travel will make recommendation to the Board.

Assistant Dir of Operations / Clinical

Director / Head of MH Nursing

28th February 2017


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Royal College of Psychiatrists Review Follow up


Action Plan

NHS Wales Audit & Assurance Services Appendix B

Audit Assurance Ratings

Substantial assurance - The Board can take substantial assurance that


areas under review, are suitably designed and applied effectively. Few matters require

attention and are compliance or advisory in nature with low impact on residual risk

exposure.

Reasonable assurance - The Board can take reasonable assurance that


areas under review, are suitably designed and applied effectively. Some matters require

management attention in control design or compliance with low to moderate impact on

residual risk exposure until resolved.

Limited assurance - The Board can take limited assurance that arrangements

to secure governance, risk management and internal control, within those areas under

review, are suitably designed and applied effectively. More significant matters require

management attention with moderate impact on residual risk exposure until resolved.

No Assurance - The Board has no assurance that arrangements to secure

governance, risk management and internal control, within those areas under review, are

suitably designed and applied effectively. Action is required to address the whole control

framework in this area with high impact on residual risk exposure until resolved

Prioritisation of Recommendations

In order to assist management in using our reports, we categorise our recommendations

according to their level of priority as follows.

* Unless a more appropriate timescale is identified/agreed at the assignment.

Priority

Level

Explanation

Management

action

High

Poor key control design OR widespread non-compliance

with key controls.

PLUS

Significant risk to achievement of a system objective OR

evidence present of material loss, error or misstatement.

Immediate*

Medium

Minor weakness in control design OR limited non-

compliance with established controls.

PLUS

Some risk to achievement of a system objective.

Within One

Month*

Low

Potential to enhance system design to improve efficiency or

effectiveness of controls.

These are generally issues of good practice for

management consideration.

Within

Three

Months*



Agenda Item 5.1

Forward Look Mental Health Act Monitoring Committee

Page 1 of 2

Mental Health Act Monitoring Committee Meeting 15 June 2017

Mental Health Act Monitoring Committee: Forward Look 2017/18

15 June 2017 at 2.00pm Ynysmeurig House Abercynon

Standard Items:

Mental Health Act Breaches / Analysis of unlawful detention Director of PC&MH

Mental Health Act Monitoring Report – Quarterly Activity Statistical Report Director of PC&MH

Mental Health Crisis Care Concordat to include: update paper on progress to date South Wales Police

Risks related to Mental Health Act Monitoring Assistant Dir.Ops

Annual Report on Suicides Assistant Dir.Ops

Additional Items:

Invite Ian Wile to present the National Benchmarking data on Breaches Director of PC&MH

Receive the Internal Audit on the Mental Health Act S117 for review and monitoring from Audit

Committee 3 April 2017 Internal Audit Report - Royal College of Psychiatrists Review Follow up

Board Secretary

Receive an update from SWP on HMIC inspection report South Wales Police

Update on Suicide (Annual Report) Director of PC&MH

Committee Annual Report Board Secretary

14 September 2017 at 2.00pm Ynysmeurig House Abercynon

Standard Items:





Additional Items:

Annual Report Board Secretary

5.1 To review

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Agenda Item 5.1

Forward Look Mental Health Act Monitoring Committee

Page 2 of 2

Mental Health Act Monitoring Committee Meeting 15 June 2017

7 December 2017 at 2.00pm Ynysmeurig House Abercynon

Standard Items:





Additional Items:

Terms of Reference Director of Governance /Board

Secretary

NB - Urgent items will be accommodated as required and the Forward Look is subject to change.

Quarterly items Annual review of the Terms of Reference in line with the Standing Orders to take place in December 2017

Items to consider

Receive national benchmarking data on MHA Breaches when available Receive update paper from South Wales Police on the new Police and Crime Act requirements when available

5.1 To review

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