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Our general concerns

We followed up on care and treatment concerns for 25% of those individuals we visited. This section provides more detail about the issues that concerned us. These were:

  • quality of documentation
  • de facto detention
  • operation of specified persons regulations

Quality of documentation

In most areas documentation of care and treatment was of a good standard. However, of all the problems we encountered issues with documentation were the most widespread. For some individuals there was no current care plan in place, or the standard of the care plan fell far short of what might be expected.

"There were very sparse nursing notes, with little of relevance to the person's current needs. The only care plan I was able to identify was one dated 2004 for personal hygiene. When discussed this with the senior nurse at a follow up visit 2 weeks later everything was in place"

Other concerns included the lack of entries from responsible medical officers  in the case notes. Sometimes there was poor documentation of the names of the people attending weekly review meetings. This makes it impossible to identify who was involved in the decisions being made regarding a person's care plan.

On occasion staff did not put their names after their signatures, although others had a system in place for identifying signatures. In some areas key - or named nurses had not differentiated their one to one sessions with patients from general nursing notes, or had not recorded attempts to see a patient one to one when the session had been refused.

Our visitors noted that in some case notes routine assessments had not been completed long after they had been started. In other notes there was no way of knowing who had completed a form, or on what date, and although there was a place for the signature of the patient, they had not signed it, and there was no note to indicate whether the patient had refused.

We were pleased to find that most NHS Boards now have a comprehensive patient information sheet that provides easily accessible information about the individual's status. These sheets record, for example, whether an individual is detained, if so when the order is due to expire, when and how the person's rights were explained to them, who their named person is, whether they have an advance statement or an advocate, and so on.

Some services have not implemented this approach and information that is important for the wider care team to know is not readily available in an individual's file.  We found variation in practice, not just across Scotland but also within single NHS Board areas and within individual services. While one hospital or ward would be using a mental health act information form, in another this would not be the case.

We recommend that all wards in all appropriate hospitals use a form that records all mental health act details in one easy to access place.

'De facto' detention

Where individuals meet the criteria for compulsory treatment in hospital they should be given the full safeguards provided by treatment under the Mental Health (Care & Treatment)(Scotland) Act 2003.  During our visits to people on short-term detention we occasionally noted that staff have written "detainable if wishes to leave" or similar, in an individual's notes.In the worst cases, notes did not even identify whose decision this was, when it was to be reviewed, or whether it has been discussed with the patient.

Even with these details, it is our view this type of statement is not acceptable.It increases the risk of a patient's rights being overlooked such that they become "de facto" detained (detained with no legal authority and without the safeguards of the law). If the RMO considers that compulsion may not be necessary and wishes to avoid continued use of the mental health act, but is still concerned that the individual may not always comply, then a written plan should be in place detailing what should happen if the patient expresses the wish to leave the ward. It may then be appropriate to record a statement in the notes such as:

"Requires to be reassessed if wishes to leave. Use of nurses holding power may be required".

This statement should be explained to the individual and, where appropriate, to his or her advocate.If the patient is unhappy with this situation, consideration should be given to whether their status as an informal patient accurately reflects their needs. If possible, the RMO should document his or her assessment of the grounds for detention at that time.

Unless an appropriately qualified nurse feels that the patient meets the criteria for the use of the nurse's holding power, an informal patient who wishes to leave the ward has that right. We will continue to review this aspect of patient care on their future visits.

Application of specified person regulations

The 2003 Act sets out the circumstances under which an individual can:

  • have regular restrictions placed on their use of a telephone, and their correspondence;
  • be subject to regular searches of their person and belongings;
  • have blood or urine samples taken to screen for drug and alcohol use.

The regulations, which cover these parts of the act, give criteria which have to be met in order for the person's RMO to make them a "specified person". This is the essential step before any specific restrictions can be applied to an individual. For people who are detained in the State Hospital all these restrictions are in place automatically. For those in medium secure facilities - currently Rowanbank and The Orchard Clinic, the "safety and security" restrictions are in place automatically. Restrictions on telephones and correspondence still have to be individually applied.

In many situations, it is expected that hospital and ward policies will be in place to cover a number of issues such as whether mobile phones are allowed and under what circumstances any in patient can be searched. However, we found a number of examples of people on STDC being required to submit to routine urine screening without being made a specified person, particularly in NHS Greater Glasgow and Clyde and NHS Tayside.

"the person is subject to urine screening for possible misuse of drugs and alcohol. Not a specified person. This was raised with nurse on the day but will be followed up with a letter to the RMO"

At the other end of the scale, we found wards where everyone who was detained was automatically a "specified person" and subject to random urine screening or searching without there being any evidence whatsoever to support the action of the staff.

We have contacted the relevant care teams to follow up on our concerns and will be issuing guidance on the operation of specified person regulations in 2010.

Other concerns that we raised during our visits and which we have followed up on have mostly been discussed earlier in this report. These were:

  • access to and awareness of advocacy;
  • lack of clarity on whether the short term detention certificate is going to progress to a compulsory treatment order, at quite a late stage in the admission;
  • environmental issues;
  • lack of evidence that service-users had been told of their rights.