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Privacy, dignity and identity

The 2003 Act spells out the principles that should be taken into account by anyone carrying out functions under the Act.Not least of these is the principle of non-discrimination. Services need to ensure, unless it can be shown that it is justified in all the circumstances, that a patient is not treated in a way that discriminates against them on the basis of their mental illness.Individuals should be treated with dignity at all times and allowed as much privacy as is safe and conducive to their recovery.They should be able to express themselves and their individual identity, background and characteristics, including sexual orientation, religious persuasion, cultural, ethnic or racial origin, without fear of prejudice or less favourable treatment. Commission visitors asked a range of questions intended to elicit how service users felt these principles were being exercised.

We asked people whether they had a single bedroom.The majority (86%), did and exactly the same number of people told us they had a safe place to keep possessions. It is hard to understand why services cannot manage to provide a safe place in which to leave personal possessions.Many people (58%) told us their rooms had been searched, some on a periodic basis.Half of these people told us they had not been given a reason for the searches although we recognise that a significant number of people would be subject to regulations under the act which permit the searching of rooms and possessions under certain circumstances. We discuss this at a later point in the report.

"He said he felt "singled out" for search and urine tests after visits, but these stopped when he spoke with the ward manager"

Nearly everyone we spoke to agreed that there was sufficient privacy in the bathroom and toilet areas, but 3 of the 5 people who disagreed were from Rowanbank, a new purpose built hospital.

Most individuals also agreed that they were able to keep in touch with people outside the hospital, although for a variety of reasons ten people expressed some difficulties with this. Over a third of all individuals interviewed told us there was no access to a private telephone

Forty of the people we interviewed told us there was a limit in their ward on the number of personal items they are allowed to keep in their room.Some had a limit of 10 DVDs and 10 CDs; others told us they were allowed no more than 7 changes of clothes. Yet in other similar wards individuals told us they were not aware of any restrictions.Whilst available space may dictate a limit, it seems odd that in some hospitals set blanket policies based on arbitrary limits, whilst in others, sensible arrangements or negotiations, which can take into account differences in personality and identity, prevail.

Feeling safe

When we asked if people felt safe, we were told that at one time or another 14 people told us they did not feel safe in the ward environment.Women were three times more likely to say they did not feel safe.

"I feel safe, only sometimes"

"I get bullied sometimes"

"There was an attitude on the ward, but I spoke to the team leader and things improved"

Risk assessment and management

With regard to assessment and risk management plans, the majority of staff we spoke to told us there was a process to ensure each patient had a plan in place. For many wards, risk assessment is incorporated into the care planning process and more than half of individuals we spoke to are subject to the care programme approach.

Plans are regularly reviewed in all wards. Where a multidisciplinary system is in place, there is regular input from social work and psychology and staff in 18 of the wards reported that family members regularly attend reviews.

Implementation of Specified Persons Regulations, restrictions on correspondence and use of telephones

The regulations of the 2003 Act provide for a compulsory patient to be designated as a 'specified person' in relation to the protection of the safety and security of themselves and others, their use of the telephone and for the withholding of correspondence.

All individuals in medium secure units, are "specified persons" in relation to safety and security - as set out in the regulations. In all other facilities the use of the regulations should be determined on an individual basis and by the Responsible Medical Officer (RMO) making a "reasoned opinion" as to the necessity of designating an individual as a "specified person". The regulations cover matters such as searching of individuals, their rooms and belongings, and visitors, restrictions on the use of telephones and on the sending and receiving of correspondence. Individuals can be a specified person in respect of any or all of the regulations.

We asked the nursing staff five questions under this heading. The answers were varied and demonstrated different understanding and interpretation of Sections 281-286 of the Mental Health Care and Treatment Act and its associated regulations.We were told that there were 97 people across all units who were "specified". It is clear from the data that many staff are unclear about the regulations and their implementation and that searches of individuals and restrictions on the use of telephones in particular are being carried out in the absence of the appropriate authority. It is also clear that where specified persons regulations are implemented in relation to safety and security, that in many cases, this is being applied in a blanket fashion and not on an individual basis. Some staff within the medium secure facilities reported that they had no patients who were "specified".

Room searches

Following on from our findings in relation to individual views around privacy, dignity and identity, as expected, room searches were being carried out in a variety of ways. The range varied from random, weekly searches, to monthly in response to incidents. In at least 5 wards it would appear that these searches are being carried out in the absence of any designation of specified persons whether by blanket regulation or individual reasoned opinion.

Two units reported that they did not carry out room searches unless there was an incident to suggest the need for it.We thought this was a positive approach and an example of minimum restriction of freedom that other units could learn from.

Use of phones

Again the interpretation of what was offered in respect of phone use varied. Of the 26 wards visited, 20 said they had no policy on the use of phones, and some of these had restrictive practices in place with no evidence of proper use of legislation.

We also found very different practices in units of similar type. For example, we were advised by individuals on our visits that in one medium secure unit private calls were allowed, while in another similar unit, people told us that they were observed during calls. This may reflect the differing levels of security within the units, or the lack of understanding on the part of individuals and staff of the restrictions authorised by "specified person" status.

In one hospital the number of calls made by individuals in a day, and the length of calls are restricted.

Mobile phones

In terms of telephone use (S284-285), use of mobile phones is not currently covered.However, we thought it useful to include our findings.

In all medium secure units mobile phones were not allowed because of concerns regarding misuse of phones with cameras. In most low secure units, mobile phones were not allowed on the ward for the same reason but very few wards or units had a policy written about this. Some allowed mobile phones to be used when out of the unit but not all followed this practice.

Internet use

No unit visited allowed internet use. However, some people could access the internet when out at college. A number of units are reviewing whether access is possible but report issues with IT security.

Restriction of correspondence

The implementation of this is much more clearly understood, perhaps because the ability to restrict people correspondence has formed part of previous mental health acts. However, it is concerning to note that in one setting (not a medium secure setting) all patients have to open their letters in front of staff.