The Care Quality Commission’s work, values, approach and impact are obviously very important to wards. Their reputation took a real hammering over the shocking treatment at Winterbourne View but the feeling we’re picking up from the sector, and strongly sensing ourselves, is that recent changes of senior personnel and their awesome new mental health team are starting to bring about very positive change. We’ve been working quite closely with the CQC and have appreciated their genuine interest in our views. We set these out (at some length!) in our response to their latest consultation: ‘The next phase: Our consultation on our strategy for 2013 to 2016’. This involved us reflecting on the document as well as conducting a consultation exercise, mainly with service users and also some ward staff.

The full submission can be read on our website. Click here to view it

Here are some of our comments:

Service improvements and encouraging best practice

We’re excited (to the point of near obsession!) about what happens to all the good practice that inspectors and commissioners observe and note on their visits. This alone could form the basis of a fantastic, service-transforming resource.

We feel the benefits of CQC seeking out and publicising good practice would include:

• A boost in frontline staff morale – the #1 factor in creating and sustaining strong, therapeutic services
• Reassurance for current and potential service users and their friends and family. Inevitably and understandably, the media report on the exceptional which means here what is going wrong. This creates a dangerously distorted impression of the state of, for example, mental health inpatient care and the extent to which the MHA Act protects detained patients. Those organisations who care about the quality of patients’ (and staff) experiences have a duty to counter-act the damaging impact of the media focusing on the negative.
• An invaluable source of how services are overcoming enormous challenges with practical ideas of replicable practices. In our experience ward staff are hungry for examples of realistic ways of improving the care they provide and other regulators do provide best practice case studies and other resources. Our favourite, frequently heard response from wards is “We could do that!”

Q1: Making greater use of information and evidence to achieve the greatest impact

What good looks like 

Not everything that counts can be counted, and not everything that can be counted counts. We don’t pretend to understand everything Albert Einstein said, but we’re definitely with him on this one. The things that are most important to patients (notably staff being warm, unpatronising, kind and generally being allowed to be themselves) are those that can be hardest or at least costliest to measure.

In relation to mental health inpatient care (for detained and voluntary patients), Wardipedia is a user-led, evidence-based, comprehensive collection of all aspects of ward life which are important to patients. We very much hope that CQC commissioners and inspectors will make use of this resource.

Getting the right information

The things that are most important to patients (notably staff being warm, unpatronising, kind and generally being allowed to be themselves) are those that can be hardest or at least costliest to measure.

We asked the question ‘What do wards need from CQC?’

• What the CQC is all about could be introduced during mandatory training.
• Appearing interested in staff and patients views.
• Telling wards what is good about what they do.
• Balanced and contextual reporting.

We asked the question ‘What’s unhelpful now?’

• Wearing suits and walking around with clipboards.
• The word ‘inspection’ is unhelpful.

Because of the disproportionately high numbers of people from some BME communities in the secure end of mental health care, and their over-representation in receiving unpleasant compulsory treatment, it’s very important that CQC collects sound data on this. The ending of the Count Me In survey reinforces this need.

The ‘snapshot’ nature of visits means that reliable sources of information across a span of time are particularly important – eg from local service user and carer groups, reports from NHS Patient Led inspection teams, findings and recommendations of SUIs, as well, of course, as the information that services themselves collect.

Sharing findings

At this stage of mental health wards’ progress, we feel star ratings (mentioned as a possible option in the State of Care report) are very dangerous. Great for wards and patients of 5 starred places, compoundingly demoralising for staff and unnecessarily terrifying for patients and loved one for low rated wards.)

Q2: Strengthening how we work with strategic partners

There are interesting dynamics and risks around expectations – of staff, patients, friends and family and ‘the public’. These need to be realistic. It’s not just pointless but damaging for people to expect perfect services at the moment, setting up more frustration and disappointment. Conversely, everyone should know what is a reasonable level of service to expect – eg warm, engaged staff and a sound programme of meaningful activities.

Q4: Building our relationships with organisations providing care

One of the service users told us:

“I felt most of the staff on the ward were really nice, and definitely don’t need surprise inspections and extra stress in an already difficult job. Sure you might get the occasional bad staff member, but I think it’s important to let the staff be who they are, and trust to have employed the right people and let them be kind of fluid. To be in that job, I think you’ve got to relax and be yourself, not be acting too professional, or like some kind of customer service. There is a certain genuineness (/soft compassion) that is needed, and surprise inspections might not make the right environment for that, and specifics on how to treat the ‘service users’.”

Q5: What are your views on whether our proposals will build respect and credibility among providers?

What creates respect and credibility? Expertise, empathy, astuteness, humanity, clear communication, a certain humility, openness, authenticity, optimism, appropriate boundaries…. All features that great frontline staff demonstrate with service users. The plans in your consultation document including in this section strongly suggest that this is CQC’s genuine intention. The views expressed in our mini-consultation illustrate the distance to be bridged from the current situation where many staff feel CQC is “punitive, dismissive, unsympathetic and unsupportive.”

There’s a dual issue here – how CQC regards, treats and reports on staffing, and how frontline staff are treated by their managers and organisations. Henry Stewart from Happy provides compelling evidence in The Happy Manifesto (and elsewhere) of the benefits of trusting, supporting and equipping staff.

One of the greatest contributions to improving inpatient care that CQC could make would be to inform and motivate Trust managers to provide sufficient support, trust and explicit appreciation for their staff.

Confidence in the judgements of our inspectors 

We think it would be worth expanding this so that it isn’t just about judgements but also expertise, values and interpersonal skills.

We’d like to draw particular attention to a point made in our mini-consultation:

“On a mental health ward the inspector should observe and write notes up in an office away from service users. Individuals especially those with paranoia may think they are being written about.”

This illustrates the importance of inspectors and commissioners visiting mental health wards having more than ‘generic’ health expertise but having specific mental health expertise and therefore not just credibility but the ability to avoid actively distressing patients.

As a service user put it: “If they come in suits suggest they take their jacket off and get rid of the tie!” And it’s always best not to have an intrusively large group of people swooping in on wards.

Tackling unnecessary regulation, supporting innovations 

Great! We’d welcome CQC using the evidence base to tackle the absurdity of clinical standards relevant to (some) physical health wards being damagingly inflicted on mental health wards.

Q5: Strengthening the delivery of our unique responsibilities on mental health and mental capacity

We feel that CQC needs to create and sustain a particularly high profile for your MHA responsibilities. The Mental Health Act Commission had the benefit of this role being incorporated into its name and it seems that the current awareness of CQC’s MHA remit is low and confused.

Given the huge complexity of patients’ experiences (or ‘journey’) and the many other agencies involved, along with the tough financial and personnel constraints CQC is under, it seems best to shift the focus from being primarily about visits.

We also think it’s really important not to penalise staff, and risk lowering their morale, when they and the patients are lumbered with crappy old buildings.

Providing information to detained patients

From our experience, there’s some way to go for detained patients to get the (complex!) information they need about their rights under the MHA. We suggest that the following would help:

• Great, accessible information eg in ward welcome packs, including sources of help eg IMHAs, solicitors and CQC itself. All the leaflets etc that we’ve seen about being detained are broadly accessible but only in normal circumstances! Firstly, it’s hard to read or absorb anything when acutely ill, especially if the illness impairs cognitive functioning. Best practice is clearly for a member of staff to go through the leaflet/information with the patient, as well as giving the patient the opportunity to read it at their own pace in private. But it would be good to have an actively engaging, attractive, human, reassuring as well as informative leaflet. As ever, CQC are best placed to know what are the best examples out there.
• Alternative formats for information would be great – eg a DVD, an interactive website, podcast etc.
• Apparently CQC has produced a poster for wards, which is an ideal format. An accessible, human, good-natured DVD would work well for many patients (and staff and visitors…) And given how many patients have mobile phones (the use of which is very thoughtfully described in the MHA Code of Practice) an app would be very useful for many people.
• A video could be created which could be used in A&E, Emergency Reception Centres in mental health hospitals, s136 suites etc.  It would need to be very gentle, mainly soothing, low-stimulation stuff plus bits of easily digested info about rights.
• Contributing to staff training – this wouldn’t need to involve CQC staff directly delivering this (although that would be good!) But perhaps CQC could contribute training exercises and resources which Trusts could use.
• CQC could encourage and equip wards to run groups about their rights as a detained patient, covering the practical, legal, emotional, domestic, financial etc implications of being sectioned, with the frequency depending on the particular ward, patient turnover etc.

The experience of being ‘sectioned’

• It’s rare to hear about the hour or so when the assessment is being made about whether or not one is going to be sent to hospital against one’s will. But it’s an exceptionally traumatic life experience for most people and we’d welcome CQC extending its focus from visits and hospitals to considering what improvements could be made.

Many thanks to everyone who helped with our response to this consultation!