1 The Care Quality Commission and Approved Mental Health Professionals Kim Forrester Mental Health Act Policy Manager

Content – Overview Regulation MHA Monitoring How this currently involves AMHPs MHA Monitoring and AMHP Reports – Crisis Concordat Project: Regulation of AMHP Services – MHA Annual Report 2014/15 2

Care Quality Commission Health and Social Care Act Our purpose We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage them to improve. Our role We register care providers. We monitor, inspect and rate services. We take action to protect people who use services. We speak with our independent voice, publishing regional and national views of the major quality issues in health and social care. Mental Health Act We have a duty under the Mental Health Act 1983 to monitor how services exercise their powers and discharge their duties in relation to patients who are detained in hospital, or subject to community treatment orders or guardianship. We must keep this under review, and investigate where appropriate, and carry out visits to meet with and interview patients in private. 3

4 CQC’s New Operating Model Any person (individual, partnership or organisation) who provides regulated activity in England must be registered with us otherwise they commit an offence

5 How has regulation changed? FROMTO 28 regulations, 16 outcomes Five key questions Part of the system On the side of people Generalist Specialist Compliance Inspector led, typically one day inspection Inspection team – MHA Reviewers on all inspection teams for MH Compliance Pass/fail Judgement Rating

6 Key Lines of Enquiry To direct the focus of their inspection, our inspection teams use a standard set of key lines of enquiry (KLOEs) that directly relate to the five key questions Inspection teams reach a rating by gathering and recording evidence against each KLOE

7 Enforcement

8 Mental Health Act Functions Duty / Related ApproachDescription Mental Health Act visitsInspection, reviews or investigations under the MHA Mental Health Act complaintsReviewing and investigating complaints relating to the MHA Second Opinion Appointed Doctor Service Responding to requests for SOAD’s to providers Withholding MailReviews of decisions to withhold mail from patients in high security hospitals Health and Social Care Notifications Receiving notifications of the death of a detained patient, absent without leave and the admission of children and young people to adult psychiatric wards National Preventative Mechanism Visit approaches and reports relating to our role as a National Preventative Mechanism Code of PracticeOur role to make proposals of change to the MHA Code of Practice Annual ReportProducing the statutory annual report to Parliament on our activities under the MHA

MHA Monitoring Visits Unannounced visits 18 month cycle Ward level and carried out by MHA Reviewer and Expert by Experience Responsive visit May be investigating a complaint or responding to notification about the provider Focussed visit Admission and Assessment Seclusion and restraint Visit: Review / investigate Provider report issued Action statement produced by provider MHA national report (national learning) Intelligence & Follow up at next visit 9

How this currently involves AMHPs 10 Provider Regulation Intelligence – notifications, safeguarding, MHA visit data Inspection – meetings with AMHPs, data packs Specialist Professional Advisors MHA Monitoring Record review during visit Focussed visits Complaints, notifications of deaths in detention National MHA External Advisory Group – BASWA, ADASS representative Department of Health work with lead Social Worker National oversight groups e.g. Crisis Concordat CQC specialist staff with social work background e.g. MHA Reviewers, Specialist Professional Advisors, Inspectors Thematic reviews e.g. Crisis review – review-mental-health-crisis-care-initial-data-reviewhttp:// review-mental-health-crisis-care-initial-data-review MHA Annual Reports: use of CQC data and other AMHP data e.g. College of Social Work reports

MHA Monitoring and AMHP Reports Our MHA visits look for evidence of the Social Circumstances report on the hospital file MHA Reviewers will look at the MHA and Code of Practice for guidance on the report; 11

Crisis Concordat Project: Regulation of AMHP Services The National Crisis Concordat have asked for a “review of the effectiveness of our current approach to monitoring the AMHP provision and whether we would recommend CQC being granted additional powers to regulate AMHP services”. The work is a joint project with Department of Health and is one part of the wider Crisis Concordat programme of work. The Crisis Concordat highlighted a concern there are insufficient regulatory powers for AMHP services so CQC are limited in our ability to lever change and offer a focus on the way AMHP services are managed or commissioned. The provision of AMHP services can be managed by either Local Authorities or MH Providers or as a joint provision. Ultimately the responsibility for AMHP services remains with the Local Authority (as per the MHA) so CQC’s current regulatory powers would not extend to the Local Authorities in this regard without a change to the HSCA or regulations. DH and CQC report expected: September

13 Key Messages Consistent regulation, improved guidance and standardised approaches to monitoring and data for AMHP services would help drive forward improvements for patients accessing services. It was welcomed that this piece of work has been highlighted through the Crisis Concordat AMHP’s believe CQC should have a key role to play in relation to monitoring, analysing and highlighting key issues within AMHP services on a national level Clear national guidelines for AMHP services and a consistent regulatory framework would be welcomed. AMHP’s have told us “there needs to be change in the regulation of AMHP services and that what doesn’t get regulated often does not get done” Any regulation of AMHP services must be led by specialists with an in depth understanding of the challenges faced by the service in order to act as a driver for improvement as opposed to purely a performance management tool. Regulation could be useful to guide best practice and provide clarity regarding working practices including the lone AMHP worker and conveyancing AMHP’s felt a regulated AMHP service could help highlight the marginalised status of AMHP provision and address variance in the way services are structured such as the declining number of AMHP lead roles in some regions There is a wealth of activity that is ‘hidden’ from national data on the MHA, crisis care and service provision. This could provide rich intelligence to support the work on patient experience, crisis services and health and social care generally. The current lack of monitoring can mean the work of AMHP’s is ‘unseen and undetected’ “There needs to be change” but concerns that the introduction of regulation would need to be balanced with other pressures on AMHP’s including the new MHA Code, implementing the Care Act, resourcing of services AMHP Project: Stakeholder Feedback Summary

14 Data and reporting Data is being provided at a local level to providers and also informally within the AMHP network, it is not being consistently collected at a national level Resourcing data is collected locally, it is not regulated or reported at a national level. Guidance surrounding the level of data to be reported would be valuable to help services identify what needs to be collected National data collection would require a clear narrative detailing the reasons for and scope of reports from any datasets “not collecting for collecting’s sake” National datasets would require regional weighting to reflect the demographics of local areas – particularly in relation to the sufficiency of AMHP provision. Due to a lack of available national datasets, there are challenges surrounding benchmarking of services. For example there is a lack of national reporting of resourcing levels within AMHP services. Local reporting was taking place, however reporting variances between regions were evident Reporting in relation to AMHP services was not regularly made publicly available. The exception would be reports submitted to Trust Boards which are made available via Trust internet sites. There is a lack of opportunity for AMHP Service Managers to engage with other AMHP services on a regional and national level to share intelligence and best practice Examples of local reporting includes gathering data manually surrounding the age range, gender and ethnicity of service users where assessments have taken place. Local reporting takes place, however this is inconsistent due to disparity between IT systems of trusts and LA’s. Some trusts host the information on behalf of LAs, however this is not fed into a national data set. At a national level it is only the guardianship returns which take place on a consistent basis. Due to the inconsistency in data collection it was discussed that variances were probable between data reported locally by AMHPs and data held by providers and local authorities. AMHP provision isn’t always subject to the same governance as hospital processes so doesn’t benefit from the improvements available. Examples include incident reporting and audits AMHP Project: Stakeholder Feedback Summary

15 Views on current regulation and monitoring MHA Admission and Assessment visits were of most value from AMHPs perspective since they were most involved in those visits. It was felt that Admissions and Assessment visits were AMHP led. During a MHA and CTO visit AMHPs felt they were invited as external attendees and any issues raised by them were not taken on board in an equitable manner by the health service provider. Regulation of AMHP services by CQC directly, may see this improved. Monitoring of AMHPs was not taking place regularly but AMHPs do have internal processes in place such as peer review to provide a level of service assurance. The current approach to regulation allows for a ‘them and us’ attitude when there are issues with assessment, admission or the MHA found by CQC. Risks and issues Regulation of AMHP may highlight concerns within services outside of the AMHPs remit – for example if a delay in response was due to the unavailability of a police officer to attend. Consideration would be required during any performance management for who is accountable for any under-performance. A major challenge would be resources particularly for whoever is funding the AMHP service to be regulated. Due to the current inconsistency nationally with reporting and data collection, additional resource may be required should a framework be implemented to ensure that there is alignment nationally. Concerns as to the scope of CQC regulation as MHA assessments are multi agency faceted and it needs to be clear who is accountable when services are found to require improvement. AMHPs often state that they receive criticism for system’s failures which are outside the remit of their control e.g. delays in assessment due to delays associated with identify s12 doctors, accessing beds or ambulance delays. There is a concern that regulation could be used as another tool to criticise workers who already feel marginalised and over worked. AMHP Project: Stakeholder Feedback Summary

16 Mental Health Act Annual Report Report will be published by December 2015 Will include information collected during 2014/15 from across CQC activities including visits, SOAD and complaints Focus on the system readiness for implementing the MHA, Code of Practice 2015 Opportunity to highlight areas of concern affecting AMHP practice

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