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Mental Health Act Annual Statement January 2010  
 
Ealing Forensic Services 
West London Mental Health NHS Trust  
               
Introduction 
Mental Health Act Commissioners from the Care Quality Commission (CQC) visit all 
places where patients are detained under the Mental Health Act 1983. Mental Health 
Act Commissioners meet and talk with detained patients in private and also talk with 
staff and managers about how services are provided. As part of the routine visit 
programme information is recorded relating to: 
 
•  Basic factual details for each ward visited, including function, bed occupancy, 
staffing, and the age range, and gender of detained patients. 
 
•  Ward environment and culture, including physical environment, patient privacy 
and dignity, safety, choice/access to services and staff/patient interaction. 
 
•  Issues raised by patients and patient views of the service provided, from both 
private conversations with detained patients and any other patient contacts made 
during the course of the visit. 
 
•  Legal and other statutory matters, including the scrutiny of Mental Health Act 
documentation, adherence to the Code of Practice, systems that support the 
operation of the Act and records relating to the care and treatment of detained 
patients.  
 
At the end of each visit a “feedback summary” is issued to the Trust identifying any 
areas requiring attention. The summary may also include observations about service 
developments and / or good practice.  Areas requiring attention are listed and the 
Trust is asked to respond stating what action has been taken. The response is 
assessed and followed up if further information is required. The information is used 
by the CQC when verifying the NHS Health check and making decisions about the 
inspection programme in both the NHS and Independent Sector. In future years it will 
be used to inform the registration decisions 
 
Background 
This report draws on findings from visits by Mental Health Act Commissioners both 
under the auspices of the Mental Health Act Commission (MHAC) and those which 
took place after 1 April 2009 when the functions of the Mental Health Act Commission 
were taken over by the Care Quality Commission  
 
The Annual Statement provides an overview of the main findings from visiting, 
highlighting any matters for further attention and / or areas of best practice. It is 
published on the CQC website, together with other publications relating to individual 
mental health providers. 
 

The Commission has visited all the wards within the Ealing Forensic Services during 
the last 12 months. 
 
Main findings 
Relations between Mental Health Act Commissioners and senior managers and the 
staff of the Trust have remained constructive throughout the reporting period. The 
Commission wishes to extend its gratitude to the staff, especially the Mental Health 
Act Administrator, for the help in arranging the visits.  
 
This can be a difficult area of mental health work and staff are commended for their 
efforts and patience with patients who can be complex and volatile.  Approaches 
made to Commissioners by medical staff to discuss difficult patient situations have 
been welcomed. 
 
The Commissioners who visit the forensic services at Three Bridges Regional Secure 
Unit (RSU), The Orchard Unit and Tony Hillis Wing are pleased that the response 
times to issues raised are improving on previous years.  They have also welcomed 
the resolution of the concerns raised by Commissioners about the inconsistency in 
the Trust's approach to searching the visiting Commissioners. 
 
Mental Health Act and Code of Practice 
The following points highlight those Mental Health Act Issues raised by 
Commissioners on visits.  The detailed evidence to support them has already been 
shared with the Trust and is not rehearsed here.  For further discussions about these 
findings please contact the authors of this report via the Care Quality Commission at 
the Nottingham office. 
 
Detention & documents related to detention 
The visiting Commissioners generally found statutory documentation in order and on 
the occasions where errors have been found, they have been quickly corrected. 
 
Evidence of detention is fundamental to all that follows and must be available for 
scrutiny at all times. Some of the deficiencies identified by the Commission include: 
• 
Copies of detention papers not being filed in the notes. 
• 
Unlawful detention on Rollo May. 
• 
On Derby 1 one of the patients’ detention was allowed to lapse on 6 December 
2008 and he was placed on section again on 9 December 2008.   
 
The Commission has reported concerns about whether the Trust is adequately 
staffing Mental Health Act Administration to cope with the increasing workload from 
more detained patients on this site with the arrival of the Orchard Unit as well as the 
extra burden Supervised Community Treatment has brought. Many Mental Health Act 
issues raised regularly by the Commission could be alleviated by more robust 
internal audit of Mental Health Act systems. It is also apparent that specific issues 
raised in one ward will continue on other wards, indicating a lack of overall action to 
address issues across the whole Trust at a strategic level. 
 
Recommendation for Action 
The Trust review Mental Health Act issues raised during the last year of visits in order 
to identify an effective audit programme to tackle recurring themes across all services 

in the Trust. The Trust’s Mental Health Act Manager should review current 
administration services to confirm whether they are able to cope with increased 
demands and fulfil existing core administration and audit requirements.  
 
Section 58 
Over the last year the visiting Commissioners found various incidents, some of them 
very serious, of breach and non-compliance with the requirements of Section 58.  
 
Incidents of unlawful treatment were found on Derby 2, Derby 1, Avebury and Aurora 
Wards. On Aurora Ward 50% of patients were found to be treated unlawfully. 
 
Responsible Clinicians (RCs) continue to fail to record assessments of capacity 
following their discussions with patients about treatment and their attitude to it, that 
should be recorded from the outset of an admission. Consent or refusal of treatment 
is only possible for patients who have the capacity to make these decisions at the 
material time and the assessment of capacity will dictate the legal safeguards that 
follow. 
 
There was also the frequent failure on their part to outline treatment plans prior to the 
Second Opinion Appointed Doctors (SOAD) visits. The requirement that Responsible 
Clinicians record the conversation they have with a detained patient following the visit 
of a SOAD remains patchy.  
 
The medicine charts require that the legal status of the patient and authorisation to 
treat is recorded with the relevant time-scales.  This is not always completed 
although the authority contained in the forms T2/T3 are usually found attached to the 
charts 
 
There were widespread failures from the parts of the Statutory Consultees to make a 
record of their consultation with the SOADs. 
 
It has to be pointed out that the reoccurrence of the above issues continue to arise 
despite the Trust’s reassurance that effective systems have been put in place to 
address the issues of non-compliance with the requirements of Section 58.  
 
Most of these issues were identified in the previous year and were included in the 
Mental Health Act Commission’s Annual Report in 2008. In response to this the Trust 
agreed that they had to do more work to improve and that the Trust has put a number 
of systems such as audits, a letter from the Medical Director to all the RMOs (RCs), 
and the introduction on a proforma, to achieve the improvements. 
 
The proforma introduced by the Trust has proved to be very effective where it is 
used. Unfortunately the use of this proforma is variable. However the Commission 
wishes to acknowledge that on the few wards the proforma is regularly used 
improvement in compliance was noted. It was widely used on Barron 1 Ward and on 
Glynn Ward. On Glynn Ward, the Commissioner was pleased with the standard 
maintained by Dr Andrews in regard to his record keeping in regard to the Mental 
Health Act issues, especially consent to treatment and renewal of detention. 
 

The Commission recognise the difficulties that the Trust has experienced in relation 
to accessing SOADs within the required timeframes.  This has been due to the 
unpredicted extra burden on the SOAD service of SCT that has necessitated an 
increase in the use of Section 62 and Section 64a emergency medication.   
 
The Mental Health Act administration has been responsive to ideas for improvement 
such as the safe haven fax system and the development of SOAD day and half day 
sessions. 
 
Recommendation for Action 
The Trust should instigate more vigorous audit systems to ensure compliance with 
the requirements of the section 58. The Medical Director to address consent to 
treatment issues with medical staff.  The Trust board should ensure that all the 
clinicians and clinical teams use the proforma across all departments throughout the 
whole Trust. 
 
Section 132
 
While the Commissioners established that there had been good compliance with the 
requirements of section 132 in some wards, they found deficiencies in this area on a 
regular basis, in many. In some cases patients have also shown little understanding 
of their rights. In others patients seem acquainted with their rights but staff are failing 
to document that they have performed their duties under section 132 on admission 
and at intervals thereafter. Despite assurances to each visit feedback summary that 
this will be rectified, there is no consistent approach across forensic services. 
 
Recommendation for Action 
The Trust must adopt a system of undertaking section 132 duties and recording that 
these have been performed in a manner that is meaningful for the patient. 
 
Section 17 Leave 
Leave is extremely important to this group of patients who are often in hospital for 
long periods of time. While the nursing staff try to facilitate section 17 leave, a 
number of patients, from different wards, have raised concerns that escorted section 
17 leave is not facilitated at times, due to staff shortage.  
 
The Commissioner was also informed that according to the Trust policy agency staff 
are not allowed to undertake escort duties. Hence the use of agency staff does 
contribute to the cancelling of the escorted leave. 
 
Recommendation for Action 
The Trust, especially the ward management, to ensure that the agreed section 17 
leave for all the patients are facilitated. 
 
Access to Advocacy 
Access to advocacy is variable and the duty to inform patients of their right to an 
IMHA and the duty to provide access to one under section 130A (commencement 
date 1 April 2009) has not been observed by Commissioners to date. 
 
 
 


Recommendation for Action 
Ealing Forensic services should ensure that patients have information about and 
access to the services of an IMHA as soon as possible. 
 
Supervised Community Treatment 
Section 17A is a new discharge provision that has become available for certain 
detained patients.  The Mental Health Act office reports 18 Community Treatment 
Orders in this Trust, in the period to the end of September many of these from 
forensic services.  The Commission has recently carried out a visit to monitor this 
part of the Act and this has been reported back on separately. 
 
The Ward Environment 
Though there had been some improvement in the ward environment in general, 
concern over environments was raised on a number of visits. These concerns range 
from lack of cleanliness, rodent infestation, poor decorative condition, ward 
temperature to general repair issues. The Commission is aware that many wards 
have been undergoing considerable physical changes and there are plans for 
refurbishing some other wards.   
 
The Commission wishes to acknowledge the considerable improvement made to the 
ward environment on Tom Main ward. 
 
The seclusion room on Tagore was of concern to the Commissioner visiting as its 
location and ventilation were noted as less than ideal.   
 
The Orchard Unit provides an environment of a high standard however access to 
baths, food quality and storage of possessions have been issues raised over this 
period.   
 
Recommendations for Action 
The Trust should ensure that environmental issues raised by the patients, ward staff 
and the Commissioners, during visits are tackled promptly.  
 
When refurbishment of wards is carried out attention to the location and climate 
control of seclusion rooms should be considered. 
 
Staffing 
Nursing staff have been praised in many reports and patient comments have often 
been positive. However a recurring theme has been concern expressed by patients 
about poor interactions with some nursing staff from being too busy to talk to them to 
more negative comments. This issue is central to the patient experience of care. 
There have been concerns expressed by the staff about having to work with less than 
adequate staffing levels from time to time. On a visit to one of the wards the 
Commissioner found that all but one Nursing Assistant were bank or agency nurses 
who did not know the ward very well. 
 
Some members of the nursing staff have also expressed the concern about the over-
dependency on bank and agency staff, which in forensic facilities can place an extra 
burden on regular staff who have more knowledge of patients as well as the burden 
of doing more escorting or moving patients around the unit.  

Recommendation for Action 
The Trust and the nursing directorate takes further action to address concerns about 
the less than adequate staffing levels and poor patient experience. The Trust may 
need to strengthen its recruitment process to ensure that the vacancies are filled 
promptly and high calibre nurses are recruited. 
 
Access to Fresh Air 
On a number of visits the Commissioners were approached by patients raising the 
concern that they do not get adequate access to fresh air. On one of the wards the 
patients complained that the access to the garden attached to the ward was very 
infrequent. 
 
Access to fresh air at the Orchard is good with walk out areas from all wards 
available to patients that should be replicated when new buildings are designed. 
 
Recommendation for Action 
The Trust to ensure that all the patients have adequate access to fresh air. 
 
Smoking 
The smoking ban has been very difficult for patients on this site and has preoccupied 
many patients during interviews with Commissioners. The concerns of staff have 
included increased levels of patient agitation, risks of fire as patients are smoking in 
bedroom and bathroom areas, concerns over the disruption to therapeutic 
relationships that increased searching has brought about and disproportionate 
amounts of leave being spent smoking leaving little time for rehabilitative activities.  
Patients who feel they have had their rights curtailed by being detained feel further 
punished by a rule that isn't applicable to prisoners. Patients have expressed a wish 
to move to units or return to prison where they can smoke.  Commissioners have 
been informed that patients are paying large amounts of money for one cigarette.  
 
While the efforts put into health promotion and smoking cessation are welcomed by 
some patients there is a significant group who will not comply and indeed have been 
observed in large numbers smoking in the grounds of the hospital.  It is reassuring 
that the Trust  has been responsive to reviewing their policy and has recently 
provided limited smoking opportunities for patients who want to smoke and do not 
have leave to do this. 
 
Recommendation for Action  
Efforts are made to encourage smoking cessation but for patients choosing to 
continue to smoke all wards should offer access to an outside area at reasonable 
intervals in which to do this. 
 
Physical Health 
The lack of routine physical health care for the Orchard Unit has been a recurrent 
theme on visits.  However it is pleasing that a Health Suite is underway that will 
provide access to a General Practitioner (GP) and practice nurse.  Services such as 
breast and cervical screening and routine dental and eye care appointments should 
be available to these patients without the indignity of being handcuffed to go outside 
the unit and reduce the escort burden for staff. 
 

Violence 
On visits to Tom Main and Benjamin Zephaniah Wards, patients expressed their 
concern about their safety due the high levels of violent incidents. It was also 
reported that a number of staff were attacked over the few months prior to the visit 
and needed to take sick leave.  
 
Of concern was the lack of police involvement when patients are attacked by other 
patients.  Opportunities to be interviewed as victims of crime seem impeded by police 
systems and effectively discriminating against detained patients who are not at liberty 
to attend a police station.  It is very encouraging to hear of the pilot Designated Police 
Officer Project that began in March 09 and it is hoped that this will be continued to 
address issues in this area 
 
Recommendation for Action  
That the Trust to continue to address the issue of safety and prevention of violence 
on wards  
 
Care Programme Approach (CPA) 
CPA meetings appear to occur at frequent intervals and most patients could articulate 
what the agreements at the last meeting had been.  However a number of patients 
indicated that they were not given a copy of their CPA care plans and were not 
always clear when they could expect another meeting. 
 
Recommendation for Action 
The Primary Nurses/care co-ordinators should ensure that all the patients are given 
copies of their care plans. 
 
Ethnicity recording 
Though the overall recording of patients’ ethnicity is found to be quite good and has 
certainly improved, the visiting Commissioners have identified some remaining 
deficiency in recording ethnicity on some wards. 
 
Recommendation for Action 
To ensure that all the patients have their ethnicity recorded throughout their notes, in 
accordance with the DH categories. 
 
Deprivation of Liberty Safeguards (DOLS) 
The CQC recognises that as all patients in this service are detained under the Mental 
Health Act, the necessity to make an application under the Mental Capacity Act‘s 
DOLS is unlikely to arise.  It would, however, be good practice for clinical staff to be 
aware of the main points of the legislation.  Of more relevance here,  is the need to 
offer continuing training to ensure staff understand the provisions of the Mental 
Capacity Act and when treatment in a person’s 'best interests' may be given to this 
patient group perhaps for physical interventions where capacity is diminished. 
 
Recommendation for Action 
Staff are reminded of the provisions for patients who lack the capacity to make 
informed decisions about their care and treatment and the requirements to record 
when capacity is diminished and decisions are made in a patients 'best interests.'  
 

Forward Plan 
 
•  Mental Health Act Commissioners will continue to visit Ealing Forensic Services in 
the coming year to monitor the operation of the Act and to meet with detained 
patients in private. 
 
•  Mental Health Act Commissioners welcome approaches from staff who may 
require assistance on individual or collective patient issues relating to their 
detention. 
 
•  The Mental Health Act Commissioners will work with other colleagues within the 
CQC to develop an integrated approach to the regulation of the hospital’s 
services. 
 
•  The Commission is committed to maintaining good working relationship with the 
staff and management of the Trust. 
 

Appendix A 
 
Commission Visit Information for  

West London Mental Health NHS Trust Forensic Services  
Covering the period between  
1 November 2008 and 19 January 2010 
  

 Det. 
Pats. 
  Records  
Date 
Ward 
seen 
checked 
Ealing Forensic 
15 Nov 2008 
Benjamin Zephaniah (Forensic) 


19 Nov 2008 
Brunel Ward (Independently Owned  


 
Tom Main (Forensic) 


23 Dec 2008 
Derby 1 (Forensic) 


4 Feb 2009 
Pearl 


12 Feb 2009 
Mott House (Forensic) 


14 Feb 2009 
Blake (Forensic) 


28 Feb 2009 
Rollo May (Forensic) 


17 Mar 2009 
Tagore (Forensic) 


21 Mar 2009 
Bevan (Forensic) 


28 Mar 2009 
Glynn (Forensic) 


29 Apr 2009 
Wells Unit (Forensic) 


23 Jun 2009 
Benjamin Zephaniah (Forensic) 


25 Jun 2009 
Tom Main (Forensic) 


11 Jul 2009 
Barron 1 (Forensic) 


5 Sep 2009 
Derby 2 (Forensic) 


28 Sep 2009 
Blenheim (Forensic) 


3 Oct 2009 
Avebury (Forensic) 


18 Nov 2009 
Derby 1 (Forensic) 


21 Nov 2009 
Brunel Ward (Independently Owned  


12 Dec 2009 
Mott House (Forensic) 


15 Dec 2009 
Rollo May (Forensic) 


19 Dec 2009 
Glynn (Forensic) 


Total for Ealing Forensic 
112 
115 
Orchard Unit (Ealing Forensic) 
29 Nov 2008 
Aurora 


3 Feb 2009 
Elstar 


12 Feb 2009 
Russett 


18 Mar 2009 
Garnet 


9 Jun 2009 
Aurora 


7 Jul 2009 
Russett 


14 Nov 2009 
Melrose 


9 Jan 2010 
Garnet 


Total for Orchard Unit (Ealing Forensic) 
26 
25 
 
Total Number of Visits: 30 
Total Number of Wards visited: 31 
Total number of Patients seen: 138 

Total Number of documents checked: 140