Monitoring questions for mental health services (NHS and independent)

S1: How do systems, processes and practices keep people safe and safeguarded from abuse?

• Are infection risks to people using the service being thoroughly assessed and managed?
• Have you changed the layout/environment of clinical and non-clinical areas to continue to provide services safely in this period? for example, clean sites, vehicle layout, separate entrances and waiting areas for known/suspected COVID-19 patients, additional signage, spaces between stations, isolation facilities, ensuring compliance with best practice guidance when visiting people in their own homes etc.
• Do you have the resources to obtain, and reliable access to, all the supplies, personal protective equipment and COVID19 testing needed, for both staff and, where appropriate, people who use the service?
• Are working arrangements and procedures clear and accessible to staff, people who use the service, their supporters and, where appropriate, visitors to the service?
• Are people using the service being protected from abuse, neglect, discrimination and loss of their human rights?
• Where applicable, have you identified when you may be depriving a person of their liberty, and followed the correct and lawful procedures, for example, DoLS application, Court of Protection?
• Are your safeguarding and other policies and practice, together with local systems, properly managing any concerns about abuse and protecting people’s human rights?
• Regarding closure cultures, do you audit/quality assure your culture or do you know how you might go about doing that? Are you aware of the CQC’s closed culture guidance? If not, this can be shared with you.

S1. Additional prompts

All inpatient services

• How have ward moves been managed (closing and re-opening wards as they have been repurposed)?

CAMHS wards

• Have children and young people been cared for in an environment separate from adult patients?

Long stay rehabilitation wards

• Is there a robust process followed to keep patients safe when going on leave/returning from leave/community activities, for example, is testing carried out/isolation from other patients until tests results are received?

Wards for people with a learning disability and/or autism

• Are you maintaining mandatory staff training to keep people safe? 
• How are managers assured that patients do not suffer abuse or improper treatment within the service? 
• Are there regular visits from other stakeholders, visiting professionals or families and friends to the service? 
• Have there been any concerns raised during quality or contracting visits by commissioners or safeguarding teams? How have you responded to these? 
• Have there been any significant concerns raised by family members or people using the service?  How have you responded to risks identified from these?

Community mental health service for people with a learning disability and/or autism

• Have there been any significant concerns raised by family members or people using the service?  How have you responded to risks identified from these?

S2: How are risks to people assessed, and their safety monitored and managed, so they are supported to stay safe?

• Are risks to the health and wellbeing of people using your service being properly assessed, monitored and managed?
• Are there enough suitable staff to provide safe care and treatment in a dignified and respectful way? Are escalation plans in place in response to surges in demand e.g. second wave, seasonal pressures?
• How are you identifying and managing risks for patients including any restrictive practices or issues affecting their legal or human rights?

S2. Additional prompts

CAMHS wards

• Are there enough staff to carry out physical interventions safely?
• Are there enough staff to support patients with leave, visits, education and activities?
• Are escalation plans in place to respond to surges in demand?

Community CAMHS

• Given there is a prediction of increased mental health difficulties as a result of COVID-19, are there plans in place to assess this in the local population and to have suitable resource to address this? At this point, this might just involve a discussion with commissioners.
• Are escalation plans in place to respond to surges in demand?

Long stay rehabilitation mental health wards

• Are there any significant trends in specific events of self-harm, violence and aggression, restraint, attempted and actual suicide?
• Are there enough staff to support patients with leave, visits and therapeutic activities?

Wards for people with a learning disability and/or autism

• Where restrictive practices are in place, are there plans to reduce restrictions to a minimum level? 
• Do staff have specific training to support people with learning disabilities and/or autistic people? 

Community mental health service for people with a learning disability and/or autism

• Do staff have specific training to support people with learning disabilities and/or autistic people?

S3: Do staff have all the information they need to deliver safe care and treatment to people?

• Do you have access to - and are following - guidelines around Treatment Escalation Plans (TEPs), anticipatory care planning, Do Not Attempt CPR (DNACPR) orders and individualised care plans?
• Are plans in place for rapid transfer to preferred places of care – relationships and planning with primary care, district nursing etc.
• Can you effectively manage referrals and, where relevant, discharges and ensure safe transfers of care?
• Where relevant, what testing arrangements are in place, and how do you handle transfers of known/suspected COVID-19 patients safely?
• How are you working with other partners?

S3. Additional prompts

Long stay rehabilitation mental health wards

• Are patients admitted to rehab services (for needs led rehab) based on rehab needs and not to create availability of beds in acute (other) services? Are the links with local services still in place to plan effective discharges? Are discharges planned appropriately and based on need?

Wards for people with a learning disability and/or autism

• Do people have access to individualised care plans including positive behaviour support plans, treatment escalation plans and anticipatory care planning? 
• Do you have systems in place to ensure people have access to primary and specialist healthcare services?  Is information shared to ensure that planned care meets the physical health needs of people using the service? 
• Are local arrangements in place for the safe transfer of patients to an acute hospital where this is necessary to meet their physical health needs? 
• Where Do Not Attempt CPR (DNACPR) orders are in place, do these follow current guidance?

Community service for people with a learning disability and/or autism

• Do people have access to individualised care plans including positive behaviour support plans, treatment escalation plans and anticipatory care planning? 
• Do you have systems in place to ensure people have access to primary and specialist healthcare services?  Is information shared to ensure that planned care meets the physical health needs of people using the service?

S4: How does the provider ensure the proper and safe use of medicines, where the service is responsible?

• Are medicines being managed safely and effectively?
• Has COVID-19 impacted your ability to manage medicines?

S4. Additional prompts

All mental health services

• How are you ensuring monitoring and addressing patient physical and mental health conditions, for example, monitoring of high dose antipsychotics, patient weight, INR monitoring, diabetic insulin, respiratory and cardiac health?
• Can you give examples of how medicines are being managed safely and effectively?
• Does COVID-19 continue to impact on your ability to manage medicines?
• Have you identified and recorded any changes/emerging trends in the prescribing and administration patterns of behavioural modifying medicines and rapid tranquilisation?

Wards for people with a learning disability and/or autism

• How do you ensure that psychotropic medicines prescribed appropriately and regularly reviewed?

Outpatient and community services

• How is the supply of medicines maintained from remote clinics?

Community CAMHS

• How have you been managing patients in community eating disorder services and getting accurate information about weight and height – usually something measured by staff on weighing scale at appointments?

Long stay rehabilitation mental health wards

• Have you made any adjustments for those patients who self-medicate, for example, frequency, monitoring?

S5: What is the track record on safety?

• Are there any significant trends in non-COVID-19 activity: never events, significant incidents, themes in incidents, mortality, unexpected deaths?
• What are you doing to assess and learn, including mortality reviews of non COVID-19 patients?
• Are there any significant trends where groups of patients are faring worse in terms of safety concerns?

S5. Additional prompts

All mental health inpatient services

• Are there any significant trends in specific events of self-harm, violence and aggression, restraint, attempted and actual suicide?

Acute wards for adults of working age (or any inpatient service)

• Has there been an increase in the use of restraint and seclusion in the last six months?

Wards and community services for people with a learning disability and/or autism

• Does the service report all deaths of people with a learning disability to LeDeR and does the service participate in LeDeR reviews?

E1: Are people's needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes?

• How are you identifying, cascading and keeping up-to-date with changes in clinical guidance?
• Where people are subject to the Mental Health Act (MHA), how are you ensuring compliance with the MHA?

E1. Additional prompts

All mental health inpatient services

• How are you managing leave in accordance with not only MHA, but government guidance in relation to pandemic restrictions?

CAMHS wards

• How are you ensuring patients can keep in touch with parents, guardians, family and other people important to them? How are visits being arranged and managed to keep patients, those visiting and staff safe?

CAMHS wards and community services

• How are you keeping patients and families informed on what is changing during the COVID-19 pandemic? Is this information available in a variety of media? Does information include practical advice on what to do in relation to COVID-19 for patients, for example, social distancing advice for children?

Long stay rehabilitation mental health wards

• Are therapeutic activities delivered with appropriate social distancing measures in place?
• Are community rehab activities appropriately risk assessed and carried out?
• Have any restrictions been placed on access to the community?
• Do you deliver care in line with most recent NICE guidance on mental health inpatient rehabilitation services?

Wards and community services for people with a learning disability and/or autism

• Have there been any deaths (COVID-19 or non COVID-19) in your service? Was full and timely access to primary and acute healthcare treatment in place prior to the patient’s death? 
• Where required, what arrangements are in place to ensure access to appropriate end of life care and support? 
• How do you ensure staff can identify the deteriorating physical health of patients who may not be able to communicate their needs?

E2: How are people’s care and treatment outcomes monitored and how do they compare with other similar services?

• How are you collecting information about people's care treatment and outcomes?
• Where relevant, are you continuing to submit to relevant national clinical audits?
• How are outcomes being monitored for groups of people that may be at higher risk, such as different ethnic groups and older people?

E2. Additional prompts

Long stay rehabilitation mental health wards

• Are outcome measures used to evaluate the effectiveness of care delivery? How are outcomes used to review care delivery?

E3: How does the service make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment?

• How are you ensuring that all staff, including those being flexibly redeployed, have the skills, training and competence to carry out their roles effectively?

E3. Additional prompts

CAMHS wards and community services

• Are there enough qualified professionals with competency in meeting needs of children and young people?

Long stay rehabilitation mental health wards

• Do patients have suitable access to the right therapy staff at the right time as required for their plan of care?
• Does the skill mix of staff include therapy staff?
• Are therapeutic activities delivered with appropriate social distancing measures in place?
• Are community-based activities appropriately risk assessed and carried out?
• Have any restrictions been placed on access to the community?

Wards for people with a learning disability and/or autism

• Are you providing regular supervision to staff?
• Are staff provided with support and debriefing following incidents?
• Do staff have training in how to support communication with people with learning disability or autistic people? 

Community services for people with a learning disability and/or autism

• Are you providing regular supervision to staff?
• Do staff have training in how to support communication with people with learning disability or autism? 

E4: How well do staff, teams and services work together within and across organisations to deliver effective care and treatment?

• How are you ensuring that the necessary staff, teams and services are involved in assessing, planning and delivering peoples care and treatment?

E4. Additional prompts

Long stay rehabilitation mental health wards

• Do you coordinate care delivery with the wider care system, for example social care, housing, third sector, charities?

E6: Is consent to care and treatment always sought in line with legislation and guidance?

• How do you ensure consent to care and treatment is always sought in line with legislation and guidance? Including, where appropriate:
  • ensuring that people are involved in decisions about not providing care and treatment, including advanced care plans and DNACPR decisions?
  • promoting supportive practice that avoids the need for physical restraint? Where physical restraint may be necessary, how do you ensure that it is used in a safe, proportionate, and monitored way as part of a wider person-centred support plan?
  • ensuring staff apply relevant legislation where people may lack capacity to consent to care and treatment, including the Mental Capacity Act 2005 (including DoLS) and where applicable to children <16 through applying Gillick competencies and Fraser guidelines

E6. Additional prompts

Long stay rehabilitation mental health wards

• Are patients who are not detained able to leave the ward (subject to their care plan) and aware of their rights?
• For all patients, is care delivered in the least restrictive way?

C1: How does the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed?

• How have you adapted how you support and engage with patients and their families/loved ones?
• How do you ensure the care delivered is compassionate and upholds people's human rights?

C2: How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?

• Where appropriate, how are you managing the impacts of limited visiting on patient's wellbeing?
• Where appropriate, how are you promoting and ensuring patients know how to access advocacy support in the absence of ward visits?

C2. Additional prompts

All mental health inpatient services

• How has access to independent Mental Health Act advocates been managed?
• How are you ensuring patients can keep in touch with parents, guardians, family and other people important to them?
• How are visits being arranged and managed to keep patients, those visiting and staff safe?

Wards for people with a learning disability and/or autism

• How do you involve family and carers in people’s care, support and treatment? 
• How do you continue to support regular contact between patients, their family and friends?

Community service for people with a learning disability and/or autism

• How do you involve family and carers in people’s care, support and treatment?

R1: How do people receive personalised care that is responsive to their needs?

• How do you ensure that they meet the needs of the population served and do they enable flexibility, choice and continuity of care?
• Where relevant, do individual patients have choices about how, when and where they are seen?

R1. Additional prompts

Long stay rehabilitation mental health wards

• Do you offer flexible, therapeutic activities to meet the needs of individual patients, while maintaining safety and in keeping with COVID-19 guidance?
• Do patients have access to activities to maintain healthier lives during the COVID-19 pandemic with access to social, cultural and leisure activities, as well as education and vocational resources?

R2: Do services take account of the particular needs and choices of different people?

• How are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances? This may include:
  • how do you ensure that each patient has their information and communication needs identified, recorded, flagged, shared and met?
  • how do you identify and make other reasonable adjustments for disabled people?
• Where new protocols for admission are being used, how are these being communicated to staff and how are they reviewed to ensure they are non-discriminatory?

R2. Additional prompts

Long stay rehabilitation mental health wards

• How do you keep patients and families informed on what is changing during the COVID-19 pandemic? Is this information available in a variety of media? Does information include practical advice on what to do in relation to COVID-19 for patients?

All mental health inpatient services

• How are you supporting people to follow their interests and take part in activities that are socially and culturally relevant and appropriate to them, including in the wider community and, where appropriate, to have access to education and work opportunities?

R3: Can people access care and treatment in a timely way?

• How are you managing access to the service to ensure that high-risk patients/pathways are being identified and prioritised appropriately, including reinstating services and handling backlogs of activity?
• Is there a structured approach to patient flow that ensures all components of the system are appreciated and managed appropriately, and flow issues are escalated appropriately? How does the approach take account of the pandemic?

R3. Additional prompts

Crisis and health based place of safety

• If your trust provides psychiatric liaison services in the A&E department of an acute trust, can you continue to safely provide this service during COVID-19? If not, has alternative provision been made?

Community mental health services for people with a learning disability or autism/CAMHS/adults of working age

• If your trust provides psychiatric liaison services in the A&E department of an acute trust, can you continue to safely provide this service during COVID-19? If not, has alternative provision been made?

Community mental health services for adults of working age

• Are patients accessing clozapine and depot clinics as usual?
• Are staff increasing face to face visits to patients?
• How are Care Programme Approach (CPA) meetings being conducted?

CAMHS community

• Do service users and parents have access to a child specific 24/7 open crisis telephone line since 10 April 2020?
• How are services being delivered remotely, for example by telephone, video call, in a clinically appropriate and confidential way?
• How are you maintaining contact with patients and relatives to deliver ongoing assessments of patients’ conditions?

Long stay rehabilitation mental health wards

• Do you use a system wide approach to planning discharge?
• Are the links with local services still in place to plan effective discharges?
• Are discharges planned appropriately and based on patient need to the right place at the right time?
• Do you consider out of area placements as a last resort?

Wards for people with a learning disability and/or autism

• Do you have effective discharge planning in place? 
• Do you work proactively with commissioners to ensure that patients are discharged to services which meet their individually assessed needs and do not remain in hospital longer than is necessary for assessment and treatment?

All mental health community services

• How are services being delivered remotely, for example by telephone, video call, in a clinically appropriate and confidential way? 
• How are you maintaining contact with patients and relatives to deliver ongoing assessments of patients’ conditions?

W1: Is there leadership capacity and capability to deliver high-quality, sustainable care?

• Has there been any impact on leadership capacity as a result of the COVID-19 crisis? Are there plans and mitigations in place should it be affected?
• Do leaders understand the challenges to quality and sustainability during this period, and can they identify the actions needed to address them?

W1. Additional prompts

Long stay rehabilitation mental health wards

• Are leaders committed to providing a recovery-based service and could explain their model of care?
• Do staff at all levels keep up to date with national guidance and best practice in rehabilitation?
• Can managers explain how they stay informed about the national agenda for rehabilitation services?

W3: Is there a culture of high-quality, sustainable care?

• Are you monitoring and protecting the health, safety and wellbeing of staff?
• How are you taking action to protect the health, safety and wellbeing of staff, for example, access to emotional support, supporting staff to raise concerns, adequately risk-assessing and placing staff in appropriate environments to protect their health and safety, including staff in different ethnic groups and other staff at high risk of COVID-19? (not for NHS trusts – this is covered at trust level)

W3. Additional prompts

Long stay rehabilitation mental health wards

• Do staff know the importance of working with each other to share responsibility to meet patient’s recovery needs?
• Do staff have opportunity to progress in their roles and undertake specialist training in rehabilitation?

Wards for people with a learning disability and/or autism

• How do you ensure a culture which encourages openness and honesty at all levels within the organisation, including with people who use services, in response to incidents?
• How do you ensure leaders and staff understand the importance of staff being able to raise concerns without fear of retribution, and is appropriate learning and action taken as a result of concerns raised?  
• During the pandemic there have been changes to commissioners’ roles and many have moved to frontline services. How have you become aware of these changes and adapted to it and personnel, have they become more closed cultures during this time?

W4: Are there clear responsibilities, roles and systems of accountability to support good governance and management?

• Can you work effectively with system partners when care and treatment is being commissioned, shared or transferred?

W4. Additional prompts

All mental health inpatient services

• Are there robust arrangements to make sure that hospital managers discharge their specific powers and duties according to the provisions of the Mental Health Act 1983?

W5: Are there clear and effective processes for managing risks, issues and performance?

• Do you have effective systems and methods for monitoring the overall quality of the service and for responding to business risks and issues as they arise? How often are these reviewed?

W5. Additional prompts

Wards for people with a learning disability and/or autism

• Are there robust arrangements for identifying, recording and managing risks, issues and mitigating actions?
• Is there alignment between the recorded risks and what staff say is ‘on their worry list’?