National Preventive Mechanism Second Annual Report 2010–11 CQC uses its regulatory powers under the Health and Social Care Act 2008 to ensure that all those who provide services to patients detained under the MHA comply with its ‘Essential Standards of Quality and Safety’. These standards cover all aspects of service provision including staffing, training, consent and appropriate use of control and restraint. Wales In 2010–11, around 50 hospitals in which patients are detained under mental health law were visited by Healthcare Inspectorate Wales (HIW), with some hospitals being visited more than once. Many of the issues highlighted by HIW in last year’s annual report remained a concern this year. HIW is concerned that the capacity of patients (for example, to consent to treatment) is not being appropriately assessed, recorded or reviewed. In addition, patients are not being adequately informed of their rights. Often, their rights are explained in a perfunctory manner and this important safeguard is treated as a ‘tick box’ exercise. There is often no record of how a patient was informed of their rights or whether efforts were made to tailor explanations about rights to the patient’s individual communication needs. HIW found that patients do not demonstrate a strong understanding of their rights. As a result of efforts to support patients in the community wherever possible, patients are increasingly admitted to hospital only when they are acutely ill. This has led to a more volatile patient mix and has heightened pressure on staff. Staffing has not always been reviewed to take account of this change in patient profile. 38 Mirroring the concerns of the CQC about mental health detention in England, HIW is concerned about whether appropriate control and restraint methods are being used in Wales. While it wishes to encourage approaches focused on de-escalation, it nevertheless recognises that staff dealing with aggressive patients should have the skills to manage them physically when required. In particular, staff working with children and young people should be trained in age-appropriate control and restraint. In relation to children and young people more generally, HIW is concerned about whether they are able to access suitable services, particularly when crises occur at evenings or weekends. This year, patients have told HIW about a lack of stimulating activities appropriate to their age, needs and skills. HIW is also concerned about a lack of psychological therapies, whether provided by psychologists or suitably trained nursing staff. Sometimes, patients are not legally detained but may agree to stay in hospital ‘informally’. Some services argue that these informal patients agree, as part of their care plan, to reside on a hospital ward except when granted leave by their doctor. HIW has noted that it is difficult to evidence whether such patients are made aware of their rights. HIW fears that many stay in hospital under coercion or due to actual or implicit threats that they will be legally detained if they are not compliant. It recommends that an informal patient’s right to freedom of movement must be respected.