The Mental Welfare Commission has published 13 new reports assessing the support for people with mental health conditions, learning disabilities, dementia or related conditions in NHS hospital wards and units. These reports raise issues of understaffing, inconsistent care planning and the pandemic’s impact on services.

The Mental Welfare Commission for Scotland (MWC) helps protect and promote the rights of people with mental health conditions and learning disabilities and those with neurological disorders, such as dementia. These reviews aim to improve services, as well as holding staff and NHS health boards accountable.

The reports are published following the annual visits from the commission to healthcare settings providing this support to patients.

Commenting on the latest reports, Claire Lamza, MWC Executive Director (Nursing) said:

“While many of today’s reports include very positive comments about staff, they also give an insight into the pressures caused by staff vacancies. The consequent over-reliance on agency or bank staff, particularly in nursing, is evident.”

Each visit has at least one nursing officer, and many have either a social work officer or engagement and participation officer and this year all visits occurred between March and June 2022.

Leverndale Hospital Glasgow

In a report from Leverndale Hospital’s Ward 4a in Glasgow, the Senior Charge Nurse (SCN) commented on the need for bank staff but said, due to the supportive workplace, they did not think it impacted patient care.

In observing the ward which oversees patients with acute mental health issues and was at capacity during the visit this May, the report added:

“There were no concerns noted and this was accepted as a need to ensure safe staffing levels on the ward. This situation is currently faced across NHS health boards at this time and is as a result of staff absence and recruitment issues.”

During this visit, eight patients shared their thoughts and spoke positively of the staff team, with one saying they are “fantastic despite being short-staffed” and another adding that the catering team were amazing.

Its neighbouring Ward 3a, which also oversees adult patients with acute mental health issues, received similarly good general feedback from patients, with its report stating:

“Without exception all patients we spoke to had only praise for the staff team. One patient who had been in the ward for several months described the staff team as “amazing” and “the quality of care is really good” The SCN spoke highly of the staff team.”

Ward 4b in Leverndale covers care for those from Govan, Ibrox, Cambuslang and Rutherglen and its patient profile is “predominantly for first presentation psychosis”, with all patients either on short term detention certificates or compulsory treatment orders.

After speaking with five patients from ward 4b, the commission reported that patients describe staff as “brand new, available and very approachable” and that people felt looked after by staff. Another patient said:

“[The] nurses are amazing, they listen, treat me with respect and the doctors are good, I’m invited and included in MDT’s and I feel listened to.”

MDT refers to multidisciplinary team, an area looked at the NHS units by the comission, and where improvement is needed in some wards, with reports reflecting poorer of patient inclusion in this process. 

Despite high praise from discussion with patients, Leverndale's wards were critiqued for their nursing care plans. Of the care plans reviewed in the report from 4b, the officers said they were “not of standard to reflect the service delivery” and not as person-centred as expected.

Staff shortages

However, Leverndale also experienced staffing challenges and had to close twice due to covid-19, once more recently during February this year. Staff across Leverndale wards 3a, 4a and 4b reported working together and doing additional shifts to ensure “adequate safe cover” for patient care.

The RCN has previously called for urgent action to increase staffing and support for nurses across Scotland.

Staff shortages and bank staffing led to relatives raising concerns about the consistency of care in East Ayrshire Community Hospital’s Marchburn ward which oversees older adults with complex care needs. This ward has five registered nursing vacancies and the team expressed struggles filling them.

Marchburn’s report reflected that, though staff are “committed” to meeting these needs and patients seem relaxed and settled, care plan reviews were inconsistent. The officers assessing this ward said that some of these reviews “appeared to be a copy of the care plan” itself.

Forth Valley’s Royal Hospital ward 5 was also critiqued for not being person-centred enough, with the commission advising a move away from generic treatment plans to more detailed plans. When reviewed in April of 2022 and – in common with Leverndale’s wards – this ward showed good MDT work in care and treatment.

However, alongside other wards, the commission recommended that Forth Valley improve its documentation not only for plans but patient consent and authorisation, and specific forms delegating decisional powers.

Forth Valley’s report reflected a lack of clarity on the ward with regards to welfare proxy and the Adults with Incapacity (Scotland) Act 2000, stating:

“Where there was a welfare proxy (guardian or power of attorney) in place, details of this were not fully recorded. Staff we spoke to were unsure of what powers were in place and there was some confusion as to where this information was held. Staff were also unaware that powers could be delegated to them as care providers.”

Some ward commission visits also included medical or specialised visitors, depending on the needs.

For example, Woodland View, Wards 10 and 11 in Irvine was also reviewed by a consultant psychiatrist. In this case, as with Forth Valley and other wards, the commission referred staff back to review their Rights in Mind guidance after noting some missing treatment certificates.

In a report from May 2022 on East Ayrshire’s Community Hospital Marchburn Ward, the commission said:

“In common with other services we have visited recently, the surge in clinical demand has resulted in a reduction by the service to offer an optimum level of meaningful activity in a busy ward.”

Reports also recognised that disability specialist nursing vacancies and recruiting for rural areas such as Seafield’s Murion ward which has ongoing staffing challenges, is especially difficult.

Despite the commission stating these reviews occur every year, adapting to the pandemic has not only impacted the services but the assessment process too. Only three of the 13 wards visited had been visited within the one-year time frame, and around half of the wards’ previous reviews were in 2018 or 2019.

For Leverndale Ward 4a which experienced closures due to covid-19, the report stated:

“Staff also worked hard to ensure that patients and their loved ones communicated throughout their stay. Whether it be via FaceTime on the iPad, access to a phone in private. Covid ward closures impacted on visiting arrangements where essential visits only were advised by the infection control team.

“Therapies staff ensured that there was also activity packs for patient who were required to self-isolate for infection control covid screening. These resources were also utilised outwith requirements for self-isolation.”

One report added that staff were concerned about social isolation, reduced service provision and anxiety in relation to the pandemic were contributing to “an increase in mental distress” among patients.

Ms Lamza said they recognise the pressure on such busy wards and will continue to raise staffing concerns in reporting while “recognising the extraordinary effort” of those working in these circumstances.

Going forward, the MWC for Scotland is looking to improve these services and made a series of recommendations to each ward, and says it 'requires' responses within 3 months.

Many of the concerns revolve around poor or strained staffing levels on wards and increasing the workforce would provide time for training around medical proxy forms and better including patients in their own care planning process.

Read more: Patient waited four years for psychology support; Scots 'completely unaware' they can inform policy;RCN: treating patients in corridors ‘scandalous'

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