Monitoring the Mental Health Act in 2024/25

Resourcing and capacity challenges

We are continuing to see systemic challenges with recruitment and retention. Despite an increase in the number of staff over the last few years, the size of the mental health workforce has not kept up with the rising demand for mental health care. Data from NHS Vacancy Statistics shows that 9% of roles in mental health trusts in the NHS were unfilled in March 2025. As a result, we have heard from providers how they feel they are not always able to cope with the increasing levels of demand.

Our MHA reviewers described how system pressures are having an impact on staff morale. This included, for example, compassion fatigue among staff because of high acuity levels and the increasing numbers of patients with highly complex needs. The NHS Keeping Well Service describes compassion fatigue as “the ‘emotional cost of caring for others or their emotional pain’, whereby the individual struggles emotionally, physically and psychologically from helping others as a response to prolonged stress or trauma.”

In another example, we heard how in some trusts, staff get moved around constantly between wards to cover absences and gaps in staffing, this can have a significant impact on staff morale, to the point that some staff are leaving because they feel as if they cannot cope with uncertainty. It can also affect the continuity of care people receive and have an impact on the therapeutic relationship between staff and patients.

Recruitment and retention issues are also leading to significant challenges around staff experience, skills and competencies. These gaps in the workforce are exacerbating pressures on services and staff, with staff feeling burnt out and overworked, and that they are constantly ‘firefighting’, with little long-term impact. This is supported by data from the 2024 NHS Staff survey, which shows that for mental health and learning disability trusts, and mental health, learning disability and community trusts:

• less than half (49%) of people felt able to meet all the conflicting demands on their time
• over a third (34%) of people reported always or often finding their work “emotionally exhausting”
• a quarter (26%) of people reported they were always or often feeling “burnt out because of their work”.

Effects of low staffing

Staff have a huge influence on people’s experience of being detained in hospital under the MHA. A positive, therapeutic relationship with staff is a key element of inpatient care and can help patients to engage with treatments and interventions, leading to a better outcome. Therapeutic relationships play an important role in helping to create a culture where people feel psychologically safe, where they feel comfortable expressing themselves.

A fundamental factor in building these supportive and therapeutic relationships is having consistent staffing.

Through our analysis of MHA monitoring reports we found that patients valued having consistent relationships with named staff, which allowed them to be involved in their care and treatment plans. Regular contact with trusted and familiar staff also allowed for better communication and support for individual preferences, including involving family and carers. Some wards that we visited have had good levels of staffing, and in others we’ve heard from patients how, despite being very busy, staff made time for them and remained approachable and attentive.

However, other reports have described challenges around low staffing levels, which can prevent people from developing therapeutic relationships and can leave them feeling unsafe (see also section on demand and system pressures).

As well as vacancies, staffing levels were affected by sickness, incidents requiring staff intervention or staff needing to provide enhanced levels of support and observation for people on the ward with higher acuity levels. For example, we heard how, in some wards, a lot of people were on enhanced observation as they were experiencing considerable levels of distress. As a result, staff were not readily available or were not quick enough to respond. At one ward, almost all patients told us they did not feel safe on the ward. The majority of patients said this was because they felt there were not enough staff around to support them.

Low levels of staffing affected people’s rehabilitation and recovery. For example, people were unable to access all areas of the service, such as outdoor environments for fresh air, or they were not able to take a shower as there were not enough staff available to observe them. It could also lead to having to cancel daily activities and section 17 leave. People described how this left them feeling frustrated or that it would negatively affect their level of confidence.

We have seen the effects that low staffing levels could have on people in long-term segregation through our Independent Care (Education) and Treatment Reviews (IC(E)TRs) programme. Being able to spend time outside long-term segregation was important for people because it meant that they could:

• experience reduced restrictions
• practise being in different environments
• connect with peers and family members
• participate in interests and hobbies they enjoyed.

However, we found examples where low numbers of staff meant that people could not spend time outside of long-term segregation because leave could not be facilitated. This seemed to be because more staff or specialist members of staff were needed to facilitate leave but they were not available.

The following experiences highlight this issue:

As highlighted in this year’s State of Care report, issues with staffing are also leading to significant challenges around staff experience, skills and competencies. Our MHA reviewers described how some wards may appear to have adequate staff numbers, but there was not always the appropriate skill mix and knowledge among staff, which could affect how clearly staff communicated with each other, and this had led to less effective responses to emergencies.

The mix of skills and experience could be a particular problem where bank and agency staff were being used, adding to the pressure placed on staff and the service, and contributing to patients feeling unsafe. Our MHA reviewers described how agency staff are generally unfamiliar with patients, and although they can read the patients’ care plans, they do not always know how to de-escalate patients. They described how agency staff don’t have enough time to build a therapeutic relationship with patients, which can lead to less effective care and patients feeling frustrated.

In services with a high staff turnover, people were reluctant to build rapport with staff because there was “no point” in getting to know them if they would be leaving again.

This theme was supported by feedback from carers who told us that when they spoke with staff who did not work at the service regularly, they often did not know the patients personally and could not provide updates on their care. We heard how this difference can be more marked during weekends and night shifts, when the use of agency staff can be more common.

The challenges around bank or agency staff were also highlighted in a 2024 report by the Health Services Safety Investigation Branch (HSSIB), Workforce and patient safety: temporary staff - integration into healthcare providers. The report found that providers often had little information about the bank or agency staff they were employing, which meant they could only give them tasks on the basis of their role, rather than skill or experience. For mental health settings this meant temporary staff were commonly allocated to carry out continuous observation, as this was considered to be a clearly-defined task which was not complex.

To be therapeutic, continuous observation requires staff to build and maintain trust and rapport with the patient. The HSSIB investigation heard of many instances where temporary staff carried out this role for many hours at a time. As we raised in our Monitoring the Mental Health Act annual report 2021/22, enhanced, continuous observation provides an opportunity for prolonged therapeutic engagement. However, it can be difficult and exhausting for both patients and staff. Carrying out continuous observation for many hours on end, particularly with staff unknown to the patient, increases the risk of this becoming a passive activity rather than active therapeutic engagement.

Guidance from NHS England on enhanced therapeutic observation states that, while senior nurses provide overall clinical governance for enhanced therapeutic observation, the nurse in charge on the ward is responsible for allocating ward staff to perform observations, ensuring the skill mix is safe and appropriate for both the ward and patient, and ensuring that staff have regular breaks.

One MHA monitoring report shared similar concerns about bank staff sleeping during night shifts and how this led to patient observations being neglected. When we raised concerns about this, the provider responded by contacting all ward staff to remind them to take care of their wellbeing, while reminding them of the consequences of being found to be sleeping on shift. The ward management team also removed staff from the bank who were found to have been sleeping on shift.

MHA reviewers who took part in our focus groups also told us they had seen examples of agency staff sleeping during night shifts. They explained that because agency staff work at different locations, and sometimes for multiple agencies at the same time, it is harder to have a clear oversight of the hours they work. This means that they might do consecutive shifts and end up exhausted by the time they have night shifts.

Low staffing levels can also affect people’s ability to get their care reviewed by a Second Opinion Appointed Doctor (SOAD). As we reported last year, ongoing difficulties with the funding of the service and insufficient numbers of SOADs has led to a backlog of requests and delays in delivering second opinions. While we are working to reduce these backlogs, communication challenges with hospitals can lead to additional delays in people receiving a second opinion. For example, we have heard about SOADs being unable to contact the ward on the phone to book an appointment as phones go unanswered, or staff are unable to book SOADs into the ward because either no staff are available, or the staff member is too junior to have permission to book on the system.

Attitudes of staff

Members of our Service User Reference Panel (SURP) highlighted the importance of patients feeling able to approach staff with their concerns. One SURP member described how approachable staff are conducive to a person’s recovery.

This was supported by the findings of our analysis of MHA monitoring reports. Several reports highlighted how staff attitudes were important in making patients feel supported and safe. Patients often described staff as caring and working hard to keep everyone safe on the wards. Some patients described how positive attitudes and behaviours contributed to an overall positive atmosphere on the ward, potentially minimising the incidence of violence.

Patients also commented positively on staff who respected their privacy, for example, by knocking on their room doors before entering. One patient highlighted the importance of being treated with respect when in seclusion, to preserve their dignity, for example when showering or using the toilet.

Analysis of our MHA monitoring reports highlights how patients feel more able to share safety concerns with staff who are friendly, helpful and approachable, which helped them to feel safe on the wards. Feeling that staff listened to their concerns seemed to be particularly important for some of the patients who had previous experience of violent assaults within the wards.

However, figures from our MHA complaints data highlight ongoing concerns around the attitude of some staff. Out of 2,552 MHA complaints received in 2024/25, 45% included concerns about the attitudes of staff, ranging from therapists and nurses being unwelcoming and/or rude, to staff being inattentive (figure 1).

Figure 1: Number of complaints about use of the MHA by category, 2023/24 and 2024/25

Source: CQC MHA complaints data

Note: A single complaint can be assigned to more than one category, therefore the figures above total more than the overall number of individual complaints.

Qualitative analysis of these complaints showed allegations of physical and verbal violence, as well as issues that patients raised about staff requiring them to take medicines authorised under the MHA without their consent or with no information about side effects. In some cases, patients described how the care offered to them was not always person-centred, as individual needs and personal history (such as background information, history of self-harm, and past adverse reactions to medicines) were not always taken into consideration.

This was echoed in some of our MHA monitoring visit reports. One report describes the effect of poor attitudes of staff on patients:

Another report spoke of how a patient mentioned feeling infantilised when staff spoke to them, while a patient in another ward described staff as “quite scary”. We also found examples where staff were not seen as approachable or did not respond to incidents quickly enough, which left patients feeling unsafe. In one ward the behaviour of staff and the response to incidents led to a frightening environment for some patients.

One report suggested a connection between negative staff attitudes – specifically staff being “abrupt and bossy” towards patients, and a high turnover of staff. This reinforces the idea, as highlighted in the section on effects of low staffing, that consistency and regular contact between staff and patients are essential to maintaining positive relationships and ensuring their psychological safety.

Our work on Independent Care (Education) and Treatment Reviews (IC(E)TRs) found concerns around staff in certain roles not understanding, or seeing the need to support people, as part of their job. We found evidence of this lack of responsibility to support and engage with people in reports.

One report stated that “a person and their family told us that staff did not always engage and support them”. Similarly, we heard that “sometimes bank staff do not engage with them, just sit and stare at them, which can be triggering”. It seemed that some people were paired with staff who may not have viewed engaging and forming meaningful relationships as their responsibility, which has been noted as an important factor in helping people to leave long-term segregation.

This disconnected care for people – with some staff, professionals and services not recognising their responsibility to support people in long-term segregation and to progress out of it – could lead to people’s needs not being met and a longer stay in a segregated environment.