A year on — Progress update on ‘Out of sight — Who Cares?’ review into restraint, seclusion and segregation

In this blog Debbie Ivanova, Deputy Chief Inspector — People with a learning disability and autistic people, and Jemima Burnage, Deputy Chief Inspector and Mental Health Lead, update on the progress since CQC’s Out of Sight report published last year detailed in a new report.

It’s been just over a year since we released our Out of Sight report last October. In this report we highlighted the high levels of restrictive practice used in some mental health hospitals in England, and the inappropriate use of long-term segregation. We worked closely with families, people who use services, providers, commissioners and system partners to get a report that reflected the current situation.

‘Since the release of our original report there has been a real step change in collaboration across the system’

We always said we didn’t want this report to just sit on a shelf — and that’s why we are reporting on progress in our new report out today. This will be one of two progress reports — a fuller update is due in Spring next year.

Since the release of our original report there has been a real step change in collaboration across the system — we have met as national partners quarterly to discuss progress in the Building the Right Support Ministerial Delivery Board chaired by the Minister of State for Care. CQC has been a part of this group to ensure that the recommendations continue to be a priority.

We recognise that COVID-19 has especially affected the health and care of people with mental ill health, a learning disability and autistic people. We also found that instances of inappropriate restraint, segregation and seclusion are still prevalent in health and care settings in England.

However, there has been some key progress at a system level, to name a few…

• Independent reviews of everyone who we found in segregation in our initial review have happened. We recommended these take place in our Interim report: Review of restraint, prolonged seclusion and segregation for people with a mental health problem, a learning disability and or autism. A report of these reviews was published by Baroness Hollins in July 2021 and highlighted improvement areas for immediate action which are currently in the process of being implemented, with support from the Department of Health and Social Care.
• In July 2021, the government published its new ‘National Strategy for autistic children, young people and adults’. The strategy contains the government’s vision for autistic people and their families across six priority areas including tackling health and care inequalities for autistic people, building the right support in the community and supporting people in inpatient care.
• NHS England is carrying out a review of advocacy for children, young people and adults with a learning disability and autistic people in inpatient settings.
• In January 2021, the Mental Health Act (MHA) white paper made recommendations to improve the way the MHA is used for people with a learning disability or autistic people.
• Where we have found poor care for people with a learning disability, autistic people and/or people with mental ill health, we are continuing to do our part to drive down unacceptable care by taking enforcement action.
• We look at the culture of learning disability and autism services through a focus on observation, inspections at different times during the day and night, and capturing peoples experience of care. Learning is shared for use across health and social care services.
• We have updated our policy ‘Right support, right care, right culture’ which outlines what we expect to see from providers supporting autistic people and people with a learning disability.
• We are also piloting communication and support tools for use on inspections including a new quality of life tool to improve how we look at how care is being provided for people with a learning disability and/or autistic people.

Call for action

It is really important to recognise the hard work that has gone on in the last year to drive forward change for people with a learning disability, autistic people and people with a mental health condition. This is particularly important for those who experience restraint, segregation and seclusion.

However, we need to see the impact of these ambitious projects and we need to see this translate into a better range and higher quality of services now.

We know from findings in the update report that:

• Use of restraint, seclusion and segregation is commonplace in some settings
• Commissioning the right support and services for people with a learning disability and autistic people is not happening quickly enough
• People are still being placed in services which are not able to give them the right care
• There are still too many people in inpatient hospital wards
• When admitted, some people are spending too long in hospital and discharge can be very slow

We cannot accept this any longer. Therefore, we are continuing to work with colleagues at CQC and to work with system partners to drive through more positive change as fast as possible in this area.

We will be updating on further progress in Spring 2022 in a fuller update. We look forward to working with the system to make this happen.