CQC: Out of sight? Who cares — a human rights issue

Dr Kevin Cleary Deputy Chief Inspector for Mental Health, Debbie Ivanova, Deputy Chief Inspector for Social Care blog about CQC’s report out today on restrictive practices and implications for equality and human rights.

At the end of 2018 the Secretary of State for Health and Care commissioned us to look at restrictive practices in hospital and social care settings — we knew from the outset that human rights would be fundamental to this work.

We published an interim report of our review in May 2019 to highlight some urgent areas of focus to safeguard people’s rights, such as the development of Independent Care and Treatment Reviews (ICT(E)R)s for people who were in segregation, and the need to strengthen advocacy services.

Our final report outlines our findings from throughout the review, bringing together what we found in visits to hospital services, surveys and visits to adult social care services and children’s services. We have told the report primarily from the perspective of the people that have experienced restrictive practices — their voices help elevate this issue beyond another set of findings and recommendations. It is their lives that have been at risk.

‘We knew from the outset that human rights would be fundamental to this work’

Early on in the report we use the illustration of ‘Anna’ to show how people’s human rights could be at risk when in hospital and subject to restrictive practices. Anna is a young woman with autism who was in long-term segregation on a mental health ward and was often secluded.

Staff did not understand how her autism affected her and they did not make any reasonable adjustments to her environment to make it easier for her to be in hospital. This meant that she was sometimes distressed — staff thought she was just being difficult. For example, they didn’t understand that the bright light in her seclusion room was a trigger for her and made her feel very distressed. They didn’t know that routine was extremely important to her, so any changes might also make her distressed and lash out at staff. This meant Anna was stuck in a cycle of being unable to leave long-term segregation and hospital.

‘People must be given accessible information about their rights’

We found that seeing things from a human rights perspective can help reduce the use of restraint significantly. When staff are able to think about things through a human rights lens, and what an individual might need in order for them to have their basic rights, they see things differently.

Our report tells the sometimes-horrific experiences of some people’s care, and instances where people’s human rights have been at risk but it also tells the story of what’s possible if the right support is in place for people.

Community-based services are widely accepted to be the best place to care for people with a learning disability and autistic people and or mental health condition — in guidance such as Building the Right Support and NICE guidance. It is possible to make this a reality even for people who have been subject to long periods in hospital and cycles of restrictive practice. Everyone has the right to live a fulfilling life.

‘We found that seeing things from a human rights perspective can help reduce the use of restraint significantly’

That’s why as part of our recommendations, we’re stating that human rights must be embedded in the commissioning and delivery of care. This is especially the case for children and adults with a learning disability, autistic people and people with a mental health condition.

People must be given accessible information about their rights such as resources produced by the British Institute of Human Rights and the Equality and Human Rights Commission.

Individuals’ needs must be taken into account and reasonable adjustments made in accordance with the Equality Act 2010 to meet these needs, thereby fulfilling the need to make adjustments that are reasonable in the context of the ward and other people. This includes training in human rights and checks against whether reasonable adjustments are taking place.

We will know that we are succeeding when people who use services know that their rights will be respected, that they will not be segregated and restrained and they have a true voice in determining where and how they live in the community.