Letter: Supporting improved care for people with a learning disability and/or autism or mental health problem

On 10 October 2019, we wrote to social care and hospital providers of mental health and learning disability to ask them to consider how the system can better protect people who have a learning disability, autism and or mental health problem in their service.

Dear colleague,

We want to make you aware of the work we are doing to support improved care for people with a learning disability and/or autism or mental health problem — and to ask you to consider how you are ensuring that the people for whose care you are responsible are receiving safe, high quality care.

We have been concerned about the quality and safety of mental health and learning disability wards for some time — we first highlighted these concerns in our report the State of Care in Mental Health Services 2014–2017.

We particularly want to highlight the factors that increase the risks of punitive environments and abusive cultures developing. These include hospitals where people may stay for months or years at a time. They may be located away from their communities and have staff that often lack the skills, training, experience or support to support people with complex needs.

In social care, our review of restraint, segregation and seclusion has highlighted that restrictive practices can be used in social care services, that can compromise people’s human rights. We will report on this in March 2020 in more detail.

In this letter we highlight the key areas for improvement, describe what action we are taking, and outline what action we expect you to take.

Improving our assessment of mental health and learning disability wards

We recognised the need to strengthen our assessment of these wards since we highlighted concerns about safety and quality through our inspections of mental health services.

In December 2018 the Independent Review of the Mental Health Act added impetus to this by recommending that we review the prompts and guidelines currently used for inspections in the assessment frameworks specific to mental health hospitals. More specifically, it recommended that ‘CQC should develop new criteria for monitoring the social environments of wards’.

We have already begun work to strengthen our assessment of mental health and learning disability wards to better review their safety, quality and the experiences of people who use them. We worked with people who use services via our Service User Reference Panel (SURP) on this work as well as providers. In March, we wrote to directors of nursing to express our concerns about the safety of mental health wards, and in June we held a coproduction meeting in which we discussed our plans on how we will strengthen our assessment.

Our review of restraint, prolonged seclusion and segregation

In May 2019, we published the interim report of our thematic review on restraint, segregation and seclusion. In the report, we highlighted the poor environment and culture that can develop in these hospitals. This work also highlighted the need to change the way we assess the care for people with a learning disability or autism.

Our in-depth visits to people being cared for in segregation have helped us to better understand the quality of care provided from the perspective of that person. The report set out our commitment to learning from the visits carried out during the first phase of our thematic review and to use this learning to strengthen our monitoring and regulation of these hospitals. Recommendations of this report have been accepted in full by the Secretary of State for Health and Social Care.

Phase two of the thematic review is currently underway and is focusing on restrictive interventions in social care services as well as mental health rehabilitation and low secure services, and some children’s residential and secure services. The final report will be released in March 2020 and will make recommendations for the health and care system.

Immediate action following Panorama

Following the exposure by BBC Panorama of the abusive culture at Whorlton Hall, a private hospital operated by Cygnet, we have conducted a review of all locations operated by this provider- looking across safeguarding, whistleblowing, incident reports and complaints — to explore whether there are any areas of concern and have carried out unannounced inspections of a number of services operated by Cygnet, taking enforcement action in several cases.

Additionally, we have commissioned two independent reviews into our regulation of Whorlton Hall. We have taken practical steps ahead of findings of these reviews to ensure that all our hospital and social care inspectors have a consistent and shared understanding of the potential risk factors for abusive cultures and can use this information to take action where necessary. We would encourage you to do the same with the services you are responsible for.

We have conducted a number of inspections of similar services in response — both independent and NHS — which admit people with a mental health problem, a learning disability and or autism. We are concerned about these services and since May 2019 we have rated twelve of these as inadequate.

The need to take a human rights based approach

Protecting people’s basic human rights is at the heart of good care. Everyone involved in the care of people in these services has a duty to act where there is a risk that a person’s human rights are being breached. We expect this of all our staff and of providers and all their staff.

We ask you to make sure that your services and staff are fully aware of what human rights are, and whether there is anyone in your care whose human rights are at risk of being breached. This could relate to the right to life, right to liberty, right not to be tortured or treated in an inhuman or degrading way, right to respect for private and family life, home and correspondence, and right to be free from discrimination.

We are currently reviewing our regulatory methodology and support for inspectors who look at services that have a high risk of a poor culture developing to see how we can strengthen our focus on human rights. Crucially, we will be focusing on placing a stronger weight on how we respond to the testimonies of people who use services, their families and staff working in services.

Moving forward

We recognise that hospitals are not the only services at risk of developing a closed and abusive culture. There is an increased risk of this happening in any setting where people reside long-term and are highly dependent on staff.

We are clear that we will not register services that do not meet the needs of people with learning disability and / or autism and are not in line with the Transforming Care and our guidance around Registering the Right Support. We expect any new service to support the agreed national policy to move away from large institutional styles of accommodation.

But the action that providers, regulators, commissioners, government and others in the system has taken to date does not go far enough to protect people. We will be working closely with providers and the public. We will also be increasing the involvement of people who use services and their families and advocates in our work, so that we can better understand the quality of care. This will be an ongoing conversation.

In terms of immediate action providers can take now, we ask you to consider what you are doing to make sure that the human rights of the people receiving care from your services are protected, and that your staff are supported and motivated to deliver good, safe, compassionate care to these people at all times.

Yours sincerely,

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Kevin Cleary, Deputy Chief Inspector of Hospitals (lead for mental health)
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Debbie Ivanova, Deputy Chief Inspector of Adult Social Care (lead for the thematic review)

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

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