The care of every hospital patient in long-term seclusion or segregation will be reviewed to tackle a system dubbed ‘not fit for purpose’ by the Care Quality Commission in a damning review published today.
Health and social care secretary Matt Hancock accepted this and four other recommendations issued by the CQC following a report examining the segregation of children on mental health wards and that of adults with a learning disability or autism in hospitals.
Hancock, who said the report revealed a ‘broken system’, said that specialist advocates would be funded as part of the reviews to support people to move into the least restrictive care, and then into the community.
Providers identified 62 people in long-term segregation – defined as receiving care in enforced isolation from others for at least 48 hours – in response to a CQC request, though the regulator found more people than this were affected by the practice. The adults identified had spent an average of 184 days in segregation and children 41 days, with 16 of the 62 having been segregated for longer than year.
The CQC report looked at the experience of 39 people whom it visited, 31 of whom had autism.
‘Highly restricted lives’
Its report, part of a review into restraint, prolonged seclusion and segregation commissioned by Hancock, found that many were living “highly restricted lives”, with some confined to a single room or required to eat food on their laps. Many experienced other restrictive interventions as well, including physical restraint and the prescription of medication for the purpose of managing behaviour staff found challenging.
Providers told the CQC that people were segregated to protect the safety of other patients or because they were unable to live with others.
But the report found that:
- Many staff “lacked the necessary training and skills” to work with people with autism who had complex needs and challenging behaviour.
- Some wards had environments that were not suitable for people with autism.
- A lack of “specialist expertise” to analyse and understand how to best support patients meant staff may not put in place the care packages appropriate to their needs and not act to de-escalate situations.
- In 26 cases, staff had stopped attempts to reintegrate the person back onto the main ward environment, usually because of concerns about violence and aggression. Meanwhile, for 25 people, staff thought the person’s quality of life was better in segregation.
- Thirteen people were experiencing delayed discharge from hospital, and so prolonged time in segregation, due to there being no suitable package of care available in a non-hospital setting.
Typical path to segregation
The CQC identified a typical pathway leading people to be placed in segregation based on a lack of appropriate support as children:
“Many of the 39 people we visited did not get the help they needed as children. There came a point when the only currently available option was to admit them to a hospital ward. The ward was an unpredictable environment with many sensory stimuli. These features may have contributed to the person’s distress, which the person communicated in ways that endangered themselves or others. The staff on the ward may not have had specialist expertise to analyse, understand and manage these behaviours. Therefore, they considered that the only safe course of action was to isolate the person from other patients. The person then became stuck.”
The CQC made five recommendations, all of which were accepted by Hancock:
- For independent and in-depth reviews to be carried out over the next 12 months of the care and discharge plans of every person in segregation on a children’s mental health or adult learning disability ward, with reviewers having necessary experience.
- For an expert group, including clinicians, people with lived experience and academics, to consider a better system of care for this group.
- For urgent consideration to be given to strengthen safeguards, including through the use of advocates.
- For all commissioners, providers and those involved in quality assurance to explicitly consider the implications for the person’s human rights of segregation.
- Informed by these findings and the further work of its review, the CQC should review its regulation and monitoring of hospitals that use segregation.
Hancock said that funding would be provided for specialist, independent advocates to work with families, join up services and work to move people to the least restrictive care and then out into the community.
He also committed to launching a new awareness campaign that will encourage staff and family members to come forward with their concerns about care.
Response from sector
The CQC report followed one issued yesterday by the Children’s Commissioner for England into the care of children with learning disabilities or autism living in mental health hospitals.
The commissioner, Anne Longfield, was among commentators to condemn the findings identified by the CQC.
Today’s CQC report is awful. Two days, two reports about very vulnerable children with learning disabilities or autism kept locked away in conditions none of us would want for our own child. @MattHancock must make good on his promise to review every case AND change the system.
— Children's Commissioner for England (@ChildrensComm) May 21, 2019
Mark Trewin, the DHSC’s mental health social work lead, said the report revealed a need for investment in social care.
Listening to the CQC today, I was struck that much of this could be resolved or avoided by proper investment in Local Authority social care. Better community resources, alternatives to hospital, s117 follow up and discharge planning are all LA responsibilities. @ContactConsult
— Mark Trewin (@markybt) May 21, 2019
Speaking to Community Care following the publication of the review, Sara Ryan, the mother of Connor Sparrowhawk, who died preventably in an NHS Trust unit in 2013, said the findings of the review were “hugely concerning”. She criticised commissioners’ lack of oversight.
“I am disgusted that commissioners are so disinterested and that they don’t seem to do the most basic of checks of these places. I assume they rely on CQC inspection reports, which isn’t good enough, and the CQC have, themselves, had to recognise the limitations of their inspection processes as an outcome of the review.
“These units are holding pens at best with little assessment or treatment conducted. In the 21st century, we should be able to do better than this. A small number of people will need to remain in an inpatient setting and I firmly believe the environment should be as conducive as it can be for a good life with highly specialised staff.”
Ryan also criticised the government’s response to the review, saying the measures did not go far enough to strengthen safeguards and held “little meaning” in practice.
She added that she had “no confidence” in the government’s ability to be able to deliver effective changed and questioned the decision to hold another review.
“There should be urgent scrutiny of every patient who is currently segregated to work out ways in which people can be brought back into a civilised setting. Once that’s done, the focus needs to turn to the remaining inpatients.”
The government linked its promises today to its plans to halve the number of people in mental health hospitals with a learning disability or on the autism spectrum, currently estimated to be 2,245, by 2024.
This is the latest in a string of targets and initiatives to get to grips with this issue in the wake of the exposure of abuse of people with learning disabilities in 2011 in Winterbourne View hospital: in 2012 the then government pledged to end the inappropriate placement of people with learning disabilities and/or autism in hospitals by 2014.
The CQC will begin phase 2 of its inquiry from June. This will look at the use of restraint in these settings, as well as the use of restrictive interventions in mental health rehabilitation and low secure wards, care homes, children’s residential services and secure children’s homes..
Eight years after it exposed the abuse at Winterbourne View, the BBC’s Panorama programme will be screening another undercover investigation into abuse of adults with learning disabilities in a hospital.
The programme goes out at 9pm tomorrow (22 May).