Skills gaps and capacity shortages have driven a deterioration in mental healthcare in hospitals for adults with learning disabilities or autism, the Care Quality Commission has found.
Too many staff in these services lack the skills, training, experience or clinical support to care for people with complex needs, the regulator said in its annual report on the state of health and social care, published today.
The problem has been exacerbated by falls in the number of mental health beds, apparently without compensatory increases in community support, limiting access to care, the CQC said.
Deterioration inpatient mental healthcare
The CQC said the quality of mental health inpatient care had deteriorated, with 6% of acute wards for adults rated inadequate in 2019, compared with 2% in 2018, and 4% of wards for adults with learning disabilities or autism carrying the lowest rating in 2019, up from 1% in 2018.
In relation to the latter group, the regulator raised particular concerns about independent providers, having rated 14 independent mental health hospitals that admitted people with autism or learning disabilities as inadequate since October 2018, putting them into special measures. Though two of these services have since improved, three are closed and one, though still registered, is closed to new admissions with on existing people resident.
The regulator said that staffing problems and skills shortages were significant factors. This included a lack of registered learning disability nurses leading to high reliance on healthcare assistants or other non-qualified staff, inadequate training, and high use of agency staff, which increased administrative duties for permanent workers, leaving them less time for patient care. Among mental health nurses, the numbers working in inpatient settings fell by 15% from 2014-19, though the numbers working in community mental health rose by a similar proportion.
Squeeze on mental health beds
The staffing and skills shortages were coupled with a squeeze on the number of mental health beds, which fell by 14% from 2014-15 to 2018-19. Though this was in line with the policy drive to shift care out of hospitals into the community, the CQC said that it was concerned that new community provision was not compensating for the fall in the number of beds.
CQC chief executive Ian Trenholm said: “Increased demand combined with challenges around workforce and access risk creating a perfect storm – meaning people who need support from mental health, learning disability or autism services may receive poor care, have to wait until they are at crisis point to get the help they need, be detained in unsuitable services far from home, or be unable to access care at all.”
Responding to the findings, NHS Providers, which represents mental health trusts, said the CQC was right to highlight the challenges in mental health, including on staffing.
“[In a survey last year], less than one in ten (9%) of trusts said they currently had the right staff in the right place,” said deputy chief executive Saffron Cordery. “We urgently need investment to grow and develop our mental health workforce.”
However, overall, the quality of NHS mental healthcare improved, with 71% rated good and 10% outstanding in 2019, up from 70% and 8% respectively in 2018.
Lack of understanding on DoLS
The regulator also found a “concerning” lack of understanding about the Deprivation of Liberty Safeguards among providers, resulting in poor practice. Providers were not always focused on taking steps to avoid the need to make a DoLS application and there was confusion around whether the DoLS or Mental Health Act 1983 should be used in particular circumstances.
In some cases training – particularly online training – was not equipping provider staff to apply the DoLS, while the CQC also criticised the quality of leadership on the issue in certain organisations.
“We have encountered senior managers who do not understand the legislation and providers who see DoLS as procedural or ‘box-ticking’, with little thought given to how the legislation could be used to properly protect people,” the report said.
Gradual improvement in adult social care
The overall quality of adult social care improved slightly, with 80% of services rated good and 4% outstanding in 2019, up from 79% and 3% respectively. As in previous years, community services performed best, with 88% rated good and 5% outstanding, and nursing homes were the least well-rated, with 72% good and 4% outstanding.
However, amid the improvement, the regulator raised concerns about funding and workforce pressures on the sector. Inspectors found that, where staff valued their staff, it could result in high-quality care and an engaged workforce. But elsewhere, they found issues with inadequate staffing and “chaotic and unorganised shift patterns” in care homes, and domiciliary care providers taking on new packages at times when existing rotas were too challenging for them to be managed safely.