Safeguarding teams took no action on ‘serious’ concerns regarding people segregated in hospitals

Councils did not act on alerts regarding poor care or environments for autistic people or those with learning disabilities on grounds that providers were 'doing what they could', says CQC

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Safeguarding teams took no action in response “serious” concerns about the care of disabled people segregated in mental health hospitals, the Care Quality Commission (CQC) has said.

Alerts were raised concerning 13 people with learning disabilities or autistic people in long-term segregation for reasons including poor-quality environments, a lack of care and observation and the person not being able to access outdoor spaces.

Long-term segregation refers to a situation where a person detained under the Mental Health Act 1983 is prevented from mixing freely with other patients on their ward or unit because they would cause a “sustained risk of harm” to others, which is a “constant feature of their presentation”. The decision should be taken following a multi-disciplinary review (source: Mental Health Act 1983 Code of Practice).

The alerts were made just prior to or as a result of independent care (education) and treatment reviews (IC(E)TRs), under which a mostly independent expert panel scrutinises the quality of the person’s care and makes recommendations for improvements.

No action taken

But despite the seriousness of concerns raised and the fact alerts were mostly made by the CQC itself or independent chairs of IC(E)TRs, the relevant local authority did not take any action.

In its annual report on its monitoring of care under the Mental Health Act 1983, the regulator said safeguarding teams concluded that “providers were doing what they could in what were difficult circumstances for patients with complex support needs”.

However, in its report, the CQC implied that councils had, in some cases, made the wrong judgment, saying chief social worker for adults Lyn Romeo had been informed of cases “where there was an apparent failure of safeguarding teams to take action where required”.

The IC(E)TRs in question were among 77 carried out of people with learning disabilities or autistic people in long-term segregation, from November 2019 to September 2020. These were ordered by the Department of Health and Social Care (DHSC) on the recommendation of the CQC, in the light of the regulator’s Out of sight review into the restraint, seclusion and segregation for autistic people and people with learning disabilities in mental health settings.

‘Undignified and inhumane care’

The review’s final report, in October 2020, found “too many examples of undignified and inhumane care, in hospital and care settings where people were seen not as individuals but as a condition or a collection of negative behaviours”.

The DHSC also appointed a panel to oversee IC(E)TRs, led by psychiatrist and learning disabilities expert Baroness Hollins, which drew similar conclusions to the CQC in a report to the department in July 2021.

The panel said that people in long-term segregation generally received poor-quality care in a poor-quality environment, on the back of poor commissioning and discharge planning.

The panel also highlighted the 13 safeguarding referrals and raised concerns about why alerts had not been raised before the IC(E)TR was carried out

It said that Romeo was examining the safeguarding concerns raised and that this would inform a forthcoming code of practice on safeguarding that the chief social worker’s office was drawing up. This would provide clarity on safeguarding processes for people in long-term segregation and strengthen mechanisms for intervention in these cases, the panel said.

The DHSC also accepted the panel’s recommendation for IC(E)TRs to continue for people in long-term segregation, and these resumed in November 2021.

In hospital for between 10 and 30 years

The CQC’s Mental Health Act monitoring report, published last week, provided further details on the failings identified by the IC(E)TRs, including that:

  • Several cases in which the person was admitted to hospital because of a lack of credible community alternatives, but with little evidence that community teams and commissioners had explored support options that were available.
  • Over a third of people had been in hospital for between 10 and 30 years, with 35% of providers not reviewing long-term segregation in line with the MHA code of practice. This states that reviews should take place every three months by an external hospital and involve the person’s commissioner and, where applicable, independent mental health act advocate (IMHA).
  • Poor care, with staff in some cases not having “even the most basic grasp” of people’s needs due to a lack of assessment, and many workers feeling ill-equipped to meet needs.
  • While most staff were caring, some were abusive, including by provoking or shouting at patients or imposing punitive sanctions.
  • Over a third of people were in poor-quality environments, with some being kept in bare rooms devoid of personal possessions and with just a mattress on the floor, or receiving all their communication and activity through a locked door, through which food was passed.
  • A third did not have access to appropriate activities or therapies, with some leading “empty lives”.
  • Distressed behaviour among some people had got worse since they entered hospital.
  • Almost half did not have an exit strategy from long-term segregation or a robust discharge plan.

‘Personalised care,  not congregate settings’

In response to the report, Learning Disability England representative body members James O’Rourke and Ivan Olbrechts said: “The report reflects our experiences of people being put into long-term segregation (LTS) often due to inadequate staffing both numerically and in terms of appropriate experience.

“The underlying theme, whilst recognising the need for timely and time bound mental health interventions for autistic and learning-disabled people when required, is the inappropriateness of hospital admission as opposed to investment in community provision. People with behaviours others perceive as challenging benefit from personalised care, not large congregate settings. ”

O’Rourke said he had come up against problems with the organisation of IC(E)TRs in the southern regions.

He added: “On all four occasions I have been invited to attend a review it has been cancelled; three of which due to the Department of Health and Social Care being unable to supply an independent chair. The fourth review has been rescheduled for this coming Friday although the likelihood of it being cancelled again is strong due, this time, to the inability to find a clinician to attend in person.”

He said he had raised the issue with Baroness Holllins and NHS England.

Councils ‘unwilling or unable to commission advocacy’

More generally, the CQC reiterated concerns about the availability of statutory advocacy services for people subject to the MHA. While local authorities were responsible, the CQC said it was concerned that many were “unable or unwilling to commission IMHA services that are sufficiently resourced to meet the needs of the area they serve, especially in terms of funding visits to wards and engagement with patients without specific instruction”.

This resulted in a postcode lottery, said the regulator, which added that the government should consider commissioning IMHA services nationally as part of its reforms to the MHA, which will extend entitlement to advocacy.

It also warned that there were signs councils were withdrawing resources from discharge planning for people subject to the MHA. It cited an example from one older people’s ward of nearest relatives reporting that social workers had not been allocated to or attended meetings on section 117 aftercare, affecting arrangements for safe and appropriate discharge.

The CQC cited this as a concern in the context of NHS plans to replace the care programme approach (CPA) for planning community care with one that was more flexible and personalised, which the regulator broadly welcomed.

It also raised concerns about “complicated and long-running disputes” over which local authorities were responsible for section 117 aftercare when a person was placed out of area, in the context of the DHSC deferring adjudications on certain disputes pending the completion of legal proceedings.

Need to resume dispute resolution on section 117 

Under a new approach the DHSC has taken, responsibility for aftercare for people detained multiple times under the Mental Health Act remains with the council where the person lived immediately before their first detention, even if they subsequently move between successive detentions.

The new DHSC policy was partially accepted by the Court of Appeal in December, but Worcestershire council has lodged an appeal to the Supreme Court to overturn it.

The CQC said it was “important to resolve the ongoing uncertainty quickly and restart dispute resolution, as this could lead to delays in making aftercare arrangements, and could mean that patients are being detained in hospital longer than is clinically necessary, which can be extremely distressing and lead to relapse”.

The MHA monitoring report also said that:

  • The pandemic had left many mental health staff “exhausted”, with high levels of stress, anxiety, burnout and vacancies. “The negative impact of working under this sustained pressure poses a challenge to the safe, effective and caring management of inpatient services and to the delivery of care in a way that maintains people’s human rights,” the CQC warned.
  • More children and young people were being cared for in inappropriate settings while they waited for an inpatient bed.
  • Black or black British people are at least four times more likely to be detained and ten times more likely to be subject to community treatment orders than those identified as white, according to latest data. They also endured longer periods of detention and more repeat admissions. It said urgent action was needed to tackle such longstanding racial inequalities, including through the roll out of the patient and carers race equality framework, which is designed to promote culturally appropriate care.

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