learning disability settings
considered, how long the seclusion lasted, and howTaken together, CQC’s themed inspection programme the person’s safety was monitored during and after it. of services for people with a learning disability and ‘Blanket rules’ governing life in a ward,�
MHA visits in 2011/12 have highlighted a range of unit or care home� concerns about the enduring use of restrictive practices
in services for people with mental health and/or Typically, blanket rules related to access to communal mental capacity problems. CQC joined with partners in rooms, kitchens, the person’s own bedroom (whether a Restrictions on Liberty symposium in October 2012 locking them out of their bedroom during the day, or to discuss the following issues, and raise awareness of insisting on a general and often early bedtime), and them among providers and their staff. gardens and outdoor space. There were also rules in
some settings about when a patient or resident might
Concerns about restrictive practices have a drink or a snack, or go for a cigarette. This
happened in all types of care setting. Physical restraint
Such rules can rarely be justified in terms of a person’s CQC saw much variation in the frequency and intensity individual care plan. They were often explained as of use of physical restraint. However, one problem having arisen as a response to a particular incident, for our inspectors and MHA Commissioners was that but may have continued long after the event. sometimes it was difficult to work out from patients’
records how often, and for how long, restraint had Blanket rules can be triggers for challenging
been applied, and what actually happened during the behaviour. They may be for the convenience of staff, restraint – raising questions of how decisions about or responses to concerns about the unhealthy choices care are accounted for and monitored.
Poor staff patient relationships; staffing� difficulties�
There were concerns in a number of visits and ir inspections about poor relations with staff, or other
staffing problems. Sometimes this was staff speaking in a derogatory way to, or about, people, or exercising petty and arbitrary controls over diet, smoking, privacy and contact with family and friends. Staffing shortages were also a contributor to other restrictions – for example, where there are few staff on duty, smoking or other outdoor activities tend to be restricted.
Where people who use services appeared isolated, it was likely that staff were also separated from support from their managers and other professionals, and also from the support and cooperation of people’s relatives and friends. Risk factors that are associated with overly restrictive practice include geographical isolation and an introspective culture, quantitative and qualitative staffing difficulties (not enough staff, of not high enough quality), a lack of training and supervision, and weak leadership both locally and within the organisation.
’ made by some patients, but their effect is to limit autonomy and make people feel overly controlled or even unable to exercise their own choices.
In some settings, staff members told people that the takeaway meal, or outing, would not be allowed as a punishment for certain behaviour. Such ‘contingency rewards’ are concerning, and often perceived by patients and residents as ‘blackmail’. As a patient explained: “If you do not do x then you will be refused section 17 leave, cigarette time or have your own music removed.”
Lack of understanding of the Mental� Health Act�
CQC’s MHA Commissioners and inspectors were concerned about the confusion over the rights and treatment of informal patients – that is, those who are voluntary patients and therefore not detained under the Mental Health Act. Examples included informal or voluntary patients being subjected to the same restrictions as detained patients, or subject to de facto detention – for example when they know they will be detained if they try to leave the ward. MHA Commissioners noted, on a ward where only a small proportion of patients were detained under the MHA: “Staff were not sure who was ‘allowed out and with which members of staff. We did not see any risk assessments on this or consideration to the deprivation of liberty that this may impose on those patients not formally detained.”
Next steps�
In line with its proposed strategic direction over the next three years, set out in its consultation documentThe next phase published in September 2012, CQC’s intention is to make more use of its unique sources of information, and the information held by others, to drive improvement in how services are provided and promote best practice. Its discussions with the public and stakeholders have strongly indicated that they would welcome CQC using its voice in this way. CQC will do this by:
Being clear about good care (what works well) and poor care.
Reporting on the state of the different sectors, identifying problems and challenges in how services are provided and commissioned and recommending action.
The State of Care report for 2012/13 will incorporate and synthesise CQC’s findings from the following pieces of work that it will be publishing in the coming months:
The themed inspection programme examining the care given to people in their own homes by 250 domiciliary care providers.
The themed inspections of dignity and nutrition in 500 care homes and nursing homes.
The follow-up inspection programme looking at issues of dignity and nutrition in 50 NHS hospitals. Reviews of information and data on three�
topic areas:�
• Dementia care during admissions to hospital
• The experiences of people waiting for�
NHS treatment�
• The physical health needs of people with�
a learning disability.�
In addition, CQC will be able to include the findings of some of the first inspections it carries out in GP surgeries and practices.
Appendix:
The Health and Social Care Act 2008 introduced for the first time a common set of standards – theThe essential
essential standards of quality and safety – that apply across all regulated health care and adult social care services in England. Working to this new regime,standards
CQC registered all NHS trusts and hospitals from April 2010 and independent healthcare and social care providers from October 2010.Therefore, 2011/12 was the first full year in which the standards had been in place across both health care and adult social care.
CQC also registered primary dental care and independent ambulance providers from April 2011. It began to inspect these services later in the year; therefore, its picture of these sectors is based on very early findings. It will be able to present a much fuller analysis in the next State of Care report.
In April 2013, GP practices and primary medical care services will also come into this regulatory system. Once providers are registered, CQC inspectors check that the essential standards of quality and safety are being met. There are 28 standards in total but, of these, they focus on 16 standards that most directly relate to the quality and safety of care. CQC produces guidance for providers that helps them understand what meeting the essential standards looks like. The guidance sets out the outcomes that a person using the service can expect to experience if the provider is meeting the essential standards – with each essential standard having a corresponding outcome. Table 3 shows the 16 outcomes and what each of them means.
Each of CQC’s inspections looks at a different range of outcomes, so not every outcome is assessed at every inspection. CQC inspectors carry out a mixture of planned inspections (conducted as part of CQC’s ongoing programme), responsive inspections (conducted in response to a problem or concern being raised with CQC) and themed inspections (looking at a particular issue or type of care). Almost all of these inspections are unannounced.