CQC restraint review

May 21, 2019

The Care Quality Commission (CQC) has made several recommendations in its interim report on use of restraint and segregation published today. The CQC restraint review shares early findings from its report into restraint, prolonged seclusion and segregation for people with a mental health issue, a learning disability or autism.

CQC is calling for an independent review of every child, young person and adult being held in segregation in hospital and mental health wards. These reviews will examine the quality of care, the safeguards in place and plans for discharge for each person.

The CQC restraint review, which was commissioned by the Secretary of State for Health and Social Care, also highlights the need for a better system of care for people with a learning disability or autism who are at risk of being hospitalised and segregated.

From an information request sent to providers, CQC was told of 62 people who were in segregation. This included 42 adults and 20 children and young people. Sixteen people had been in segregation for a year or more and one person had spent almost a decade in segregation.

CQC has so far assessed the care of 39 people in segregation, most of whom had an autism diagnosis. Reasons for prolonged time in segregation included delayed discharge from hospital due to there being no suitable package of care available.

The safety of others and inability to tolerate living alongside other people were the most common reasons for people being in segregation.

Dr Paul Lelliott, Deputy Chief Inspector of Hospitals and lead for mental health at CQC, said, 'The 39 people we have visited who are cared for in segregation are in a very vulnerable situation. Their world is narrowed to a highly restricted existence in a single room, or small suite of rooms. For many, their interactions with other people are characterised by distress and sometimes by the use of force by staff who consider this necessary to protect the person or others from harm. They have little or no say over decisions about their lives or their future. Many are also a long way from home – which can make it difficult for families to maintain contact.

'We are calling for urgent action to strengthen the safeguards that protect the safety, welfare and human rights of people held in segregation. We think that independent advocates have an important role to play in this – if they are trained and supported to recognise what is good care and what is not.

'Given the severity and complexity of their problems, people held in segregation should be receiving expert care in an environment that is adapted to their specific needs. Although this was the case for some, for others the care was simply not of an acceptable standard...

'The people we have visited have had contact with health, care and education services for many years, pointing to missed opportunities...these people have been failed by the current ‘system of care’ and that system must be changed.

'A better system of care would provide effective help early in life for people with complex problems and challenging behaviour. It must respond effectively when crises occur, so preventing the need to admit the person to hospital. If a spell in hospital is right for the person, this should be close to home and not prolonged because of lack of an alternative place for them to go. In short, the system must put the person at the centre and be engineered around their needs. This has implications for commissioning and for who controls the funding.

'We will also be reviewing and revising CQC’s approach to regulating and monitoring hospitals that use segregation to ensure we are gaining a true view of the quality of care for people subject to such restrictive practices.'

The interim CQC restraint review report makes recommendations for the health and care system, including:

1. Over the next 12 months, there should be an independent and an in-depth review of the care provided to, and the discharge plan for, each person who is in segregation. Those undertaking these reviews should have the necessary experience and might include people with lived experience and/or advocates.

2. An expert group should be convened to consider what would be the key features of a better system of care for this specific group of people (that is those with a learning disability and/or autism whose behaviour is so challenging that they are, or are at risk of, being cared for in segregation). This group should include experts from other countries that have a better and/or different approach to the care for people with complex problems and behaviours that challenge.

3. Urgent consideration should be given to how the system of safeguards can be strengthened, including the role of advocates and commissioners, and what additional safeguards might be needed to better identify closed and punitive cultures of care, or hospitals in which such a culture might develop.

4. All parties involved in providing, commissioning or assuring the quality of care of people in segregation, or people at risk of being segregated, should explicitly consider the implications for the person’s human rights. This is likely to lead to both better care and better outcomes from care.

5. Informed by these interim findings, and the future work of the review, CQC should review and revise its approach to regulating and monitoring hospitals that use segregation.

The Government has confirmed that it will accept all of the CQC's recommendations and will fund 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.

Health and Social Care Secretary, Matt Hancock has responded to the CQC restraint review, saying, 'I have been deeply moved and appalled by the distressing stories of some autistic people and people with learning disabilities spending years detained in mental health units. These vulnerable people are too often left alone, away from their families, friends and communities.

'At its best, the health and care system provides excellent support to people, backed by a dedicated workforce. But a small proportion of some of the most vulnerable in society are being failed by a broken system that doesn’t work for them.

'I commissioned the Care Quality Commission to review the use of segregation in health and care settings to tackle this issue head on. Today I have accepted their recommendations in full. I hope this is a turning point so everyone receives the care they need.

'I will not let these people down - they deserve better.'

The Health and Social Care Secretary has also announced a wider package of measures designed to improve care for autistic people and those with learning disabilities, including:

  • A new working group for learning disabilities and autism, bringing together experts, clinicians, parents and carers to develop a new model of care.
  • A new awareness campaign, to encourage staff, families and friends to come forward if they have concerns about care.

As well as exploring the use of restraint in hospitals, CQC will expand its review to a wider group of settings in phase two (June to December 2019) including low secure and rehabilitation mental health wards and adult social care services.

CQC will report in its full findings and recommendations in a final report in the Spring of 2020.

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