Out of sight – who cares?

October 22, 2020

The Care Quality Commission (CQC) has published Out of Sight - who cares?, its findings and recommendations from its review into restraint and segregation.

CQC was commissioned by the Secretary of State for Health and Social Care to review the use of restraint, seclusion and segregation for autistic people and people with a learning disability and/or mental health condition.

In the report, the regulator is calling for improved community-based capacity and capability across education, health and care for people with a learning disability, autistic people and people with a mental health condition, after the review found undignified and inhumane care in some hospital settings providing complex care.

Recommendations in Out of sight - who cares? suggest that health, education, social care, justice and local government pool their budgets and work together to provide support for people with a learning disability, autistic people and people with a mental health condition as soon as they need it.

CQC heard from people in services that they were often subject to restrictive practices because they failed to get the right care early on. To avoid this in the future will require development of appropriate housing and specialist teams to provide the right services and support in the community.

Additionally, CQC states there must be a named national specialist commissioner for complex care with oversight for ensuring commissioners are held to account for their decisions. This person would also ensure that the care of people with complex needs is reviewed every three months and their care is in line with human rights.

CQC found that mental health hospitals are not always therapeutic environments and can be distressing, particularly for people with a learning disability and or autistic people. In some cases, they saw examples of people’s human rights being at risk, such as not being able to access fresh air and not having access to toilets.

Overall, people in community-based services were experiencing more person-centred care and a better quality of life than individuals with comparable complex needs in hospitals. The environments were generally more homely, and people had more access to the community. However, quality of care varied, and was affected by the number and skills of staff available.

Restraint was used less in community-based services than in hospitals but there is currently no national oversight for people living in adult social care services who are subject to highly restrictive environments. As a result, CQC's Out of sight - who cares? is recommending that a national reporting mechanism is developed for the use of restrictive interventions in children’s services and adult social care services to mirror that used in hospitals.

Debbie Ivanova, Deputy Chief Inspector of adult social care, said, 'We have seen that it is possible to get complex care right, even for people who have previously been in hospital for a long time and require a lot of support. We found examples of person-centred care where staff were supporting people who require complex care to live fulfilling lives. Most examples of this were in community-based settings, where people were integrated into their local areas with a specialist staff team.

'Increased support in the community can prevent people who might otherwise be labelled ‘too complex’ from needing to go into hospital. However, a lack of specialist community support that meets the needs of people, has directly contributed to people being admitted to hospital and delayed their discharge. Our end goal is to see more autistic people, and people with a learning disability and/or mental health condition to be supported to live in their communities. The NHS Long Term Plan already has goals to increase community mental health provision, but this needs to happen as quickly as possible for people who need complex care.'

Dr Kevin Cleary, Deputy Chief Inspector of hospitals and lead for mental health, said, 'It is clear there needs to be fundamental change in the way care is planned, funded, delivered and monitored for people with a learning disability, autistic people and people with mental health conditions. Increased oversight and accountability are key to ensuring people are properly safeguarded. This must be underpinned by a firm foundation of human rights, to deliver a culture where restraint, seclusion and segregation are no longer accepted and are only used in extreme cases. We know this is difficult to get right but it is vital to prevent people who need complex care from being admitted to inappropriate hospital settings.'

CQC is making a number of recommendations for the health and care system, including its own role as the regulator. These can be read in the full Out of sight - who cares? report.

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