Half of learning disability services failing to meet government standards: CQC

Almost half of hospitals and care homes subjected to unannounced inspections are not meeting government standards for learning disability services, a review conducted by the Care Quality Commission has found.

The watchdog said inspections at 150 NHS, private care and social care services – carried out in response to the Panorama programme on abuse and poor standards of care at Winterbourne View – also revealed that assessment and treatment services admitted people for disproportionately long spells of time and that discharge arrangements took too long to arrange.

The locations were measured against two outcomes: care and welfare of people who use services; and safeguarding people who use services.

Specific safeguarding concerns were identified in 27 care services – or 18% of the locations inspected – and these needed to be referred to the relevant local authority safeguarding adult team. The CQC said it would monitor these referrals.

The CQC report called for a review of independent advocacy services, as advocacy was available in those services which were non-compliant with the standards, and said there was an "urgent need" to reduce the use of restraint. 

It found that providers were “sometimes unclear about the use of deprivation of liberty and the safeguards needed, and those that were unclear did not have internal or external mechanisms in place to address that knowledge gap".

The CQC recommended that staff needed to be given training in appropriate techniques for those cases where restraint was unavoidable.

The report said: “Restraint was not well understood in terms of what constituted restraint, the monitoring of the use of restraint or learning lessons following incidents of restraint and analysis of these. The use of seclusion was not always recognised as a form of restraint.

“The use of deprivation of liberties and the safeguards needed are not well understood, reported and lessons learned.”

The report’s main findings included that:

  • 48% of all locations were non-compliant with both outcomes;
  • NHS locations were twice as likely to be compliant with both of the outcomes than independent healthcare services (IHC);
  • Less than half of the 32 adult social care services inspected were compliant with both outcomes;
  • The majority of assessment and treatment centres were compliant with both outcomes (51%). However, there were more people in the services that were non-compliant (58%);
  • The range of length of stay in NHS and IHC assessment and treatment and secure services ranged from six weeks to 17 years. “Generally, these were unacceptably long, and inconsistent with the descriptions of assessment and treatment”;
  • Assessment and treatment services and secure services run by the NHS were significantly less likely to have patients resident for longer than two and three years compared to services run by IHC providers;
  • The main concerns with non-compliance with the care and welfare outcome across all care settings related to care planning (38%), “meaning that people and their families were not involved in the design of the care and therefore were not in control of their own needs – a lack of person-centred planning was a significant feature”;
  • The main concerns with non-compliance with the safeguarding outcome across all care settings related to the use of restraint, “meaning that restraint was not recorded and monitored appropriately”. There were no systematic review and lessons learnt approaches taken to incidents where restraint was used.

Summing up the report overall, the CQC said many failings were a direct result of care that was not centred on the individual or tailored to their needs. It called on commissioners to review the care plans for people receiving this type of care “so that they can move on to community-based services”.

A copy of the CQC report can be found here. 

Philip Hoult

THE CQC’S RECOMMENDATIONS

Recommendations for commissioners

  • Commissioners need to urgently review the care plans for people in treatment and assessment services and identify and plan move on arrangements to the next appropriate service and care programme.
  • The emerging Clinical Commissioning Groups and the NHS Commissioning Board, as well as the local authorities in England need to work together to deliver innovative commissioning at the local level to establish person-centred services. “This is much more likely to lead to people being able to stay in their local communities and so maintain important relationships.”
  • Commissioners also need to review the quality of advocacy services being provided, particularly in those locations where non-compliance with the standards was identified.

Recommendations for providers

  • Providers must ensure that people using services are routinely involved and ‘own’ their care planning and activities. These must be available in appropriate formats and must be accessible.
  • There are still lessons to be learned by providers about the use of restraint. There is an urgent need to reduce the use restraint, together with training in the appropriate techniques for restraint when it is unavoidable. There also needs to be systematic monitoring about the use of restraint and ongoing analysis so that lessons can be learned and patterns of use better understood, which should all lead to less use of restraint. The use of seclusion needs to be recorded as a form of restraint.
  • Providers must ensure that staff understand and can apply the deprivation of liberty safeguards.

Recommendations for providers, commissioners and the CQC

  • Providers and commissioners should ensure that there are appropriate quality assurance systems in place. This includes having appropriate complaints procedures, access to and use of advocates, welcoming approaches to visitors and a fundamentally sound and appropriate support and supervision structure for all staff.
  • The CQC should determine when it is most appropriate to visit and inspect services at weekends and evenings, rather than Monday to Friday between 09.00 and 17.00. Visits at these times can sometimes provide the additional evidence needed to assess visitor access, and judge the quality of care, staff, support and supervision.

Recommendations for the CQC

  • The sample of learning disability providers inspected outside this thematic programme (52) was small by comparison. However, the differences in judgments about compliance and non-compliance warrant further evaluation, to help understand and explain the differences. 

Source: Learning Disability Services inspection programme - a national overview