What CQC has done to improve people’s experiences

Recommendation 6 (CQC)

Following our Out of sight review, we knew that we needed to improve, as we had not always identified poor care and abuse.

We therefore made a recommendation for CQC to make the improvements necessary.

If this recommendation was fully implemented, people would:

• benefit from our improved focus on human rights, positive cultures and person-centred care
• know we are better able to identify unsafe services and take action
• know that we would not rate services as good or outstanding where people are unnecessarily restrained, segregated or secluded
• know whether services are meeting the recommendations from independent reviews of seclusion and segregation and Care (Education) and Treatment Reviews (C(E)TRs), as we report on this
• know that we will listen to them about their experience and use this information to improve our monitoring and inspecting of services and share their concerns with appropriate agencies for investigation
• be more likely to be receiving advocacy services due to our increased monitoring of this
• know that we are monitoring waiting times for assessments for autistic people and checking they have timely assessments, care plans and discharge plans
• know we will take action where providers have not ensured their staff are suitably trained to meet people’s needs
• be supported using the least restrictive interventions possible as we will monitor use of restrictive interventions more effectively.

Has recommendation 6 been achieved?

Improving our regulatory approach

We said that we needed to improve our regulatory approach. We have outlined below some of the work that we have done towards this.

People with lived experience, their families, and stakeholders such as NHSE/I have told us that they can see that we have changed our approach and are taking more enforcement action within learning disability services. However, we recognise that there is still much more to do to replicate this person-centred approach in mental health and community services.

Improving our regulation of services for people with a learning disability and autistic people

We have developed a new approach to improve the way that we look at hospital and adult social care services for people with a learning disability and autistic people. This includes ensuring inspectors focus on specific areas that are particularly relevant to people with a learning disability and autistic people, such as communication and engagement, their individual health needs, out-of-area placements, access to advocacy and use of restrictive practices. We also encourage inspectors to look into the use of surveillance.

In order to put people’s experiences at the centre of our new approach, and make sure that services are in line with our guidance, Right support, right care, right culture, we have:

• reviewed and updated our guidance for inspectors, so that we promote inclusivity and champion human rights, dignity and equality. We encourage inspectors to assess and report on aspects of care that are particular to people with a learning disability, such as their aspirations and achievements, progress with life skills, sense of fulfilment and whether the provider has made suitable reasonable adjustments. Going forward, we will be asking providers of a range of services how they meet the needs of autistic people and using learning from our work in learning disability services to change the way we inspect
• spent more time speaking to more people in the service (and their families and carers​), supported by new communication tools
• increased our contact with commissioners and professionals who may visit a service to get their views on the service
• increased the range of tools, guidance, and experts to support our inspection teams​
• visited services unannounced and out of hours, often going back to a service to see what care is like at different times of the day.

During our review, we found that many staff working in services had not received meaningful training to understand what it meant to be autistic or have a learning disability. This is essential and we have started to look at this by:

• improving the training for our own staff on learning disability and autism (which was developed by CQC autistic staff)
• ensuring new providers proposing to deliver a service for people with a learning disability and autistic people have an induction programme, ongoing learning, and development plan for staff
• looking at poor training as an indicator of a closed culture
• piloting a quality of life tool that focuses on the implementation of peoples plans, effective staff training and evidence of this being embedded into practice.

We have used this new approach to inspect hospitals and care homes where there was the highest risk that people may not be safe, and their rights may not be respected.

Latest ratings data for March 2022 show there are 16 independent hospitals and NHS trusts that provide mental health services rated inadequate and 60 that are rated requires improvement. Both the number and proportion of overall ratings of inadequate or requires improvement have slightly increased since we published our Out of sight report in October 2020.

Our latest ratings (as of March 2022) for inpatient wards for people with a learning disability and autistic people show that nine services (13%) were rated inadequate while 12 (17%) were rated requires improvement. While the number and proportion of ratings for inpatient wards for people with a learning disability and autistic people that are requires improvement has decreased since October 2020, inadequate ratings have increased (figure 4). This is partly due to improvements in the way we identify poor care, and also that our recent inspections have been based on risk. Figure 4 suggests the quality of inpatient care for people with learning disability and autistic people has not improved.

Since our Out of sight report was published in October 2020, 16 adult social care services and two independent hospitals that provided care for people with a learning disability and autistic people have closed because of the enforcement action we have taken.

Our enforcement activity in services for people with a learning disability and autistic people increased by 25% in 2021 compared to 2020.

Out-of-hours inspections

In our Out of sight review, people frequently told us that we needed to do more out-of-hours inspections. This was also included in Glynis Murphy’s recommendations. We therefore stated in our closed cultures guidance that inspection teams should undertake out-of-hours visits where possible.

Between April 2021 and January 2022, over half (52%) of the 42 inspections of learning disability and autism services that used the new inspection approach have included some out-of-hours inspection activity.

Care (Education) and Treatment Reviews

In Out of sight, we saw that the recommendations from Care (Education) and Treatment Reviews (C(E)TRs) were not always being implemented. We therefore recommended that CQC track progress made against these.

We have created guidance for our operational staff to enable this to be implemented from April 2022. In order to have a rating of good for the question “is the service effective”, providers will need to progress C(E)TR recommendations. However, this has not had an impact yet, as it is still to be implemented.

Reporting on timely diagnosis of autism

We are currently developing our approach to monitor and report on the length of time that both children and adults are on waiting lists for a diagnosis of autism and if this is in line with NICE guidelines or not. However, this has not had an impact yet as it is still being developed.

Improving how we look at services for people with a learning disability, autistic people and people with mental ill health

Human rights

We published our new strategy in May 2021, which said we would:

• identify better ways to gather experiences from a wider range of people, including people with a learning disability and those who are detained under the Mental Health Act
• work with others to develop a better understanding of risk across all health and care to help reduce avoidable harm, neglect, abuse and breaches of human rights
• look to see how people are able to influence the planning and prioritisation of safe care, as equal partners.

We are carrying out a range of tasks to fulfil these strategy commitments, including:

• publishing an ‘equality objective’ on amplifying the voices of people more likely to have poor access to care or poor experiences of using care and appropriately weighting the feedback we receive from them
• considering which tools we need to develop to ensure that we receive feedback from a wide range of people, including those with needs for accessible communication
• embedding human rights into our draft new single assessment framework. In particular, the key question about ‘caring’ is more aligned to human rights in principles of fairness, respect, equality, dignity and autonomy
• considering the relationship between safety and human rights in our programme of work on safety.

Independent reviews of seclusion and long-term segregation under the Mental Health Act Code of Practice

In the review we saw that there was inconsistency in the quality of independent reviews for people in long-term segregation or prolonged seclusion. We therefore recommended that CQC tracked the progress of these reviews.

We are updating and revising the methodology for our Mental Health Act (MHA) reviewers to complete focused reviews of seclusion and long-term segregation. These reviews will include scrutiny of the quality of independent reviews for people in long-term segregation or prolonged seclusion. The revised methodology is due to be trialled from April 2022.

Monitoring restrictive interventions

Through our Mental Health Act monitoring duties we highlight concerns about restrictive interventions in services that treat people who are detained. We recognised that we needed to improve our monitoring of restrictive interventions. We have done this by:

• improving our training on restrictive interventions
• requiring our inspectors to report on restrictive interventions in adult social care services for people with a learning disability and autistic people, which gives us more ability to monitor and identify concerns
• ensuring all operational staff have annual training on human rights and know how this relates to restrictive interventions
• developing our new regulatory model, which will allow us to review and update ratings in a more dynamic and responsive way
• asking adult social care providers to submit data annually on how many people have restraints or restrictions in their care plan, the number of recorded restrictions, and whether there are any restrictions on people visiting
• checking if all providers’ training on restrictive interventions complies with the Restraint Reduction Network training standards.

Regulatory change

Under the current system there is no legislation that requires providers to notify us of incidents of long-term segregation, seclusion or restraint. We are discussing the possibility of legislative change with the Department of Health and Social Care, as suggested in recommendations 11 and 17.

Reviewing our registration processes

All providers must register with us before they are able to provide a service. In our Out of sight review we found that some providers were applying to register a service under a different name after we had taken enforcement action to close their service.

To tackle this, when a provider wants to open a new service, we review all available information, including the regulatory history of a previously registered provider or registered manager. For services for people with a learning disability and autistic people we have improved the way we assess an applicant’s understanding of our guidance, Right support, right care, right culture, to ensure they understand the expectations for good quality care.

Supported Living Improvement Coalition

Our regulation of services for people with a learning disability and autistic people focuses on what it means to be a citizen. Our ambition for people receiving care and support is to have more choice, independence and control over their lives and the care they receive.

We have convened a Supported Living Improvement Coalition, led by people with lived experience, their relatives, and carers. The group is structured so that people can tell their stories to a range of stakeholders who can work with them to identify, resolve, and embed the improvements that are needed.

The Coalition has representatives from advocacy groups, care providers, clinical commissioning groups, local authorities and housing developers. With leadership and support from across social care, the Coalition aims to achieve greater safety and quality of supported living options for people with a learning disability, autistic people and people with mental ill health and drive improved outcomes for them.

Listening to people and acting on what they tell us

We are improving how we gather the views of people who use services.

In our closed cultures guidance we have included details on how CQC teams can review intelligence before and during inspection, gather feedback from advocates and request contact details for relatives, advocates, staff and visiting professionals.

In 2021, we received 20% more whistleblowing notifications relating to services for people with a learning disability and autistic people than we did in the previous year, increasing from 1,336 to 1,607.

We are also improving:

• how we escalate issues in health services, in collaboration with NHSE/I
• the way we use the knowledge and work of advocates across CQC
• our tools to help us to listen to people, such as talking mats (a communication and interactive tool that uses specially designed symbols to help communication).

Advocacy

In our Out of sight review, we identified that we were not listening to advocates enough to help us to hear people’s voices more effectively. We are addressing this through:

• including details on how our teams can do this in our closed cultures guidance. The guidance also helps our teams to ensure that information is gathered from relatives and other important people to develop care plans
• ensuring we check how services are involving advocates through our quality of life tool
• developing training on the different types of advocacy for CQC’s operational staff
• ensuring that advocacy is a key area of focus in our new assessment framework.

Trauma-informed care

We are developing training for our staff on trauma-informed care so that our staff can better reflect how services are using a trauma-informed approach.

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