Recommendation 1 (single ministerial ownership)
If this recommendation was fully implemented, people:
- would experience more joined-up care as there would be a single minister overseeing this work
- would receive more responsive support as different sectors could pool budgets together locally
- could access the right support at the right time across education, health, and social care, including specialist community teams that understand their needs
- would have access to the right type of housing
- would only be admitted to mental health inpatient units when this is essential for their treatment.
Has recommendation 1 been achieved?
We consider that recommendation 1 has not been achieved
There is a single minister overseeing the Building the Right Support Delivery Board. However, the action plan is not yet finalised and without clarity of governance and clear responsibility for delivery there is insufficient evidence of impact on people’s lives.
Action needed:
- The action plan needs to be finalised and fully implemented, supporting the delivery of a model of care based on meeting individuals’ needs.
- There needs to be stability of leadership
- Accountability should be clear; each partner should be held responsible for their actions and called into account where progress is insufficient.
What we are seeing and hearing
We have reported in the above chapters what we are seeing and hearing about progress towards people having the right services with the right support at the right time. People are telling us that they are pleased about the initiatives and discussions that are taking place, but that this is not enough. They want to see positive impact.
The Department of Health and Social Care is key to driving forward many of the recommendations in our Out of sight report. An important lever for this has been through the establishment of the Building the Right Support Delivery Board to take forward the work. The Board is chaired by the Minister of State for Care and Mental Health. The Department is working with the Building the Right Support Delivery Board to develop an action plan. We are waiting for the action plan to be published.
However, an action plan is not enough and there needs to be delivery, alongside further investment, to ensure this recommendation is progressed and that people feel the impact of the plan.
Recommendation 11 (oversight of long-term segregation)
During our Out of sight review we found that it was not possible to identify the numbers of people in long-term segregation. It was not reported to NHSE/I and there was not a regulatory obligation for providers to notify us. We therefore made a recommendation to change this.
If this recommendation was fully implemented, people in long-term segregation would be known about:
- by commissioners and NHSE/I regional teams
- by CQC.
This would lead to increased oversight of the service.
Has recommendation 11 been achieved?
We consider that recommendation 11 has not been achieved
Action needed:
- CQC and the Department of Health and Social Care are currently discussing regulatory change proposals due to go to public consultation in autumn 2022.
What we are seeing and hearing
One of the findings from the IC(E)TRs and this progress review is that it is still difficult to know in real time how many people are segregated and where those people are. It is therefore difficult to have sufficient oversight of the numbers of people in long-term segregation.
Since the publication of our Out of sight report, we have been discussing with the Department of Health and Social Care about changing the regulations. We have put forward an initial proposal. This work is due to go to public consultation in autumn 2022 before a decision is made if the proposal will be put forward for legislative change.
Recommendation 13 (reviews of long-term segregation)
During the Out of sight work we had concerns about the quality of independent reviews recommended by the Mental Health Act Code of Practice for people in long-term segregation. We therefore made recommendations to improve these.
If this recommendation was fully implemented, people:
- would have regular reviews by a responsible clinician looking at why they were in long-term segregation and whether it was necessary to continue it
- would have consistency in independent reviews of long-term segregation. These reviews would be of a high standard and would reduce and end restrictions.
Has recommendation 13 been achieved?
We consider that recommendation 13 has not been achieved
Action needed:
- The Department of Health and Social Care needs to progress this recommendation.
We remain concerned about the quality and frequency of reviews by independent clinicians. This will have been compounded during the pandemic. The Department of Health and Social Care will be refreshing the Code of Practice as part of the Mental Health Act reforms.
Recommendation 15 (definition of long-term segregation)
During our review we found that some providers were uncertain as to what constituted long-term segregation. We used a wider definition than is in the Mental Health Act Code of Practice to ensure that we looked at people who were in long-term segregation for reasons other than violence, such as protecting them from themselves or others.
We therefore recommended that the Mental Health Act Code of practice definition of long-term segregation was changed.
If this recommendation was fully implemented, people in inpatient units:
- would be safeguarded when they were separated from others, whatever the reasons for that separation.
Has recommendation 15 been achieved?
We consider that recommendation 15 has not been achieved
Action needed:
- This proposal has been accepted by the Department of Health and Social Care. It needs to be progressed through legislative changes as part of the Mental Health Act reforms.
What we are seeing and hearing
There can still be different interpretations of what constitutes long-term segregation across different organisations.
We have developed a new brief guide for our staff that uses this wider definition to include people who are segregated because they are at harm from themselves or others.
Currently CQC, Independent Care (Education) and Treatment Reviews and NHSE/I are using the same definition as is in our brief guide.
The Department of Health and Social Care have accepted the recommendation and committed to making the change to the Mental Health Act Code of Practice. This will happen when it is able to be laid before parliament.
Recommendation 17 (reporting of restrictive interventions in adult social care and children’s services)
During our review, we highlighted that there was no reporting mechanism for when restrictive interventions are used in adult social care services or children’s services registered with both Ofsted and CQC. We therefore recommended that a national reporting mechanism was developed that reflected the one used for hospitals (MHSDS). We also requested regulatory change to ensure providers notify us of certain restrictive practices.
If this recommendation was fully implemented, people in adult social care and dual Ofsted and CQC registered children’s services would:
- have better care, as the improved reporting mechanisms and data mean we can monitor it and act when concerned. This would reduce the use of restrictive interventions, as they will only be used when appropriate.
Has recommendation 17 been achieved?
We consider that recommendation 17 has not been achieved
Action needed:
- CQC and the Department of Health and Social Care are currently discussing regulatory change. These discussions are ongoing.
What we are seeing and hearing
Since the publication of our Out of sight report, we have been discussing with the Department of Health and Social Care about changing the regulations. We have put forward an initial proposal that includes recommendation 11 and 15. This work is due to go to public consultation in autumn 2022 before a decision is made if the proposal will be put forward for legislative change.
Recommended further work
In addition to the recommendations, our Out of sight report highlighted further work that was out of scope of our review.
This work included:
- The government should consider a cross-departmental review of restrictive practice for children with special educational needs and disabilities, including schools and anywhere children are living away from home.
- The Department for Education should ensure that there is a clear definition of restrictive practices, including the use of restraint, segregation and seclusion, in educational settings and children’s services.
- The government should ensure that a wider system discussion takes place regarding the practice of people being prosecuted by providers for the injuries caused to staff from people who are highly distressed in hospital, leading them to have a criminal conviction that they did not have before being admitted to hospital.
What progress has been made towards this further work
There have been reported cases in the media about inappropriate use of seclusion and physical restraint in schools, which the Challenging Behaviour Foundation reported on in April 2021.
The Department for Education is considering recent recommendations on restraint from the Equality and Human Rights Commission (published in June 2021) including definitions of restrictive practices, and will respond to that report in due course.
These areas of work need to be taken forward urgently.
The Department of Health and Social Care have explored the prosecution of inpatients but have not identified a way to build any evidence on this beyond anecdote. We would recommend that a cross-organisational discussion takes place, to include or be led by people with lived experience to take this forward.