Regulator on restraint, segregation and seclusion review

CQC published this stark report on 22 October. It is a review of restraint, seclusion and segregation for autistic people and people with a learning disability and/or mental health condition.

It is a follow up to their interim report in May 2019.

During their review (pre Covid-19) they visited 56 hospital wards, 27 care homes, 11 children’s residential services and five secure children’s homes.

The foreword starts by saying “This review has shown that for some people who need complex care the system lets them down.”  It goes on to say how CQC found “too many examples of undignified and inhumane care in hospital and care settings…”.  CQC note that comprehensive oversight of the care provided and specifically responsibility and accountability for the commissioning of care is lacking.  They therefore conclude that there needs to be fundamental change in the way care is planned, funded, delivered and monitored for this group of people.  They want this to be led by national and local leaders to deliver a culture where restraint, seclusion and segregation are no longer accepted and are only used in extreme cases.

They conclude that there is a system where people with complex needs fall through the gaps and they cannot be confident that their human rights are upheld, let alone be confident that they are supported to live fulfilling lives.

The final paragraph of their conclusion on page 46 states that:

“There have been too many missed opportunities to improve the lives of autistic people and people with a learning disability and / or mental health condition, whose behaviour others find challenging.  Immediate action is needed to put an end to abuses in human rights that we have seen in this review. This action must be owned and led from the top by government, delivered by local systems working together and involved people and their families to ensure the needs of the individual are met”.

The report highlights the care provided to different named people. Whilst CQC saw some services taking a human rights based approach they say this was not the case across all services so in too many instances they found people’s human rights were at risk of being breached.

Part 1 of the report covers hospital based services

Points to note include:

• The poor physical environment and the restrictive practice culture of hospitals often lay the groundwork for the use of restrictive practices.
• Often people did not receive specialist care or access to high quality advocacy.
• Staff were not always receiving the right training.
• The quality of care plans was often poor.
• Access to high quality advocacy varied and there was some confusion between the provider and the commissioner about who the advocate was / which organisation provided the services.
• In the month before their information request:
  • 81 per cent of 313 wards for children and young people and for people with a learning disability and autistic people had used physical restraint
  • 56 of out 313 wards had used prone restraint at least once
  • 34 per cent used rapid tranquilisation
• They explore the differences between secure children’s homes and hospital services.
• Out of 66 people who were subject to prolonged seclusion or long term segregation they only found evidence of consistently good quality care and treatment for three people.
• The length of time people spent in prolonged seclusion ranged from two days to seven months and in long term segregation from three days to 13 years. 
• Almost 71 per cent of people whose care they reviewed had been segregated or secluded for three months or longer.
• Some people were caught in cycles of being placed in gradually higher security hospitals with no reflection about what was not working.
• The physical environments for many people in long term segregation or seclusion were unacceptable and not in line with the Mental Health Act Code of Practice.
• Records about reviews and reasons for placing someone in seclusion or long term segregation were not always clear or detailed enough and were not always reported to the commissioner.  Reviews were sometimes of poor quality or did not take place.

Part 2 of the report covers community based services

Points to note include:

• Restraint was used a little less, however the quality of care varied and was affected by the numbers and skills of staff involved.
• At present there is no way of collating the figures nationally for the use of seclusion or segregation in social care settings and the use of these restrictive practices and restraint is not currently notifiable to CQC.
• Overall people in adult social care were experiencing better person centred care than people in hospital.
• Three out of 452 services that completed a questionnaire said they used prone restraint.
• 26 out of 27 services visited were using physical restraint on occasion.
• The term seclusion is not common in adult social care services and different terminology was being used across the services.
• The term segregation is not widely recognised in adult or children’s social care services.
• They met 27 people who were locked in their flats and then monitored outside of their flat or room.
• Children’s residential services were in very high demand with one service having 48 different local authorities placing there and another receiving 200 applications a week.

Part 3 of the report covers commissioning

Points to note include:

• A central theme throughout services CQC visited were issues and disputes about funding and commissioning placements.
• It was not always clear whether commissioners had the oversight or knowledge required to ensure care was meeting the person’s needs.
• Money available could often be better spent on providing individual person centred care in the community.
• They highlight the Community Discharge Grant so all Transforming Care Partnerships should have access to a pot of £20 million to support discharges for the next two years.

Recommendations: 17 are made

These are set out in full at pages 47 – 52.   These cover both national system change and restrictive practices. They include:

• Named national specialist commissioner for complex care
• Human rights embedded in commissioning
• CQC must improve its regulatory approach
• Commissioners should encourage and support the creation of smaller bespoke services in line with Building the Right Support 
• There must be a contractual requirement on providers to inform commissioners and NHS England regional team when segregation or seclusion begins
• There must be enhanced monitoring by commissioners to ensure a plan for ending restrictions is in place
• Department of Health and Social Care must amend the MHA to change the definition of long term segregation

CQC will publish a brief report on progress that has been made on their recommendations in winter 2021/22.

CQC have also recently published three other reports which readers might find of interest: State of Care and mental health care in acute hospitals and mental health rehabilitation inpatient services.