South Gloucestershire Council has published the Serious Case Review into Winterbourne View, looking at the role of the various statutory agencies, as well as the provider of the former service, Castlebeck Limited.
Running to over 150 pages, it makes a range of recommendations. Some of the key ones include:
- The Department of Health, Department for Education and the Care Quality Commission should consider banning the t-supine restraint of adults with learning disabilities and autism in hospitals and assessment and treatment units. The authors state, “An investment comparable to the banning of the corporal punishment of children is required.”
- Local adult safeguarding boards, CQC and all stakeholders should regard hospitals for adults with learning disabilities and autism as high risk services i.e. services where patients are at risk of receiving abuse and restrictive practices within indefinite timeframes. The authors write, “They [i.e. such services] require frequent, more thorough, unannounced inspections, more probing criminal investigations and exacting safeguarding investigation.”
- There is a compelling case for mandatory visits by the Nominated Individual for the service and by the Board member to whom reports about the service are sent under the governance framework. There should then be an annual report accompanying the accounts. The Department of Health should consider amending registration requirements to require such mandatory visits and public reporting.
- The authors are concerned that managers are not required to be distinct registered professionals individually accountable through a governing body and code of ethics. This is a recommendation that some have speculated may come out of the Mid Staffordshire Public Inquiry, the report for which is due in October.
- CQC should ensure that inspections are carried out by sector specialists and experts by experience so that warning signs can be identified earlier. Tellingly, the authors write, “Inspectors should be qualified and competent to carry out inspections, and demonstrate that they have sufficient knowledge about (i) the services that they inspect and (ii) the abuse of vulnerable adults, including the crime of assault.” This is a recommendation that will be welcomed by providers who often find themselves frustrated by the fact that inspectors have no background in the type of care in question. Indeed, some only have an administrative background rather than a professional qualification in health or social care.
- CQC and the Health Professions Council should work together to describe what effective systems of clinical supervision look like in hospitals for people with learning disabilities and autism. “The guidance should identify the roles of registered managers and nominated individuals in developing such systems in practice.” Again, there has been speculation that the Mid Staffordshire Inquiry might recommend having a standardised approach to clinical governance.
- Reducing the use of anti-psychotic medication with adults with learning disabilities and autism requires attention. Commissioners should ensure there are pharmacy led medicines reviews for individual patients as well as the service as a whole. CQC should also consider using pharmacy led medication reviews in future.
- Commissioners funding placements should ensure that they have up-to-date knowledge of services e.g. (a) adverse incidents/serious untoward incidents, including injuries to patients and staff; (b) absconding; (c) police attendances in the interests of patient safety; (d) criminal investigations; (e) safeguarding investigations; and (f) the occurrence of Deprivation of Liberty Safeguards applications and renewals.
A theme running through the Review is the importance of promoting the involvement of relatives and carers and having access to and provision of advocacy, in particular Independent Mental Capacity Advocates. In relation to informal patients, the authors stress that, “Adults with learning disabilities and autism, who are currently placed in assessment and treatment units, should have the full protection of the Mental Capacity Act.” The report notes that although some voluntary patients were subject to locked doors and wards and to threats of being sectioned, they were not protected by the safeguards of the first-tier Tribunal – Mental Health.
This is in an important Review that merits careful scrutiny by the sector. It highlights the importance of corporate accountability, scrutiny and responsiveness. It will be interesting to see what comes out of the Mid Staffordshire Inquiry in October and, more importantly, what tangible changes will emerge from these various reviews in terms of regulation, commissioning and governance generally. We will be publishing regular reports for the benefit of the sector.
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