The Care Quality Commission, the independent regulator of health and social care in England, has pledged to review the use of restraint, prolonged seclusion, and segregation for people with learning disabilities, autism, and mental health problems.
The review, commissioned by Matt Hancock (the Secretary of State for Health and Social Care), will look at the use of these restrictive interventions in settings that provide inpatient and residential care.
"This has the potential to amount to inhuman and degrading treatment of some of the most vulnerable people in our society".
CQC's statement acknowledges the prevalence of these practices across a variety of settings: "we have encountered the use of physical restraint, prolonged seclusion, and segregation in wards for people of all ages with a learning disability and/or autism and in secure and rehabilitation mental health wards".
May 2019 will see CQC produce an interim report of its findings and, by March 2020, a full review with recommendations will be published.
Settings that will be reviewed
The review will look at different settings in which people with learning disabilities, autism, and mental health problems may be subject to restraint, prolonged seclusion, and segregation. These settings can be divided into four groups:
Group 1: The first settings for review are specialist NHS and independent sector wards for people with learning disabilities and autism, including assessment and treatment units (ATUs), and low to medium secure wards. Such wards which treat children and adolescents for mental health difficulties will also be included.
Group 2: Focusing only on segregation and prolonged seclusion, the review of this group will come after Group 1. It will look at both NHS and independent mental health wards covering rehabilitation and low security wards.
Group 3: This section of the review will be exploratory to identify and describe whether and how restrictive interventions are used in residential care homes for people with learning disabilities and autism, as well as the equivalent services for children. Because the latter are jointly registered with CQC and Ofsted (the Office for Standards in Education, Children's Services, and Skills), the review will be undertaken collaboratively. Also undertaken with Ofsted will be an examination of the fourteen secure children;s homes in England - these homes are registered with Ofsted but not CQC.
Group 4: CQC has deemed these settings to be currently out of scope. However, CQC may extend the scope to explore one or more of them if evidence is found of misuse of restrictive interventions and CQC has the authority to visit/inspect that setting. Settings that fall into this category include medium or high secure mental health wards* and mental health admission wards for working age adults or for older people with mental health problems**. Residential care homes designated for any other groups of clients*** (for example, care homes for older people) and any other non-health or non-social care setting are also in this category.
Methodology for the review
Literature review: This will determine what is already known and what is good practice in such scenarios. CQC will supplement the literature review with a call for evidence and invitation for submissions from interested parties, providers, academics, and groups that speak on behalf of people using these services. The literature review will also examine information in the public domain about people’s lived experience.
Collation and further analysis of the various sources of data
Bespoke information requests of providers: This will be used to identify settings in which segregation or prolonged seclusion are being used and to determine how many people are subject to these practices.
Visits to providers: Assessing actual practice against what is known to be best practice.
Interviews with people who have been subject to segregation/prolonged seclusion and with families and carer
Interviews with commissioners and other parties to the wider system
Co-production and engagement with people with lived experience CQC will involve those with lived experience – as either a service user or a carer - in the governance of the review (for example, as members of advisory groups) and in all elements of the work – including as experts by experience on site visits. CQC will invite people with lived experience to make verbal or written submissions about their experience.
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Response by Dr Paul Lelliot, Deputy Chief Inspector of Hospitals (lead for mental health)
“There is understandable public concern about the use of restraint, prolonged seclusion and segregation for people with mental health problems, a learning disability or autism. It is vital that services minimise the use of all forms of restrictive practice and that providers and commissioners work together to find alternative, and less restrictive, care arrangements for people who are currently subject to seclusion or segregation. Failure to do this has the potential to amount to inhuman and degrading treatment of some of the most vulnerable people in our society.
“We welcome the Secretary of State’s commission for CQC to undertake a thematic review of this important issue. The review will examine the range of factors that lead to people being subject to restraint, prolonged seclusion or segregation, and will assess the extent to which services follow best practice in minimising the need to use force. The experience and perspective of the people affected by these practices, either as a patient or as a carer, will be central to this work. It is vital that society protects the rights, welfare and safety of children and adults with a mental illness, learning disability or autism and that they receive the safe, high quality care that they deserve.”
Read CQC's statement here.
* There are significant safeguards in place already for people in these settings, CQC says. The statement notes that secure units that admit children and young people or that are specifically designated for the care of people with learning disabilities would be considered in group 1.
** CQC’s inspection teams rarely encounter problems with segregation/prolonged seclusion in these settings.
*** Although CQC has some involvement in the inspection of, for example, immigration detention centres, it is not the principal regulator/inspectorate for these settings.