Following the discovery of the abuses of patients in Winterbourne View, the Observatory agreed with our Monitoring and Advisory Group that one of our spare project slots should be used to see what was known about this type of care in other hospitals around the country.
Both studies were done in collaboration with the Care Quality Commission and we are grateful to them for their help in providing access to data not previously available to researchers.
Review of inspection reports
Eric Emerson undertook a detailed review of the special inspection reports of the 72 assessment and treatment units and 39 secure units included in the 145 learning disability services inspected by the Care Quality Commission.
- Overall, less than one in four of the units inspected were fully compliant with both the Care and Welfare and the Safeguarding aspects of the inspections.
- Only one in seven of the current residents of the units were being supported in units that were compliant with both aspects.
- Concerns raised regarding Care and Welfare fell into two broad categories:
- Deficiencies in care planning (including discharge planning);
- The range, nature and extent of activities and support available within the setting.
- Concerns raised regarding Safeguarding fell into three broad categories:
- The competence of staff regarding their understanding of safeguarding procedures;
- The consistency of the implementation of local safeguarding procedures;
- The use of restrictive behaviour management practices such as physical restraint and seclusion.
- There were marked differences in compliance between units operated by NHS Trusts and independent healthcare providers. For every comparison made, units operated by NHS Trusts were more likely to be compliant than services operated by independent healthcare providers. For many
of these comparisons odds of compliance were at least twice as great in units operated by NHS Trusts.
A review of the results of the 2011/12 focused CQC inspection of services for people with learning disabilities.
Review of Count-Me-In censuses
The Count-Me-In census was an annual survey of everyone in a mental healthcare hospital bed, including those specifically for people with learning disabilities, done each year from 2006 to 2010. This survey covered all NHS funded care, whether provided by the NHS or in the independent sector. Gyles Glover collected together data from all five years censuses and reviewed what it showed about the quality and use of these facilities.
The study showed that in these units:
- People stay a long time. In the most recent year, 55% of patients in A&T units had been there more than a year and 38% more than two years.
- Adverse experiences are common, but the frequency of them varies between providers.
- 40% of people experienced hands-on restraint and 35% suffered assaults in the three months before census.
- 10% had 10 or more experiences of hands-on restraint and 6% suffered 10 or more assaults in the three months before census – equivalent to once per week or more.
- Assaults are reported less commonly in medium secure units than in low secure or general A&T wards, but seclusion is used more commonly. Accidents are reported more commonly in general A&T wards.
- Hands-on restraint and assaults are more common for patients in independent sector than NHS units; this finding remained after adjustment for the different patient mix. Allowing for differences in relation to age and sex profiles, stay-length, ward security level, detention under the Mental Health Act, autism, impaired mobility and tendency to self-harm, patients in independent sector units were 60% more likely to have experienced hands-on restraint and 30% more likely to have been assaulted.
- Of the 109 units for which these analyses could be done, a small number stood out as associated with increased (7% of reported units) or decreased (6%) risk of two or more of these types of experience for patients. There were examples of good and bad units in both the NHS and independent sectors.
- Use of these facilities varied widely around the country.
- The national average rate for use of A&T facilities in the most recent census was 5 placements per 1000 adults on GPs learning disability registers. The rate in the North East Strategic Health Authority (StHA) was more than twice this, whilst the South East Coast and the South West StHAs were using fewer than 3 A&T placements per 1000.
- The extent to which placements were outside the patient’s home StHA varied widely with 93% of North East patients placed within their home StHA, but only 34% of those from the South East Coast and 39% of those from London.
This study highlights the urgent need for a better monitoring and better evidence. The figures raise substantial concern about the quality of care some of these units provide, and there is no obvious reasons why there should be such large differences in the numbers of people with learning disability from different parts of the country needing it at any time. In order to make more sense of this we need similar detail about people are being looked after outside hospital in different areas.
A&T and other specialist inpatient care for people with LD in the Count-Me-In census
Count-Me-In study press release