Assuring quality in health services for people with learning disabilities Dr Theresa Joyce CQC National Professional Advisor – Learning Disabilities

Role of CQC CQC is the independent regulator of health and social care services in England. It uses a number of methods, including registering care services to ensure they meet standards monitoring, inspecting and regulating care services to make sure they meet standards protecting the rights of vulnerable people, including those detained under the Mental Health Act taking enforcement action when services fall below standards talking to users of services about their care

Legal framework CQC powers and duties arise from the Health and Social Care Act 2008 and associated regulations Mental Health Act 1983 and 2007 Mental Capacity Act 2007 Links to other Acts ( eg Children Act 1989 and 2004, Human Rights Act 1998) Policy and guidance associated with relevant legislation Must relate findings and actions to the legal framework

How do we decide what to look for? Consider: Good practice guidance Evidence Policy Statutory requirements and legal frameworks General and relevant to LD

Includes No Secrets/Safeguarding policies Transforming Care/Building the Right Support MHA and Code of Practice MCA/DoLS and Code of Practice Positive and Proactive care NICE guidance Medication prescribing guidance Positive Behaviour Support Five Good Communication Standards

Includes Waiting time and discharge targets Health Action Plans Compassion in Practice Staff training and qualifications; staffing levels Clinical governance systems and structures Service user and family involvement and feedback Complaints and incidents Leadership and communication Learning from incidents Etc….

Domains Safe Effective Caring Responsive Well-led Same for all services But specific focus on what they mean for LD services

Ratings Ratings of the 5 domains are in one of 4 categories – outstanding – the service is performing exceptionally well – good – the service is performing well and meets CQC's expectations – requires improvement – the service isn't performing as well as it should and CQC has told the service how it should improve – inadequate – the service is performing badly and CQC has taken action against the person or organisation that runs it

Process Teams follow structured process to gather evidence on the domains Teams include clinical specialists and experts by experience Evidence obtained is compared to good practice Evidence is corroborated from more than one source Ratings then applied

Regulates…. Acute hospitals Community trusts Mental health trusts GP services Dentists Primary care services Learning disability is considered in each of these Core service Vulnerable group

Acute hospitals Questions asked during inspections: – How many people with learning disabilities are inpatients today? – How do you know? (are they flagged….) – Do you have a liaison nurse – can we meet them? – Who is the Board member responsible for assurance in relation to people with learning disabilities

Mental health & Community Includes inpatient services and community teams Learning disability is a core service, therefore teams focus on it specifically and report separately Include Specialist Advisors and Experts by experience Lot of information gathered prior to inspection (and also between inspections) Follow structured process in gathering evidence Reports go through QA process (including checking information with the trust being inspected)

Key Lines of Enquiry – Inpatient services Are services safe? We look for: – Safe and clean environments, including ligature points, line of sight, state of repair – Safe staffing, including levels, use of agency and bank staff, qualified staff available – Risk, including assessment and management, use of restraint, seclusion, record keeping, staff training in restraint, use of blanket restrictions

Key Lines of Enquiry – Are services safe? We look for: Information about adverse events and actions taken, number of incidents How incidents are reported and learnt from, reporting and recording of abuse, safeguarding systems and policies, how service responds to protect people (including from incidents between patients), staff awareness of duty to report

Are services effective? We look for: – Comprehensive assessment on admission (including physical health and communication) – Care plans are individual and relate to needs identified on assessment – Interventions are evidence –based (PBS understood and implemented) Include functional assessment, proactive strategies, environmental support, skills development, reactive strategies – Outcomes are measured – Audits are undertaken

Are services effective? We look for: – Skilled staff, including access to MDT – Staff are supervised, trained, appraised, meet regularly, performance issues managed – Good practice in MHA, CTT requirements followed, rights explained and upheld, IMHA’s available – Good practice in MCA, capacity and consent assessed/recorded, people supported to make decisions, understanding and use of DoLS – Organisation has oversight of MHA and MCA

Are services caring? We look for: – Positive interactions with patients – Respect, dignity, support – What patients say about how they are treated – Staff knowledge and understanding of individual needs – Participation in care planning – Involvement of families and carers – Use of patient surveys and feedback

Are services responsive? We look for: – Discharge plans and timely discharge – Environment supports treatment and care – Private phone calls possible, access to outside space, quality of food and choices available, access to drinks, possessions in bedrooms, and secure space for them, activities available – Accessible information – Complaints listened to and acted upon

Are services well-led? We look for: – Knowledge of organisation’s values and objectives, senior managers visible – Governance : systems ensure training, supervision, safe staffing levels, incident reporting, audit etc – Leadership: morale, job satisfaction, sickness, personal development, staff able to raise concerns etc – Commitment to improving quality

Community teams Use same domains Look at how teams support people in their own homes/supported living/residential care Look for how they link in with wider service system

Some characteristics of an outstanding inpatient service Staff worked flexible shifts to meet patient need Effective assessment and care planning (including risk) Restraint closely monitored and risk assessed every time Very good staff support Staff worked collaboratively with patients with equal involvement in care Medicines managed well and safely Safeguarding knowledge good and applied well

Some characteristics of an inadequate inpatient service Poor environment and lack of privacy when patients distressed No formal risk assessment High levels of prone restraint Poor medicine management Poor staff training, including in specific needs of patients Lack of DBS clearance for some staff MHA not always followed Poor Trust leadership

Some characteristics of an outstanding community team Well resourced, skilled and experienced staff Holistic assessments, individually focused on people’s needs Involved people and their familes in developing care plan Respectful and constructive in their interactions with service users Worked effectively with local support networks Prompt and effective support to carers

Some characteristics of an inadequate community team Lack of assessment and management of risk – including managing waiting lists Poor assessment and care plans, including poor quality behaviour support plans Service users not involved in care planning Poor partnership working, meaning service users did not access mainstream services Poor governance

Summary Lot of information and evidence gathered Aim to improve services, as well as ensure they meet standards Structured process for inspections Ongoing monitoring Action taken when regulations are breached With the person using the service at the centre

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