Eleanor Roosevelt, 1958

'Where, after all, do universal human rights begin? In small places, close to home -- so close and so small that they cannot be seen on any map of the world. Yet they are the world of the individual person... Unless these rights have meaning there, they have little meaning anywhere. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world.' Eleanor Roosevelt, 1958

The Small Places has moved...

The Small Places has moved to a new home here, including all the old posts. Any posts after 6th March 2014 will appear on the new website, but old posts are preserved here so that URLs linking here continue to work. Please check out the new site.

Monday, 9 July 2012

Is there an ongoing lack of CQC inspections in residential care for adults with learning disabilities?

Back in 2004 the Commission for Social Care Inspection (CSCI) and the Healthcare Commission were tipped off by a local branch of Mencap that adults with learning disabilities were being abused in services run by Cornwall Partnership NHS Trust. The report that followed their joint inspection made headlines, a police investigation followed and documented horrific abuses - although in a decision that continues to puzzle abuse victims and their families, no prosecutions ever followed. Last year, abuse victims from Cornwall won a large payout from a civil claim, but as one carer told a local newspaper, 'the scars never go away'.

The Cornish scandal is often associated with assessment and treatment centres, but what is often forgotten is that the majority of victims were not in healthcare settings but in supported living services run by the health trust. Following the Cornwall scandal, the Healthcare Commission launched a nationwide audit of inpatient healthcare services, producing a hard hitting report entitled A Life Like No Other (2007). The report concluded that adults with learning disabilities in healthcare settings experienced highly restrictive and institutional regimes, had little support to maintain or build relationships, had few meaningful activities to occupy them, little access to advocacy services. The report concluded 'We cannot be sure that the human rights of people with learning difficulties are always upheld.' In the early days of the Care Quality Commission (CQC) a small sample of these healthcare services were revisited, and depressingly the report found that little had improved (2009).

Important though these reports are, they related only to healthcare settings. This strikes me as a little odd, given that the majority of people abused in Cornwall were in what CSCI called 'illegal unregistered care homes', and what the trust called 'supported living services'. It's an interesting question, and one I don't really have any answers to, why no equivalent audit of services registered with the CSCI - rather than health services - was not conducted. As readers will know, the CQC undertook another national study of services for adults with learning disabilities in the wake of BBC Panorama revealing horrific abuse at a private assessment and treatment centre, Winterbourne View. The CQC released its report on this national study last month, and yet again concerns were raised about excessively institutional and restrictive regimes, which offered few meaningful activities, poor access to advocacy (and CQC also questioned the quality of advocacy services that were available), problems with the use of restraint and seclusion, etc etc.

Unlike the previous national audits, this report focussed also on residential care services, as well as healthcare settings. The reason for this appears a little spurious - CQC couldn't locate 150 healthcare services that met their criteria, so in order to have a sample size of 150 they included 34 residential care homes (two run by the NHS). Whatever their reasons, the inclusion of this small sample of residential care services revealed something important: that residential care services had just as many problems as assessment and treatment centres. This is something that seems to have passed quite a few people by - much of the response to Winterbourne View has been along of lines that we need to close down these assessment and treatment facilities and move people into the community. Sure - I agree - but what the sample of residential care services reveal is that community services may have just as many problems. In fact, the CQC report identified that residential care homes had worse compliance than assessment and treatment centres for Outcome 4 (Care and welfare of people who use services), and the majority of 'major' safeguarding concerns were also in residential care - not assessment and treatment centres.

The sample size is relatively small, but it suggests we need to expand our thinking beyond closing down what has effectively become a privatised long-stay healthcare system, to thinking about how we can address 'institutionalisation' in services of all sizes. I don't have any answers for this that others have not already proposed. However, I do want to briefly make a point about scrutiny of such services. In the police report into the abuse in Cornwall, a key issue they raised was the lack of regulatory inspections. No regulator could be held accountable for this as Cornwall Partnership NHS Trust had overlooked actually registering these services. In A Life Like No Other the Healthcare Commission complained that there was a lack of external scrutiny from advocacy services, highlighting that 'scrutiny' is not a regulatory issue alone. In its latest report, CQC reflects on the importance of scrutiny only indirectly: 'The secure services are generally subject to more external scrutiny and this may explain the highest proportion of compliance with care and welfare'. Scrutiny need not only come from a regulator, and some forms of scrutiny (for example, commissioning decisions) cannot be undertaken by CQC, but clearly CQC's inspection program plays and important role. Concerningly, supported living services are not subject to any regulatory scrutiny at the site level at all.

In the wake of Winterbourne View and the whistleblower evidence given by CQC's own staff to the Mid Staffordshire Inquiry, the CQC came under fire for the drop-off in inspections since it took over regulation of social care. Vern Pitt at Community Care found that it hadn't inspected a single learning disability hospital in months. Johann Hari wrote a piece based upon some statistics that, well, didn't resemble anything I'd obtained under the Freedom of Information Act, and blamed the Coalition government for cutting care inspections.  Even the Financial Times expressed concerns about a lack of regulatory inspections in care in 2010-11.  I'm no fan of the Coalition government, but I feel obliged to point out that care inspections fell through the floor in 2007 under Labour, as part of a wider policy of a move towards risk-based regulation that wouldn't overly 'burden' services. Nevertheless, it was only after Winterbourne View that the general public got their knickers in a twist about inspection frequency. So, backed into a corner, the CQC promised it would double the number of inspections, which allegedly were currently taking place once every two years, to annual inspections. This announcement was made almost exactly a year ago. But has this actually happened?

I can't answer for the entire country, but today I finally got around to a task I'd meant to do for ages - which is to conduct a small audit of CQC reports on learning disabilities services in Cornwall. Learning disabilities - because that's what my PhD research is on - Cornwall because that's where my research is located. So, I asked CQC's search engine to find me residential care homes for adults with learning disabilities in Cornwall, planning to take a copy of each inspection report and look at their coverage of various key issues like human rights, mental capacity and deprivation of liberty. I had put this task off until this late in my research because I wanted to give CQC a chance to actually complete inspections of all these services under its new regulatory regime. What I hadn't expected to find, was that the majority of these services hadn't actually received an inspection from CQC at all, many had no reports from even the old regulatory regime online, and only 14% of services had been inspected within the last 12 months. I've put my findings into a Google spreadsheet so you can see for yourselves, but the summary sheet looks like this:

Number of registered residential care services for adults with learning disabilities in Cornwall - 36, 100%
Number recorded non-compliant - 3, 8%
Number of services with no inspection reports online - 8, 22%
Average (mean) number of months since last inspection - 29
Average (median) number of months since last inspection - 32
Longest period (months) since last inspection - 39
Shortest period (months) since last inspection - 1
Number of services inspected in last 12 months - 5, 14%
Number of services inspected in last 24 months - 7 19%
Number of services inspected in last 36 months - 22, 61%
Number of services inspected 3 years or longer ago - 10, 28%

I can't generalise from these findings to the rest of the country, but if the picture of compliance in residential care for adults with learning disabilities is as bad as the CQC's national study suggests it is, then we should be very concerned indeed that in this sample it has only managed to inspect 14% of those services in the last year. Of course a separate question is the quality of those inspections - and one of the concerns raised by CQC whistleblowers at the Mid Staffordshire Inquiry was that an increase in inspection frequency would lead to a decline in inspection quality. But the content of those inspection reports is another matter, for another post, another day.

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