Agenda Item:
Paper No:
MEETING:
Board Meeting
DATE:
31 July 2013
9
CM/06/13/08
TITLE OF PAPER: Winterbourne View - Update on CQC activity
SUMMARY:
This paper provides an update on the progress made by CQC in response to the failures
of care at Winterbourne View. The detail covers our on-going actions from four of the key
reports which made recommendations for improving our regulatory work and managing
risk so that we play our part in protecting those people in learning disability services who
are made vulnerable by their circumstances.
RECOMMENDED ACTION:
The Board are asked to review the progress being made by CQC on post Winterbourne
View hospital actions and comment on these. Additionally the Board are asked to
comment where there is still more to be done to deliver commitments.
Executive Decision/
Board for information
LEAD DIRECTOR:
Paul Bate
AUTHOR:
Alan Rosenbach
DIRECTORATE
Regulatory Development
DATE:
July 2013
SUPPORTING PAPERS:
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GOVERNANCE
AUDIT TRAIL:
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This paper is a follow up paper that has been
commissioned by the Board following the June 2013
meeting. The paper to the last Board meeting only
covered the actions we were taking in response to the
Winterbourne View Serious Case Review.
LINK TO STRATEGIC
OBJECTIVES AND
BUSINESS PLAN
IMPLICATIONS FOR NCSC
Implementation of post Winterbourne View commitments
are linked to our strategic objectives and business plan
FINANCIAL IMPACT:
None
RISK IMPACT:
Failure to deliver the commitments or to mitigate the risks
to delivery potentially means that poor care is
perpetuated for those patients in learning disability
hospital settings.
REPUTATION IMPACT:
There are reputational risks for CQC, if we fail to deliver
our internal and external commitments
None
None
LEGAL IMPLICATIONS:
HEALTHWATCH IMPACT:
EQUALITY IMPACT
ASSESSMENT:
None
Not Applicable
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Background
1.1 Following the abuse at Winterbourne View Hospital there were a number of reviews,
reports and investigations carried out by CQC and others that identified and required
CQC organisational and wider system improvements. For the purpose of this Board
report an update on the CQC progress is set out for the following reviews, reports
and investigations:
- CQC internal management review of the regulation of Winterbourne View1
- CQC learning disability services inspection programme – national overview2
- South Gloucestershire Safeguarding Adults Board: Winterbourne View
Hospital – A Serious Case Review3
- DH Transforming care: A national response to Winterbourne View Hospital4
1.2 The paper sets out the achievements to date but also records further work to be done
by CQC regarding our unique and specific contributions to making services safer for
people with learning disability and their families as set out in the four documents cited
above. We will continue to inspect all learning disability hospital services with experts
by experience, professionals and lead inspectors who have a detailed knowledge
about these services.
1.3 We have a clearer understanding from our national inspection programme that there
are risks to patients in services where they are in hospitals for disproportionally long
periods of time and away from their families. We have shared this information with
Health and Adult Care commissioners and NHS England. They are mitigating the risk
through ensuring that all relevant patients had a review by end of June 2013. All
former patients of Winterbourne View were amongst the sample to be reviewed.
2.
Executive Summary
2.1 This section sets out the key issues from the four documents cited and deals with
each in turn.
CQC internal management review of the regulation of Winterbourne View
2.2 The internal management review (IMR) was carried out in the immediate aftermath of
the BBC Panorama expose about Winterbourne View Hospital. The IMR terms of
reference ensured that it was possible to review everything that we knew about
Winterbourne View Hospital from the time it was first registered by the Healthcare
Commission in 2006 until we withdrew its registration in June 2011. The IMR was
signed off by the CQC Board and published in October 2011. The IMR report was
also the formal CQC contribution to the South Gloucestershire Safeguarding Adults
Board Serious Case review.
2.3 The unacceptable events at Winterbourne View revealed a number of system
weaknesses and, from a CQC perspective, process, and performance and
management failures. The 13 recommendations from the IMR identified changes we
needed to make not just to the way we work, but to the ways in which we work with
1
CQC:(October 2011) Internal management review of the regulation of Winterbourne View
CQC: (June 2012) Learning disabilities services inspection programme: National overview
3 South Gloucestershire Safeguarding Adults Board (August 2012): Winterbourne View Hospital – A Serious
Case Review
4 DH Review(December 2012): Final Report – Transforming care: A national response to Winterbourne View
Hospital
2
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the adult safeguarding teams and boards, commissioners, other regulators, the
system performance managers and providers of care.
2.4 There has been significant progress made since 2011 in implementing the 13
recommendations. For the purpose of this update for the Board and to drive the
discussion the 13 recommendations have been clustered into 6 themes. Clustering
this way does not mean that individual recommendations are not covered in the
update; they are. There are now new opportunities to take some of these to the next
level in line with the changes we are making to our regulatory model. The 6 themes
from the recommendations are:
-
-
-
2.5
2.6
2.7
Predictive risk modelling based on notifiable incidents including safeguarding
alerts from learning disability providers and these being systematically
recorded in the quality and risk profile (QRP);
Reviewing the performance of corporate care providers whose services are
delivered across regions or the whole of England;
Improving the information flows and co-ordination for visits and inspections
between compliance inspectors and mental health act commissioner
colleagues;
Strengthened management oversight of inspectors portfolios by focussing on
those services with serious concerns;
Strengthening our information exchange and relationships with Adult
Safeguarding Teams
Six monthly reports providing analysis of whistle blowing alerts into CQC and
actions taken.
Predictive risk modelling
We now incorporate the relevant notifications from learning disability services into
the QRP and use these data to determine and manage risk. These notifications
include safeguarding concerns, injurious behaviours, and number of absconders.
The hospitals providing care for those with learning disabilities who also have
mental health needs and autism will become part of the cycle of new hospital
inspections and this data will be vital to identifying levels of performance and risk to
patients. There must also be opportunities to develop these data into ‘smoke
alarms’ through weighting and benchmarking the information.
Corporate care providers
We established the corporate provider compliance team in the aftermath of
Winterbourne View for the explicit purposes of being able to monitor individual
location performance of corporate providers as well as having the oversight of their
corporate performance. The response by these corporate providers to poor quality
care amongst their portfolio has the potential to support our new approach to
making assessments and judgements about leadership and governance.
Compliance inspections and mental health act commissioner visits to locations
There is by virtue of organisational improvements in CQC a more aligned approach
between compliance inspectors and mental health act commissioners and improved
information exchange. We have not however established base line metrics that
supports the outputs or outcomes from these changes. We have not managed to
routinely capture how many inspections/visits are made jointly by inspectors and
commissioners across all the learning disability services. The Executive will oversee
recommendations for this to be captured and reported and for evidence that
information flows between the inspectors and mental health act commissioners
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have improved regulatory judgements.
2.8
2.9
Case management approach to dealing with risk
In the aftermath of Winterbourne View CQC managers were asked to provide a case
management approach to oversight and supervision of inspectors portfolios where
there are learning disability services. Such an approach is intended to ensure that
high risk concerns are understood, being managed, shared, reported and
monitored. The recommendation proposed that we should have an annual audit to
ensure that the most serious concerns about providers were being captured and
managed. This was to culminate in a public report to the Board. This latter part of
the recommendation has not been implemented.
Working safeguarding systems and structures
We have reviewed and revised our approach about how we work with adult
safeguarding teams and the strategic adult safeguarding boards. This has been
delivered through revised protocols and guidance for our staff. These revisions to
our guidance are to ensure a consistent approach is taken across the country about
how and when we engage and work with adult safeguarding teams. The guidance
sets out clearly the importance and significance of information sharing and making
sure that where actions by adult safeguarding team members are required these
are listed and individuals identified and accountable.
Responding to whistleblowing concerns
2.10 There is a routine and systemised data collection of whistleblowing information that
comes into CQC. We have established close links with the national whistleblowing
helpline for health and social care run by Mencap. We have not yet developed a
typology that weights the content of the whistleblowing information. We can be
confident that we will now respond immediately to any whistleblowing information
that provides us with names, dates times and nature of abuse but this is only one
end of a spectrum. Accordingly, we have not yet set out how whistleblowing
information about poor quality care has systematically driven regulatory responses.
CQC learning disability services inspection programme – national overview
2.11
Whilst this report was principally a detailed account of the findings from our
inspections of the 150 services the report made recommendations for the system
as a whole and CQC in particular.
2.12 The recommendations were drawn from conclusions made from the analysis of the
evidence. The conclusions about the inspection programme led to 2
recommendations for us. These conclusions and recommendations were:
Conclusion: Inspecting services Monday to Friday and in regular working hours
will provide a partial view about the quality, safety and effectiveness of the
services.
Recommendation: CQC should determine when it is most appropriate to visit and
inspect services at weekends and evenings, rather than just on Monday to Friday
between 09.00 and 17.00. Visits at these times provide the additional evidence
needed to assess visitor access and judge the quality of care, staff support and
supervision.
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Conclusion: During 2011, CQC inspected 52 locations offering comparable
services to those included in the sample of 150 locations for this inspection. The
inspectors also assessed compliance against the same two standards in these 52
locations. In the inspection of those services we found three-quarters (73%) of
locations to be compliant with the same outcomes, which is significantly higher
than is the case with this thematic inspections.
Recommendation: We acknowledge the sample of learning disability providers
inspected outside this thematic programme (52) was small by comparison.
However, the differences in judgments about compliance and non-compliance
warrant further evaluation, to help understand and explain the differences.
2.13 The first of the recommendations is now considered to be a key part of the new
inspection regime for hospitals. As the model is implemented across the hospital
sector for those with learning disability and mental health needs this will become
routine.
2.14 In April 2013 we launched an eight week pilot to trial new arrangements for out of
hours inspections. These are not out of hours inspections specifically for learning
disability services although some may be part of the sample. The pilot ran in the
North East patch (the old Yorkshire & Humberside and North East regions) of the
North Region, and inspectors were invited to volunteer to take part. The pilot which
has now concluded covered 80 services with positive feedback from participating
inspectors and providers. The recommendations from the pilot will be discussed by
the Executive Team in September and the results fed into the transformation
programme.
2.15 The second of the recommendations is part of an evaluation programme that is
reviewing any differences in regulatory judgments between the current generic
inspection model and the themed inspection program. This evaluation of all the
themed inspections versus generic inspections that have been carried out in the
life of the organisation will be reported later this year.
2.16
However, the inspection team for this themed programme is noteworthy. The team
of 18 were drawn together after there were invitations for expressions of interest.
All but one of the staff had some experience of learning disability and mental
health services, although for many that was some time ago. The inspectors were
all experienced with 93% of them having been an inspector for 10 years or longer.
There is evidence from this programme that more specialist inspectors even
though they have not necessarily worked more recently in services they know
about, they still know the difference between good and poor care when they see it
in practice.
South Gloucestershire Safeguarding Adults Board: Winterbourne View Hospital –
A Serious Case Review
2.17 The paper which the Board had at the last meeting covered the recommendations
made to CQC by the Serious Case Review. The paper had a forward look at how
the actions we were taking linked to the work we are doing with the system wide
transformation programme. The transformation programme work is covered
separately below in 2.30 to 2.34.
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As cited in 2.2 above the CQC internal management review was our formal
contribution to the serious case review (SCR). Therefore there are overlaps
between the 13 recommendations in the IMR and the SCR. It is worth noting that
in her SCR Dr. Flynn noted of our IMR that “the regulator’s self –scrutiny is
refreshingly honest” (page 120 paragraph 6.14).
2.19 In brief the SCR made clear that the regulatory model was not fit for purpose when
registering or inspecting services for people with learning disability and mental
health needs. It also made clear that inspections needed to be carried out by
specialist’s accompanied by experts by experience. There were concerns that data
about notifiable incidents was not routinely captured and acted on and that
information flows across CQC inspectors and mental health act commissioners
was poor. Additionally the SCR raised concerns that we had taken no action
against Castlebeck who failed to have a registered manager in place for at least
two years. The way in which we capture notifiable incidents, record these and use
these to determine risk has improved but can be further improved as we move
towards in depth inspections. The inspectors and mental health act commissioners
have worked more closely particularly as we follow up inspections into the hospital
services.
2.20 The Board after the last meeting wanted an update on specific issues that were
listed or referred to in the paper they were presented with but for which the
information was absent.
2.21 Some of this updated information will be covered off in the last section where the
actions we are taking which are from the SCR are being delivered through our
commitments in the Department Health Review national response to Winterbourne
View.
2.22
Until such time as we include the hospitals providing care to with people with
learning disability and mental health needs into our new model we will continue to
inspect these services as part of our annual programme of unannounced
inspections. We will by default always take experts by experience with us and a
relevant professional with learning disability services experience. The lead
inspector will also be a professional with a deep knowledge of learning disability
services.
2.23
Notwithstanding the complexities of what is meant by and defined as assessment
and treatment units we know that there are 168 hospitals running services for
people with mental health needs and learning disabilities. All 168 of the services
will be inspected at least once in the cycle from 01/04/203 – 31/03/2014 and we
expect an expert by experience to be included in all inspections. These 168
services operate across 823 locations. The Independent sector services account
for around 54% of the total and the NHS for 46%. The NHS services do not require
under the registration regulations a Registered Manager (RM). The independent
hospitals and adult care providers do require a RM.
2.24 Based on the analysis carried out by Professor Eric Emerson from Lancaster
University for us on the inspections of the 150 services and by Professor Gyles
Glover from Public Health England of the count me in census data we hold we
anticipate that there are around 3,500 patients in these services.
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2.25 The Board wanted an update on the number of independent hospital services that
do not have a RM and the duration for which that has been the case. The details
for this are set out in Table 1 and cover the period to 5th July 2013.
Table 1
Time without RM
Band 1
< 6 months
Band 2
6 – 11 months
Band 3
12 -23 months
Band 4
24 – 35 months
Band 5
35 + months
Numbers
3
5
4
8
9
2.26 As set out in the previous paper to the Board the services which do not have a RM
in place and consistent with our commitment to deliver the recommendations in
the SCR and the concordat to action (see 2.30 below) we are taking regulatory
action against providers in Bands 2 – 5. The actions now being enforced are either
the issuing of a fixed penalty notice or placing restrictions on the registration
depending on the provider and levels of regulatory concern.
2.27 The changes we have made to registration by raising the bar has now been
implemented for potential learning disability registrants and is reported in the next
section.
DH Transforming care: A national response to Winterbourne View Hospital
2.28
This Department of Health Review was the final report into Winterbourne View
and set out the government response to the various reports and reviews. The
response is underwritten by a programme of action or concordat from many
signatories including CQC. We pick those recommendations made in the SCR
where we needed to work with government to make changes to support our new
model for registration and inspection. These have been incorporated into the
concordat commitments we have made.
2.29 We agreed through the concordat to take steps now to strengthen the way we use
our existing powers to hold providers to account. Since the 1st July we have raised
the bar for all potential registrants of learning disability services. We have made
changes to the application process including a much more stringent requirement
on aspirant providers to make clear in the statement of purpose how their service
is consistent with the model set out in the concordat. Additionally we require them
to identify who at corporate level is responsible for overseeing delivery of quality
and safety on a day to day basis. Potential providers will also need to set out
clearly how they will recruit, induct, supervise and provide ongoing training for care
staff.
2.30 The process of raising the bar to registration is so that aspirant registrants
understand the legal commitment they are making to quality and safety of care.
Having rolled out this new approach in the first instance to potential learning
disability providers we have made clear our commitment to deliver an approach
that does all it can to contribute to quality and safety of care for people with a
learning disability and mental health needs.
2.31
The new approach to inspection is being delivered by a specialist group of
registration assessors who will have a good working knowledge of the sector. We
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also intend to bring experts by experience into the registration process for learning
disability services later in 2013.
2.32 We were explicit that we would as result of our strategy consultation review the
model of regulation and in doing so consider how we deliver our responsibilities
under section 120 of the Mental Health Act 1983. This covers the rights of patients
to complain to CQC.
Conclusion
3.1 The abusive practices at Winterbourne View were a seminal moment for CQC,
commissioners and providers. The expose by the BBC of these abuses and the
subsequent reviews and reports highlighted the limitations of CQC process,
procedures and the regulatory model. It also highlighted a wider system malaise in
delivering appropriate and relevant care services for those with a learning disability
and mental health needs.
3.2 We committed to making positive and appropriate changes to the way we work in
direct response to the limitations highlighted by the abuses at Winterbourne View.
Many but not all of these commitments are being delivered. We have made changes
to internal processes and procedures and strengthened our relationships and
information sharing with external partners. We are a main contributor through our ion
going regulatory registration and inspections to the braider plans for system
transformation. These plans are to see the emptying of these institutions of the
majority of the patients in them whilst at the same time commissioners must slow the
flow of new patients into the hospitals. Our changes to registration will ensure over
time that the right services are registered to offer the right care in the right place.
3.3 The next significant change will be the move to specialist teams carrying out in depth
inspections of these services under the Chief Inspector of Hospitals. They will be able
to build on the current improvements we have made to data and information
collections which highlight risk.
4.
Next Steps
4.1 The work will be scoped as part of the on-going programme of change for our
regulation of Mental Health Services. We will continue to work with the learning
disability expert reference group which includes people who use services and family
carers. We will as always seek to ensure they work with us in a co-productive way to
help design and deliver the future requirements as well as maintain an input to our
current work.
4.2 There will be learning that emerges about the changes to the approach to registration
which will be relevant for the wider changes we make for all sectors later in 2013.
This analysis and lessons learned will be shared as will the benefits of using experts
by experience.
4.3 Updates on this the regulatory action against providers with no registered managers
and our actions in response to the recommendations from the other reports and
reviews will be brought back to the Board whenever it deems it relevant to do so.
Alan Rosenbach
July 2013
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