Q Care Quality Commission
Mike Smith
Lead Commission - Disability Harassment Inquiry
Equality and Human Rights Commission
Arndale House
The Arndale Centre
Manchester M4 3AQ
9 February 2012
Dear Mike
Thank you for giving us the opportunity to respond to you on the
implementation of the recommendations in the 'Hidden in Plain Sight' report.
There is much that needs to be done to prevent disability-related harassment
and to ensure that where disability-related harassment takes place,
organisations are responding appropriately. The Care Quality Commission is
committed to challenge disability-harassment and to play its part in ensuring
that people who experience disability harassment are supported and
responded to appropriately.
The Care Quality Commission is the independent regulator of health care and
adult social care services in England. We also protect the interests of people
whose rights are restricted under the Mental Health Act.
Whether services are provided by the NHS, local authorities or by private or
voluntary organisations, we focus on:
 Identifying risks to the quality and safety of people's care.
 Acting swiftly to eliminate poor-quality care.
 Making sure care is centred on people's needs and protects their rights.
I will respond to each of your points in turn:
 How will adoption of the 7 core recommendations inform and support
your sector/organisation's actions to achieve real progress in
tackling harassment? Are you able to commit to these? In your
response please also indicate how these will support your work with
other agencies.
The first core recommendation is about leadership to drive change. At CQC
we have shown leadership relating to disability related harassment by taking
an active role in the advisory group for your inquiry on this topic and
participating as a 'sector leader' in your recent 'manifesto for change' event
which focused on moving the report recommendations into reality. We will
also consider how the leadership group at CQC can drive action on the
recommendations both within the work of CQC and by messages to the
health and social care sector that we regulate, for example through our
provider newsletter which reaches around 30,000 health and social care
providers
The second recommendation is about improving data on disability related
harassment which enables better measurement of the scale, severity and
nature of the harassment and better monitoring of the performance of those
responsible for dealing with this. Clearly, measurement on a local and
national scale would be more robust if monitoring was carried out through a
cohesive system. The report makes it clear that disability related harassment
should be treated as a crime, so the primary responsibility for this may lie with
the police and criminal justice system. However, some disability related
harassment may not be reported to the police but be dealt with as a
safeguarding issue.
We are just starting a project, working with EHRC, to develop the equality
information that we use to alert us to whether health and social care providers
are at risk of non-compliance with our essential standards. Part of this work
will be prioritising areas for information development based on known issues
for people with different protected characteristics under the Equality Act 2010.
We can assess whether improved data to better monitor of the risk of
disability related harassment is a priority area for this project.
We are already taking a number of actions to improve how we can monitor
safeguarding issues. Health and social care providers have a duty to notify
CQC of safeguarding incidents. We do record the type of abuse reported to
us, using information supplied by providers based on the categories in the 'No
secrets' guidance on safeguarding adults. The categories include
discriminatory abuse but not disability related harassment specifically. Where
providers give us relevant information, we also record the protected
characteristics of the person experiencing abuse and the alleged perpetrator.
We are working on systems to improve our reporting of this notification
information at local and national levels. However, as local authorities have the
prime responsibility for categorising abuse and producing collated information
about scale and nature of abuse, the specific monitoring of disability related
harassment in safeguarding would be best addressed through engagement
with local authority bodies.
We are also improving the system we use to record the safeguarding referrals
that we make to local authorities. We will be able to collate these referrals by
different types of abuse - we will therefore be able to monitor and report
numbers of referrals that we make about discriminatory abuse. We are also
influencing others to consider the recommendations of the Inquiry when
designing data collections, for example we have recently flagged this inquiry
recommendation in our response to the Information Centre about the
proposed new national Adult Social Care monitoring categories.
The third recommendation is about making the criminal justice system more
accessible and responsive and is outside our regulatory remit. The fourth
recommendation is about understanding the motivations and circumstances
of perpetrators and is also outside our regulatory remit. However, we
potentially have an interest in this the outcomes of this work in relation to our
role in registering individuals as managers of health and social care services.
We currently work with other bodies such as the Independent Safeguarding
Authority and professional regulators, through to ensure that we refer
registered managers and other health and social care staff where we have
concerns that the person is not suitable to carry on their work. This would
include where the person had perpetrated disability-related harassment.
The fifth recommendation is that the wider community has a more positive
attitude towards disabled people and better understands the nature of the
problem. Whilst changing attitudes of the public at large is also outside the
remit of our work, we recognise that under the Equality Act 2010 we have a
duty to foster good relations between disabled people and non disabled
people. We do this in a number of ways. COC has adopted the social model
of disability. We involve disabled people in the development of COC in
various ways, including through our Experts by Experience programme where
people who use services are part of our inspection teams. We see this
involvement as crucial to developing positive attitudes to disabled people both
within COC and with other stakeholders that we work with. We have a
Disability Equality Network for staff which also promotes positive attitudes
towards disabled people within the wider COC workforce. We ensure that our
communications advance positive attitudes about disabled people - through
explaining the social model of disability and our approaches to both human
rights for all people using health and social care services and the specific
work that we carry out about equality for disabled people. This includes
reporting on what we know from our regulatory work about disability equality
in the health and social care sector in our annual State of Care report. Our
equality objectives for April 2012 onwards will further this work.
The sixth recommendation is that all frontline staff who may be required to
recognise and respond to disability-related harassment receives proper
training. All COC staff receive safeguarding training. Frontline staff, such as
inspectors, receive more in-depth training. This is backed up by guidance,
procedures and templates for all staff accessible via our staff intranet in a
dedicated safeguarding section of the site. I know that there are concerns in
the report that disability related harassment is often dealt with as a
safeguarding issue, when it should also be a criminal justice issue. Our
guidance to COC staff makes it clear that where an offence has been
committed, the member of staff should contact the police as well as the local
safeguarding authority. All staff also receive training on their duties under the
Equality Act 2010 and our innovative 'Equally Yours' training which covers
disability equality issues. Again, this is supported by intranet resources,
including the joint guidance that we have produced with the EHRC for
inspectors about equality and human rights. We are planning a further
programme to embed equality and human rights in staff training for April 2012
onwards. The EHRC are involved in this work through our Memorandum of
Understanding.
The last recommendation covers evaluating and disseminating promising
approaches to preventing and responding to harassment. Whilst we do not
propose to undertake any specific evaluation work on disability related
harassment, we are currently undertaking an evaluation of our regulatory
action in response to all the equality and human rights aspects of our
essential standards. Our coding framework for this evaluation includes a
number of issues relevant to disability related harassment. The learning from
this evaluation will primarily be for COC as an organisation but we will
consider whether any key points need disseminating to other audiences. We
will also consider key equality issues in our forthcoming wider project to
evaluate the impact of our regulatory work.
How will adoption of the recommendations specific to your sector
inform and support your actions to achieve real progress in tackling
harassment? Are you able to commit to these? In your response please
also indicate how these will support your work with other agencies.
The sector recommendations relevant to COC are the recommendations for
regulators.
The first recommendation is that the appropriate regulator should always
intervene when a serious case of repeat disability-related harassment, such
as one which leads to death or serious injury of a victim, emerges in the
sector under their supervision. We intervene where we have concerns about
whether a health and social care provider is meeting essential standards of
quality and safety. However it is the provider's primary responsibility to take
the appropriate action to ensure that people using their service are protected
from harassment. It is the local authority's primary responsibility to lead the
co-ordination of a safeguarding investigation and the responsibility of the
police to deal with the criminal aspects of any harassment. Our role is to see
how the disability related harassment has affected the compliance of a
provider with the essential standards of quality and safety. Where serious
disability related harassment has taken place, this might trigger regulatory
action - such as an inspection - if we think that there is a risk that the service
no longer complies with the essential standards. This would depend on
whether staff working in a regulated service are the perpetrators, whether the
service should have taken action earlier and other information that we have
about the overall risks in the service. We may also have a responsibility to
contact a council in case they need to initiate safeguarding procedures, for
example if we are the first agency to discover the harassment; this is covered
in our safeguarding guidance to staff and our safeguarding training.
Not all our work to improve safeguarding is triggered by actual incidents. We
regularly check that health and social care providers are meeting essential
standards around safeguarding and this includes that " ... all staff are
committed to maximizing people's choice, control and inclusion and
protecting their human rights as important ways of meeting their individual
needs and reducing the potential for ebuse". In the 9 months to July 2011 we
took regulatory action in 37 NHS hospitals, 57 home care agencies and 475
care homes to improve the safeguarding of people using services." But this in
an underestimate of the work we do which will contribute to the prevention of
disability related harassment because our work in ensuring compliance with
other outcomes in the essential standards, such as the outcomes on
respecting and involving people who use services and recruitment of suitable
staff, will also contribute to a reduction in the potential for disability related
harassment.
The second recommendation for regulators is that Measures for how all
public bodies deal with the issue of disability-related harassment, and other
forms of hate crime, should be built into all of the appropriate regulatory and
inspection regimes. We look at how all providers - whether public bodies or
not - deal with disability related harassment under Outcome 7/ Regulation 11
of the Health and Social Care Act 2008 (Regulated Activities) Regulations
2010. As explained above, our work includes checking how providers prevent
abuse - including harassment as well as how they respond to actual
instances of abuse. The culture of organisations is very important. Inspectors
will focus on outcomes more than processes, looking at questions such as -
do disabled people using the service feel confident about raising issues with
managers? Are there good relations between disabled people and staff
supporting them? This is at least as important as checking policy and
procedure such as whether there is an accessible complaints procedure or
information about harassment.
The third recommendation is that regulators and inspectorates, along with
senior representatives of those service providers and their clients, should
work together to devise and disseminate procedures and standards which
seek to minimise further the risk of harassment. Lessons should be learnt
from previous serious cases, regularly embedded in training and practice and
lessons from all areas shared effectively across other areas. We do give
guidance on our standards. However it is not our responsibility to devise or
disseminate procedures; it is the responsibility of providers to have
appropriate procedures for their particular service. We have a system in place
for us to learn from serious case reviews, where the review involves a
regulated service. We collate the learning for us from reviews across the
country on a monthly basis and report these to our safeguarding committee.
The committee checks whether the learning indicates that we need to change
the way that we work. We also share learning with regional safeguarding
leads who can disseminate learning to regional staff such as our inspectors.
We also have a safeguarding development plan in place. This includes
actions that we have identified in response to our internal investigation of our
handling of the concerns at Winterbourne View hospital. Significant changes
have been made already as a result of this learning, such as enhanced COC
staff guidance and training and improving our processes to handle
safeguarding and whistle blowing concerns.
1 Taken from Care Quality Commission (2010) : Essential standards of
quality and safety, p 95
2 Taken from Care Quality Commission (2011)
The final recommendation is that regulators should ensure their responses to
harassment are joined-up and use common standards and criteria for its
identification. Poor performers should be identified and sanctioned if no
improvement is apparent within a reasonable period of time. We are required
by legislation to regulate against specific standards and are not in a position
to develop joint standards. But we can develop information sharing with other
regulators and co-working where we do joint inspections (e.g. prison health).
We share information with other regulators where we discover evidence that
suggests another regulator needs to take action, for example the Independent
Safety Authority or professional regulators such as the Nursing and Midwifery
Council. This is achieved through formal Memoranda of Understanding and
referral processes with these other regulators. We feel it would be useful for
the EHRC to identify a lead regulator to develop joint work on regulating
around disability related harassment.
 Which of the recommendations do you consider to be most practical and
achievable, with the potential for the greatest impact on tackling disability
related harassment?
The seven core recommendations are all necessary elements of a strategy to
tackle disability-related harassment. However, leadership on the issue may
be a necessary pre-requisite to achieving the other recommendations. The
need for clear leadership on this issue was a strong theme in the 'manifesto
for change' event that COC attended.
 If you do not agree with specific recommendations, please specify which,
and indicate what alternative measures might achieve the same or similar
goals?
Some of the regulatory recommendations are not applicable to all regulators.
I have outlined the limits of some of the recommendations in this response
already.
The recommendation about reviewing eligibility criteria to increase social
interaction and reduce social isolation for disabled people is very important
for the prevention of disability-related hate crime. However, in the report it is
currently a recommendation for health and local agencies. Whilst health and
social care providers may undertake some assessments to enable people to
access particular services, the core responsibility for eligibility criteria in adult
social care' lies with local authorities so we believe that this recommendation
should also be included in the local government section of the report.
 What additional actions do you propose to take to tackle disability
related harassment?
We do not propose to take any additional action, other than that outlined
above. We would be happy, however, to continue a dialogue with EHRC
about potential joint working on disability related harassment through our
Memorandum of Understanding review arrangements.
Our current and future actions are summarised in the attached table, as
Annex A.
Once again, the Care Quality Commission is committed to play its part in
reducing disability-related harassment. hope this response is useful to you. If
you require any further information, please contact me.
Yours Sincerely,
Phillip King
Director of Regulatory Development
Annex A - summary of CQC actions in response to
EHRC disability related harassment inquiry
Inquiry Recommendation Current CQC action
Leadership
Participating in Inquiry
advisory group
Participating as a sector
leader in Manifesto for
Change event
Data improvement
Improving cac data on
notifications and
safeguarding referrals to
include discriminatory
abuse
Raising awareness of this
recommendation in joint
data improvement work
with other agencies
Planned or possible
future CQC action
Consider promoting the
report recommendations
to health and social care
providers through provider
newsletter
Consider raising CQC
staff awareness of
recommendations through
internal communication
methods
Consider whether
disability-related
harassment data should
be a priority in CQC
equality data development
project (jointly with EHRC)
Inquiry Recommendation Current CQC action
Planned or possible
future CQC action
Further staff training
planned which embeds
equality and human rights
Promote positive attitudes Adopted social model of
to disabled people in wider disability Involvement of
community
disabled people in cac
development work and as
experts by experience
Commitment to reporting
on equality, including
Promote positive attitudes equality for disabled
towards disabled people in people, in State of Care
public communications
report 2012
including State of Care
report produced 2011
Inspector guidance on
equality and human rights
jointly produced with
EHRC available on public
internet CQC staff
Disability Equality Network
Training for frontline staff Equality training for all staff Further staff training
including disability equality planned which embeds
equality and human rights
Safeguarding training for
all staff
Consider adding some key
points from inquiry into
Training backed up by
next version of 'Equally
safeguarding and equality
and human rights guidance Yours 'training
available via staff intra net
Inquiry Recommendation Current CQC action
Evaluating approaches to
minimising harassment
Regulator intervention In
serious and repeat
harassment
Measures built into
inspection regimes
Devising and
disseminating
guidance and lessons
learned
Planned or possible
Future CQC action
Some learning may come
from the current
evaluation of equality and
human rights in reviews of
compliance
Already part of our
regulatory activity, where
this is within our regulatory
remit
Already part of our
regulatory activity, where
this is within our regulatory
remit
COC provides guidance to Further development of
providers on all essential safeguarding development
standards - including those plan - e.g. to incorporate
recommendations of
relating to safeguarding
and other issues that relate Winterbourne View SCR
when it reports
to harassment (such as
access to advocacy)
We monitor lessons from
SCRs involving regulated
providers and use these to
refine our approach and
disseminate learning to
inspectors
Safeguarding development
plan developed from
lessons learned
Joint working between
regulators
Referral mechanisms set Will consider participation
up through MOUs with ISA in joint working
and professional regulators
- to use when other
We recommend that
regulators may be better EHRC agree a lead
placed to take action
regulator to take this work
forward
against perpetrators