Paper No: / CM/06/13/08
MEETING: / Board Meeting
DATE: / 31 July 2013
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:
GOVERNANCE
AUDIT TRAIL: / 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 / Implementation of post Winterbourne View commitments are linked to our strategic objectives and business plan
IMPLICATIONS FOR NCSC / None
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
LEGAL IMPLICATIONS: / None
HEALTHWATCH IMPACT: / None
EQUALITY IMPACT
ASSESSMENT: / Not Applicable
1. Background
1.1Following 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 View[1]
-CQC learning disability services inspection programme – national overview[2]
-South Gloucestershire Safeguarding Adults Board: Winterbourne View Hospital – A Serious Case Review[3]
-DH Transforming care: A national response to Winterbourne View Hospital[4]
1.2The paper sets out the achievements to datebut 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.
1.3We have a clearer understanding from our national inspection programmethat 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
2.1This 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 wassigned 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 IMRidentified changes we needed to make not just to the way we work, but to the ways in which we work with 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:
-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
2.5 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
2.6 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
2.7 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 Executivewill oversee recommendations for this to be captured and reported and for evidence that information flows between the inspectors and mental health act commissioners have improved regulatory judgements.
Case management approach to dealing with risk
2.8 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
2.9 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.
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.
2.18 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.