Monitoring the quality of care and safety for people with a learning disability and/or people who are autistic in inpatient care

The NHS Long Term Plan made a commitment to making sure that people with a learning disability and/or people who are autistic are safe and are getting high quality inpatient care.

In May 2019, Minister of State for Care, Caroline Dinenage said: “Where it is essential that someone is supported at distance from home, we will make sure that those arrangements are adequately supervised. We cannot have people out of sight and out of mind. That is why we are introducing stronger oversight arrangements.

“Where someone with a learning disability or an autistic person is an inpatient out of area, they will [be] visited every six weeks if they are a child and every eight weeks if they are an adult, on site.

“The host clinical commissioning group will also be given new responsibilities to oversee and monitor the quality of care.”

To do this it is really important that we have good systems in place that work well to find out if there are any problems with someone’s care and to do what is needed to make their care better quickly.

To support this work guidance has been produced through working with people with a learning disability and/or people who are autistic who are currently, or have previously been inpatients, families with lived experience, providers, and the organisations who plan and pay for care – sometimes called commissioners.

Learning disability and autism safe and wellbeing reviews

As part of the NHS response to the Safeguarding adults review (SAR) concerning the deaths of Joanna, Jon and Ben at Cawston Park, a national review, confirmed by Claire Murdoch, National Director for Mental Health is being undertaken to check the safety and wellbeing of all people with a learning disability and autistic people who are being cared for in a mental health inpatient setting. This includes people whose care is being funded by clinical commissioning groups (CCGs), specialised commissioning and provider collaborative commissioning. Our expectation is that individual reviews of care will be completed early 2022.

Undertaking these reviews is very much a priority for NHS regional and national teams. Every part of the system will have a role in ensuring that they are done swiftly and diligently.

Themes emerging from the review findings will be shared with NHS England and NHS Improvement regional and national teams. The regional and national teams will make sure the learning from the reviews is used to develop any new guidance and to shape the work being delivered.

Roles and responsibilities

Integrated care systems (ICSs), mental health inpatient care providers, NHS England and NHS Improvement and NHS teams all have a vital role to play in the delivery of the review programme.

Placing commissioner: clinical commissioning groups (CCGs), provider collaboratives, NHS England and NHS Improvement specialised commissioning

  • Undertake the review considering the needs of the individual and adapting the approach appropriately.
  • Ensure the purpose of the review is communicated to the individual and those to be involved in the review in a format that they understand.
  • Commissioners and their managers should confirm who will do the reviews (ensuring they have the skills, level of authority and support to undertake the full assessment comprehensively and effectively).
  • Using the risk stratification template to support prioritisation, draw up a timetable of reviews of people for whom they commission mental health inpatient care or who are in learning disability or autism specific hospitals
  • for any other reason. This means the review should include anyone who is identified in the assuring transformation data collection as at 31/10/21.
  • Communication with the person and their family carers that the review will take place, to gather their input and to share the findings of the review.
  • Carry out the face-to-face visit to the person in hospital.
  • Complete the standard review template to be returned to the relevant CCG/provider collaborative for oversight and then to the ICS oversight panel.
  • Summary template to be returned to the regional NHS learning disability and autism team.
  • Responsibility for taking required remedial actions to address any concerns raised in the review.
  • CCGs and provider collaborative leads should consider the outcomes of the reviews of all individuals they commission for and determine any themes or challenges.

Integrated care systems

  • Establish an oversight and assurance panel to include:
    • a learning disability and autism senior responsible officer
    • at least one expert by experience
    • a medical director
    • a senior clinician with expertise in learning disability and autism.
  • ICS should (using the support template) review all people from the footprint who have been reviewed and be able to assure itself that they are safe and well or that appropriate measures are taken if there are concerns.
  • Take into account additional quality assurance intelligence available such as host commissioner reports and safeguarding information.
  • Ensure there are assurance processes to check any actions that may need to happen as the result of a review have been completed.
  • ICS should discuss with regional learning disability and autism team whether it would be beneficial to have the regional team attending the panel.
  • Work collaboratively with and share findings of the panel review with the NHS England and NHS Improvement regional teams.

Data sharing

Purpose of data sharing: patient safety

Data to be shared by the commissioners with the ICS assurance panel in line with local organisational information governance policies.

Host commissioners

  • Host commissioners are expected to support reviews to take place in the hospitals that they work with. This includes sharing any relevant quality concerns with the placing commissioner in line with host commissioner guidance.
  • Ensure there is a system in place to receive intelligence and feedback regarding quality of care from placing commissioners following completed reviews.
  • Triangulate intelligence and information regarding the service to support decision making of level of surveillance for the service.

Responsible clinicians

  • Share the findings and recommendations of the Norfolk SAR within your organisation.
  • Raise awareness with staff in your organisation regarding the purpose of the reviews.
  • Support and engage with the process and enable access to appropriate clinical records that will support the review to ensure people’s mental health and physical health needs are being met.
  • Support the multidisciplinary team to engage with the review.

Chief executives: NHS and independent provider organisations of mental health and learning disability inpatient care and NHS lead provider of provider collaboratives

  • Share the findings and recommendations of the Norfolk SAR within your organisation.
  • Raise awareness with staff within your organisation regarding the purpose of the reviews.
  • Ensure commissioners can access key information and staff to support the swift completion of the review.

Regional NHS learning disability and autism teams

Regional teams will work closely with ICSs, CCGs and provider collaboratives to support the implementation and rollout of the reviews, and as part of the overall assurance and scrutiny process. This includes:

  • support for commissioners in establishing a process to undertake the reviews.
  • membership of the ICS oversight and assurance panel to review the findings of the review (to discuss with ICSs to discuss whether membership would be of benefit).
  • escalating any issues or concerns that cannot be addressed sufficiently at a regional level to the national learning disability and autism team via the national unit of concerns process/individuals of concern process.
  • developing a regional summary report detailing the findings, themes, and actions to be taken from the reviews.
  • showing evidence of how review findings feed into the regional delivery plan.

Data sharing

Purpose of data sharing: patient safety

Data to be shared by the commissioners with the ICS assurance panel in line with local organisational information governance policies.

 National NHS learning disability and autism team

The national team, working collaboratively with regional teams, will lead the national rollout of the safe and wellbeing reviews. This includes:

  • development of the review template and support resources for the reviews
  • a role as part of the overall assurance and scrutiny process.
  • regional and national teams will work closely together to triangulate learning and ensure relevant intelligence is shared with host commissioners.
  • a point of contact for regional teams to support the process implementation and attend regional events as required.
  • escalation of any significant quality concerns.
  • triangulating regional findings and set out a national response and next steps.
  • ensuring key findings feed into relevant national learning disability and autism programme workstreams.

For further information please email england.safeandwellbeingreviews@nhs.net

Learning disability and autism host commissioner guidance

Where inpatient services are commissioned by clinical commissioning groups (CCGs) specifically for a person this can lead to someone’s care being planned and paid for by more than one organisation.

These organisations could be CCGs, transforming care partnerships (TCPs), sustainability and transformation partnerships (STPs), integrated care systems (ICSs) and even regional teams, and they could be in different parts of the country. To make sure that the care people get is the same quality wherever they are in the country we have published new guidance for the hosting commissioner – that means the CCG in the same area as the inpatient unit will be responsible for monitoring the care people get in the unit.

Responsibility and oversight for people’s care is held by the placing commissioner. The new guidance has been designed to help CCGs, TCPs and regional teams put host commissioner arrangements into place.

Minimum expectations during the coronavirus pandemic

  • Host commissioners should continue to maintain their responsibilities for keeping an oversight of concerns in relation to the provision in their areas.
  • We do not expect host commissioners to visit provider settings during this period, but we do expect them to continue to oversee and accept any concerns raised with them and to follow the agreed process for raising this with the region and if necessary, through the agreed safeguarding processes.
  • All placing commissioners need to make contact with the relevant host commissioners for inpatient services where they have an individual placed.
  • Host commissioners may be in the first instance in a better position to visit their allocated inpatient services rather than placing commissioners due to geographic constraints and on a risk-based approach.

Learning disability and autism framework for commissioner oversight visits to inpatients

Where a person with a learning disability and/or people who are autistic goes into a  specialist mental health, learning disability or autism hospital as an inpatient, commissioners need to be sure that they are safe and that they are being cared for in the best way.

To do this commissioners need to spend time with the people they are responsible for so that they can build a trusted relationship where people and their families and carers feel they can talk and be listened to.

It is the commissioners job to make sure this happens for all of their patients with a learning disability and/or who are autistic who are inpatients in specialist hospitals.

New guidance has been published which will help commissioners and case managers make sure that regular visits take place and support them to know how to share and resolve any concerns they have about someone’s care.

Minimum expectations during the coronavirus pandemic

  • Commissioner oversight visits will continue with adjustments for coronavirus on a risk-based approach: section 15 of the guidance gives information about the additional measures for carrying out commissioner oversight visits during the coronavirus pandemic.
  • Commissioners will use their best endeavours to make sure that face-to-face visits take place, safely, with a minimum requirement that the commissioner will use telephone and/or virtual methods of communication with people that they commission care for.
  • Visits should be prioritised and enhanced for people identified in services where quality concerns have been raised, or where the service has a Care Quality Commission rating of inadequate or requiring improvement.
  • There is no change to the frequency of commissioner oversight visits during the coronavirus pandemic; i.e virtual visits should take place at least every eight weeks for adults, and at least every six weeks for children and young people.
  • There have been no changes to requirements in relation to safeguarding during the coronavirus pandemic

Accessible versions of both of these publications will be published in February which will set out what support children, young people, adults and their families should expect in relation to the visits, and how to raise a concern if the visits are not taking place.