This is the 2021/22 edition of State of Care
- The quality of maternity care is not good enough. Action to ensure all women have access to safe, effective and truly personalised maternity care has not been sufficiently prioritised.
- Women from ethnic minority groups continue to be at higher risk of dying in pregnancy and childbirth than White women, and more likely to be re-admitted to hospital after giving birth.
- We are prioritising our operational and inspection resources to ensure we and others have an up-to-date and accurate view of the quality and safety of maternity services.
- The care for people with a learning disability and autistic people is still not good enough. Despite multiple reviews and reports, people continue to face huge inequalities when accessing and receiving health and social care.
- Our review of the care in hospital for people with a learning disability and autistic people will highlight how they are not being given the quality of care they have a right to expect.
- Mental health services are struggling to meet the needs of children and young people, increasing the risk of their symptoms worsening and reaching crisis point, and being cared for in unsuitable environments.
- Ongoing problems with the Deprivation of Liberty Safeguards process mean that some people are at risk of being unlawfully deprived of their liberty without the appropriate legal framework to protect them or their human rights.
The whole of the 2021/22 year was spent under the continuing pressure created by the COVID-19 pandemic, and it will continue to have an impact for years to come. In 2021/22 we continued to focus on higher risk providers and where people were most at risk of receiving poor care.
Overall, when people have been able to access the care they need, we have been able to reassure people that the quality of care at the point of delivery is mostly good. As of 31 July 2022:
- 83% of adult social care services were rated as good or outstanding.
- 96% of GP practices were rated as good or outstanding.
- 75% of NHS acute core services were rated as good or outstanding.
- 77% of all mental health core services (NHS and independent) were rated as good or outstanding.
These figures are testament to the relentless hard work of health and social care staff across the country in ensuring people are kept safe and refusing to buckle under the enormous pressures that COVID-19 brought.
Similar to previous years, these headline figures can hide the dynamic picture underneath. When looking at overall ratings as of July 2022 compared with July 2021, forensic inpatient wards, child and adolescent mental health wards, and specialist community mental health services for children and young people all saw lower ratings overall.
Adult social care services saw a small increase in the number of ratings of requires improvement and inadequate across all 3 service types: residential homes, nursing homes and homecare. When we have identified problems on inspection these were often related to the leadership, management and oversight of the service, driven by staffing challenges. These challenges included the availability of experienced managers, staffing levels and staff burnout. They manifested themselves in poor person-centred care, and not meeting basic care needs (for example pressure area care, oral care and nutrition and hydration). We saw examples of exhausted staff responding inappropriately to challenges and an increase in the use of unauthorised or overly restrictive restraint.
The ratings for urgent and emergency services in NHS acute hospitals are still unacceptably poor: more than half (54%, 109 services) were rated as requires improvement or inadequate as of 31 July 2022.
There have been a wide range of programme and policy initiatives in recent years to improve the quality and safety of maternity care in England. But, despite the greater national focus, the pace of progress has been too slow. Action to ensure all women have access to safe, effective and truly personalised maternity care has not been sufficiently prioritised to reduce risk and help prevent future tragedies from occurring.
In fact, our ratings as of 31 July 2022 show that the quality of maternity services is getting worse, with 6% of NHS services (9 out of 139) now rated as inadequate and 32% (45 services) rated as requires improvement. This means that the care in almost 2 out of every 5 maternity units is not good enough (figure 9).
Figure 9: Overall maternity core service ratings, England, July 2021 and July 2022
The findings of recent reviews and reports – including our own report on Safety, equity and engagement in maternity services – show the same concerns emerging again and again. The quality of staff training, poor working relationships between obstetric and midwifery teams, and a lack of robust risk assessment all continue to affect the safety of maternity services. These issues pose a barrier to good care, which is compounded when the voices of frontline staff and women using services are not listened to or acted on.
Furthermore there are some deeply embedded inequalities. Women from ethnic minority groups experience additional risks compared with White women that, without the right interventions, can lead to poor outcomes. For example, from our maternity report, we know that:
- Black women are 4 times more likely to die in pregnancy and childbirth than White women. For Asian women it is 2 times more.
- Mortality rates remain higher for Black or Black British babies and Asian or Asian British babies. This is also supported by more recent analysis from the Office for National Statistics (ONS) published in May 2021.
In the report we also shared our analysis of Hospital Episode Statistics data for 2020. This showed that Black women had a significantly higher rate of re-admission in the 6-week postpartum period than women of other ethnicities. We have updated this analysis to examine how re-admissions during the postpartum period changed in 2021.
Broadly, our new analysis shows that re-admission rates continued to increase throughout 2021. Where ethnicity was recorded, the data suggests that Black women still had significantly higher rates of re-admission than women of other ethnicities. Conversely, White women continued to have the lowest rates. The percentage difference between postpartum re-admission rates for Black women and White women also increased to 32% in 2021 compared with 30% in 2020 (102 re-admissions per 1,000 deliveries for Black women compared with 74 re-admissions per 1,000 deliveries for White women).
In May 2022, Birthrights published the findings of its year-long inquiry into racial injustice and human rights in UK maternity care, called ‘Systemic racism, not broken bodies’. It said that participants in the review reported feeling unsafe, ignored and disbelieved, and had experienced racism by caregivers.
This was echoed by the findings of a survey by Five X More, also published in May 2022. This looked at the experiences of maternity care of more than 1,300 women, who identified as Black or ‘Black mixed’ (defined in the report as Black Caribbean and White, Black African and White, or Other mixed), between 2016 and 2021. This found that 43% of women reported feeling discriminated against during their maternity care, with the most common reasons being race (51%), ethnicity (18%), age (17%) and class (7%). Women responding to the survey also similarly described feeling dismissed by caregivers and that genuine concerns were being ignored.
Tiyanna, a 22-year-old Black British woman, told us about her experiences of care when she gave birth to her first child.
Tiyanna told us that through previous research, as well as the experience of friends and family, she was aware of the higher risks to her as a Black woman. As a result, she did a lot of research to create a bespoke birthing plan for a home birth.
Despite initial concerns, Tiyanna said that her midwife supported her plans for a home birth. However, when Tiyanna’s waters broke her partner phoned the midwifery team only to be told she would have to go into hospital because of the risk of infection.
Once in hospital, Tiyanna told us that she felt that she was labelled as a “problematic patient” because of trying to advocate for herself. Throughout the whole experience, Tiyanna was given little information and at every point felt that her wishes were being ignored.
Tiyanna is happy that her son is here and healthy, but she says that she sometimes cries and gets flashbacks about the procedures she went through at the hospital. While she understands the need for speed in the case of an emergency, she wants doctors to listen and communicate with people giving birth.
Interview with a member of the public
It is widely recognised that there is a severe shortage of midwives both nationally and globally. NHS England workforce statistics show the number of full-time equivalent (FTE) midwives fell by 633 between April 2021 and April 2022, the largest annual decrease since records began in 2009. The total number of midwives dropped further again, in May 2022, to 21,685.
Services are finding it very difficult to recruit; and where one service is able to recruit, it has an impact on neighbouring services. We are seeing high turnover of senior midwives, leading to inconsistent leadership and difficulty in embedding a good culture.
In its July 2021 evaluation of the government’s commitments for maternity services in England, the Health and Social Care Committee described continuing evidence of a shortfall in maternity staffing and said that urgent action was needed to address this. This was supported by the recommendations of the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust, led by Donna Ockenden. In a further report by the Health and Social Care Committee, on recruitment, training and retention in health and social care and published in July 2022, the committee again stressed the urgent need for a robust and funded maternity-wide workforce plan, to be delivered without further delay.
The final Ockenden report in March 2022 also noted how many of the failures in care they found are not unique to that individual trust, and they identified 15 ‘immediate and essential actions’ to improve care and safety that should be considered by all trusts in England providing maternity services.
We recently brought together maternity professionals from across England to discuss the challenges that they face. We held 2 separate sessions – one for frontline staff and another for senior leaders.
At the event, we heard first-hand how staff are working in exceptionally demanding circumstances. They described how staffing shortages and pressures, a drive to meet targets, and insufficient funding are all factors that are directly affecting their wellbeing and their ability to implement safety improvement programmes and ensure high-quality care. We heard that staff don’t always feel they are working in a culture or environment where they are empowered to grow and learn – and that staff feeling safe and supported to speak up, alongside close, trusting and respectful multiprofessional teamwork, is crucial.
They said that different maternity professionals sometimes lack a common understanding of what ‘good’ maternity care looks like. A view shared by many staff was that ensuring the availability of training for multidisciplinary teams would be incredibly beneficial in supporting safety improvements, and in building stronger team relationships. Simulation scenario training for all professionals in the maternity team, more secondment opportunities to enable cross-system learning, and the introduction of a new national standard for team training and team building were all suggestions put forward.
There were also ideas about how to develop team skills and use the workforce more flexibly, by maximising the role of maternity support workers to increase capacity among more senior staff or those with specific expertise. Additionally, better support for students, such as bursaries and buddying schemes, was proposed as a way of improving staff retention.
What was apparent throughout the discussion was the overwhelming desire of all involved to provide the best care possible. Colleagues welcomed the various national initiatives that have been introduced to help strengthen safety, but felt that closer alignment between them would give services and staff a clearer direction and help focus their improvement efforts.
From summer 2022, we are prioritising our operations to ensure we and others have an up-to-date and accurate view of the quality and safety of maternity services nationally. Our inspection programme will focus on supporting improvements at both a local and national level.
Our ambition is to use what we learn from the programme as a whole, together with the insight from our event , to support frontline staff in delivering care. We are committed to doing all we can to accelerate safety improvements, facilitate wider learning across services, and influence action from national partner organisations where it is needed to alleviate the current challenges that staff face.
People with a learning disability and autistic people
Care for people with a learning disability and for autistic people is still not good enough. Despite multiple reviews and reports over decades, people continue to face huge inequalities when accessing and receiving health and social care.
Two years ago, our report ‘Out of sight – Who cares?’ shone a light on the consequences of people not getting the right care and support in the community when they need it. This, we highlighted, can lead to crisis point and admission to a mental health hospital.
We also raised our concerns that while admission to hospital should be temporary, poor environments, lack of discharge planning and difficulties in finding suitable community placements were leading to people staying in hospital for years. We were particularly concerned that these hospitals were often far from people’s friends, family and support networks, raising the risk of closed cultures developing.
A closed culture is a poor culture that can lead to harm, including human rights breaches such as abuse. In these services, people are more likely to be at risk of deliberate or unintentional harm. Closed cultures, and the possibility of breaches of human rights, may occur across a wide range of health and social care settings. However, we are particularly aware of the increased risk in services that care for people with a learning disability, for autistic people, and for people with a mental health condition.
The situation for people with a learning disability and autistic people has been exacerbated by the COVID-19 pandemic. For example, for a large part of the past year, visiting a service has been restricted. The impact of this on people living in these services and their loved ones cannot be underestimated.
Our Out of sight report made 17 recommendations for change. A review of the progress on these recommendations, published in March 2022, revealed that not enough progress has been made to address these. Of the 17 recommendations, we found that just 4 had been partially met and 13 had not been met.
Although we were able to report that the number of people with a learning disability in hospital has halved since March 2015, we are concerned that there are still too many people in hospital. More worryingly, the number of autistic people in hospital has increased considerably over the same period.
A report from the House of Lords, published in October 2021, also raised concerns that since 2012, successive government targets to reduce the number of people with a learning disability and autistic people in hospital have not been achieved.
Registering the right service
Our 2021 report Home for Good showed that there is a better way. Using the stories of 8 people with lived experience, we illustrated that bespoke homes in the community, that are tailored to meet people’s individual needs, can transform people’s lives.
Diane, 38, who has a learning disability and a mental health need, spent 16 years living in secure hospital care and tried to take her own life many times.
"I felt like there was no hope," she says of her self-harm and attacks on staff. Driven by despair and frustration, Diane injured herself "to get away from the feelings and the thoughts".
A provider, working in partnership with the local authority and clinical commissioning group to develop services in response to Transforming Care, agreed to look at Diane’s case. The provider had to review its approach to risk, convincing colleagues that working with adults with complex histories was safe and deliverable.
Support staff were trained to meet Diane’s requirements. In addition to mandatory induction, they received training in Positive Behaviour Support, suicide avoidance, self-harm, mental health and autism.
Diane left the hospital 8 years ago and has never looked back. She lives in a supported living flat close to where she grew up. More confident and independent, Diane takes the bus on her own and, for the first time in years, visits her family alone.
"I feel like I’ve got a life now," says Diane of her experiences since leaving institutional care. "It feels better because it feels like someone cares about you…I’m thinking positive instead of negative."
As an organisation, we are committed to improving the quality of care in supported living across the country. A key part of this will be listening to the experiences of people who use services. We believe that they, their unpaid carers, families, friends and advocates are the best sources of evidence about their lived experiences of care and how good it is from their perspective.
In our strategy, we committed to improving how we encourage and enable people to engage with us and tell us about their experiences, particularly those most likely to have a poorer experience of care, or who have difficulty in accessing care.
While we are aware of the pressure on commissioners to provide for people moving on from hospital care, our role is to ensure that any new service meets statutory guidance and will provide the best possible care for a person with a learning disability.
However, a lack of commitment in some areas to following the ‘Right support, right care, right culture’ guidance, combined with local financial pressures, means that we are still seeing providers wanting to register services that do not meet good practice standards. This includes, for example, registration requests for large-scale services, rather than small-scale ordinary housing. These large-scale services, often situated apart from local communities, can have a negative impact on the quality of outcomes for people living there.
A substantial proportion of applications we receive are refused based on inappropriate models of care or the applicant’s poor understanding of how the model should be delivered. We have found that often providers do not recognise the importance of being part of the local community and the value attached to people feeling at home in their wider environment, leading a full life of their choosing.
Over the last year we have also taken more enforcement action against adult social care providers of services for people with a learning disability and autistic people. Types of enforcement action taken include cancelling providers’ registrations, imposing conditions and restricting admissions.
We welcome the government’s Building the Right Support Action Plan, published in July 2022. The plan builds on a broad range of existing evidence and work underway, including the objectives set out in the 2015 Building the Right Support national plan. It sets out the actions, which must be implemented immediately, to strengthen community support for people with a learning disability and autistic people, and reduce reliance on mental health inpatient care.
Physical health care
It is not just about the quality of residential or supported living services. We continue to have concerns about the quality of physical health care for people with a learning disability and autistic people.
Our concerns are echoed in the findings of the 2021 Norfolk Safeguarding Adults Board Review into the deaths of Joanna, Jon and Ben at Cawston Park, and the LeDeR (Learning from Lives and Deaths of People with a Learning Disability and Autism) review into the death of Clive Treacey. Both of these reviews highlighted the devastating impact of people not receiving the physical health care they need while in mental health hospitals.
This year, in response to recommendations in the multi-agency review into the death of Oliver McGowan, we carried out a review into the experiences of people with a learning disability and autistic people in acute hospitals. Early findings from our review, which will be publishing in the autumn, echo many that have come before – that when people with a learning disability and autistic people go to hospital, they are not being given the quality of care and treatment they have a right to expect. These include issues around:
- reasonable adjustments when accessing care
- listening to and involving people, their families and carers
- the knowledge and understanding of staff about inequalities that people with a learning disability or autistic people may experience
- the knowledge and skills of staff in caring for people with a learning disability and autistic people.
Through our work, we have heard much praise for dedicated staff that have made a real difference for people. Competent well-trained staff, and an open, transparent and learning culture are essential for providers to be able to deliver good quality services for people in a person-centred way.
However, a June 2022 report from the Healthcare Safety Investigations Branch (HSIB) raised concerns about a shortage of learning disability nurses, with the number of people joining the profession each year matched by those leaving. The report highlights that this shortage could have an impact on the care of patients in secure units for people with a learning disability, and raises concerns about staff lacking the relevant knowledge and skills to understand the world from people’s point of view and support them well.
From 1 July 2022, there is a legal requirement for a new legal requirement introduced by the Health and Care Act 2022 all CQC registered providers to ensure their staff receive training in how to interact with people with a learning disability and autistic people, at a level appropriate to their role. This applies to all health and care settings, including acute hospitals, and providers need to consider the training needs of staff who deliver care directly as well as ancillary and administrative staff, for example reception and call-handlers.
To support this new requirement, the government will be rolling out the Oliver McGowan training package. Co-designed by autistic people, people with a learning disability, family, carers and subject matter experts, the training is intended to ensure that health and social care staff have the skills and knowledge to provide safe, compassionate and informed care.
Supported Living Improvement Coalition
Fundamental to the work we are doing to improve how we regulate services for people with a learning disability and autistic people is a focus on what it means to be a citizen. We want to understand how we can be ambitious for people receiving care and support, so they have more choice, independence and control over their lives and the care they receive.
With this in mind, we have set up the Supported Living Improvement Coalition. People with lived experience, their relatives and representatives are actively involved in the group so they can tell their stories to a range of organisations who can work with them to identify and embed the improvements that are needed.
Members of the coalition currently include people who use supported living services, advocacy groups, care providers, local authorities and housing developers. With leadership and support from across social care, together we aim to drive the improvements needed to change outcomes for people who access supported living.
The group has identified 5 areas of focus for their work:
- Staff must have the right knowledge, motivation and positive culture to support them and to support people to live their best lives.
- People should receive high-quality care and support that understands and meets their individual needs to allow them to be active members of their local community.
- There should be excellent, joined-up working where everyone understands their role.
- Person-centred housing and home options must be flexible and start with the individual.
- Regulation must have people’s voice and that of their loved ones at heart, by listening well and being accessible.
Children and young people’s mental health
Last year we shone a light on the impact of the pandemic on children and young people’s mental health and the increase in demand for child and adolescent mental health services (CAMHS), particularly eating disorder services. We raised our concerns about providers’ ability to meet this increasing need, and the risk of children ending up in inappropriate environments.
This has been supported by the findings of our provider collaboration review on the mental health care of children and young people during the COVID-19 pandemic. Published in November 2021, we found:
- Services struggled to meet demand, increasing the risk of children and young people’s symptoms worsening and reaching crisis point, and being cared for in unsuitable environments.
- While there were positive examples of systems working collaboratively together to ensure continued access to mental health support, there were some concerns around silo working.
- Communication – both between services and with families – was mixed, with some people not always aware of what support was available.
- The pandemic shone a light on, and exacerbated, health inequalities faced by some children and young people, in particular those living in deprived areas.
- Digital technology enabled services to adapt almost overnight, ensuring continuation of care. But we heard that this could lead to risks such as staff missing cues or issues that would have been picked up face-to-face.
Joseph, who is 10, has been diagnosed with depression and anxiety. Here, his mum Carla tells us about her experiences of accessing mental health support for Joseph.
Joseph’s symptoms first started when he was 6 or 7. It began with him being a bit snappy, which I put down to behaviour. So I went on a parenting course to try and figure it out. But I knew it was something more. Joseph also started to complain of headaches – he would go really pale and then be sick.
When I took him to the GP, I suggested to the doctor that he might have depression and anxiety. But the GP wouldn’t listen to me and told me he was too young.
I wasn’t happy with the GP’s response, so requested to see another doctor. The second GP was fantastic and gave us a referral for therapy and to see the team at the hospital.
Then the pandemic hit and everything slowed down. In total, Joseph has been on the waiting list for nearly 2 years. During this time my dad, his grandad, passed away – this has had a huge impact on Joseph’s wellbeing as he and his grandad were really close.
While we’ve been waiting, the GP has given us some information by email and linked me in with our local Sure Start Centre. She has also emailed the school to get them involved. In addition to this, I have done a lot of my own research.
Now Joseph is older, he has recently been prescribed some medicine to help manage his symptoms, but we’re still waiting to see a therapist.
Interview with a member of the public
In 2021/22, we have continued to see increases in demand for services, particularly eating disorder services. This is supported by data from the Mental Health Services Dataset (MHSDS), which shows that the number of children and young people starting treatment for an eating disorder increased following the onset of the pandemic , particularly the number of urgent cases.
The MHSDS data for January to March 2022 shows there were 249 urgent cases waiting to start treatment, an increase of 92% on the same period in the previous year. More than 8 out of 10 (86%) of these children and young people awaiting urgent treatment had waited longer than the 1-week target. The number of children and young people waiting for routine treatment between January and March 2022 had increased by 21% over the same period in the previous year. Two-thirds (66%) of these 1,697 under-18s had been waiting longer than the 4-week target.
Increased demand can mean that there is not always a bed available for all patients living in the local area who need one, so they might end up being placed ‘out of area’ or on acute paediatric wards.
Data from statutory notifications to CQC shows there were 260 admissions of under-18s to adult psychiatric wards during 2021/22. These notifications showed there was a 32% rise in the number of under-18s admitted to adult psychiatric wards (260 admissions in 2021/22 compared with 197 in 2020/21). The main reason given for admitting the child to an adult ward (70%, 182 admissions) was because there was no alternative mental health inpatient or outreach service available for children and young people. In over half of the notifications received, providers recorded that the child needed to be admitted immediately for their safety (58%, 152 admissions). Only 13% of providers recorded that admission to the adult ward was clinically preferred and 4% that it was socially the preferred option.
In February 2022, NHS Confederation raised concerns that, without more action to respond to this growing demand, a generation of children and young people will face longer waits for their treatment and their mental health will deteriorate.
A report by the Centre for Mental Health, published in July 2022, similarly warned that children's mental health services are buckling under pressure post-COVID. ‘Heads Up: Rethinking mental health services for vulnerable young people’ describes a growing crisis of mental health problems among children and young people in England, and highlights the increase in the regularity and extreme nature of mental health problems for many young people.
Healthwatch carried out a review of the feedback it received during 2021/22 about children’s mental health services. The findings included:
- Children and young people face long waiting times for diagnosis and treatment.
- Experiences of care are generally poor, with young people feeling like their symptoms are not taken seriously and increased demand on services limiting what support is available.
- People aren’t always offered follow-up support once discharged from services, including discharge from inpatient services.
- Young people continue to face difficult transitions to adult services, often being cut off from support once they turn 18.
- Neurodivergent children, including children with autism and ADHD, struggle to access appropriate support for their mental health.
In response to concerns around increasing demand, NHS England announced in July 2022 that 4,500 more NHS staff are working in children’s mental health services. This is 40% more than before the pandemic. This includes the recruitment of psychological practitioners to specifically help young people aged 13 to 17 years-old with mental health problems such as severe depression, self-harm and more complex conditions. Support offered includes assessments, coping strategies and support in the community.
Our progress report on the ‘Out of sight’ recommendations, published in March 2022, highlighted some positive developments. This includes nearly £1 billion of additional funding for children and young people’s community, crisis and school services. In addition, the Children’s Commissioner has stated that children’s mental health is one of her top priorities. In July 2022, she published ‘A Head Start: Early support for children’s mental health’, which sets out 6 ambitions for early mental health support for children.
Deprivation of Liberty Safeguards
The Deprivation of Liberty Safeguards (DoLS) are an important part of the Mental Capacity Act (MCA) 2005 legislation. The DoLS can be used in care homes and hospitals of all types. Where someone who lacks capacity to consent is deprived of their liberty as part of their treatment and care, DoLS is a vital safeguard to ensure that such deprivation of liberty only occurs if necessary, proportionate and in their best interests. Many people who are made vulnerable by their circumstances are safeguarded by ensuring the proper use of the DoLS, including the right of appeal it confers.
The principles of the wider MCA run through the DoLS, including assessments to establish lack of capacity and ensuring arrangements are only as restrictive as they need to be.
The DoLS are due to be replaced by the Liberty Protection Safeguards (LPS). Introduced in the Mental Capacity (Amendment) Act 2019, the LPS have been designed to put the rights and wishes of those people subject to the LPS process at the centre of all decision-making on deprivation of liberty. At the time of writing the government is considering responses to its consultation on the MCA and LPS code of practice and relevant regulations, held between March and July 2022.
In last year’s State of Care, we highlighted continuing concerns around the DoLS process, and how these were exacerbated by the COVID-19 pandemic. 2021/22 has been another incredibly challenging year for the system, including DoLS local authority teams. We are concerned ongoing problems with the process mean that some people are at risk of being unlawfully deprived of their liberty, with no safeguards, rights or protection in place.
In particular we have continuing concerns around:
- the knowledge and understanding of staff about the DoLS, and the quality of training
- poor quality Mental Capacity Act (MCA) assessments
- delays and backlogs in applications
Through our monitoring activities, we have heard of continued staff shortages in providers and local authorities. In the adult social care sector in particular, we have seen a high number of experienced registered managers leaving. In some local authority areas this had created a knowledge gap, with less experienced managers lacking an understanding about the need to apply for DoLS, particularly when previously granted authorisations had expired. Evidence from our monitoring and assessment activities has raised concerns that there had been an increase in restrictive practice where DoLS hadn’t been applied for or authorised.
In mental health hospitals, we have seen how a lack of training means that staff still have difficulty in understanding the interface between the Mental Health Act (MHA), MCA and DoLS. In some cases, this meant that a DoLS application wasn’t always considered when at times it should have been. There was also a misconception that if people were happy to be on a ward, then they could be classed as informal patients, without considering whether they had capacity to consent. As a result, we are concerned that people could be confined in hospital without the appropriate legal framework to protect them or their human rights.
Applications and waiting times
Providers must notify CQC without delay when the outcome of an application for a DoLS authorisation is known, including when an authorisation has not been granted.
Last year, we highlighted how DoLS notifications had been impacted by the pandemic, with numbers of notifications from adult social care services and hospitals reaching their lowest point in early 2020/21 before starting to recover. Since last year’s report, we have identified some errors in the categorisation of our DoLS notifications data. The data has been updated (figure 10) and this has not affected the trends we have been seeing in adult social care, with figures rising back up this year, but still below 2019/20 levels. In hospitals, the data shows that notifications had been falling before the start of the pandemic but total counts have been higher in 2020/21 and 2021/22. This categorisation error has not affected the right regulatory action being carried out.
Figure 10: Deprivation of Liberty Safeguards notifications, England, 1 April 2019 to 31 March 2022
The impact of the pandemic continues to be felt, with increasing waiting times and delays in assessments for DoLS applications. Data from NHS Digital shows that the proportion of standard applications completed within 21 days fell from 24% in 2020/21 to 20% in 2021/22. At the same time, the average length of time to complete applications rose to 153 days, compared with 148 days in the previous year.
Members of our Expert Advisory Group told us that they have seen increasing waiting times for DoLS authorisations over the last year, as well as an increase in the use of urgent applications. This is supported by the NHS Digital data, which shows that the proportion of urgent DoLS applications rose from 54% in 2020/21 to 56% in 2021/22.
We heard how delays in DoLS authorisations leave provider staff feeling ‘in limbo’ about their legal authority to deprive people of their liberty where there are welfare concerns. Equally this leaves family, friends and staff unsure of how to raise concerns or make necessary decisions. The NHS Digital data shows that there were just over 124,000 DoLS applications not completed, that is where a formal decision whether to authorise a DoLS application has not been reached and recorded. This is an increase of 4% over the previous year.
Poor quality mental capacity assessments and unavailability of Best Interest Assessors (BIAs) have contributed to these delays. For example, in one instance we heard that BIAs from the local mental health trust, who had previously been supporting with assessments, had been re-deployed during the pandemic and had not yet returned. Taken together, the issues are likely to have put at risk the upholding of people's human rights.
However, members of our Expert Advisory Group told us how BIAs have continued to work around difficulties to carry out their roles. This includes, for example, the use of remote assessments. We have also found evidence of local systems taking a hybrid approach to carrying out assessments.
Impact on people and carers
We looked at themes emerging from comments shared through our Give Feedback on Care service through our website between April 2021 and March 2022. There were 310 comments that were identified as being relevant to DoLS. Here, we are using the insights from our analysis of the comments to discuss what we are hearing from people’s experience of the DoLS process.
It is important to note that some groups of people, including groups of people more likely to experience good care, may be less likely to contact us using Give Feedback on Care. As a result, the insights derived from our Give Feedback on Care analysis should be used as the start of a conversation around what is driving people’s experience of care, but should not be seen as representative of the population.
A key theme emerging is around involvement. Some families told us they were involved in their loved ones’ risk assessment and person-centred care planning, as well as being kept actively informed of incidents and progress.
However, the majority of families and friends told us they were unhappy with a lack of involvement in their loved one’s care. They were also unhappy about the lack of information they receive around the DoLS process.
Where a person has a DoLS authorisation in place, family or close friends may sometimes be their Relative Person’s Representative (RPR) and/or have power of attorney. They have a role in ensuring any decisions made are in the person’s best interests. As a result, in some cases a lack of involvement has led to concerns about the safety of the person using the service. They described how this left them feeling suspicious, concerned, frustrated or angry and very often in distress themselves.
My son, Joshua, is 22 years old and has been in residential school and college since before he was 18. Over the years, we have had to fight for everything for our son. As a result, I am familiar with many of the relevant laws and policies, and my husband and I are court appointed deputies for Joshua.
Our first experience of the DoLS was during the first COVID lockdown. I was phoned at home out of the blue by a total stranger (who I think was a doctor or psychiatrist), who asked to come to our home to see my son who was home since he could not cope in college. I did not catch who it was and they did not explain anything. I guessed that it might relate to DoLS and asked that question. I happened to know that DoLS does not relate to my home and so based on that, and that our son was shielding, I said that they could not come to our home.
It was very worrying and scary to get a call like that out of the blue and not know who these people are or what it was about. We have never had any communication from the local authority, clinical commissioning group or anyone about DoLS.
Joshua has been back in college since September 2021. Just before Christmas that year, he had an annual review, and shortly after we were told that a DoLS application was going to be made for Joshua. Because Joshua wasn’t at home, we weren’t contacted about this at the time and again were given no information – it was all kept very secret.
Out of the blue we were contacted by a stranger who told us they were a Best Interests Assessor (BIA) and would be assessing Joshua and writing a report. This was incredibly distressing because, as court appointed deputies, it is our responsibility to assess what’s in Joshua’s best interests. It was not clear why the BIA was involved or what their role was.
A DoLS authorisation has now been granted for Joshua. This affects every aspect of his life – everything from personal care and food, to which areas he can go in. We had to ask for the right to support Joshua so that we could fight for the things that make him happy, like being able to get off site.
Interview with a member of the public
As discussed in our section on Access to care, restrictions on visiting people in residential settings have had a big impact on some people using services and their families. We also heard how restrictions imposed by care homes and hospitals in response to the COVID-19 pandemic had exacerbated feelings of concern and suspicion. There were also concerns that some restrictions were still in place, even though those imposed by the government had been removed.
Restricting people’s movements and their ability to see friends and family, without it being strictly necessary, can lead to them becoming isolated and suffering poor mental wellbeing, and potentially cause distress. In some instances that would have resulted in a reduction of people’s social networks.
People also told us about concerns that individuals were being prevented from making their own choices in their day-to-day life, with little consideration of their wishes or capacity. For example, many family and staff members raised concerns about individuals being restricted from having access to their personal items, including money, cigarettes and alcohol.
While these types of restrictions may not automatically indicate a deprivation of liberty, it does raise concerns that the culture of some services may be overly restrictive, and not adhering to the wider principles of the Mental Capacity Act.
“The government has relaxed the rules around COVID [but]… I'm absolutely mortified about not being able to help my parent at a time they need us the most. They are vulnerable and NEED to see us. It feels like they are in prison and they/we have no rights… I am completely lost for words and feeling absolutely powerless.”
Anonymous, through Give Feedback on Care
Many of the submissions we received through our Give Feedback on Care service raised concerns that, while applications were in progress, people may have been subject to unlawful deprivations of their liberty. For example, people told us that doors to services and rooms were regularly locked or people confined to their rooms, preventing them from leaving the service – for example to return home, to go outside for fresh air, and to go out into the community.
“I feel they are being deprived of their liberties illegally as they don’t have a DoLS [authorisation] in place, they aren’t asking for much, to be assisted to sit up in their bed and wheeled to the yard a few times a week.”
Anonymous, through Give Feedback on Care
People told us that whether their experience of the DoLS process was positive or negative was often linked to a provider’s staff understanding and/or awareness of whether a DoLS authorisation was in place.
Issues raised by people with lived experience included:
- DoLS applications not being person-centred
- applications only being made after a deprivation of liberty has occurred
- reviews of existing DoLS authorisations not being carried out at the right time, if at all.
Families and friends also told us about problems with a lack of care plans, missing information, and information not being recorded correctly. This could mean that staff may not have all the information they need, and could lead to people being cared for in unsafe conditions.
We continue to have concerns about some baby scan services. Women’s understanding of the job title ‘sonographer’ may lead to them believing the keepsake scan is the same as a diagnostic scan that aims to detect abnormalities on the fetus. This, coupled with concerns about competency of some of these staff, has prompted us to carry out further joint work with the Society of Radiographers in 2022/23 to raise awareness among pregnant women.
In November 2021 we updated our published guide that aims to help women choose a baby scan service. This was in response to concerns we found on inspections where staff in non-diagnostic services use the title of sonographer, which is not a protected title and does not assure the person is medically qualified in any way.
Independent cosmetic services have been of concern for some time and we continue to find evidence of poor services placing people at risk of harm. In response, we published a guide to support people in choosing good cosmetic surgery services. The guide focuses on consent and the importance of cooling-off periods, as well as which procedures need to be registered with CQC.
We have seen a number of safety and quality issues in non-emergency transport services for secure and mental health patients. These relate to a number of key areas:
- unsafe recruitment practices
- failure to ensure vehicles and equipment are maintained and used safely
- failure to train staff to assess physical and medical needs before and during transport
- safeguarding and restraint
- failure to ensure subcontracted patient journeys are safe and high-quality.
Where we have found concerns, we have held those providers to account and have been clear where they must improve. We have also written to all independent ambulance providers, highlighting our concerns and pointing to regulatory requirements alongside appropriate good practice guidance for the sector.
Medicines safety – the role of pharmacy professionals
We know that people’s physical and mental health outcomes improve when medicines are used in the best way. When medicines are not prescribed or administered correctly, they can cause harm. Medicines safety is an important aspect of our regulation of registered services. Pharmacy professionals offering specialist advice can help support staff and contribute towards better outcomes for people.
Adult social care
Pharmacy professionals are increasingly working directly with adult social care providers. While the consistency of service that pharmacy professionals offer is variable, we see that having a medicines expert available for advice benefits both staff and people receiving care. This includes improved frequency and quality of medicines reviews, monitoring of high-risk medicines, de-prescribing of unnecessary medicines, improved governance, and training for care staff.
Nationally we have seen an increase in the delegation of specialist medicines administration tasks to care staff. When managed effectively, delegating tasks can work well for people, helping to ensure they get their medicines correctly and on time. However, variation in the availability of training, supervision and access to support can mean that people don’t get their medicines correctly.
Providers are increasingly using electronic systems to record and store information about medicines, for example electronic medicines administration records (eMAR). eMAR can offer benefits such as making it easier to identify missed doses. However, poor training, implementation and IT literacy of staff, and variable quality of equipment and software, can mean that people don’t have their medicines administered as prescribed.
During 2021 we reported on NHS hospital pharmacy services during the pandemic and the work of medication safety officers. In early 2022, our Medicines Optimisation team discussed medication safety with medicines leads in all NHS ambulance trusts.
Staffing, governance and roles
We heard there was significant variation in the scope of roles and responsibilities of pharmacy professionals working in ambulance trusts. Those leading on medicines optimisation told us they did not always have adequate time and support to carry out their role. Some services had better capacity in their medicines optimisation workforce than others. Where services lacked capacity, we heard that initiatives to improve medicines optimisation were placed on hold.
However, we did find examples of initiatives designed to improve people’s outcomes, such as rapid access to ambulance staff trained in using medicines for the early treatment of sepsis. In one trust, public health registrars used data to help focus work on outreach and health inequalities, such as developing preventative initiatives to reduce harm for homeless people at risk of illicit drug overdose.
Transfer of care
When people move between services, poorly managed medicines processes can result in harm. We heard that joint agreements about roles and responsibilities when ambulance trusts transferred people between services was a problem. Increased wait times for transfer into acute services meant that people missed their regular medicines if ambulance staff were not authorised to administer them.
We heard about a “Green Bag Scheme” used across many different areas, whereby patients who are taken to hospital bring their medicines in an easily recognisable green bag. This helps to ensure people don’t miss doses of their regularly prescribed medicines when they are being admitted to hospital. Further partnership working across geographical areas is needed to fully realise the benefits of this scheme, as there was variation in the processes adopted and outcomes in different areas.
Access to up-to-date medicines care records is equally as important as a supply of medicines. We were told that this could sometimes be a problem, especially when ambulance staff arrived to treat people at care services that used electronic records that were not easily accessible. We heard that this was a challenge for patients receiving medicines for care at the end of their life, as ambulance staff could not obtain information on the medicines that had been prescribed or administered.
Ambulance trusts and primary care
Ambulance trusts were aware of priorities and pressures in primary care. There was a perception of increased demand on emergency services, due to GPs not being able to access adult social care services during the pandemic.
Across the country we heard of situations when paramedics were deployed in primary care to support general practice. Trusts were positive about this activity, and viewed it as helping to reduce pressure on urgent care services as well as GPs. In some cases, these were pilots or projects, which means long-term sustainability was not assured. We also heard that prescribing by paramedics was sometimes made more challenging by IT problems. Concerns were raised about lack of clarity of governance and oversight arrangements for paramedics working in general practice.
Some ambulance trusts were able to use digital systems to refer people to community pharmacists or primary care network (PCN) pharmacists for a medication review. This ensured people received medicines safely and in line with their needs. It also helped reduce the inappropriate use of some medicines that can increase the risk of adverse effects associated with hospital re-admissions, such as falls.
Within the primary care setting, the number of pharmacy professionals working in PCNs has increased. Pharmacy professionals in PCNs help to enhance workforce capacity and provide additional services to support people with their medicines. This includes providing effective medication review and ensuring safe reconciliation of medicines when people move between services. However, we have seen examples of pharmacy professionals not receiving appropriate support and working beyond their competence, with limited oversight of their activities. This has the potential to put people at risk.
The Centre for Pharmacy Postgraduate Education provides a learning pathway to support pharmacy professionals moving to PCN roles. Our Medicines Optimisation team has provided input to this learning pathway, introducing the role of regulation in primary care, to more than 1,200 learners in the past 18 months.