Dale, C. (2012), "Editorial", Journal of Learning Disabilities and Offending Behaviour, Vol. 3 No. 1. https://doi.org/10.1108/jldob.2012.55403aaa.001Download as .RIS
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Copyright © 2012, Emerald Group Publishing Limited
Article Type: Editorial From: Journal of Learning Disabilities and Offending Behaviour, Volume 3, Issue 1
The mistreatment of people with a learning disability in secure environments revealed at Winterbourne View by the BBC continues to dominate the headlines (BBC, 2011). The Care Quality Commission (CQC) response to this has been the introduction of 150 unannounced visits to services; and their web site is now populated with the first reports arising from these visits (CQC, 2012). They make depressing reading and suggest echoes of the past which many of us had hoped we had put behind us. At the beginning of March 2012 the results showed just four out of 20 providers met both essential standards for welfare and safeguarding. Of 67 inspection reports published so far; just 17 providers were compliant with both standards (CQC, 2012).
The most worrying aspect of this is the role of the regulator, CQC. It has clearly dented confidence in the ability of the regulator to identify and protect vulnerable people from abuse.
The three-month programme of reviews has involved unannounced inspections at a sample of the 150 hospitals that provide care for people with learning disabilities. Where the CQC identifies care that is not meeting requirements, it will be able to use its full range of enforcement powers to take immediate action to require hospitals to make necessary improvements.
However, have not we been here before? “We seem to have forgotten the lessons of the Cornwall and Sutton and Merton abuse scandals”. Findings of institutional abuse at NHS long-stay services for learning disabled people in Cornwall and Sutton and Merton led to two national audits of specialist inpatient health services for people with learning disabilities (Commission for Healthcare Audit and Inspection, 2006, 2007) by the CQC’s predecessors, the Healthcare Commission and the Commission for Social Care Inspection.
CQC’s report of the second audit, published in December 2009, concluded that services were “at best inconsistent and at worst damaging” (CQC, 2012). It said annual inspections served to keep the pressure on staff to improve quality and pledged to “continuously monitor and check how well providers are meeting the [essential] standards [under the Health and Social Care Act, 2008], which include critical areas such as protecting people from abuse, safeguarding vulnerable people, and respecting and involving people who use services” (CQC, 2012).
The other issue is concerning the so-called “unannounced” visits themselves. This term attempts to give the public solace that any wrong doing such as that witnessed on the Panorama programme will be discovered by such visits and put to a stop. The term “unannounced” refers to the fact that the service provider is not given prior warning that the visit is to take place and the inspectors roll up to “catch out” the staff in any wrong doing. The reality is that these units have locked front doors and the front door bell would need to be used to gain entrance also it would be fairly obvious to anyone answering the door what this was about as credentials are checked prior to their admittance. Any brutality that might be taking place is stopped on the arrival of the strangers as they are left to tour the establishments and take measurements against their standards. Breaches of standards could well be identified during such visits as the unit is unable to bureaucratically cover their tracks but it is highly unlikely that any of the abuse that we witnessed on the Panorama programme will ever be detected by such visits.
One known way of improving services is through improved commissioning. In February 2012, the learning disabilities observatory published “Supporting clinical commissioning and joint strategic needs assessment for people with learning disabilities”. The learning disabilities observatory was set up in 2010 to support improvements in health and life expectancy for people with learning disability by helping the NHS and local government improve commissioning. The observatory is a three way collaboration, with bits from the NHS North East Public Health Observatory, the Centre for Disability Research at Lancaster University and the National Development Team for Inclusion, a not-for-profit, third sector organisation promoting inclusion and equality.
The observatory’s work is focussed on three areas:
Knowledge – identifying what is known (with an emphasis on numerical information) about the health and healthcare of people with learning disability nationally and locally.
Gaps in information for planning, managing and auditing care and how these can be filled.
Advising about the best evidence and case examples showing how commissioners should use the evidence and numerical data available.
The observatory’s database of reasonable adjustments provides a searchable source of information about solutions people have found for making healthcare more accessible (www.ihal.org.uk/adjustments/). You can search this in relation to regions, types of trust, clinical areas and types of adjustment as well as simply for words of your choice. Entries currently provide details of 140 initiatives.
For further information of their work, visit the IHaL web site at: www.ihal.org.uk where you can find all their publications.
This edition of the journal includes the description of a study by Fajumi, Manzoor and Carpenter which tested the hypothesis that Clozapine reduces rates of self-injury and the use of restraint in female patients in a medium secure setting who have a diagnosis of borderline personality disorder and mild learning disability. Previously NICE guidelines had not identified a positive effect for medication with this group. The study therefore provides some helpful possibilities of where use of medication may be a useful adjunct to treatment.
Social identity theory proposes that identity and thinking style are strongly related. Research also suggests that the process of depersonalization is responsible for shifting from personal identity to social identity and assimilating group attitudes. An article in this edition by Daniel Boduszek, Gary Adamson, Mark Shevlin and Philip Hyland from the University of Ulster describes a study which investigated the nature of personality in the relationship between criminal social identity and criminal thinking style. These findings provide the first empirical support for the moderating role of personality in the relationship between criminal identity and criminal thinking style of offenders with learning difficulties.
The article by Esan, Case, Louis, Kirby, Cheshire, Keefe, and Petty describes how a patient centred recovery approach was implemented in a secure learning disabilities service. Whilst much has been written about recovery in services for the mentally ill there are no specific tools for measuring recovery in a secure learning disabilities service. The Recovery Star; a measure of individual recovery was adopted for use. Training was cascaded to staff throughout the service and use of the Recovery Star tool was embedded in the care program approach process. The study found that implementing a recovery approach with the Recovery Star tool was a beneficial process for the service but that services will require a whole systems approach to implementing recovery. Key workers working with patients thought that the structure of the Recovery Star tool opened up avenues for discussing topics covered in the domains of the Recovery Star tool which may otherwise have not been discussed as fully. The article concludes that the availability of a tool, integrated into existing service processes, e.g. care programme approach and accompanied by a systems approach equips patients and staff for articulating and measuring the recovery journey.
In the last edition of the journal, I was one of the co-authors of a study looking at the medical theories behind restraint-related deaths. In this edition, we have an article which contains a review of staff injuries reported in a forensic learning disabilities service. This involved looking at the prevalence of staff injury from data collected by the governance department and carrying out an analysis of the point at which the injury occurred during the incident which required physical intervention. Some consideration is also given to the type of injury and other factors evident at the time of the incidents.
The final two articles in this edition are linked in that they describe aspects of the introduction of a therapeutic community approach into a secure environment caring for people with learning disabilities. The first article explains that the National Offender Management Service commissioned the development of an offending behaviour intervention for men with an intellectual disability and personality disorder. The paper describes the process of accreditation of a treatment model and the preparatory work undertaken to prepare for the opening of the first LDTC in the UK Prison Service.
The second paper presents preliminary evaluation of a planned TC service intervention in a secure setting for men with mild intellectual disabilities and personality disorder over a period of 12 months.
The TC intervention group were compared on repeated measures of violent incidents, seclusion hours, and informant and self-report clinical outcome measures collected six months prior to, six months post and 12 months post the start of the intervention. The TC group were also compared with a pragmatic control group receiving treatment as usual.
The article describes that clinical changes in the predicted direction were evident, with the TC group showing comparatively less pathology both over time and in relation to the comparison group. Whilst the mean number of violent incidents did not reduce over time there was nevertheless a strong trend towards reduction in seclusion hours in the TC treatment group over time, with significant differences between groups also being observed at the six- and 12-month stage.
BBC1 (2011), “Panorama”, Undercover Care: The Abuse Exposed, Television Programme, Tuesday 31 May, 21.00, British Broadcasting Company
CQC (2012), “Reports from its review of services for people with learning disabilities”, Care Quality Commission, available at: www.cqc.org.uk/LDReports5
Commission for Healthcare Audit and Inspection (2006), “Joint investigation into services for people with learning disabilities at Cornwall Partnership Trust”, available at: www.healthcarecommission.org
Commission for Healthcare Audit and Inspection (2007), “Investigation into services for people with learning disabilities provided by Sutton and Merton Primary Care Trust”, available at: www.healthcarecommission.org
The Learning disabilities Observatory (2012), “Supporting clinical commissioning and joint strategic needs assessment for people with learning disabilities”, available at: www.ihal.org.uk