Editorial

Journal of Learning Disabilities and Offending Behaviour

ISSN: 2042-0927

Article publication date: 7 September 2012

131

Citation

Dale, C. (2012), "Editorial", Journal of Learning Disabilities and Offending Behaviour, Vol. 3 No. 3. https://doi.org/10.1108/jldob.2012.55403caa.001

Publisher

:

Emerald Group Publishing Limited

Copyright © 2012, Emerald Group Publishing Limited


Editorial

Article Type: Editorial From: Journal of Learning Disabilities and Offending Behaviour, Volume 3, Issue 3

October 2012 saw BBC Panorama screen a follow up to their initial revelations into the ill treatment of patients at Winterbourne view hospital one year ago, “The hospital that stopped caring”. Since the original programme Winterbourne view (the unit at the centre of the controversy) has been closed and the people in the service re-located (BBC Panorama, 2012).

The new programme repeated much of its earlier allegations but there were two new issues identified: the revelation that more than half of the people transferred remain in similar hospitals, and apparently 19 have been subject to further safeguarding alerts over their well-being; and the questionable methods for inducting new staff on physical intervention. It is the issue of physically restraining people that I would wish to comment further on.

The undercover reporter described how he was shown how to restrain patients using physical force – and then how to “justify” it in the paperwork. He stated that, “If we had to ‘resort to using reasonable force’ and ‘knee’ a patient ‘in the b******s’, we were told to put on the form that the patient was big and that we feared death by strangulation if we didn’t knee them in their private parts”.

In the first three months of the undercover reporters time on the unit he states that there were 129 restraints and that, “many were not pretty”; one of the carers said to the reporter, “If you have to smash her, you smash her… I just whack ‘em all down’”.

I believe that this highlights one of the core issues of poor regulation and control of a critical area of patient safety which is well-known to have the potential for serious harm and in some cases death. What makes the Winterbourne view revelations all the more worrying is that the training provided for physical restraint was via a well-known national organisation (MAYBO) who provide training into many other health and social care environments and has been accredited by the British Institute of Learning Disabilities (BILD).

At present the problem of responding to aggression and violence is tackled by different organisations in different ways. There is no central training, no central accreditation of trainers, no clear definition of the content of the training or of the people who should go for training or on the time, they should spend being trained.

In 2004 the inquiry following the death of David Bennet, at the time a patient in a medium secure unit, following restraint stated that this “badly needs central control” (Independent Inquiry into the Death of David Bennett, 2003).

The Bennett inquiry recommendation stated:

A national system of training in restraint and control should be established as soon as possible and, at any rate, within twelve months of the publication of this report.

Despite the Department of Health accepting this recommendation and receiving detailed proposals for a national system of accreditation and regulation in 2005 (Dale et al., 2005) they have failed to implement any changes to control this chaotic situation.

The Winterbourne view revelations provide further evidence of why control of the prevention and management of violence and aggression is so necessary. In particular any national system needs to ensure that:

  • it should be mandatory;

  • it has credibility; and

  • it will only be delivered by appropriately registered trainers providing nationally accredited courses.

The main purpose of accreditation and regulation is to ensure that safety is maximised for all involved and encourages trainers to deliver training courses that are of a high standard and evidence based. Training should be “fit for purpose” and be tailored specifically to individual services and include bespoke physical interventions around individuals. It is a sad indictment of the Department of Health’s apathy in getting to grips with this problem and has left it to pioneering initiatives such as the voluntary BILD system which in itself is insufficient to ensure appropriate levels of safety.

The main response from the Care Quality Commission (CQC) to the initial revelations of Winterbourne view was the introduction of 150 unannounced inspections to services across the country. These inspections revealed an increasing use of restrictive and institutionalised approaches to managing disturbed behaviour which was the subject of a recent CQC symposium on restrictive practices in mental health and learning disability services (CQC, 2012a-c).

The symposium was presented with the analysis from the 150 unannounced inspections, and the findings of Mental Health Act (MHA) Commissioner visits in 2011/2012 to people detained under the MHA. Themes identified included: the use of physical restraint, seclusion and segregation; the imposition of “blanket rules”; a lack of understanding of the MHA; poor staff-patient relationships; and staffing difficulties. Concerns often centred around the difficulty of working out from the records how often, and for how long restraint was applied, and what actually happened during it. Other concerns included the lack of information about what might have triggered the challenging behaviour, and the lack of learning that came out of the event.

Safeguards for people in seclusion were not always implemented, and recording was often insufficient to give a clear picture of the use of seclusion and longer term segregation. A range of different terms were used to describe circumstances in which people might be, in practice, detained in seclusion: “Nursed in his room”, “Placed in the low-stimulus area for a sustained period” or “Chose to be in the safe-care suite”.

The treatment of people who were being secluded also gave rise to further concerns, about how meals and drinks were provided in some cases.

Blanket rules related to matters such as access to various communal rooms, kitchens, the person’s own bedroom (whether locking people out of their bedrooms during the day, or insisting on a general or early bedtime), and to the gardens or outdoor space.

Rules were also in place in some settings about when a patient or resident might have a drink or a snack, or go for a cigarette. These rules were rarely justified in terms of a person’s individual care plan, or based on consent of the individual or on their best interests. They were often explained as having arisen as a response to a particular incident or accident, but continued long after the event.

Confusion over the rights and treatment of informal or voluntary patients also gave rise to concern, with some being subjected to the same restrictions as detained patients.

Inspections also exposed concerns over staff who spoke in a derogatory way to, or about, patients, and who exercised petty and arbitrary controls over diet, smoking, privacy and contact with family or friends.

Staffing shortages were a major contributor to other restrictions, such as people not being able to go out as planned, and in the development of blanket rules.

The CQC intend to publish a briefing paper detailing the issues along with a report of the symposium and recommendations early in the New Year. Also the CQC have announced that between December 2012 and March 2013, they will be carrying out their first thematic probe into restrictive practices in inpatient mental health wards.

During this period, they will be asking ward managers and Mental Health Act (MHA) Commissioners to complete short surveys during routine visits to mental health inpatient wards.

The probe will collect information on restrictive practice in the following five areas:

  1. 1.

    The right for non-detained patients to leave the ward.

  2. 2.

    The use of blanket rules and restrictions.

  3. 3.

    Appropriate security arrangements.

  4. 4.

    Staffing.

  5. 5.

    Police presence on the ward.

The CQC have also brought together the findings from over 13,000 inspections to produce a report on the shape of health and social care in England. The report highlights that issues around staffing and ensuring they have the right skills to care for people with complex conditions are beginning to affect the quality of care that services deliver. This is especially having an impact on respecting people who use services and nutrition.

The report notes many examples of organisations that meet these challenges and deliver an excellent quality of care, but the inspectors have seen examples of services that have not been able to cope with these changes. Many displayed common factors including an attitude to care that is based on getting tasks done and where unacceptable care has become the norm.

The reports key findings show:

  • One in ten NHS hospitals failed to treat people with the respect they deserve and failed to involve them in decisions about their care.

  • 15 per cent of social care services were not providing care that respected people.

  • 23 per cent did not have adequate staffing levels.

The CQC information, revealing as it is, gives the appearance of an organisation stuck on the assessment stage of a cycle with little idea of how it moves into addressing the identified issues and hence bringing about any real change. Further assessment of restraint practices will tell us that it is a problem and is frequently practiced; the real issue is what we are going to do about it and I sense it is here that the CQC get stuck. Interestingly there is no mention of looking at the physical restraint of people in any of the CQC initiatives, perhaps that has been left in the “too difficult” pile.

In this edition of the journal we have a fascinating series of articles including a contribution from Australian services.

Kathy Ellem from Australia describes how the support given to prisoners when they leave prison has bearing on their success in starting a new life and on community safety. Kathy’s paper examines the community re-entry experiences of ten people with an intellectual disability in Queensland, Australia.

Seven male and three female participants with intellectual disability were interviewed using a semi-structured life story method. Participants found the process of leaving prison an emotional event, often clouded with both confusion about when release was to occur, and uncertainly as to what they could expect on the outside. The need for concrete information and coordinated hands-on assistance in negotiating supports in the community have significant implications for correctional and community services.

Julia Kelly, Angie Collier, and Julie Stringer describe the provision of a learning disability in-reach service for young adult offenders serving a sentence of imprisonment for Public Protection.

Their article explains that a number of young adult offenders with learning disabilities are still being “overlooked” by the CJS for diversion to hospital before they reach prison. Their data support the need for, and the current development of, adapted OBPs and individual work to meet the needs of young offenders serving an IPP and they feel that without these changes, there is a risk that these prisoners could unnecessarily serve sentences beyond their tariffs.

Initial evaluation suggests that this need can be identified through systematic screening of prisoners at an early stage of their sentences. While the present evaluation supports the use of the KBIT-2, further research is required if these findings are to be generalised to the wider prison population. Screening and identification in itself is insufficient to address the offending behaviour and well-being of these prisoners. Assessment of social functioning using existing standardised measures remains problematic within the prison context. Further research into the development of a valid and reliable, structured assessment of social functioning is needed to undertake full assessments of learning disability in accordance with best practice guidelines.

Judy Eaton and Rosie Banting outline the diagnosis and subsequent treatment and intervention planning for a young woman in a low secure hospital. They explain that patients in both residential and secure services can be difficult to manage due to aggressive or challenging behaviour. Many will have no diagnosis or an array of different (and often conflicting) psychiatric and medical diagnoses. A number of these individuals may be on the autistic spectrum.

This paper briefly summarises the literature in relation to the diagnosis of pathological demand avoidance (an atypical presentation of autism spectrum disorder) in children and describes how this diagnosis may present in adults. A detailed literature search revealed that whilst there was a growing literature around pathological demand avoidance in children, there was very little with regard to either the clinical presentation or management guidance in adults.

A case study design was adopted primarily to provide an initial exploration of the potential benefits of screening for autism spectrum conditions in females presenting with complex and challenging behaviour and adopting strategies that have proved effective within this population.

The paper concludes that the lack of an appropriate diagnosis and inappropriate formulation of the underlying causes of challenging behaviour can lead to some patients becoming almost impossible to manage. Adults with atypical forms of Autism can benefit from diagnosis and autism-specific intervention and incidents of challenging behaviour can be significantly reduced.

Joel Harvey describes a preliminary model of forensic practitioner resilience within a learning disabilities service. This study set out to develop a conceptual model of working within a forensic learning disability service. It starts from the perspective of staff and aims to articulate what staff need in order to manage the complex challenges of their work effectively and to meet the needs of service users. As a prerequisite to developing a conceptual model, it is argued that it necessary to develop an understanding of what staff perceive to be the key complexities and challenges in their role. It is argued that such challenges need to be acknowledged, unravelled and understood before any meaningful model of service delivery can be conceptualised. The conceptual model put forward in this paper, which was developed from a thematic analysis of interviews with staff, is a model of forensic practitioner resilience. At the core of this model is the important of developing positive relationships and trust with service users, colleagues and partner agencies. It is argued that the development of relationships and trust is the conduit for managing the key challenges of the work, and that trust, which flows from and into relationships, is the bedrock of a model of practitioner resilience and service delivery.

Colin Dale

References

British Broadcasting Company, Panorama (2012), The Hospital that Stopped Caring, Broadcast on 29 October, BBC1

CQC (2012a), CQC’s Symposium on Restrictive Practices, Care Quality Commission, 30 October, available at: www.cqc.org.uk/organisations-we-regulate/registered-services/information-professionals/cqc’s-symposium-restrictive-

CQC (2012b), Independent Evaluation of the Learning Disability Inspection Programme, Care Quality Commission, June

CQC (2012c), The State of Health Care and Adult Social Care in England in 2011/12, Care Quality Commission, November

Dale, C., O’Hare, G. and Rae, M. (2005), “Proposals for a national system for the accreditation and regulation for the prevention and management of violence”, unpublished

Independent Inquiry into the Death of David Bennett (2003), Norfolk, Suffolk and Cambridgeshire Strategic Health Authority

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