Published: 17 January 2007
Failures in Management and Leadership at all levels
The Healthcare Commission has released a report detailing how outmoded, institutionalised care had led to the neglect of people with learning disabilities at Sutton and Merton Primary Care NHS Trust.
The report described some of the environments in which people lived as impoverished and completely unsatisfactory.
Staff were not properly trained or supported to provide an acceptable level of care and inadequate levels of staff meant that people were often left day in day out with little to occupy their time.
There were failures in management and leadership at all levels, from managers to the Trust’s board.
Anna Walker, the Commission’s Chief Executive, said:
“The standard of services at Sutton and Merton was simply not acceptable in the 21st century.
Orchard Hill Hospital is an institution and should be closed as soon as it is possible to place residents in appropriate alternative care settings.
We have examined care plans for people who will continue to live at the Hospital until they are moved to different services.
We acknowledge the considerable improvements made by the Trust in the meantime, in particular the substantial increase in numbers of staff.
We will, however, continue to monitor the Trust closely during this time.”
The impetus for the investigation came from the Sutton and Merton PCT itself, which wrote to the Commission in January last year to request an independent investigation of its services for people with learning disabilities, as the Trust was concerned by a number of serious incidents.
The Commission’s investigation team found that, in most cases, the Trust had followed correct procedures for the protection of vulnerable adults when responding to these serious incidents.
The report, however, details a series of failings by the Trust to provide safe & adequate care for people with learning disabilities:
· The overall model of care promoted dependency. People were cared for rather than supported to be as independent as possible.
· The views of people with learning disabilities were seldom heard and few staff had any specialist training in ways of communicating with people with learning disabilities.
· There was inadequate specialist support for people with behaviour that challenges and there were few outings or meaningful activities, which exacerbated behavioural problems and led to increased risks.
· Most of the environments that people lived in were unsatisfactory with inadequate access for disabled people, poor decoration & furnishings and insufficient space for hoists in bedrooms & bathrooms.
· In some instances, limited space compromised the privacy and dignity of people with learning disabilities.
· There were serious deficiencies in meeting the requirement for people to have an up-to-date person-centred care plan.
· There was no robust system for monitoring the service either at the managerial or board levels.
· Constant change in the Trust, including seven chief executives within 10 years, created a lack of continuity & follow-up action of managers.
· Inappropriate use of restraint was identified as a serious matter of concern. In one case, a woman had routinely been restrained for many years through the use of an arm splint, which was applied to prevent her putting her hand in her mouth. Such practices have long been deemed inappropriate and harmful.
Ms Walker continued:
“Some of the findings are classic examples of staff being unaware that certain practices are no longer acceptable and could in some cases constitute abuse.
This report should not be seen as a condemnation of individual members of staff, some of whom even worked on their days off to ensure adequate cover.
But they were often not sufficiently trained or supported to provide adequate care.”
This latest report comes just over six months after a report which detailed neglect and physical, emotional & financial abuse of people with learning disabilities at Cornwall Partnership NHS Trust.
The Cornwall report prompted the first national audit of learning disability services, currently underway in England.
The Commission has now announced that the learning disability audit will include the inspection of up to 200 NHS and private services and that it will aim to identify any problems in the sector, as well as examples of best practice.
It will also produce guidance on what a modern learning disability service should look like.
The findings are expected to be published by the end of this year.
Ms Walker said:
“The Sutton and Merton case is very different from what was uncovered at Cornwall. But it is the second report of neglect of people with learning disabilities within the space of just six months.
This confirms that we are right to be concerned about the quality of care for people with learning disabilities throughout England.
Credit must be given to the Trust and particularly to the Chief Executive, who on taking up to the post, asked us to undertake an investigation knowing that it would be made public.
The Trust has worked with us at every stage of the investigation and this should be commended. But clearly it does not excuse the neglect of the people with learning disabilities in its care.
The Trust was providing institutionalised care which sacrificed the needs of vulnerable individuals in favour of the needs of the service.
It is simply not good enough.”
The Commission’s report contains 25 recommendations and the Trust is required to prepare an action plan within nine weeks to address these, which the Healthcare Commission will closely monitor during its implementation.
Ms Walker concluded:
“I’m pleased to see that the Trust has already taken significant steps to address our concerns, such as putting in place person-centred care plans, increasing numbers of staff and providing more effective training.”
The Trust has developed a plan to relocate most of the people living at Orchard Hill Hospital by the end of 2008 and to close the site by 2009. A schedule for the closure of Osborne House is also being developed.
Further information
Sutton and Merton report
Cornwall report
Draft three year strategic plan for adults with learning disabilities 2006-2009
On-going National Audit
Valuing People Support Team website
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