Public Inquiry Recommendations

Each facility or service should have an integrated workforce plan that includes all allied health professionals (AHPs) and all staff involved in …

It is critical for the wellbeing of people with learning disabilities and autistic people that they are well supported by, and have …

Like anyone else, people with learning disabilities and autistic people require a variety of meaningful activities on a daily basis to enhance …

Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply …

All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.

Observation records detailing all use of restraint and seclusion should be completed by the individual observing. In HSCT facilities, if the observer …

Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and …

If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using …

Creating a co-produced care environment, where people with learning disabilities, families and professionals work collaboratively, requires a fundamental shift in practice. As …

Specific processes rather than policies should be designed to ensure there is good communication with families and carers to ensure co-production takes …

The 2006 Quality Standards for Health and Social Care should be amended to require HSC organisations to provide all people with learning …

Properly trained independent advocates should be made available to service users and families to support effective communication with staff and for raising …

All providers of learning disability services should appoint a human rights officer, as seen in Sheffield Health Partnership University NHS Foundation Trust …

All documents relevant to the service user’s experience and intended for their information must be made available in Easy Read format.

All organisations taking responsibility for property and/or finance for people with learning disabilities and autistic people should institute regular checks of adherence …

Policies must be specific as to records to be kept and for routes to disclosure for relevant family members and people with …

The records kept must be easy to manage by staff and easily comprehensible to others, including people with learning disabilities and autistic …

Information about the use of cash and other property and six-monthly accounts (or such period as appropriate upon discharge of the person) …

RQIA should examine the provider organisation’s internal assurance processes and make recommendations where they are insufficient.

The Restraint Reduction Network identifies six principles to avoid the use of restrictive practice. While there is evidence that some Trusts have …

All facilities providing residential services for people with learning disabilities and autistic people should provide sufficient psychology input for each patient, to …

HSCTs should appoint a non-executive director (NED) to act as a champion for restraint reduction, with a mandate to hold executive directors …

The effectiveness of the education programme for staff in relation to restraint reduction should be measured through defined data metrics. This is …

HSCTs should implement a comprehensive set of balanced performance measures across all services for people with learning disabilities, including those commissioned from …

To ensure meaningful interpretation of these trends, all HSCTs should adopt statistical process control (SPC) charts, as developed by Walter Shewhart in …

All HSCTs should develop two clear operational debriefing policies. The first should apply to both staff and people with learning disabilities and …

Given the elevated risk of inappropriate use of restrictive practices with individuals with learning disabilities and/or autistic people, BHSCT and all HSCTs …

Use of seclusion should be considered an extraordinary and exceptional intervention. Each intervention should be subject to a serious event audit, conducted …

Education and training on the use of restrictive practices should be grounded in human rights principles and the dedicated human rights specialist …

People with learning disabilities and autistic people and their families should be provided with clear, written information outlining the available pathways for …

People with learning disabilities and autistic people and their families should be provided with a short description of how best to record …

In HSCTs all complaints, regardless of whether they are resolved immediately at ward level, should be recorded in the Trust’s electronic complaints …

Complainants should immediately be informed of how their complaint will be managed (locally or through the corporate complaints process) along with a …

Complainants must be regularly updated and informed of the progress of any investigation, including when the process concludes without a specific finding.

All complaints managed at corporate level and rated as red (using the red, amber and green (RAG) rating matrix) should be shared …

Complaints alone are a poor indicator of quality of care, particularly in a vulnerable population such as those admitted to MAH. A …

Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed …

Where people with learning disabilities can participate, the provider should actively seek their lived experience feedback in relation to staff attitudes and …

The provider should actively seek family or carer feedback on the service user’s experience on a quarterly basis via an external agency …

HSCTs must review and improve governance of safeguarding to ensure that findings from different safeguarding investigations are considered holistically, synthesised and presented …

Hospital settings for people with learning disabilities and autistic people are very high-risk environments for abuse and poor practice, partly because those …

Guidelines should be agreed in relation to providing CCTV systems in residential and day services where requested. Guidelines should be agreed by …

The installation of CCTV in non-public areas should be considered only where this will be in the best interests of the individual …

Policies governing the use of CCTV should be agreed only after consultation with staff, residents and their families using the service.

Policies should include careful consideration of the circumstances in which the CCTV should be viewed; for example, that it should be viewed …

Viewers of the CCTV should be independent of the setting, i.e. not involved in day-to-day care of the residents.

Oversight of the CCTV analysis should sit outside the setting in which the CCTV is recording, and should include audits of referrals …

Policies should include clear guidance and definitions of behaviour and circumstances in which information should be passed to PSNI about possible offences.

Policies should be clear about the circumstances in which a regulator, such as RQIA, could access the CCTV.

Those drafting the policy should consider whether CCTV could ever be used for staff training and, if so, how this would be …