Public Inquiry Recommendations

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 …

All service users and their families should have the CCTV explained to them in easily understood language and with easy access materials, …

All staff should receive training on the reasons for the use of CCTV and the processes for its analysis.

Vulnerable children and adults are inherently more susceptible to abuse or neglect than other people. Adult safeguarding should be formally recognised as …

Metrics on both child and adult safeguarding processes should be reported monthly via a safeguarding dashboard, with the same visibility and status …

Incidents of peer-on-peer abuse should be included in adult safeguarding metrics and included on a published safeguarding dashboard.

The dashboard should include the number of allegations reported, together with the screening decision (referral to the Adult Safeguarding Gateway, referral to …

There should be common standards for the conduct of safeguarding investigations. These should be drafted and approved by the Northern Ireland Adult …

A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with …

Where there is evidence or suspicion of widespread abuse involving multiple staff and residents, focusing solely on individual perpetrators is insufficient. An …

Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable …

Staffing should be based on service user needs rather than a fixed budget, using daily acuity measures designed specifically for units caring …

Clinical supervision (where individuals’ practice with individual patients is discussed) should be mandatory for all ward staff, including healthcare assistants, and should …

All healthcare assistants working with people with learning disabilities and autistic people should be provided with training, which should include specialist learning …

SPPG must commission a review of the potential models for supervision of staff in private and third sector services commissioned by HSCTs, …

Consideration should be given to enhancing the post of healthcare assistant by creating Band 4 associate practitioners in both hospital and community …

Consideration of staffing (including skill mix as well as total numbers) should be a mandatory part of safeguarding investigations in all settings.

There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance …

NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical …

The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.

HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months …

The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should …

Consideration should be given to the creation of a role for a NED in each HSCT with the specific remit to receive …

The DoH should establish an expert clinical/social governance advisory function to support providers.