The National Safe and Wellbeing Review Programme was identified as part of the NHSE response to the Safeguarding Adult Review (SAR) that will be undertaken to check the safety and wellbeing of all people with a learning disability and autistic people (children, young people, and adults) who were in any mental health hospital, learning disability or autism inpatient setting and including people on Section 17 leave funded by clinical commissioning groups (CCGs) or provider collaboratives, NHSEi specialist commissioning on 31 October 2021. The reviews are expected to be completed by 31 January 2022.
- The findings from the recent Safeguarding Adults Review (SAR) report from Norfolk Safeguarding Adults Board into the premature deaths of Joanna, ‘Jon’ and Ben at Cawston Park, the National Unit of Concerns work and impact of the COVID-19 pandemic have shown that current quality oversight processes are not always robust enough to identify poor standards of care particularly in relation to people’s physical wellbeing and quality of life, for example, daily activities.
- The National Safe and Wellbeing Review Programme was identified as part of the NHSE response to the Safeguarding Adult Review (SAR) that will be undertaken to check the safety and wellbeing of all people with a learning disability and autistic people (children, young people, and adults) who were in any mental health hospital, learning disability or autism inpatient setting and including people on Section 17 leave funded by clinical commissioning groups (CCGs) or provider collaboratives/NHSEi specialist commissioning on 31 October 2021. The reviews are expected to be completed by 31 January 2022.
- The purpose of the National Review Programme is to
- undertake a safe and wellbeing check for each person
- to seek assurance that people are being properly cared for and are leading good lives in hospital
- for commissioners to take immediate remedial action if a review shows that a person is not safe and well
- to be carried out swiftly and at a point in time so that any key themes and learning can be identified
- The National Review does not replace existing mechanisms to monitor quality of care i.e. Care (Education) and Treatment Reviews (C(E)TRs), Care Programme Approach (CPA) or alternative approach in line with The Community Mental Health Framework for Adults and Older People and six to eight week oversight visits. However, the Safe and Wellbeing Review can be undertaken in part within these existing mechanisms.
- Every Integrated Care System (ICS) should establish an Oversight and Assurance Panel to hear about the reviews undertaken for their citizens who were in hospital on 31 October 2021. The panel should also include an expert by experience. Although not specified, it would be positive for the panel to include representation from the local authority or local authorities in the ICS footprint.
- It is likely that safeguarding concerns will be identified through some of the Safe and Wellbeing Reviews and it will be important for the relevant Safeguarding Adults and Safeguarding Children Partnerships to be sighted on these situations. Where an individual is placed outside their local area, this will involve more than one Board – the one where the hospital is located and the one where the placing commissioner is located. It should be noted that the response to safeguarding concerns will be undertaken by following the procedures in place in the location where the hospital is situated, with liaison with the placing commissioner.
- Some of the Safe and Wellbeing Reviews may identify that the individual is not in an appropriate setting or that they are ready to be discharged. Joint working between NHS organisations and local authorities through the Transforming Care Partnership arrangements will be essential to respond effectively in these situations.
National Safe and Wellbeing Review Programme in more detail
The Programme is divided into three phases:
- Phase 1 November 2021 – January 2022: Undertake the Safe and Wellbeing reviews and take immediate action in response to any safety and wellbeing concerns raised during the review.
- Phase 2 November 2021 – February 2022: Assurance, oversight and challenge of review findings and evidence how findings of the reviews feeds into the ICS delivery plan.
- Phase 3 February 2022 – March 2022: Develop a regional summary report detailing the findings, themes and actions to be taken from the reviews and evidence how findings of the reviews feed into the Regional delivery plan; triangulate regional findings and set out a National response and next steps; share findings and intelligence with the Care Quality Commission (CQC); Ensure key findings feed into relevant National Learning Disability and Autism Programme workstreams.
The approach adopted for the Safe and Wellbeing Reviews is one that listens to and considers the views and information available from a range of sources including:
- The individual
- Family and loved ones
- Responsible clinician and multi-disciplinary team (MDT) including community
- Commissioner – this could include the host commissioner and the placing commissioner.
The approach also requires reviewers to determine their level of confidence in the care provided (not at all confident; somewhat confident; confident; highly confident), to think ASK, LISTEN, DO and to identify actions and to feedback on these actions and the outcomes to the individual.
The Safe and Wellbeing Reviews have four steps
Step 1: desktop review of the two most recent C(E)TRs and CPA records to include:
- a review of the quality of the completed documents, associated action plan and areas covered within them
- identification of any points to escalate and actions to be taken.
Step 2: telephone/virtual meeting to gather feedback regarding the care being delivered:
- with the individual’s permission, discussion with the individual and family/friends/advocates regarding the care being delivered prior to the face-to-face meeting with the individual.
Step 3 and Step 4: face to face review of the individual and the care delivered to them (this can form part of the six to eight week oversight visit or C(E)TR to include:
- review of the individual’s safety, physical health assessment and treatment, mental health assessment and treatment, and quality of life and must include direct conversations with the responsible clinician/consultant responsible for the individual’s inpatient care and the therapeutic team including care assistants
- meeting with the individual and find out what they think of their care and action any matters raised by the individual with the service during the visit
- considering that there may be differing views on the type of care delivered or how the care is delivered for example between the individual and their team
- undertaking the ‘sit and see exercise’ to get a sense of how the individual experiences living at the service.
This Programme will provide placing commissioners with a comprehensive overview of the care being delivered to autistic children, young people, and adults and those with a learning disability who are in mental health inpatient hospitals. The review of each individual’s safety will have been informed by information gathered from a number of different sources and the reviews will identify where individuals are inappropriately placed or where there re barriers to discharge.
The Programme offers an opportunity to review how the quality of existing mechanisms, for example, C(E)TRs, CPA and six to eight week oversight visits are being monitored locally and to strengthen these arrangements.
It will also provide CCGs and host commissioners with key intelligence regarding the quality of specific inpatient services.
Advice for councils and chairs of Safeguarding Adults and Safeguarding Children’s Partnerships
- Although local authority representation on the Oversight and Assurance Panel is not specified in the requirements set out for ICSs, local authority directors (DASSs and DCSs) may want to ensure that there is local authority representation, and that this representation helps to facilitate links to Safeguarding Adults and Safeguarding Children Partnerships.
- Chairs of Safeguarding Adults and Safeguarding Children Partnerships (where hospitals are located and where the placing commissioner is located) are strongly encouraged to agree mechanisms for informing the Board of any safeguarding concerns arising from the Safe and Wellbeing Reviews and providing assurance that action is being taken to safeguard the individual.
- Monitoring the quality of care and safety for people with a learning disability and/or people who are autistic in inpatient care (NHS England)
- Care, (Education) and Treatment Reviews: October 2021 policy update (LGA)
- Out of Sight, Who Cares? (CQC, December 2021)
- How CQC identifies and responds to closed cultures (CQC, July 2021)
- Care Programme Approach: NHS England and NHS Improvement position statement (July 2021)
- The Community Mental Health Framework for Adults and Older Adults (NHS England, September 2019)
- Lenehan review
February 2023 update
As part of the response to the safeguarding adults review about the deaths of Joanna, Jon and Ben at Cawston Park, a national review was been undertaken to check the safety and wellbeing of all people with a learning disability and autistic people who are being cared for in a mental health inpatient setting. The 2023 thematic review and lessons learned document sets out the themes emerging from the review findings. These findings have helped inform the development of the January 2023.