Learning Disabilities Hospital Inpatient Provision

Recommendations

This National Care Review makes 70 specific recommendations to be considered by providers and commissioners of care, as well as Welsh Government.

Providers

Recommendation 1. Providers should ensure that staff are aware of differences in presentation and need of male and female patients.

Recommendation 3. Providers should ensure that staff are trained to recognise and meet the needs of older persons with a learning disability.

Recommendation 11. Providers should ensure that all patients, not subject to detention under the Mental Health Act or to Deprivation of Liberty Safeguards, have the capacity to consent to being an inpatient.

Recommendation 12. Providers should ensure that all patients subject to detention under the Mental Health Act or to Deprivation of Liberty Safeguards are aware of their rights.

Recommendation 17. Providers should ensure that hospital support plans are reviewed regularly, within a maximum time period of three months.

Recommendation 19. Providers should ensure that all care plans and hospital support plans are developed with specific objectives, measurable outcomes and clear timescales.

Recommendation 22. Providers should ensure that the patient’s outcomes are discussed as part of the care plan and hospital support plan reviews.

Recommendation 24. Providers should ensure that all medication is prescribed at the minimum dosage to alleviate the verified symptoms.

Recommendation 26. Providers should ensure that all medications are regularly reviewed for effectiveness and discontinued where efficacy is not demonstrated.

Recommendation 27. Providers must ensure that the patient, local care team and carers are involved in the decision to commence or discontinue any psychotropic medication.

Recommendation 28. Providers should ensure that all patients prescribed psychotropic medication have a recognised side-effects monitoring tool completed.

Recommendation 29. Providers should ensure that patients and families receive information, in an accessible format, on desired effects and possible side-effects of medication.

Recommendation 30. Providers should record all incidents of behaviours that challenge.

Recommendation 31. Providers should deliver a safe, effective and therapeutic environment of care, in order to reduce frustration and boredom which could lead to behaviours that challenge.

Recommendation 32. Providers should ensure that staff are trained to recognise escalating behaviours and to deliver positive and preventative interventions.

Recommendation 34. Providers must ensure that staff well-being is protected if they are regularly exposed to behaviours that challenge.

Recommendation 35. Providers should ensure that any restrictive intervention involves the minimum degree of force, for the briefest amount of time and with due consideration of the self-espect, dignity, privacy, cultural values and individual needs of the patient.

Recommendation 36. Providers should ensure that all incidents of restrictive interventions are recorded, reviewed and reported.

Recommendation 37. Providers should ensure that any restrictive intervention is proportionate to the risk posed by the behaviour that challenges.

Recommendation 40. Providers should ensure that the rationale for application and planned duration for any and all personal restrictions should be clearly documented in the patient’s hospital support plan and be regularly reviewed.

Recommendation 42. Providers should ensure that any dedicated support balances the risk to patients’ safety with the promotion of dignity and independence.

Recommendation 43. Providers should ensure that all patients are enabled and encouraged to access the local community safely.

Recommendation 44. Providers should ensure that all patients have access to primary care services as and when required.

Recommendation 45. Providers should ensure, where safe to do so, that attendance at urgent care services is prevented by pre-emptive interventions, staffing levels and staff training.

Recommendation 49. Providers should undertake regular patient experience surveys in partnership with independent advocacy services and use the findings of these surveys to improve care.

Recommendation 51. Providers should ensure that their environments of care are safe, high quality, fit for purpose and repaired and redecorated when necessary.

Recommendation 52. Providers should ensure that patients have access to a ‘patient’s kitchen’ and hot and cold drinks, after appropriate risk assessment.

Recommendation 54. Providers should review, record and discuss the patients Level of Care on a monthly basis to support recording of progress.

Recommendation 56. Providers should ensure that they regularly review and revise each unit’s staffing requirements to ensure that the needs of patients are met.

Recommendation 58. Providers should ensure that the patients have access to staff with specific skills, training and experience to enable them to achieve optimal functioning and well-being.

Recommendation 59. Providers should ensure that staff are delivering high quality, evidence-based interventions to achieve the patients’ outcomes.

Recommendation 60. Providers should ensure that all patients are assessed for behaviour that indicates institutionalisation.

Recommendation 61. Providers should ensure that the maintenance and promotion of self-advocacy, self-resilience and the reduction in dependency is a primary focus of care delivery.

Recommendation 65. Providers should ensure that patients and their families and carers are involved in developing and enacting the transition plan.

Recommendation 66. Providers should ensure that the transition plan is discussed and progressed by the unit staff and local care team at their regular meetings.

Commissioners

Recommendation 2. Commissioners should take account of the differences in the needs of male and female patients in the design and delivery of services.

Recommendation 4. Commissioners should ensure that they have planned learning disability services to take account of an aging population profile.

Recommendation 5. Commissioners should ensure that they have planned learning disability services to take account of patients with specific needs such as autistic spectrum disorders, dementia and mental illness.

Recommendation 6. Commissioners should ensure that staff are trained to recognise and meet the needs of patients with a learning disability that are concurrent with other conditions such as an autistic spectrum disorder, dementia and mental illness.

Recommendation 7. Commissioners should identify those individuals most at risk of being admitted to hospital, so that the right support can be made available to prevent the need for admission.

Recommendation 8. Commissioners should have clear pathways in place to promote a ‘community first’ approach and to minimise transfer of patients from one hospital to another.

Recommendation 9. Commissioners should ensure that no hospital bed is classed as an individual’s home and every endeavour should be made to see community care as the ‘default option’ for all patients.

Recommendation 10. Commissioners should target resources at transitioning those patients in assessment & treatment units with a length of stay over one year, and those in other providers with a length of stay over five years.

Recommendation 13. Commissioners should ensure that all patients subject to detention under the Mental Health Act or to Deprivation of Liberty Safeguards are subject to regular review.

Recommendation 14. Commissioners should ensure that all patients in hospital are assigned a care coordinator.

Recommendation 15. Commissioners should ensure that all care coordinators understand their role in ensuring the patient is cared for in a safe and high quality environment and in planning and expediting the patient’s transition.

Recommendation 16. Commissioners should ensure that care plans are reviewed regularly, within a maximum time period of six months.

Recommendation 18. Commissioners should ensure that all care plans and hospital support plans are co-produced with the patient and with the involvement of the care coordinator and the patients’ families.

Recommendation 20. Commissioners should ensure that the desired outcomes for the patient are agreed on admission with the patient, families, provider and local care team.

Recommendation 21. Commissioners should monitor the achievement of outcomes closely, intervening if outcomes are not being achieved in a timely manner.

Recommendation 25. Commissioners should ensure the adoption of evidence-based prescribing by all providers.

Recommendation 33. Commissioners should ensure that providers are taking considered positive risks and are not focusing exclusively on historical risk.

Recommendation 38. Commissioners should ensure that all providers of restrictive intervention training comply with the 2019 Restraint Reduction Network Training Standards.

Recommendation 39. Commissioners should ensure that providers have a restraint reduction plan in place for each patient.

Recommendation 41. Commissioners should ensure that all blanket restrictions are proportionate, have a clear rationale for application and are subject to regular review.

Recommendation 46. Commissioners should ensure that general healthcare staff have access to training on learning disabilities and autistic spectrum disorders.

Recommendation 47. Commissioners should ensure that providers deliver best value.

Recommendation 48. Commissioners should ensure that patients, families and carers have a voice in service design.

Recommendation 50. Commissioners should ensure measures of patient satisfaction are obtained and used as indicators of responsive and quality services.

Recommendation 53. Commissioners should ensure that patients with low Levels of Care that demonstrate that a less restrictive environment could meet their care needs are considered for transition.

Recommendation 55. Commissioners should ensure that providers have a sufficient level of staffing to provide safe and progressive care.

Recommendation 57. Commissioners should ensure that any outcomes that require contribution by therapy staff are being addressed.

Recommendation 62. Commissioners should recognise and address the negative effects and impact of institutionalisation.

Recommendation 63. Commissioners should ensure that all transition plans are enacted.

Recommendation 64. Commissioners should ensure that all patients have a plan in place identifying the outcomes to be achieved in order to transition to the next step on their care journey.

Recommendation 67. Commissioners should have in place a mechanism to review transition plans across the services they commission to ensure barriers to progress are removed.

Recommendation 68. Commissioners should consider optimal planning arrangements for new models of enhanced inpatient services at a local, regional and national level.

Recommendation 69. Commissioners should consider investment in early intervention and admission prevention community services.

Welsh Government

Recommendation 23. Welsh Government should consider establishing a national campaign to support the reduction in the inappropriate use of psychotropic medication.

Recommendation 70. To support transition and improve community services the Welsh Government should support Regional Partnership Boards to develop a sustainable funding model, including social investment and social enterprise.