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D December 2 013 Winterbourne View: Transforming Care One Year On
DDecember 2013
WWinterbbournee Vieew: TTransfoormingg Caree Onee Yearr On
Winterbourne View: Transforming Care One Year On
Department of Health Update
December 2013
Contents Ministerial Foreword ................................................................................................................... 5 Simon's Story ............................................................................................................................. 8 Chapter 1 - Right Care, Right Place, Right Time ....................................................................... 9 Chapter 2 - Regulation; Inspection; Corporate Accountability ................................................. 13 Chapter 3 - Quality and Safety: Good Practice, Standards and Advocacy .............................. 18 Chapter 4 - Information and Data ............................................................................................ 21 Chapter 5 - Quality and Safety: Medication, Positive Behaviour Support and Physical Interventions. ........................................................................................................................... 25 Chapter 6 - Quality and Safety: Workforce .............................................................................. 28 Chapter 7 - Children and Transition ........................................................................................ 31 Appendix 1: Summary of progress on actions from Transforming Care & Concordat .............. 34 Appendix 2: Joint Health and Social Care Self-Assessment Framework 2013 ........................ 72 Appendix 3: Investment Summary ........................................................................................... 80
December 2013
Ministerial Foreword
WINTERBOURNE VIEW: TRANSFORMING CARE – ONE YEAR ON
i. Winterbourne View was a scandal which shocked and appalled us all. The systemic failings there are as bad as those uncovered by Robert Francis in his report into Mid Staffordshire. We are not looking at one or two poorly-trained or malicious members of staff but at something much more insidious. That is why we need this full programme of work to address all the different aspects and underlying causes which allowed this to happen. We must take every step to be as sure as we possibly can be that this will not happen again.
ii. One key aspect to this is transparency, at every level. This report is a part of that
transparency. It does not pretend that we have solved every problem, or even met every milestone in the extensive programme of work we put in place. We are involved with a wide range of partners across the health and care sectors and making full use of the expertise of people with learning disabilities themselves, and family carers. But the report is able to summarise an impressive array of the products of many people’s commitment and effort.
iii. This report is a chance to remind ourselves how important it is that we get care right for people with learning disabilities and whose behaviour challenges. Reading through it you will see what looks like a lot of process – legislation, consultation, data collection and the rest - which can seem a long way from the people we are trying to care for. We need to get those processes right in order to get the care right, but we must never forget the real reason we’re doing all of this, which is people.
iv. We have set ourselves, and the system, a series of major challenges with this
programme. This report sets out how far we have come in a short time, and over a period of major upheaval as the NHS reforms have been implemented. A great many people have worked extremely hard to achieve this. Appendix 1 summarises progress across all the Concordat commitments, and provides links to all the products associated with them. These provide the springboard for the next phase of the programme.
v. In particular, we have between us
• Completed the Learning Disabilities Census; • Published the Joint Improvement Programme’s stocktake report, including
information at local level; • Established an Enhanced Quality Assurance Programme to pursue the June 2014
deadline; • Developed a new planned approach to Care Quality Commission (CQC) inspection
of mental health and learning disabilities services from next year, to be led by Professor Sir Mike Richards;
• Developed new fundamental standards, which we will set out in regulations; • Ensured Adult Safeguarding Boards will be written into law.
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vi. However, while we take heart from all of this, we cannot begin to sit back. There is still a great deal to do. We still cannot point to routine evidence of the quality of outcomes from care – let alone demonstrate better outcomes. We know that there are individuals from Winterbourne View itself who are still not in the right care setting for them. We need to pick up the pace in order to meet our June 2014 milestones.
vii. We are all hugely impatient to see improved outcomes for the patients and families who
need these services, and it is right that we should be. Our impatience and determination are what have driven this programme so quickly, and will take it to the next level. However we must also be patient if our changes are to be sustainable. Without the right preparation and groundwork we shall be wasting our time. Worse, we might end up actually causing harm.
viii. Our starting point for this work is the 48 former residents of Winterbourne View. Sadly,
one has since died so we are now tracking progress for the remaining 47. ix. For now, NHS England is keeping a track of where those residents are. One thing they
do not need is media intrusion so we cannot identify them individually. We know that in June this year 24 of them were in residential care homes, 10 in supported living and 13 still in an NHS setting.
x. Of those 13, 5 were in assessment and treatment centres, 3 in medium secure and 5 in
low secure settings. Sadly, 12 of these people were being cared for out of area. xi. NHS England has established an Enhanced Quality Assurance programme (EQAP)
which will be responsible for future collection of information about these patients, including – if the individuals consent to this – additional assurance that they have had high-quality reviews, have clear care plans and are receiving the best possible support.
xii. While we must not lose sight of the Winterbourne View residents themselves this programme of work goes much wider. Transforming Care estimated that there were 3,400 people altogether in NHS-funded learning disability inpatient beds. We now have data from the Learning Disabilities Census, commissioned as part of this programme, which found that on 30 September provider organisations reported that there were 3,250 service users meeting the inclusion criteria. From the commissioning side, NHS England and Clinical Commissioning Groups have identified 2,677 individuals. These data need now to be reconciled, using common definitions, but they tell us for the first time with some confidence the number of people we are talking about. They also show us that: • Many people are spending a long time in inpatient care. 60% of service users had
been inpatients for a year or more while around one in six had been inpatients for five years or longer. Older people were more likely to have these long lengths of stay.
• Patterns of care vary enormously across the country. More than half of inpatients with home postcodes in the South West were in placements more than 100 km from home, but fewer than one in ten from the North East were so far from home.
• Strikingly, providers could not supply a valid residential postcode for 28% of
inpatients. Some providers were unable to supply this information for most of their inpatients.
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xiii. This sort of information underlines, yet again, the scale of the task – as well as pointing out some clear areas for attention. One of these is to get behind the data and understand what is happening locally, as well as for individuals. While we expect the total inpatient numbers to come down over time, there will always be people who need this care and there will be some who need it for the long term. Always, our focus must be on what is right for individuals.
xiv. The target date for everyone to be in appropriate care is June 2014. This is one of the chief areas for impatience. The right care is more important than the exact date – but there is no excuse for delay.
xv. To get us to that point as quickly as possible we need to accelerate progress on the
Concordat commitments. I have identified five key actions for the next six months. They are:
• Meet the commitment to ensure that individuals have moved or are moving to
settings closer to family by June 2014. • Establish robust systems for service users, their supporters and clinicians to feed into
and challenge the initiatives being taken forward. • Drive concerted effort to ensure that services are provided to a 21st century
standard, including Positive Behaviour Support and guidance on minimising the use of restraint.
• Establish Key Performance Indicators, using data from the Single Assessment Framework and the census.
• Disseminate the model service specification to both children’s and adults’ services to that it can be used to drive up quality.
xvi. I do not pretend that this will be easy. The agenda is crowded and resource is tight. But
we are spending public money, putting many people inappropriately in institutionalised care. This is intolerable.
xvii. We all remember the shock we felt when we first discovered what had been happening at Winterbourne View, and none of us wants to read that story happening again somewhere else.
NORMAN LAMB Minister of State for Care and Support
DDecember 2013
Siimon’s sttory – byy his mumm
Onnce more I ffind myself recounting Simon’s stoory but this ttime I do it with an elemment of hoppe. Simmon’s story of his adultt life starts wwhen we weere extraordiinarily luckyy to find a nnew, small caare home juust 100 minutes awway from uss. Simon waas proud to be the first one in and he got first choice of bedrooms! Agged 18 he wwas to spend the next fiffteen happy years here. His life waas stable, he was close too his friendss and family andd had a richh, social life balanced wiith a commuunity-based work placeement. Buut Simon alsso had unpreedictable annd sometimees challenginng behaviour. The homme put on an additional staaff member to help Simmon cope . TThis workedd reasonablyy well with ssome extra ffunds from social servicces. Buut not for long. WWe were told that Simonn had to go aaway for asssessment: thhis would “ggive him the best chancee of obtaininng thaat funding”.. Our objecttions were iggnored: if wwe failed to aagree “he woould be secttioned and pphysically remmoved in ann ambulancee”. It was to be over thrree years beffore Simon ccame home.. Thhe new homme was unablle to deal wiith Simon. HHe was lockked in the hoome, which made him bbehave worsse and they resorrted to usingg restraint. His psychiaatrist (despitte little day to day conttact with himm) said “he waas too dangeerous ever too return homme.” Hee was movedd again and the same thhings happenned. We latter learned tthat Simon had on at leeast three knnown occasioons been subbjected to illlegal restraiints. Simonn was sectiooned and sennt to Winterrbourne Vieew whhere he enduured 15 monnths of systeematic and ssustained toorment bothh emotional and physicaal. Simmon has a pphobia abouut toilets: thee staff held hhis head down the pan and flushedd it. They loocked him ovvernight in aan empty rooom with just a duvet. SSometimes tthey locked him out at mmealtimes. Unniquely, Simmon was ablee to return tto his originnal home whhere he was welcomed wwith open arrms. But thhe staaff noticed hhow he had changed, annd how his llife was noww limited. HHis anger annd frustration caused them huuge problemms but not onnce have theey had to resstrain him. Simon noww self-harms quite badlyy at times. Hiis anxiety haas reached nnew heights so that his dday has to bbe filled fromm start to finish. MMany things hhave changed for Simonn but I stronngly believe that being iin a familiarr place amonngst family and friends haas gone a lonng way towaards healingg some – thoough not alll - of the dammage. Amaazing staff have cared forr him and looved him. TThis shiningg example oof care at its best has enaabled Simonn to managee hiss life in the community though at ttimes the abbility to do sso has seemeed very fragile. Thhis is Simonn’s story. Annd this is whhy Transforrming Care is so badly nneeded.
Chapter 1 - Right Care, Right Place, Right Time.
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Reviewing placements and supporting everyone who is inappropriately in hospital to move to community based support. Locally agreed plans to ensure quality care and support services based on the model of good care. 1.1 One of the key messages from the Winterbourne View review is that care of people with
learning disabilities and challenging behaviour is the responsibility of a whole range of organisations and agencies. Each one needs to provide its own leadership but this programme needs to work with them all. As a first action we set up the Joint Improvement Programme (JIP) to work across the health and care system, to provide leadership and support to the transformation of services locally. Its role is to provide leadership, support and challenge where it is needed.
1.2 NHS England and the Local Government Association support this jointly. The JIP works in partnership with a whole range of other stakeholders including the National Forum of People with Learning Disabilities, the National Valuing Families Forum, the Challenging Behaviour Foundation, providers, Clinical Commissioning Groups, the Department of Health, the Society of Local Authority Chief Executives and Managers, the Association of Directors of Adult Social Services, the Association of Directors of Children’s Services, the Learning Disabilities Professional Senate and the Care Quality Commission.
1.3 A strong element of the improvement programme is
direct involvement with family carers and self-advocates and the JIP has established an engagement plan. This includes Engagement Strategy and Reference Groups which are advising theProgramme on how best to promote effective engagement with family carers and those who have experience of services, providing a direct link to individuals and groups who have a direct interest in the work of the Programme.
1.4 The JIP itself needs the right staff and resource to do its job. Appendix 3 gives a
breakdown of how we have funded the JIP and how it has used that money.
1.5 NHS England is responsible for specialised commissioning and for assuring the commissioning undertaken by Clinic Commissioning Groups (CCGs). NHS England has a key role in the leadership of this programme and its business plan includes the commitment to ensure personalised care and support to people needing this care and support by June 2014.
1.6 Commissioning is key to this agenda. The right commissioning by expert commissioners,
based on the right data, is the way to ensure the right capacity. CCGs and local authorities need joint strategic plans to commission the range of local health, housing and care support services to meet the needs of people with challenging behaviour in their area. The Association of Directors of Adult Social Services (ADASS) has been working with NHS England and others on commissioning standards to help drive quality up consistently. For example, they have used the Commissioning for Quality and Innovation (CQUIN) framework and developed model CQUINs for adult services.
Action … “Continuing to connect up families, inform, support, and staying strong for the challenge. Asking the difficult questions.” Asking the difficult questions.”
1.7 In addition, ADASS and the Care Provider Alliance published Finding Common Purpose1, developing strategic commissioning relationships to support people with learning disabilities in November 2013. It suggests how commissioners can build on what works and avoid the “short term, adversarial relationships which can harm valuable services – and the people who depend on them”.
Worries … “That providers have financial perverse incentives to keep people in long-term NHS provision.”
CCG registers
1.8 A first step for the programme was to be sure that all local NHS commissioners knew who they were responsible for who fell within the scope of this programme. Data issues are a question in their own right and are covered in Chapter 4: Transforming Care recognised the challenges and Appendix 1 shows how much work has been going on to address them, but there is still more to do. By April 2013 all Primary Care Trusts had developed registers of all people with learning disabilities or autism who have mental health conditions or behaviour that challenges in NHS-funded care. These were handed over to CCGs. With the local authority, they have also undertaken reviews of care plans for all the people on the registers, and have identified someone who should be the first point of contact for each individual. CCGs identified 1,317 individuals for whom they had commissioned care. All of these people had had reviews by 31 July 2013.
1.9 In addition, NHS England undertook to monitor progress for specialised commissioners. This work identified 1,360 patients in specialised services. 46 of those people were either discharged or had transferred into a care setting (usually home) so an in-patient review was no longer required, and 10 more were found by the Area Teams not to need one for other reasons – for example, 4 were confirmed as not having a learning disability. The remaining 1,304 have all now had their care reviewed.
1.10 NHS England has - subject to formal approval by the Health Research Authority
Confidential Advisory Group - established quarterly monitoring for NHS commissioners to ensure delivery of the June 2014 commitment. It will also ensure that all future reported figures are robust. It has also set up an Enhanced Quality Assurance Programme (EQAP) to ensure that that people are safe and to assure the quality of reviews. EQAP is looking at:
• Reviews of the former patients of Winterbourne View and others of concern; • Assessment of the quality of reviews completed by NHS England and CCGs; • Reviews of patients in providers (NHS and Independent Sector) where CQC has
concerns. 1.11 The next – and most important – step is to put the newly agreed plans into action for each
of these 2,621 individuals. This will be the test of the quality of the reviews and is now underway. At the same time, we must use the new Learning Disability Census information to make sure that we identify anyone who has been missed so far, and make sure that they too have plans in place.
1 http://www.vodg.org.uk/news/316/111/Report-breaks-down-barriers-to-better-commissioning-of-learning-disability-services.html
“Focus on people and their lives and not get buried by process, bureaucracy and organisational preciousness.”
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1.12 The milestone date for all people with care and support needs to be receiving personalised care and support is June 2014. This is likely to prove challenging and is why the programme needs to pick up the pace. People with care and support needs and their families are at the centre of this and their needs are paramount. We have set the deadline to concentrate minds. We have learned from the Francis report that targets must not be allowed to take priority over good care. But neither can this be used as an excuse for not moving as swiftly as possible for the benefit of people with care and support needs.
1.13 This programme of work does not finish at the June 2014 deadline. We are aiming for sustainable improvements, not a quick fix. To meet our aims of delivering personalised care closer to people’s homes and communities for the future means maintaining our focus on this work beyond the immediate timetable. Many of the people with care and support needs who have been in hospitals as in-patients for disproportionately long periods of time will need proper psychological support when they relocate to their home areas. This means that there are requirements for appropriate housing to be available, and teams with the skills needed to help people with institutionalisation and post traumatic issues based on their hospitalisation. These teams will also need the necessary support from professionals who can provide the continuing supervision, training and advice to enable them to respond to ongoing and new risks and challenges.
1.14 Work on the registers also showed that there was more to do to be sure that they were
comprehensive. In particular, they need to capture people in secure services and those in the care of Child and Adolescent Mental Health Services (CAMHS). There are also a number of children and young people in residential schools away from home who need support to move back to community-based personalised care where that is the right setting for them.
“We all need to promote the culture change between commissioners and providers – how do we get from an us and them position to how are ‘we’ going to tackle these challenges.”
The Housing Learning and Improvement Network has kept its members updated with key housing and safeguarding information through its newsletter and on its website. They have run learning and improvement workshops at regional “look and learn” events on safeguarding. With 46,000 members, 94% of whom read the newsletter, this is an effective way of communicating to a key audience.
Local planning
1.15 The JIP conducted a detailed stocktake with all Local Authorities, CCGs and Health and Wellbeing Boards. Every locality returned the questionnaire. The local work to complete the stocktake itself created much of the discussion and decision making needed to meet the Concordat requirements.
1.16 The stocktake returned some very encouraging information. It showed that all localities were engaged and working on the Concordat commitments and that there is a bedrock of skilled and committed staff at commissioner, care management and provider levels, and in leadership roles supporting change.
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1.17 It also found significant variations between localities. Although the programme emphasises the importance of joint ownership across health and social care, only 49% of returns had clearly been completed jointly. For the remainder, in 18% of returns it was unclear whether they were a shared effort and the rest had evidently been handled by one or other part of the system. This suggests that there are still issues of leadership to be addressed and the JIP will be dealing with this as a priority, working with partners to develop options. However, if this work finds continuing underperformance, there is backstop provision in regulation to support local authorities, while NHS England has powers which it can use as appropriate.
Pooled budgets
1.18 Shared funding arrangements go alongside shared leadership in ensuring that people’s care is determined by their needs rather than by bureaucratic processes. The Concordat highlights pooled budgets as the way to achieve this. The stocktake showed that these are still not widely used, although some localities use other mechanisms to support the flow and flexibility of resources. This is another area for further work by the JIP.
1.19 Where this flexibility is not available, it appears that rigid and sometimes arbitrary division between areas of commissioning are acting as a brake on progress. This clearly needs attention and the JIP will develop this when it undertakes local in-depth reviews as part of its development programme.
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Chapter 2 - Regulation; Inspection; Corporate Accountability Strengthen corporate accountability and responsibility of providers, and their management, for quality of care. Tighten regulation and inspection of providers. 2.1 Transforming Care is high on the agenda for the
Department of Health. The Learning Disability Programme Board leads on delivery of this programme of change by measuring progress against the Concordat’s milestones, monitoring the risks to delivery and publishing regular updates. The Board is chaired by the Minister of State for Care and Support and by Jon Rouse, Director General for Social Care, Local Government and Care Partnerships. The Board includes people with learning disabilities and representatives of family carers to keep it honest and grounded in the reality of what it is trying to achieve.
2.2 The Board’s papers are available online to ensure full transparency. This report has been published to meet a specific commitment in the Concordat. The Department of Health has held two Concordat events to share progress and invite feedback. Throughout this report there are quotations from some of those who attended the event on 5 November, including people with learning disabilities themselves.
2.3 This report begins with a case study – Simon’s story. It reminds us powerfully why this
programme was, and is, needed.
“The Winterbourne View Programme represents a huge programme of action that can seem overwhelming but if partnerships forged through this process remain strong, change can be delivered for individuals.”
Mencap and the Challenging Behaviour Foundation have campaigned with the families of people who were at Winterbourne View, and others, to keep these issues high on the national and local agendas. They have ensured that families have a voice with Ministers and key decision makers. Their involvement is greatly appreciated.
Regulation
2.4 The Care Quality Commission (CQC) has undertaken a rigorous process of development and consultation to change the way it inspects services for people with learning disabilities and improve systems and checks when providers apply to register a service.
2.5 These changes improve the statement of purpose, and provide guidance for registration assessors on site visits and interviews with registered managers. These raise the bar and require that providers set out in their statement of purpose how values-based recruitment is handled and how care staff are inducted, trained and supervised against appropriate standards and best practice. Aspirant registrants must also indicate how their proposed service fits with the model of care as set out in the Concordat. Organisations must now
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identify individuals at Board level who have day to day accountability and responsibility for quality, safety and compassionate care.
Inspection
2.6 The CQC has set out its strategy for inspections over 2013-16. Its inspections of hospitals, including those with learning disabilities services, will be led by Professor Sir Mike Richards, the Chief Inspector of Hospitals. There will be a pilot wave of some of these services, using the new methods, in January 2014. However, where there is information and evidence of concerns about quality and safety CQC will continue to respond and inspect services as part of their programme of work.
2.7 Inspections of adult care learning disability services will be led by Andrea Sutcliffe, the Chief inspector of Adult Social Care. The new approach to adult care inspections will be trialled from spring 2014. In the meantime CQC will continue to inspect adult care services as part of its on-going programme.
2.8 This programme involves unannounced inspections of providers of learning disability and
mental health services. CQC will be asking about issues such as the length of time people have been in assessment and treatment units. As well as the professional staff involved in this, CQC is using experts by experience: service users and their families are part of the inspection team to ensure that their perspective is not lost in the formalities of standards and paperwork.
“My motivation is a belief in the basic human right of all individuals to lead a valued and equal life. Why should people with learning disabilities have anything less?”
The Helsey Group – an independent service provider and a member of the Adults with Learning Disabilities Services (ALDS) Forum – has taken action where they felt most attention was needed without waiting for further national guidance. Their Non-Executive Board members are each taking personal responsibility for visiting each of their services every two months. This is in addition to quality monitoring visits from the arm’s length quality team. The Chief Executive Officer is undertaking fortnightly walkabouts of services. Quality indicators and outcomes provided at Board meetings include physical intervention, complaints, quality assessments, and health and safety information. The company has facilitated full and frank discussion with the Non-Executive board if there are concerns.
Corporate Accountability
2.9 The previous accountability arrangements failed to detect the true picture at Winterbourne View hospital. The Department of Health committed to examine how corporate bodies and their Boards of Directors can be held to account for the provision of poor care and harm.
2.10 In July 2013 the Government issued a consultation on Strengthening Corporate Accountability in Health and Social Care. This proposed a new requirement that all Board
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Directors (or equivalents) of providers registered with the Care Quality Commission must meet a new fitness test. This will apply to providers from the public, private and voluntary sectors.
2.11 The failings at Winterbourne View centred on abuse and assault, while those at Mid
Staffordshire involved neglect. Although the symptoms differ there are similarities in the underlying causes. The Francis report of the inquiry into Mid Staffordshire NHS Foundation Trust published in February 2013 raised concerns about corporate accountability which apply to both care settings. Hard Truths,2 the final Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry, published in November 2013, noted that the public has the right to expect that people in leading positions in NHS organisations are fit and proper persons; and that where it is demonstrated that a person is not fit and proper, they should not be able to occupy such a position.
2.12 Hard Truths announced that the Government will establish a new fit and proper person’s
test for Board-level appointments, which will mean that the Care Quality Commission is able to bar Directors who are unfit from individual posts at the point of registration. Where a Director is considered by the Care Quality Commission to be unfit it could either refuse registration, in the case of a new provider, or require the removal of the Director on inspection, or following notification of a new appointment.
2.13 Further details will be set out in the response to the consultation on corporate
accountability which will be published shortly. The Government plans to publish the draft regulations for consultation at the same time and to introduce the new regulations during 2014.
Golden Lane Housing (Mencap’s housing arm) has successfully launched a £10 million bond which they have used to invest in housing across the country for people with a learning disability. They have provided new tenancies in community-based settings for over 137 people with a learning disability in the first six months of this financial year. This is through a combination of housing acquired through the bond resources and housing leased form other landlords. We are exploring how this model might be used more extensively.
Fundamental Standards
2.14 The Care Quality Commission (CQC) has consulted on its approach to regulating providers of health and care services. When inspections are carried out in any care setting, teams will ask five key questions - is a service safe, effective, caring, responsive and well led?
2.15 The Department of Health has been working with the CQC to develop a set of fundamental standards and will consult on these in due course.
2.16 These will set a clear bar for the safety, effectiveness and compassion below which
standards of care should not fall. There will be immediate and serious regulatory consequences for services where care falls below these levels, including services going
2 Hard Truths: the Journey to Putting Patients First
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into special measures, being prosecuted, or having their registration and licensing withdrawn.
2.17 The CQC published the responses to its public consultation on 17 October 2013, which
showed that there is agreement with the new approach.3 The Department will consult shortly on the draft regulations which will set in legislation the fundamental standards of care that providers must meet. The new regulations will come into effect during 2014 and 2015 and will apply to all providers of health and social care that are required to register with the CQC.
United Response has reviewed its whistle blowing policy and is implementing a full review of its Quality Assurance system. They have set up a trustees’ ethics committee to sign off case studies and photos of people who cannot demonstrate capacity to consent under the mental capacity Act but whose stories will help raise awareness of people with profound disabilities in a positive way. They are finalising a checklist for managers to use when supporting people moving from an institutional setting to the community. They are revising Challenging Behaviour and Physical Intervention Standards to clarify responsibilities and develop standardised local and national reporting procedures for the use of physical interventions.
Duty of candour
2.18 The Government will introduce an explicit, statutory duty of candour as a Care Quality Commission registration requirement. The duty will apply to health and adult social care providers of regulated activities and will be enforced using the CQC’s powers. This duty will ensure that providers are open with patients and service users about failings in care and provide an explanation and, where appropriate, an apology. As a further incentive for Trusts to promote a culture of openness across their organisations, the Government will consult on proposals about whether Trusts should reimburse a proportion or all of the NHS Litigation Authority’s compensation costs when they have not been open about a safety incident.
2.19 Similarly, the General Medical Council, the Nursing and Midwifery Council, the Health and Care Profession Council and others will be working to agree consistent approaches to candour and reporting of errors, including a common responsibility across doctors and nurses and other health professionals to be candid with patients when mistakes occur whether serious or not, and clear guidance that professionals who seek to obstruct others in raising concerns or being candid would be in breach of their professional responsibilities. The Department of Health will ask the Professional Standards Authority to advise and report on progress with this work. The professional regulators will develop new guidance to make clear professionals’ responsibility to report ‘near misses’ or errors that could have led to death or serious injury, as well as actual harm, at the earliest available opportunity and will review their professional codes of conduct to bring them into line with
3 http://www.cqc.org.uk/public/news/support-our-inspection-changes
My motivation is …”Stopping the injustice to some of the most vulnerable people in society.”
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this guidance. The professional regulators will also review their guidance to panels taking decisions on professional misconduct to ensure they take proper account of whether or not professionals have raised concerns properly and openly.
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Chapter 3 - Quality and Safety: Good Practice, Standards and Advocacy Improve quality and safety so that best practice in learning disability services becomes normal practice. Ensuring good information and advice, including advocacy, is available to help people and their families.
Advocacy
3.1 The complexities of the health and care systems, and the complexity of the needs of individuals, mean that people with learning disabilities and their families have a particular need for well trained and independent advocates. These services can be invaluable in negotiating a path through the options, ensuring that everyone understands what is happening and why.
3.2 The Joint Improvement Programme (JIP) covered advocacy in its stocktake and the results were encouraging. 85% of localities reported that advocacy services were ‘routinely available’, and 76% said that they had confidence in the quality of advocacy support. Some areas were also able to describe how they evidenced the availability and quality of advocacy. However, the overall figures in the responses do not match the experience reported by third sector organisations and family carers. Their reports fit better with the smaller number of places who say that they have inclusive reviewing arrangements in place. In some places there are problems with the quality of advocacy services, while in many others there are problems around easy access to advocacy services.
3.3 This mismatch means that this is a significant area for
follow-up by the JIP, which plans now to explore further the availability and quality of advocacy services both locally and regionally.
3.4 The Department has been working with independent
advocacy organisations such as Inclusion North to improve the quality of the services available. The Department also works with Independent Mental Capacity Advocate (IMCA) services in some of the regional networks, with discussions of recent case-law. IMCA services have been active in considering which people need access to the Court of Protection, and have started acting as Litigation Friends, enabling people to have access to courts where there is no one else to bring a case in front of a judge.
3.5 Underlining the importance of advocacy, the Care Bill has been amended to introduce a
duty on local authorities from 2015 to provide independent advocacy in certain circumstances where it is considered that a person would otherwise experience substantial difficulty in being involved in their social care assessment, support planning or review. This will apply to adults and carers as well as children and young people at points of transition. The next step is to develop draft regulations and guidance to flesh this out. These will be ready for consultation in Spring 2014.
3.6 As part of the work to improve quality, the Department has been supporting work to
strengthen the Action for Advocacy (A4A) Quality Performance Mark (QPM) and review
“As a self-advocate I wanted to use my voice to speak up for other people who are in units.”
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the Code of Practice for advocates to clarify their role. The QPM is the only national advocacy-specific quality assessment system which applies to all forms of one to one advocacy. Organisations can be awarded the QPM if they meet specified quality standards which demonstrate their commitment and ability to provide high quality independent advocacy. The Department of Health entered into an agreement with A4A to take this work forward. However, A4A have ceased all operational activity and, following an interview with its trustees, its acting Chief Executive and representatives from Department of Health, the responsibility for taking forward the future of the QPM national advocacy accreditation scheme, has been passed to the National Development Team for Inclusion (NDTi) in order that the commitment given in Transforming Care can be delivered.
3.7 NDTi will aim to undertake a review of the Quality Performance Mark (QPM) and Code of
Practice (CoP), alongside associated materials, within this financial year. Their aim is that the revised tools will be ready for re-launch by April 2014.
3.8 At a local level, Inclusion North have developed a scope of work to provide people with
learning disabilities with good access to information, advice and advocacy in hospital.
Inclusion North The North East advocacy project aimed to develop thinking around advocacy in specialist services that was more than a paid professional role. This example shows what can happen when people are supported to come together to explore rights and speak up on more than an individual basis. Mr F had lived at home with family for all of his life. He came into hospital for a period when he was very unhappy and unsettled and his behaviour was challenging to the family. Mr F was asked if he was interested in coming along to the self-advocacy group and, with time and support to understand what it all meant, he agreed. Mr F came along to the group every week for the 12 weeks. He grew in confidence from week to week and became a vocal member of the group. It was noticed on the ward that he had more to contribute on a day to day basis. Mr F said being part of such a group had been great for helping him speak up and learn about his rights. He said that he has now spoken up about what he wants for his future and people are listening. He said he would come back to hospital to share his story and tell people it’s not that scary after all.
3.9 The Department is committed to work with the Local Government Association (LGA), Healthwatch England and the NHS to embed the importance of involving people with learning disabilities and their families in all planning and decision making which affects them. The LGA and Local Healthwatch England has agreed a joint work programme to address this. There is a national Healthwatch implementation team in place and working with local commissioners.
Healthwatch England has agreed with the National Valuing Families Forum that local Healthwatch should be supported to engage and work with people with learning disabilities. They are finalising the approach to producing tools to support this, with guidance from NVFF. This will help people with learning disabilities to hold local commissioners and providers to account. Healthwatch England will be seeking out feedback from people with learning disabilities and learning disability partner organisations about their engagement with local Healthwatch.
3.10 On the provider side, in September the Driving Up Quality Alliance launched a code for
organisations to follow, based on Think Local Act Personal Making It Real Principles. This
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aims to translate the high level vision into practical terms which will engage individuals on a personal level. It recommends that providers take responsibility for improving their services. Providers need to make a commitment first to listen to the people they support and then to support them to build lives that have meaning for them.
NICE Quality Standards
3.11 National Institute for Health and Care Excellence (NICE) Quality Standards are helpful and
influential to both commissioners and providers, setting out evidence-based definitions and measures of quality. Clinical guidelines set out clearly and in detail what good practice should look like. NICE’s collaborative and inclusive production process means that key organisations are involved in developing these materials.
3.12 The Concordat includes commitments that NICE will publish quality standards and clinical guidelines on challenging behaviour and learning disability. This is well under way. The clinical guideline will ready for publication in May 2015. They will be doing the same for mental health and learning disability but this work is not due to start yet. Winterbourne View stakeholders, including representatives of carers and families, have been involved. while Mencap are a stakeholder on NICE quality standards.
“Evidence-based guidance can’t come soon enough! Indicators and support for commissioners can follow guidance from NICE.”
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Chapter 4 - Information and Data Ensure transparent information and robust monitoring to deliver transformed care and support and make sure the public, people with challenging behaviours and families know if we are making progress
4.1 Transforming Care reported that there was a major intelligence gap in this area. There was little clarity on the number of people with behaviour that challenges in hospital settings, or on who was responsible for them. Since then there has been a great deal of activity to improve the situation which has itself uncovered a series of challenges. In particular, we need to agree on the definitions we use for both the individuals and the care settings. This is not simply a technical issue. While there is scope for misunderstanding on the current scale we shall struggle to state with confidence that we understand the position fully, either nationally or locally.
Learning Disability Census
4.1 In Transforming Care the Department committed to commission “an audit of current services for people with challenging behaviour to take a snapshot of provision, numbers of out of area placements and length of stay”. This is a provider-based exercise, covering mental health and learning disability providers in the statutory, voluntary and private sectors. The Health and Social Care Information centre (HSCIC) collected and analysed the data. The full results published on 13 December can be found on their website.4
4.2 The census date was 30 September 2013. All localities provided data. 4.3 3,250 services users met the inclusion criteria for the 2013 Learning Disabilities Census.
This is larger than the total of 2,677 identified by Clinical Commissioning Group’s (CCGs) as people in services they commission, and by NHS England for specialist commissioning. It is smaller than the 3,400 estimated in Transforming Care. This is a moving population, with people entering and leaving it, which complicates the picture, but commissioners will be anxious to use this information to triangulate with their own, so that they can be certain about numbers of people for whom they are commissioning care – and this is not always as simple as it might seem: Chapter 2 describes how NHS England’s monitoring of progress by specialised commissioners almost immediately found 56 people out of their initial 1,360 who no longer met the criteria. Complexities of definition – such as the understanding of “challenging behaviour” - and complexities of care commissioning are likely to be the other main reasons for the discrepancies, and the Joint Improvement Programme (JIP) and NHS England have been waiting for the census results to be able to work to reconcile the numbers. We know that the data in this area present significant challenges and a great deal of work has already gone on to resolve them. More is still needed and the census is a major contribution.
4 http://www.hscic.gov.uk/ldcensus
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4.4 The Local Government Association (LGA) and NHS England are today publishing local status reports which will be an important step in resolving these issues. These follow up the JIP stocktake published in October. Status reports show the numbers of people who are currently funded by CCGs, though where CCGs and local authorities do not share boundaries this can be less straightforward. Specialist and forensic commissioning is more complex and works to different boundaries. For each of the ten specialist areas it is now urgent that local areas (CGG and local authority) working with specialist commissioners and area teams, agree the local numbers and then work together from the reviews on the commissioning and funding challenges.
4.5 There are key findings from the census which will help to direct this work. Overall,
providers could not supply a valid residential postcode for 28% of inpatients. Some providers were unable to supply this information for most of their inpatients. This clearly needs to be resolved before we can be confident that systems are joining up to provide the best care for these people, and in particular that everything is being done to maintain contacts with family, friends, advocates and commissioners.
4.6 On out of area placements, the census found that just over one in five inpatients were
staying in wards 100km or more from their residential postcode. About the same proportion were within 10 km of their home postcode.
4.7 There were wide regional variations in how close to home people were cared for. More
than half of those with home postcodes in the South West were in placements more than 100 km from home, while this was the case for fewer than one in ten of those from the North East. Almost 40% of service users who lived in London received inpatient care within 10 km of home, while in the South East this applied to almost 20% - reflecting the difference between urban centres and more rural areas. Appendix 2 illustrates the variation at Local Authority level between people from that location known to have a learning disability and people known to be receiving inpatient treatment in that location.
4.8 On length of stay, 60% of service users had been inpatients for a year or more while
around one in six had been inpatients for five years or longer. Length of stay varied with age: around 40% of patients aged 65 and over had been inpatients for five years or more, around twice the proportion for all inpatients. Service users aged 18 and under were much more likely to have been inpatients for three months or less: more than 45% of them were in this position compared with almost 19% overall.
4.9 This audit provides baseline data so that we can track progress for the future. We shall be
repeating the census next year.
“Still problems with commissioners and providers working together – after all this time.”
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Self-assessment framework
4.10 The Concordat included a commitment that NHS England and Association of Directors of Adult Social Services (ADASS) would implement a joint health and social care self-assessment framework to monitor progress of key health and social care inequalities from April 2013. These data would be published at local as well as national level, so that commissioners and providers can see how they are performing against the average and against their peers. The framework has been implemented and data from local areas have been collected by Public Health England’s Learning Disabilities Observatory. Data collection finished only on 6th December, so there has not been time to report the findings in detail here. A full analysis will be published early in the New Year. Appendix 2 provides an overview of the coverage of the exercise and a number of key results with direct relevance to the Joint Improvement Programme.
Local Stocktake
4.11 The Joint Improvement Programme stocktake captured a wide range of information from all localities. It was designed to provide comprehensive, detailed and helpful feedback to both commissioners and providers about strengths and development needs. It is not a formal data collection like the census. The analysis was undertaken to regional level, providing a high level picture. However, for full openness and transparency – and to make it as practically useful as possible - it has now been developed to show details on a place by place basis. This shows progress in commissioning, funding and work to meet the June 2014 deadline set out in the Concordat. This material has been published at the same time as the One Year On report, and gives local areas the information they need to identify the real, practical steps they need to take from here.
Key Performance Indicators
4.12 Key Performance Indicators (KPIs) are essential to allow both the Learning Disabilities Programme Board and local areas to get a firm grip on how services are working locally. However it is also critical to choose the right KPIs. The Francis Report underlines the danger of perverse incentives, with the risk that organisations will concentrate on hitting the target while missing the point.
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4.13 This means that the process of developing KPIs is necessarily longer than we would like. We have to be certain that we are using the right definitions, that everyone understands them in the same way, and that we are not inadvertently building in problems for the future. Department of Health, Health and Social Care Information Centre (HSCIC) and NHS England have been working together to produce initial draft KPIs. The areas under consideration are:
• Proportion of inpatients with stays of 6 months / 1 year / 2 years whose discharge has been delayed due to a lack of appropriate discharge destination.
• Total number of incidents of challenging behaviour and physical restraints per inpatient per year
• Proportion of inpatients with Care Programme Approach (CPA) review and care plan (or other assessment and review) within the last 6 months.
• Total number of safeguarding alerts / serious untoward incidents per in patient per year.
• Total number of people moved from inpatient to community settings in a given number of months
• Total number of complaints over a given number of months
• Achievement of person centred planning outcomes
• Number of in-patient days in all mental and behavioural in-patient care in all sectors (NHS and independent) in the quarter for people with learning disabilities and /or autistic spectrum conditions
• The number of children in residential special schools with learning disabilities
• The number of current in-patients, at the end of each quarter who have been in hospital throughout the quarter, in all mental and behavioural in-patient care in all sectors (NHS and independent) with learning disabilities and / or autistic spectrum conditions
• The number of current in-patients who have had a face to face clinical review with the psychiatry of learning disabilities team for their home area within the quarter.
4.14 This range shows the challenge of finding forms of data which actually measure outcomes
and quality. We must remember, for example, that for some people residential care is the right care. The Health and Social Care Information Centre (HSCIC) indicator development team is now checking underpinning data sources and the robustness of the draft KPIs themselves. The next step will be to test the drafts with stakeholders, including engaging with family carers and self-advocates and we are anxious to ensure that people have a full opportunity to contribute views and suggestions. The final KPIs will be ready for implementation from April 2014.
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Chapter 5 - Quality and Safety: Medication, Positive Behaviour Support and Physical Interventions Improved quality and safety to give a better understanding of good practice on positive behaviour support and the environment so that challenging behaviour and the need for physical restraint are reduced. Antipsychotic and antidepressant medicines are used to ensure the best course of action for the patient and not over-used.
The Mental Health Act 1983
5.1 Winterbourne View raised very serious concerns that the principles and safeguards of the Mental Health Act 1983, and the Mental Capacity Act 2005 were not being correctly applied to individuals. People were having their freedom and movement constrained without clear justification. The principles of personalisation in the NHS Constitution were also being ignored.
5.2 To address this, the Department of Health is leading a cross-system review of the implementation of Mental Health Act 1983 and is due to consult on changes to the Code of Practice in early 2014. The Department is also reviewing implementation of the Mental Capacity Act 2005 and is committed to work with the Care Quality Commission (CQC) to agree how best to raise awareness of and ensure compliance with Deprivation of Liberty Safeguards provisions. This is a serious issue: it is unlawful to deprive someone of their liberty outside of these provisions. That work is under way and is due to report by Spring 2014.
5.3 Alongside this, the English Community Care Association (ECCA) undertook to produce
extra support and explanatory material for its members on Deprivation of Liberty Safeguards and Human Rights. Those materials will be published, in conjunction with the Joint Improvement Programme, in April 2014.
Safeguarding Adults Boards
5.4 The Department of Health had an existing commitment to put Safeguarding Adults Boards on a statutory footing. This will be achieved through the Care Bill which has now reached its second reading in the House of Commons. The Department will revise both statutory and good practice guidance to reflect new legislation and, specifically, to address the findings from Winterbourne View. The Care Bill, and those supporting materials, will be implemented from 2015.
5.5 In the meantime, and to prepare for this, the Concordat sets out the need for Safeguarding Adults Boards to review their existing arrangements. In particular, they need to be sure that they have the right information sharing processes in place across health and care to enable them to identify and deal with safeguarding alerts.
5.6 Association of Directors of Adult Social Services (ADASS) has pursued this and found that
many Safeguarding Adults Boards had considered Winterbourne View issues and looked at local arrangements. The Joint Improvement Programme (JIP) stocktake picked up
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concerns expressed at the first Concordat event about assurance mechanisms, and was able to provide reassurance that there was reasonable evidence of local understanding and use of safeguarding processes.
Spotting abuse early
5.7 A major concern from Winterbourne View was the length of time individuals had been subject to abuse before anything was done about it. The police recognise that they have a role to play here. Avon and Somerset police have developed a process to trigger early identification of abuse, which they are now using. In January 2014 the police will plan how to disseminate this nationally. All associated learning will be incorporated into training and practice, including Authorised Professional Practice.
“Worried about children’s safety and families’ anxiety over not being able to see them”
Positive Behavioural Support and the minimisation of restrictive practices
5.8 Positive Behavioural Support (PBS) is a technique to identify what environmental factors and other influences can be used to discourage problematic behaviour and encourage desirable behaviour. It can reduce the need for interventions such as physical restraint, chemical restraint, mechanical restraint and seclusion. It therefore has huge potential to improve the quality of life and outcomes for individuals across health and social care and in particular those treated in inpatient settings or in residential care.
5.9 The Concordat committed the Department of Health, with external partners, to publish guidance on best practice around positive behaviour support and the minimisation of restrictive practices across health and adult social care. The Royal College of Nursing agreed to take the lead role in producing this with a group of clinical professionals and experts by experience. They will publish a draft for consultation by the end of December 2013 and the Department of Health will publish a final version of the guidance by the end of March 2014. Aligned with this, Skills for Care and Skills for Health are developing a framework for commissioning training and other workforce development activities in positive behaviour support, including physical interventions as part of this approach.
5.10 In the summer Skills for Care published a framework for commissioning learning and
development more generally in the context of support for people whose behaviour may challenge. Work now is focused on implementation of the workforce commissioning framework.
5.11 As part of the Concordat, the British Psychological Society (BPS) has undertaken to
provide leadership to promote training in, and appropriate implementation of, Positive Behavioural Support across the full range of care settings.
5.12 To meet this commitment, the Learning Disability faculty of the Society has enrolled
thirteen experienced psychologists on the South Wales Advanced Professional Diploma in Positive Behavioural Support. The British Psychological Society has revised the accreditation criteria for clinical psychology and is identifying additional core competencies in this area. This work has the potential to contribute more widely to a programme to reduce restrictive practices and restraint.
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5.13 Winterbourne View also raised questions about whether people were being given the right medications to improve their condition, or whether they were being over-medicated for the benefit of staff. The JIP has commissioned two reviews of current data held on the prescribing of antipsychotic and antidepressant medication for people with learning disabilities and challenging behaviour. These reviews are with the CQC and Medicines and Healthcare Products Regulatory Agency. In September 2013, NHS Improving Quality (NHSIQ) was commissioned to lead on scoping and establishing a collaborative to share learning and develop best practice to address these prescribing issues. It will launch in early 2014.
5.14 CQC is also carrying out an audit of use of medication for those patients with a learning
disability detained under the Mental Health Act based on the Second Opinion Appointed Doctors (SOAD) data that they hold. It is a six month retrospective review. The output will give an insight into the way medications are used and the basis for their use. It will also set out how CQC can routinely capture the information.
5.15 All of this work needs to be effectively aligned and coordinated, including with the work by
National Institute for Health and Care Excellence (NICE) to develop quality standards, and fundamental standards for CQC registration. In order to embed the required training, cultural and leadership changes required the Department is currently working with partners to develop a wider work programme to reduce restraint/restrictive practices across health and adult social care, including in particular learning disability and mental health services. This should allow us to maximise the benefits offered by synergies, avoid wasteful duplication and ensure that we do fundamentally transform services.
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Chapter 6 – Quality and Safety: Workforce Improve quality and safety through improving the capability of the workforce so that staff are properly trained in essential skills supported by good clinical and managerial leadership. Health and care professionals should understand and be supported in achieving minimum standards and aspire to best practice. Staff should feel it is safe to raise concerns when things go wrong and be listened to. 6.1 Workforce development is key to successfully changing the way in which people are
supported. In the last year a range of different organisations have been involved in meeting the workforce challenges raised by Winterbourne View.
6.2 Appendix 1 sets out detailed progress on the different resources that are either in preparation or have been completed. Skills for Care has been working with the Department of Health, providers, clinical leaders, commissioners, carers and people with care and support needs to improve skills and capability to respond the needs of people with complex needs. The new resources in preparation include:
• Guidance for social workers on good practice in working with people with learning
disabilities who are distressed or whose behaviour challenges those around them. • Good practice standards for commissioners and providers to promote reasonable
adjustments to meet the speech, language and communication needs of people with learning disabilities / autism in specialist hospital and residential settings.
• A refreshed “Challenging Behaviour: A Unified Approach” to support clinicians in community learning disability teams to provide better integrated services.
• Minimum standards of conduct and training for all healthcare workers and social care workers (published).
• A guide for social care employers on how good workforce development can aid positive behaviour support.
• A guide to different mental health inpatient services available for people with learning disabilities, mental health and or other needs.
• Core principles on a statement of ethics to reflect wider responsibilities in the health and care system.
• A progress report on implementation of the recommendations in Strengthening the Commitment, the report of the UK Modernising learning disability Nursing Review.
• Advice for employers on whistleblowing.
6.3 Skills for Care is working with the Department of Health and partners on implementing the
response to the Cavendish and Francis reports. A common theme is that all care workers need the right training, not just the traditional professionals such as doctors, nurses and social workers. That is behind the introduction of the Care Certificate. The Government has asked Health Education England to work with Skills for Care, Skills for Health and other stakeholders to consider how the ‘Certificate for Fundamental Care’ (now the Care Certificate) can be developed.
The Royal College of Nursing highlights good practice in learning disability nursing. They provide support for the Learning Disabilities Academic network group. RCN has seen a year on year rise in Learning Disability forum membership. There is better awareness of learning disabilities career options, and better communication with the widest RCN membership.
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6.4 In addition to these activities other workforce development projects include a Skills for Care and Skills for Health workforce commissioning guide for social care and health employers on workforce development and the workforce development needs of workers who may need to carry out physical interventions, and a review of the curriculum for psychiatrists in training by the Royal Collage of Psychiatrists.
6.5 Social Care and Health employers have expressed a high degree of interest in using the
workforce resources that have been developed.
6.6 Many of the workforce resources have sound advice and requirements.
6.7 Putting the resources into practice will require workforce development support and action that ensures that the reach and impact of the resources collectively can be measured. Most resources are aimed at one section of the workforce but their implementation requires changes to the workforce and organisational structure surrounding them as well as to the individual’s practice.
6.8 Employers who provide services have suggested that working with commissioners can still
be a challenge. An interest and commitment from commissioners in contracting to provide person-centred, effective and efficient, close to home support is not always evident. From a workforce development perspective this provides an opportunity to champion shared learning between commissioners, providers, people with care and support needs and family carers.
6.9 Commissioning and brokerage services should support families and individuals to find the
right support and creatively build individual support packages. Families need to be supported to train individual support staff to work with their family member so the support is tailored. Workforce development support that enables these relationships to grow in the context of work in social care on assessment and eligibility will be important.
6.10 Ensuring that the workforce resources that have developed are widely shared, people and
organisations know how to use them and know how the resources make an impact on how people are supported will be a key challenge over the next year.
6.11 Hard Truths, the response to the Francis Inquiry
into Mid Staffordshire Foundation Trusts also set out a number of proposals which will help to improve services for people with learning disabilities. They are not aimed specifically at this group but people with learning disabilities should expect to benefit like anyone else from the range of developments including:
• A new national safety website which will publish all the information relevant to
safety in every hospital in the country on a monthly basis, so that people with care and support needs have the same information about their hospitals that the system has.
• A new national patient safety programme across England to spread best practice and build safety skills across the country. NHS England will start the programme in April 2014 and will bring together frontline teams, experts, people with care and
“Those areas that want to change are changing. We are still left with too many areas that have not changed enough.”
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support needs, commissioners and others to tackle specific patient safety problems, develop and test solutions, and learn from each other to improve safety.
• A new criminal offence for wilful neglect: the government will legislate at the
earliest available opportunity to make it an offence to deliberately neglect patients - so that organisations and staff, whether managers or clinicians, responsible for the very worst failures in care are held accountable.
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Chapter 7 - Children and Transition To deliver integrated support to vulnerable children and young people with behaviour that challenges. This should include early and effective intervention with care co-ordinated around and tailored to the needs of the individual child or young person.
7.1 The Concordat’s Programme of Action made clear that a life course approach needs to be adopted to transform health and care services and improve the quality of care offered to individuals with learning disabilities or autism who have mental health conditions or behaviour that challenges. If children and young people do not receive effective support at an early enough stage in life, it can set them on a path where their problems are exacerbated and their life chances affected. In responding to the terrible abuse which occurred at Winterbourne View a key issue has been to ensure that stakeholders representing children and young people, their families and carers, have been fully involved.
7.2 The Joint Improvement Programme has emphasised the commitment to this area by recently appointing a Special Advisor to lead on children and young people and life course planning, and recognising the development of the core service specification in line with the model of care in Transforming Care as a key piece of work yet to be completed.
7.3 The independent Children and Young People’s Health Outcomes Forum has been asked
to provide recommendations in relation to prioritising improvement outcomes for children and young people with behaviour that challenges and agree how best to support young people with complex needs in making the transition to adulthood. On behalf of the Forum, the National Network of Parent Carer Forums has issued guidance on integration of services for supporting children with complex needs in making the transition to adulthood, The Forum continues to be an advocate of supporting improved outcomes relating to the transition from children’s to adult services and will recommend that supporting young people with complex needs, including autism or who exhibit challenging behaviour, is a significant element of the transition guidelines in development by the National Institute for Health and Clinical Excellence (NICE). The Department is working with NHS England in developing measures of the experience of care of chilintention is that this will include meaningful measures of the effectiveness of transition. NHS England is developing a service specification for transition for the NHS.
7.4 Whilst progress has been slower than originally anticipated on the core service specification, there are now clear plans to produce a document for consultation in December 2013 which is focussed and practical and helpful and that will be used by commissioners. The all-age core specification will focus on how commissioners can ensure that high quality care and support are provided, with services designed around the needs of the individual and their family and provided as locally as possible. It will signpost how arrangements will change
dren and young people, and the
What matters most …”Getting it right from the start with children, so that children and young people have the right support in the local communities”
“My hope is for prevention: young people not following the specialist, exclusion route.”
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with the passage of the Children and Families Bill, and provide clarity around the interface both with the commissioning of specialist health services and education. An Expert Advisory Group containing representatives from a number of key organisations bringing together their experience and expertise is supporting this work.
7.5 Work to align child health and learning disability data sets is underway and includes:
• a new learning disability measure was added to the Children and Young People’s Improving Access to Psychological Therapies (IAPT) data set in October 2013;
• identification of those with learning disabilities in new large scale surveys of child health;
• a census of inpatient hospital beds for people of all ages with a learning disability or autism who may also have behaviour that challenges or a mental health condition;
• exploring and strengthening links between the availability of data on children and young people and adults through the work of the Child and Maternal Health Intelligence Network and the Learning Disability Observatory; and,
• developing links between data sets. 7.6 The Department of Health agreed funding in July 2013 for stage one of the two year
development of a Disability E-Learning Portal by a Royal College of Paediatrics and Child Health (RCPCH) led Consortium. The Project Team for developing the e-learning portal were in post by early October 2013. This exciting project, which will specifically cover individuals with learning disabilities or autism who have mental health conditions or behaviour that challenges, will make available interactive online programmes to extend the skills and knowledge of
• NHS staff working with children and young people on evidence-based outcomes-
focussed delivery; • Staff working in universal settings, such as healthcare assistants, care home
workers, teachers, social workers, police, probation, faith group workers, prison staff, to understand and recognise disability challenges and problems, particularly at the early stages, to provide simple strategies which staff can use to support children and young people where appropriate, and to help staff refer on where necessary.
7.7 In addition the Challenging Behaviour Foundation, in partnership with the Council for
Disabled Children, is in receipt of three year project funding from the Department of Health to review and develop resources which support good practice in services for children and young people with learning disabilities and challenging behaviour and to work with stakeholder groups to increase the reach and access of these resources. The project started in July 2013.
7.8 The Children and Families Bill, which entered Committee Stage in the House of Lords on 6 October 2013, will extend the Special Educational Needs (SEN) system from birth to 25, giving children, young people and their parent’s greater control and choice in decisions and ensuring needs are properly met. The Bill, in its current form, would introduce from September 2014:
• new joint-arrangements for assessing, planning and commissioning services for
children and young people with special educational needs, which make it clear what will be offered, and who will deliver and pay for it, underpinned by a process to swiftly resolve local disputes between partners;
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• a new local offer, so children, young people and their families are clear what is available locally, with a clear complaint process and redress system;
• local Education, Health and Care (EHC) Plans from 0 to 25 which set out in one place the support from education, health and care services children and young people will receive; with a new focus on helping to improve outcomes, including future employment and independent living;
• personal budgets for those families who want to have them; and, • a duty on clinical commissioning groups (CCGs) (and in some cases, NHS England)
as health commissioners to secure the provision of health services which they have agreed in the EHC plan, similar to the duty on local authorities in respect of special educational services.
7.9 The Special Educational Need and Disabilities (SEND) pathfinder programme includes
partnerships between local authorities and the health service to test out the new arrangements. This new approach has tremendous potential not only to ensure that children and young people who have extremely complex needs are supported with integrated packages of care planned and delivered according to their individual needs, but also to set an example to the wider NHS and social care of how to deliver integrated care co-ordinated around the patient.
7.10 The commitment to develop and issue statutory guidance on children in long-term residential care in 2013 is progressing well. The draft guidance has had input from external key stakeholders, and a revised draft will be shared between the Department for Education and the Department of Health at the start of December, which will then be sent for Ministerial approval.
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port
to th
e tra
nsfo
rmat
ion
of s
ervi
ces
loca
lly.
They
will
invo
lve
key
partn
ers
incl
udin
g Th
e D
epar
tmen
t of H
ealth
(DH
), th
e A
ssoc
iatio
n of
Dire
ctor
s of
Soc
ial S
ervi
ces
(AD
AS
S),
the
Ass
ocia
tion
of D
irect
ors
of C
hild
ren’
s S
ervi
ces
(AD
CS
) and
the
Car
e Q
ualit
y C
omm
issi
on (C
QC
) in
this
wor
k, a
s w
ell a
s pe
ople
with
cha
lleng
ing
beha
viou
r and
thei
r fa
mili
es.
The
prog
ram
me
will
be
oper
atin
g w
ithin
thre
e m
onth
s an
d B
oard
and
le
ader
ship
arr
ange
men
ts w
ill b
e in
pla
ce b
y th
e en
d of
Dec
embe
r 201
2.
DH
will
pro
vide
fu
ndin
g to
sup
port
this
wor
k.
From
D
ec
2012
By
Mar
ch
2013
CO
MPL
ETE
The
Join
t Im
prov
emen
t Pro
gram
me
(JIP
) is
in fu
ll op
erat
ion.
Chr
is B
ull l
ed a
s P
rogr
amm
e D
irect
or,
wor
king
par
t tim
e, to
Nov
embe
r 201
3. H
is s
ucce
ssor
is
expe
cted
to b
e an
noun
ced
shor
tly.
Dec
embe
r 201
3
35
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
RA
G
Com
men
ts
18A
The
NH
S E
ngla
nd w
ill w
ork
with
Ass
ocia
tion
of D
irect
ors
of S
ocia
l Ser
vice
s (A
DA
SS
) to
deve
lop
prac
tical
reso
urce
s fo
r co
mm
issi
oner
s of
ser
vice
s fo
r peo
ple
with
le
arni
ng d
isab
ilitie
s, in
clud
ing
new
NH
S
cont
ract
sch
edul
es fo
r spe
cial
ist l
earn
ing
disa
bilit
y se
rvic
es
B
y M
arch
20
13
ON
GO
ING
A
n A
ll A
ge S
peci
ficat
ion
will
be
issu
ed b
y th
e en
d 20
13.
This
will
repl
ace
the
adul
t onl
y sp
ecifi
catio
n.
18B
NH
S E
ngla
nd w
ill w
ork
with
Ass
ocia
tion
of
Dire
ctor
s of
Soc
ial S
ervi
ces
(AD
AS
S) t
o de
velo
p pr
actic
al re
sour
ces
for
com
mis
sion
ers
of s
ervi
ces
for p
eopl
e w
ith
lear
ning
dis
abili
ties,
incl
udin
g m
odel
s fo
r re
war
ding
bes
t pra
ctic
e th
roug
h th
e N
HS
; co
mm
issi
onin
g fo
r Qua
lity
and
Inno
vatio
n (C
QU
IN) f
ram
ewor
k
B
y M
arch
20
13
ON
GO
ING
Mod
el C
QU
INs
for a
dults
ser
vice
s ar
e cu
rren
tly in
dra
ft an
d w
ill b
e m
ade
avai
labl
e sh
ortly
.
18C
NH
S E
ngla
nd w
ill w
ork
with
Ass
ocia
tion
of
Dire
ctor
s of
Soc
ial S
ervi
ces
(AD
AS
S) t
o de
velo
p pr
actic
al re
sour
ces
for
com
mis
sion
ers
of s
ervi
ces
for p
eopl
e w
ith
lear
ning
dis
abili
ties,
incl
udin
g a
join
t hea
lth
and
soci
al c
are
self-
asse
ssm
ent f
ram
ewor
k (S
AF)
to s
uppo
rt lo
cal a
genc
ies
to m
easu
re
and
benc
hmar
k pr
ogre
ss.
B
y M
arch
20
13
CO
MPL
ETE
D
ata
colle
ctio
n fo
r the
new
SA
F w
as c
ompl
eted
in
Nov
embe
r 201
3, w
orki
ng w
ith P
ublic
Hea
lth E
ngla
nd
(PH
E).
ht
tp://
ww
w.im
prov
ingh
ealth
andl
ives
.org
.uk/
proj
ects
/hsc
lds
af.
A
naly
sis
of th
e da
ta c
an b
e fo
und
in A
ppen
dix
2 of
this
re
port
18D
N
HS
Eng
land
will
wor
k w
ith th
e D
epar
tmen
t of
Hea
lth to
set
out
how
to e
mbe
d Q
ualit
y of
H
ealth
Prin
cipl
es in
the
syst
em, u
sing
NH
S
cont
ract
ing
and
guid
ance
.
B
y M
arch
20
13
CO
MPL
ETE
NH
S c
ontra
ct te
chni
cal g
uida
nce
incl
udes
the
Qua
lity
of
Life
Prin
cipl
es a
t par
agra
ph 9
.38:
ht
tp://
ww
w.c
omm
issi
onin
gboa
rd.n
hs.u
k/nh
s-st
anda
rd-
cont
ract
/
36
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
RA
G
Com
men
ts
19
NH
S E
ngla
nd a
nd A
ssoc
iatio
n of
Dire
ctor
s of
S
ocia
l Ser
vice
s (A
DA
SS
) will
dev
elop
ser
vice
sp
ecifi
catio
ns to
sup
port
Clin
ical
C
omm
issi
onin
g G
roup
s in
com
mis
sion
ing
spec
ialis
t ser
vice
s fo
r chi
ldre
n, y
oung
peo
ple
and
adul
ts w
ith c
halle
ngin
g be
havi
our b
uilt
arou
nd th
e m
odel
of c
are
in A
nnex
A to
Tr
ansf
orm
ing
Car
e.
B
y M
arch
20
13
ON
GO
ING
A
n A
ll A
ge S
peci
ficat
ion
will
be
issu
ed b
y th
e en
d 20
13.
This
will
repl
ace
the
adul
t onl
y sp
ecifi
catio
n.
20
The
Join
t Com
mis
sion
ing
Pan
el o
f the
Roy
al
Col
lege
of G
ener
al P
ract
ition
ers
and
the
Roy
al C
olle
ge o
f Psy
chia
trist
s w
ill p
rodu
ce
deta
iled
guid
ance
on
com
mis
sion
ing
serv
ices
fo
r peo
ple
with
lear
ning
dis
abili
ties
who
als
o ha
ve m
enta
l hea
lth c
ondi
tions
.
B
y M
arch
20
13
CO
MPL
ETE
Com
mis
sion
ing
guid
ance
on
Men
tal H
ealth
Ser
vice
s fo
r P
eopl
e w
ith L
earn
ing
Dis
abili
ties
was
pub
lishe
d in
Jun
e.
http
://w
ww
.jcpm
h.in
fo/re
sour
ce/g
uida
nce-
for-
com
mis
sion
ers-
of-m
enta
l-hea
lth-s
ervi
ces-
for-
peop
le-
with
-lear
ning
-dis
abili
ties/
22
NH
S E
ngla
nd w
ill e
nsur
e th
at a
ll P
rimar
y C
are
Trus
ts d
evel
op lo
cal r
egis
ters
of a
ll pe
ople
with
cha
lleng
ing
beha
viou
r in
NH
S-
fund
ed c
are.
From
N
ov
2012
By
Apr
il 20
13
CO
MPL
ETE
A
ll lo
cal a
reas
are
now
usi
ng re
gist
ers.
Wor
k co
ntin
ues
to re
fine
thei
r qua
lity
and
cove
rage
.
25
The
Dep
artm
ent o
f Hea
lth w
ill w
ork
with
key
pa
rtner
s to
agr
ee h
ow Q
ualit
y of
Life
pr
inci
ples
sho
uld
be a
dopt
ed in
soc
ial c
are
cont
ract
s to
driv
e up
sta
ndar
ds.
B
y 1
Apr
il 20
13
FIN
ALI
SIN
G T
OO
LKIT
Q
ualit
y of
Life
sta
ndar
ds h
ave
been
writ
ten
and
test
ed
and
a to
olki
t to
acco
mpa
ny th
e st
anda
rds
is in
de
velo
pmen
t. It
will
incl
ude
a gu
ide
to “Q
ualit
y C
heck
ing”
whi
ch w
ill o
utlin
e un
derly
ing
prin
cipl
es o
f qu
ality
che
ckin
g w
ork
led
by E
xper
ts b
y E
xper
ienc
e.
The
tool
kit d
escr
ibes
som
e of
the
way
s th
e Q
ualit
y of
Li
fe s
tand
ards
are
bei
ng u
sed
by c
omm
issi
oner
s to
de
velo
p ou
tcom
e ba
sed
com
mis
sion
ing
and
by C
ounc
il co
ntra
cts
depa
rtmen
ts to
rais
e th
e qu
ality
of l
ocal
su
ppor
t and
pro
visi
on.
The
stan
dard
s an
d to
olki
t will
be
laun
ched
ear
ly in
20
14.
37
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
RA
G
Com
men
ts
26
The
NH
S C
omm
issi
onin
g B
oard
will
mak
e cl
ear t
o C
linic
al C
omm
issi
onin
g G
roup
s (C
CG
’s) i
n th
eir h
ando
ver a
nd le
gacy
ar
rang
emen
ts w
hat i
s ex
pect
ed o
f the
m in
m
aint
aini
ng lo
cal r
egis
ters
, and
revi
ewin
g in
divi
dual
’s c
are
with
the
Loca
l Aut
horit
y,
incl
udin
g id
entif
ying
who
sho
uld
be th
e fir
st
poin
t of c
onta
ct fo
r eac
h in
divi
dual
.
From
1
Apr
il 20
13
By
June
20
13
CO
MPL
ETE
The
NH
SC
B w
rote
to R
egio
nal D
irect
ors
in J
anua
ry
2013
. ht
tp://
ww
w.im
prov
ingh
ealth
andl
ives
.org
.uk/
uplo
ads/
doc/
vid_
1879
9_Le
tter%
20to
%20
Reg
iona
l%20
Dire
ctor
s%20
re%
20W
inte
rbou
rne%
20vi
ew%
2024
.1.1
3.pd
f N
HS
Eng
land
wro
te a
gain
to C
CG
’s in
Jun
e.
http
://w
ww
.impr
ovin
ghea
lthan
dliv
es.o
rg.u
k/up
load
s/do
c/vi
d_18
800_
1306
03%
20B
arba
ra%
20H
akin
%20
WV
.PD
F
30
Car
e Q
ualit
y C
omm
issi
on (C
QC
) will
sha
re
the
info
rmat
ion,
dat
a an
d de
tails
they
hav
e ab
out p
rovi
ders
with
the
rele
vant
Clin
ical
C
omm
issi
onin
g G
roup
s (C
CG
’s) a
nd lo
cal
auth
oriti
es.
Fr
om A
pril
2013
ON
GO
ING
C
QC
con
tinue
to p
rovi
de in
form
atio
n an
d da
ta v
ia th
e Jo
int I
mpr
ovem
ent P
rogr
amm
e.
33
The
stro
ng p
resu
mpt
ion
will
be
in fa
vour
of
pool
ed b
udge
t arr
ange
men
ts w
ith lo
cal
com
mis
sion
ers
offe
ring
just
ifica
tion
whe
re
this
is n
ot d
one.
The
NH
S C
omm
issi
onin
g B
oard
(now
NH
S E
ngla
nd),
Ass
ocia
tion
of
Dire
ctor
s of
Soc
ial S
ervi
ces
(AD
AS
S),
the
Ass
ocia
tion
of D
irect
ors
of C
hild
ren’
s S
ervi
ces
(AD
CS
) will
pro
mot
e an
d fa
cilit
ate
join
t com
mis
sion
ing
arra
ngem
ents
.
From
A
pril
2013
O
ngoi
ng
ON
GO
ING
Th
e st
ockt
ake
show
ed th
at th
ese
are
still
not
wid
ely
used
, alth
ough
som
e lo
calit
ies
use
othe
r mec
hani
sms
to
supp
ort t
he fl
ow a
nd fl
exib
ility
of r
esou
rces
. Th
is is
an
othe
r are
a fo
r fur
ther
wor
k by
the
JIP
.
34
NH
S E
ngla
nd w
ill e
nsur
e th
at C
linic
al
Com
mis
sion
ing
Gro
ups
(CC
Gs)
wor
k w
ith
loca
l aut
horit
ies
to e
nsur
e th
at v
ulne
rabl
e pe
ople
, par
ticul
arly
thos
e w
ith le
arni
ng
disa
bilit
ies
and
autis
m re
ceiv
e sa
fe,
appr
opria
te a
nd h
igh
qual
ity c
are.
The
pr
esum
ptio
n sh
ould
alw
ays
be fo
r ser
vice
s to
be
loca
l and
that
peo
ple
rem
ain
in th
eir
com
mun
ities
.
From
A
pril
2013
O
ngoi
ng
ON
GO
ING
Th
e N
HS
Eng
land
Bus
ines
s P
lan
incl
udes
a
com
mitm
ent t
o ha
ve a
chie
ved
all t
he a
ctio
ns in
the
Con
cord
at b
y Ju
ne 2
014.
The
Enh
ance
d Q
ualit
y A
ssur
ance
Pro
gram
me
(EQ
AP
) is
wor
king
with
CC
Gs
and
Are
a Te
ams.
38
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
RA
G
Com
men
ts
35
Hea
lth a
nd c
are
com
mis
sion
ers
shou
ld u
se
cont
ract
s to
hol
d pr
ovid
ers
to a
ccou
nt fo
r the
qu
ality
and
saf
ety
of th
e se
rvic
es th
ey
prov
ide.
From
A
pril
2013
O
ngoi
ng
ON
GO
ING
N
HS
Eng
land
and
the
Join
t Im
prov
emen
t Pro
gram
me
(JIP
) are
wor
king
with
the
Ass
ocia
tion
of D
irect
ors
of
Soc
ial S
ervi
ces
(AD
AS
S) a
nd th
e A
ssoc
iatio
n of
D
irect
ors
of C
hild
ren’
s Se
rvic
es (A
DC
S) o
n in
form
atio
n sh
arin
g.
An
all a
ge c
ore
spec
ifica
tion
will
be
publ
ishe
d al
ongs
ide
the
NH
S s
tand
ard
cont
ract
in D
ecem
ber a
long
side
oth
er
mod
el s
peci
ficat
ions
.
42
Hea
lth a
nd c
are
com
mis
sion
ers,
wor
king
with
se
rvic
e pr
ovid
ers,
peo
ple
who
use
ser
vice
s an
d fa
mili
es, w
ill re
view
the
care
of a
ll pe
ople
in
lear
ning
dis
abili
ty o
r aut
ism
inpa
tient
bed
s an
d ag
ree
a pe
rson
al c
are
plan
for e
ach
indi
vidu
al b
ased
aro
und
thei
r and
thei
r fa
mili
es’ n
eeds
and
agr
eed
outc
omes
.
From
N
ov
2012
By
1 Ju
ne
2013
CO
MPL
ETE
The
mai
n ac
tion
is c
ompl
ete
and
wor
k is
ong
oing
by
the
Enh
ance
d Q
ualit
y A
ssur
ance
Pro
gram
me
to u
nder
stan
d an
d im
prov
e th
e qu
ality
of t
he p
lans
.
57
Clin
ical
Com
mis
sion
ing
Gro
ups
(CC
Gs)
and
lo
cal a
utho
ritie
s w
ill s
et o
ut a
join
t stra
tegi
c pl
an to
com
mis
sion
the
rang
e of
loca
l hea
lth,
hous
ing
and
care
sup
port
serv
ices
to m
eet
the
need
s of
peo
ple
with
cha
lleng
ing
beha
viou
r in
thei
r are
a. T
his
coul
d po
tent
ially
be
und
erta
ken
thro
ugh
the
heal
th a
nd
wel
lbei
ng b
oard
and
cou
ld b
e co
nsid
ered
as
part
of th
e lo
cal J
oint
Stra
tegi
c N
eeds
A
sses
smen
t and
Joi
nt H
ealth
and
Wel
lbei
ng
Stra
tegy
(JH
WS
) pro
cess
es.
From
A
pril
2013
By
Apr
il 20
14
ON
GO
ING
Th
e M
inis
ter f
or c
are
serv
ice
Nor
man
Lam
b w
rote
to th
e ch
airs
of a
ll H
ealth
and
Wel
lbei
ng B
oard
s in
May
201
3.
The
Join
t Im
prov
emen
t Pro
gram
me
(JIP
) will
be
follo
win
g th
is u
p as
a p
riorit
y, u
sing
the
info
rmat
ion
from
th
e st
ockt
ake.
ht
tps:
//ww
w.g
ov.u
k/go
vern
men
t/new
s/no
rman
-lam
b-hi
ghlig
hts-
role
-of-h
ealth
-and
-wel
lbei
ng-b
oard
s-in
-re
form
ing-
care
-follo
win
g-w
inte
rbou
rne-
view
39
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
RA
G
Com
men
ts
58
Hea
lth a
nd c
are
com
mis
sion
ers
shou
ld p
ut
plan
s in
to a
ctio
n as
soo
n as
pos
sibl
e an
d al
l in
divi
dual
s sh
ould
be
rece
ivin
g pe
rson
alis
ed
care
and
sup
port
in a
ppro
pria
te c
omm
unity
se
tting
s no
late
r tha
n 1
June
201
4.
From
N
ov
2012
By
1 Ju
ne
2014
ON
GO
ING
N
HS
Eng
land
thro
ugh
oper
atio
nal m
anag
emen
t ar
rang
emen
ts is
set
ting
up q
ualit
y m
onito
ring
to p
rovi
de
assu
ranc
e. T
heir
pape
r to
the
Lear
ning
Dis
abili
ty
Pro
gram
me
Boa
rd in
Nov
embe
r set
s ou
t pro
gres
s to
ac
hiev
ing
this
by
the
June
201
4 de
adlin
e.
http
s://w
ww
.gov
.uk/
gove
rnm
ent/p
olic
y-ad
viso
ry-
grou
ps/le
arni
ng-d
isab
ility
-pro
gram
me-
boar
d
65
The
natio
nal m
arke
t dev
elop
men
t for
um
with
in th
e Th
ink
Loca
l Act
Per
sona
l (TL
AP
) pa
rtner
ship
will
wor
k w
ith D
H to
iden
tify
barr
iers
to re
duci
ng th
e ne
ed fo
r spe
cial
ist
asse
ssm
ent a
nd tr
eatm
ent h
ospi
tals
and
id
entif
y so
lutio
ns fo
r pro
vidi
ng e
ffect
ive
loca
l se
rvic
es.
From
Ju
ne
2012
By
1 A
pril
2013
CO
MPL
ETE
Be
Bol
d, d
evel
opin
g th
e m
arke
t for
the
smal
l num
bers
of
peo
ple
with
ver
y co
mpl
ex n
eeds
, was
pub
lishe
d in
D
ecem
ber 2
012.
ht
tp://
ww
w.th
inkl
ocal
actp
erso
nal.o
rg.u
k/La
test
/Res
ourc
e/?c
id=9
412
TLA
P a
re n
ow w
orki
ng re
gion
ally
to e
nsur
e th
at th
is a
nd
othe
r res
ourc
es a
re b
eing
use
d.
66
The
Dev
elop
ing
Car
e M
arke
ts fo
r Qua
lity
and
Cho
ice
prog
ram
me
will
sup
port
loca
l au
thor
ities
to a
rticu
late
loca
l nee
ds fo
r car
e se
rvic
es a
nd p
rodu
ce m
arke
t pos
ition
st
atem
ents
, inc
ludi
ng fo
r lea
rnin
g di
sabi
lity
serv
ices
.
From
D
ec
2012
By
Dec
20
14
ON
GO
ING
Th
e P
rogr
amm
e is
bei
ng d
eliv
ered
by
the
Inst
itute
of
Pub
lic C
are,
offe
ring
supp
ort t
o al
l Eng
lish
Loca
l A
utho
ritie
s to
hel
p de
velo
p m
arke
t pos
ition
sta
tem
ents
an
d pr
ovid
e a
supp
ort t
oolk
it. W
ork
is p
rogr
essi
ng to
pl
ans
with
the
expe
ctat
ion
that
alm
ost a
ll au
thor
ities
will
ha
ve re
ceiv
ed a
ssis
tanc
e by
Mar
ch 2
014.
40
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
RA
G
Com
men
ts
67
The
Dep
artm
ent o
f Hea
lth w
ill w
ork
with
se
ctor
lead
ers
on c
o-pr
oduc
ed re
sour
ces
to
supp
ort h
ealth
and
wel
lbei
ng b
oard
s on
sp
ecifi
c as
pect
s of
Joi
nt S
trate
gic
Nee
ds
Ass
essm
ents
(JS
NA
s) a
nd J
oint
Hea
lth a
nd
Wel
lbei
ng S
trate
gies
(JH
WS
s).
As
part
of
this
wor
k, w
e w
ill e
xplo
re h
ow, i
n re
spon
ding
to
the
issu
es ra
ised
in th
e W
inte
rbou
rne
Vie
w
revi
ew, w
e w
ill e
nsur
e th
at h
ealth
and
w
ellb
eing
boa
rds
have
sup
port
to u
nder
stan
d th
e co
mpl
ex n
eeds
of p
eopl
e w
ith c
halle
ngin
g be
havi
our.
Jan
2013
B
y S
ep
2013
ON
GO
ING
N
HS
Con
fede
ratio
n, w
ith th
e Jo
int I
mpr
ovem
ent
Pro
gram
me,
is p
rodu
cing
gui
danc
e fo
r Hea
lth a
nd
Wel
lbei
ng B
oard
s.
SUM
MA
RY
OF
PRO
GR
ESS
ON
AC
TIO
NS
FRO
M T
RA
NSF
OR
MIN
G C
AR
E &
CO
NC
OR
DA
T (D
ECEM
BER
201
3)
WO
RK
STR
AN
D 2
: REG
ULA
TIO
N, I
NSP
ECTI
ON
, CO
RPO
RA
TE A
CC
OU
NTA
BIL
ITY
Str
engt
hen
acco
unta
bilit
y an
d re
spon
sibi
lity
of p
rovi
ders
, and
thei
r m
anag
emen
t, fo
r qu
ality
of c
are.
Tig
hten
ing
the
regu
latio
n an
d in
spec
tion
of
prov
ider
s.
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
41
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
1
Car
e Q
ualit
y C
omm
issi
on (C
QC
) will
con
tinue
to
mak
e un
anno
unce
d in
spec
tions
of p
rovi
ders
of
lear
ning
dis
abili
ty a
nd m
enta
l hea
lth
serv
ices
em
ploy
ing
peop
le w
ho u
se s
ervi
ces
and
fam
ilies
as
vita
l mem
bers
of t
he te
am.
From
Ju
ne
2012
O
ngoi
ng
O
NG
OIN
G
CQ
C p
ublis
hed
its fr
esh
star
t app
roac
h to
the
regu
latio
n an
d in
spec
tion
of m
enta
l hea
lth, l
earn
ing
disa
bilit
y an
d su
bsta
nce
mis
use
serv
ices
on
29/1
1/20
13. T
he C
hief
Insp
ecto
r of H
ospi
tals
will
be
resp
onsi
ble
for t
he in
spec
tions
of s
ervi
ces
for p
eopl
e w
ith m
enta
l hea
lth n
eeds
, lea
rnin
g di
sabi
litie
s or
au
tism
, who
are
adm
itted
to h
ospi
tal t
o st
ay fo
r as
sess
men
t or t
reat
men
t. Th
is m
ight
incl
ude
prov
idin
g ca
re, t
reat
men
t and
sup
port
for p
eopl
e de
tain
ed u
nder
th
e M
enta
l Hea
lth A
ct 1
983
(MH
A) o
r by
an
auth
oris
atio
n un
der t
he M
enta
l Cap
acity
Act
D
epriv
atio
n of
Lib
erty
Saf
egua
rds.
The
firs
t wav
e of
in
spec
tions
will
com
men
ce in
Jan
uary
201
4.
2
Car
e Q
ualit
y C
omm
issi
on (C
QC
) will
take
to
ugh
enfo
rcem
ent a
ctio
n in
clud
ing
pros
ecut
ions
, res
trict
ing
the
prov
isio
n of
se
rvic
es, o
r clo
sing
pro
vide
rs d
own,
whe
re
prov
ider
s co
nsis
tent
ly fa
il to
hav
e a
regi
ster
ed
man
ager
in p
lace
.
From
Ju
ne
2012
O
ngoi
ng
O
NG
OIN
G
In S
epte
mbe
r 201
3 it
was
agr
eed
by th
e C
QC
boa
rd
that
a p
roje
ct w
ould
be
set u
p to
add
ress
the
unac
cept
ably
hig
h nu
mbe
r of l
ocat
ions
ope
ratin
g w
ithou
t reg
iste
red
man
ager
s. C
QC
requ
ired
all
prov
ider
s w
ith lo
catio
ns th
at h
ave
been
with
out a
m
anag
er fo
r mor
e th
an 6
mon
ths
to re
solv
e th
at
imm
edia
tely
or a
fixe
d pe
nalty
not
ice
wou
ld b
e is
sued
.
http
://w
ww
.cqc
.org
.uk/
site
s/de
faul
t/file
s/m
edia
/doc
umen
ts/c
hief
_exe
cutiv
e_re
port_
to_b
oard
_12_
sept
42
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
3
Car
e Q
ualit
y C
omm
issi
on (C
QC
) will
take
en
forc
emen
t act
ion
agai
nst p
rovi
ders
who
do
not o
pera
te e
ffect
ive
proc
esse
s to
ens
ure
they
ha
ve s
uffic
ient
num
bers
of p
rope
rly tr
aine
d st
aff.
From
Ju
ne
2012
O
ngoi
ng
O
NG
OIN
G
NH
S E
ngla
nd, C
QC
and
the
Join
t Im
prov
emen
t P
rogr
amm
e (J
IP) a
re w
orki
ng to
geth
er o
n ar
eas
of
conc
ern.
The
y ar
e al
so w
orki
ng o
n an
Enh
ance
d Q
ualit
y A
ssur
ance
pro
cess
. The
Har
d Tr
uths
, Fra
ncis
re
spon
se h
as s
et o
ut a
dditi
onal
requ
irem
ents
for
staf
fing.
27
NH
S E
ngla
nd w
ill h
old
Clin
ical
Com
mis
sion
ing
Gro
ups
(CC
Gs)
to a
ccou
nt fo
r the
ir pr
ogre
ss in
tra
nsfo
rmin
g th
e w
ay th
ey c
omm
issi
on
serv
ices
for p
eopl
e w
ith le
arni
ng
disa
bilit
ies/
autis
m a
nd c
halle
ngin
g be
havi
ours
.
From
A
pril
2013
O
ngoi
ng
O
NG
OIN
G
CC
G’s
Win
terb
ourn
e V
iew
act
ion
plan
s ar
e in
clud
ed in
N
HS
Eng
land
’s C
CG
ass
uran
ce fr
amew
ork.
ht
tp://
ww
w.e
ngla
nd.n
hs.u
k/w
p-co
nten
t/upl
oads
/201
3/05
/ccg
-af.p
df
43
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
29
Car
e Q
ualit
y C
omm
issi
on (C
QC
) will
take
ac
tion
to e
nsur
e th
e m
odel
of c
are
is in
clud
ed
as p
art o
f ins
pect
ion
and
regi
stra
tion
of
rele
vant
ser
vice
s fro
m 2
013.
CQ
C w
ill s
et o
ut
the
new
ope
ratio
n of
its
regu
lato
ry m
odel
, in
resp
onse
to c
onsu
ltatio
n, in
Spr
ing
2013
.
From
A
pril
2013
O
ngoi
ng
O
NG
OIN
G
Ove
r the
sum
mer
CQ
C c
onsu
lted
on th
eir o
vera
ll pl
ans
for i
nspe
ctio
n, a
nd th
ey a
re c
urre
ntly
dev
elop
ing
thei
r m
odel
s fo
r ins
pect
ing,
regu
latin
g an
d ra
ting
hosp
itals
, G
P a
nd a
dult
soci
al c
are
prov
ider
s.
In th
e co
min
g ye
ar, C
QC
will
pro
duce
gui
danc
e fo
r ea
ch s
ecto
r, an
d st
art t
o ro
ll ou
t the
ir ne
w in
spec
tion
and
ratin
gs re
gim
es, s
tarti
ng w
ith H
ospi
tals
from
Ja
nuar
y 20
14.
CQ
C p
ublis
hed
its S
trate
gy fo
r ins
pect
ions
ove
r the
pe
riod
2013
-16
in A
pril.
It e
mph
asis
es s
treng
then
ing
prot
ectio
n to
thos
e de
tain
ed u
nder
the
Men
tal H
ealth
A
ct. T
he li
nk to
the
rece
ntly
pub
lishe
d fre
sh s
tart
for
insp
ectin
g an
d re
gula
ting
men
tal h
ealth
ser
vice
s is
he
re.
http
://w
ww
.cqc
.org
.uk/
publ
ic/n
ews/
insp
ectin
g-an
d-re
gula
ting-
men
tal-h
ealth
-ser
vice
s
31
Car
e Q
ualit
y C
omm
issi
on (C
QC
) will
ass
ess
whe
ther
pro
vide
rs a
re d
eliv
erin
g ca
re
cons
iste
nt w
ith th
e st
atem
ent o
f pur
pose
mad
e at
the
time
of re
gist
ratio
n.
From
A
pril
2013
O
ngoi
ng
O
NG
OIN
G
The
regi
stra
tion
chan
ges
that
CQ
C h
ave
intro
duce
d in
clud
e ch
ange
s to
the
stat
emen
t of p
urpo
se, g
uida
nce
for r
egis
tratio
n as
sess
ors
on s
ite v
isits
and
inte
rvie
ws
with
regi
ster
ed m
anag
ers.
The
se ra
ise
the
bar a
nd
requ
ire th
at p
rovi
ders
set
out
in th
eir s
tate
men
t of
purp
ose
that
an
orga
nisa
tion
mus
t nam
e in
divi
dual
s at
B
oard
leve
l who
hav
e da
y to
day
acco
unta
bilit
y an
d re
spon
sibi
lity
for q
ualit
y, s
afet
y an
d co
mpa
ssio
nate
ca
re.
CQ
C w
ill re
view
exi
stin
g st
atem
ent o
f pur
pose
. Fu
ture
insp
ectio
ns w
ill li
nk th
e st
atem
ent o
f pur
pose
w
ith fu
ndam
enta
l sta
ndar
ds.
44
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
32
Mon
itor w
ill c
onsi
der i
n de
velo
ping
pro
vide
r lic
ence
con
ditio
ns, t
he in
clus
ion
of in
tern
al
repo
rting
requ
irem
ents
for t
he B
oard
s of
lic
ensa
ble
prov
ider
ser
vice
s to
stre
ngth
en th
e m
onito
ring
of o
utco
mes
and
clin
ical
go
vern
ance
arr
ange
men
ts a
t Boa
rd le
vel.
From
A
pril
2013
O
ngoi
ng
O
NG
OIN
G
Mon
itor’s
lice
nsin
g re
gim
e st
arte
d in
Apr
il 20
13 fo
r fo
unda
tion
trust
s an
d it
is a
ntic
ipat
ed th
at M
onito
r’s fu
ll lic
ensi
ng re
gim
e w
ill c
ome
into
effe
ct in
Apr
il 20
14.
Mon
itor w
ill re
view
lice
nsin
g in
201
4, a
nd w
ill c
onsi
der
this
issu
e as
par
t of t
hat r
evie
w.
36
Dire
ctor
s, m
anag
emen
t and
lead
ers
of
orga
nisa
tions
pro
vidi
ng N
HS
or l
ocal
aut
horit
y fu
nded
ser
vice
s to
ens
ure
that
sys
tem
s an
d pr
oces
ses
are
in p
lace
to p
rovi
de a
ssur
ance
th
at e
ssen
tial r
equi
rem
ents
are
bei
ng m
et a
nd
that
they
hav
e go
vern
ance
sys
tem
s in
pla
ce to
en
sure
they
del
iver
hig
h qu
ality
and
ap
prop
riate
car
e.
From
A
pril
2013
O
ngoi
ng
O
NG
OIN
G
Pro
vide
rs h
ave
unde
rtake
n a
rang
e of
act
ions
to m
eet
this
com
mitm
ent.
The
Driv
ing
up Q
ualit
y C
ode
(see
ac
tion
43 fo
r det
ails
) dev
elop
ed a
nd s
igne
d up
to b
y a
rang
e of
lear
ning
dis
abili
ty p
rovi
ders
incl
udes
gui
danc
e an
d go
od p
ract
ice
on d
evel
opin
g a
good
cul
ture
in
orga
nisa
tions
and
on
lead
ing
and
runn
ing
an
orga
nisa
tion
wel
l. T
he c
ode
also
incl
udes
a s
elf-
asse
ssm
ent g
uide
to h
elp
orga
nisa
tion
asse
ss th
eir
own
perfo
rman
ce.
The
Car
e Q
ualit
y C
omm
issi
on is
cha
ngin
g th
e w
ay th
ey
asse
ss le
ader
ship
and
cor
pora
te re
spon
sibi
lity
in
serv
ice
prov
ider
s fo
r thi
s se
ctor
.
45
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
40
The
Dep
artm
ent o
f Hea
lth w
ill im
med
iate
ly
exam
ine
how
cor
pora
te b
odie
s, th
eir B
oard
s of
D
irect
ors
and
finan
cier
s ca
n be
hel
d to
acc
ount
fo
r the
pro
visi
on o
f poo
r car
e an
d ha
rm, a
nd
set o
ut p
ropo
sals
dur
ing
Spr
ing
2013
on
stre
ngth
enin
g th
e sy
stem
whe
re th
ere
are
gaps
. We
will
con
side
r bot
h re
gula
tory
sa
nctio
ns a
vaila
ble
to C
are
Qua
lity
Com
mis
sion
(CQ
C) a
nd c
rimin
al s
anct
ions
. W
e w
ill d
eter
min
e w
heth
er C
QC
’s c
urre
nt
regu
lato
ry p
ower
s an
d its
prim
ary
legi
slat
ive
pow
ers
need
to b
e st
reng
then
ed to
hol
d B
oard
s to
acc
ount
and
will
ass
ess
whe
ther
a fi
t an
d pr
oper
per
sons
test
cou
ld b
e in
trodu
ced
for b
oard
mem
bers
.
By
S
prin
g 20
13
C
ON
SULT
ATI
ON
CO
MPL
ETE,
ON
GO
ING
WO
RK
In
Jul
y 20
13 th
e G
over
nmen
t iss
ued
a co
nsul
tatio
n on
Stre
ngth
enin
g C
orpo
rate
Acc
ount
abili
ty in
H
ealth
and
Soc
ial C
are.
ht
tps:
//ww
w.g
ov.u
k/go
vern
men
t/con
sulta
tions
/impr
ovin
g-co
rpor
ate-
acco
unta
bilit
y-in
-hea
lth-a
nd-s
ocia
l-car
e
The
cons
ulta
tion
prop
osed
a n
ew re
quire
men
t tha
t al
l Boa
rd D
irect
ors
(or e
quiv
alen
ts) o
f pro
vide
rs
regi
ster
ed w
ith th
e C
are
Qua
lity
Com
mis
sion
mus
t m
eet a
new
fitn
ess
test
. H
ard
Trut
hs5 , t
he fi
nal G
over
nmen
t Res
pons
e to
the
Mid
Sta
fford
shire
NH
S F
ound
atio
n Tr
ust P
ublic
Inqu
iry,
publ
ishe
d in
Nov
embe
r 201
3, a
nnou
nced
that
the
Gov
ernm
ent w
ill e
stab
lish
a ne
w fi
t and
pro
per p
erso
n’s
test
for B
oard
leve
l app
oint
men
ts, w
hich
will
mea
n th
at
CQ
C is
abl
e to
bar
Dire
ctor
s w
ho a
re u
nfit
from
in
divi
dual
pos
ts a
t the
poi
nt o
f reg
istra
tion.
Whe
re a
D
irect
or is
con
side
red
by th
e C
QC
to b
e un
fit it
cou
ld
eith
er re
fuse
regi
stra
tion,
in th
e ca
se o
f a n
ew p
rovi
der,
or re
quire
the
rem
oval
of t
he D
irect
or o
n in
spec
tion,
or
follo
win
g no
tific
atio
n of
a n
ew a
ppoi
ntm
ent.
Furth
er
deta
ils w
ill b
e se
t out
in th
e re
spon
se to
the
cons
ulta
tion
on c
orpo
rate
acc
ount
abili
ty w
hich
will
be
publ
ishe
d sh
ortly
. The
Gov
ernm
ent p
lans
to p
ublis
h th
e dr
aft r
egul
atio
ns fo
r con
sulta
tion
at th
e sa
me
time
and
to in
trodu
ce th
e ne
w re
gula
tions
dur
ing
2014
.
5 h
ttps:
//ww
w.g
ov.u
k/go
vern
men
t/pub
licat
ions
/mid
-sta
fford
shire
-nhs
-ft-p
ublic
-inqu
iry-g
over
nmen
t-res
pons
e
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
41
Car
e Q
ualit
y C
omm
issi
on (C
QC
) will
take
st
eps
now
to s
treng
then
the
way
it u
ses
its
exis
ting
pow
ers
to h
old
orga
nisa
tions
to
acco
unt f
or fa
ilure
s to
pro
vide
qua
lity
care
. It
will
repo
rt on
cha
nges
to b
e m
ade
from
Spr
ing
2013
.
From
S
prin
g 20
13
Ong
oing
O
NG
OIN
G
The
Dep
artm
ent o
f Hea
lth h
as b
een
wor
king
with
CQ
C
to d
evel
op a
set
of f
unda
men
tal s
tand
ards
. The
se
fund
amen
tals
will
set
a c
lear
bar
bel
ow w
hich
car
e m
ust n
ot fa
ll. T
here
will
be
imm
edia
te a
nd s
erio
us
regu
lato
ry c
onse
quen
ces
for s
ervi
ces
whe
re c
are
falls
be
low
thes
e le
vels
, inc
ludi
ng s
ervi
ces
goin
g in
to s
peci
al
mea
sure
s, b
eing
pro
secu
ted
or p
lans
to w
ithdr
aw
regi
stra
tion
and
licen
sing
.
The
CQ
C p
ublis
hed
the
resp
onse
s to
its
publ
ic
cons
ulta
tion
on 1
7 O
ctob
er 2
013,
whi
ch s
how
ed th
at
ther
e is
agr
eem
ent w
ith th
e ne
w a
ppro
ach6 . I
n th
e ne
w
year
, the
Dep
artm
ent o
f Hea
lth w
ill c
onsu
lt sh
ortly
on
the
draf
t reg
ulat
ions
whi
ch w
ill s
et in
legi
slat
ion
the
fund
amen
tal s
tand
ards
of c
are
that
pro
vide
rs m
ust
mee
t. Th
e ne
w re
gula
tions
will
com
e in
to e
ffect
dur
ing
2014
, and
CQ
C w
ill in
corp
orat
e th
em in
to th
eir
insp
ectio
n an
d ra
tings
regi
mes
.
55
Car
e Q
ualit
y C
omm
issi
on (C
QC
) will
als
o in
clud
e re
fere
nce
to th
e m
odel
in th
eir r
evis
ed
guid
ance
abo
ut c
ompl
ianc
e. T
heir
revi
sed
guid
ance
abo
ut c
ompl
ianc
e w
ill b
e lin
ked
to th
e D
epar
tmen
t of H
ealth
tim
etab
le o
f rev
iew
of t
he
qual
ity a
nd s
afet
y re
gula
tions
in 2
013.
H
owev
er, t
hey
will
spe
cific
ally
upd
ate
prov
ider
s ab
out t
he p
ropo
sed
chan
ges
to th
eir
regi
stra
tion
proc
ess
abou
t mod
els
of c
are
for
lear
ning
dis
abili
ty s
ervi
ces
in 2
013.
From
A
pril
2013
By
end
2013
O
NG
OIN
G
This
cha
nge
was
intro
duce
d in
Jul
y 20
13. W
ork
is n
ow
in h
and
on im
plem
enta
tion.
ht
tp://
ww
w.c
qc.o
rg.u
k/or
gani
satio
ns-w
e-re
gula
te/s
ervi
ces-
peop
le-le
arni
ng-d
isab
ilitie
s
6 h
ttp://
ww
w.c
qc.o
rg.u
k/si
tes/
defa
ult/f
iles/
med
ia/d
ocum
ents
/cqc
_new
star
tresp
onse
_201
3_14
_tag
ged_
sent
_to_
web
46
47
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
68
Dep
artm
ent o
f Hea
lth w
ill re
view
the
regu
lato
ry
requ
irem
ents
in re
spec
t of c
rimin
al re
cord
s ch
ecks
and
whe
ther
pro
vide
rs s
houl
d ro
utin
ely
requ
est a
crim
inal
reco
rd c
ertif
icat
e on
re
crui
tmen
t fro
m 2
013
once
the
impa
ct o
f the
ne
w s
ervi
ce is
und
erst
ood.
Spr
ing
2013
C
OM
PLET
E
The
revi
ew fo
und
no n
eed
to c
hang
e th
e C
RB
che
ck
regu
latio
ns.
App
lican
ts c
an n
ow s
ubsc
ribe
to a
n U
pdat
e S
ervi
ce w
hen
they
mak
e a
new
app
licat
ion
for
a ce
rtific
ate.
Thi
s se
rvic
e w
ill th
en k
eep
the
certi
ficat
e up
to d
ate,
mea
ning
that
inst
ant o
nlin
e ch
ecks
can
be
mad
e by
em
ploy
ers.
Onc
e su
bscr
ibed
the
indi
vidu
al
can
take
thei
r cer
tific
ate
with
them
from
role
to ro
le
whe
re th
e sa
me
type
and
leve
l of c
heck
is re
quire
d D
BS
che
cks
are
only
one
par
t of e
nsur
ing
effe
ctiv
e an
d sa
fe re
crui
tmen
t pro
cess
es. P
rovi
ders
sho
uld
also
be
usin
g ot
her m
echa
nism
s, in
clud
ing
chec
king
em
ploy
men
t his
tory
and
gap
s, a
nd re
view
ing
refe
renc
es.
69
Car
e Q
ualit
y C
omm
issi
on (C
QC
) will
use
ex
istin
g po
wer
s to
see
k as
sura
nce
that
pr
ovid
ers
have
rega
rd to
nat
iona
l gui
danc
e an
d th
e go
od p
ract
ice
set o
ut in
the
mod
el o
f car
e at
Ann
ex A
.
Jul-1
3
C
OM
PLET
E Th
is n
ow fe
atur
es in
the
new
app
roac
h to
regi
stra
tion
for l
earn
ing
disa
bilit
y pr
ovid
ers
publ
ishe
d in
Jul
y 20
13.
http
://w
ww
.cqc
.org
.uk/
orga
nisa
tions
-we-
regu
late
/ser
vice
s-pe
ople
-lear
ning
-dis
abili
ties
48
SUM
MA
RY
OF
PRO
GR
ESS
ON
AC
TIO
NS
FRO
M T
RA
NSF
OR
MIN
G C
AR
E &
CO
NC
OR
DA
T (D
ECEM
BER
201
3)
WO
RK
STR
AN
D 3
: GO
OD
PR
AC
TIC
E, S
TAN
DA
RD
S A
ND
AD
VOC
AC
Y Im
prov
ing
qual
ity a
nd s
afet
y so
that
bes
t pra
ctic
e in
lear
ning
dis
abili
ty s
ervi
ces
beco
mes
nor
mal
pra
ctic
e. E
nsur
ing
good
info
rmat
ion
and
advi
ce,
incl
udin
g ad
voca
cy, i
s av
aila
ble
to h
elp
peop
le a
nd th
eir
fam
ilies
. R
ef
No.
A
ctio
n St
art
Dat
e Fi
nish
D
ate
Prog
ress
C
omm
ents
49
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
49
The
Dep
artm
ent o
f Hea
lth w
ill w
ork
with
in
depe
nden
t adv
ocac
y or
gani
satio
ns to
driv
e up
the
qual
ity o
f ind
epen
dent
adv
ocac
y.
In
201
3
ON
GO
ING
Th
e C
are
Bill
, cur
rent
ly b
efor
e P
arlia
men
t will
intro
duce
a
new
dut
y on
loca
l aut
horit
ies
to a
rrang
e an
in
depe
nden
t adv
ocat
e to
be
avai
labl
e to
faci
litat
e th
e in
volv
emen
t of a
n ad
ult o
r car
er w
ho is
the
subj
ect o
f an
asse
ssm
ent,
care
or s
uppo
rt pl
anni
ng o
r rev
iew
if th
at
loca
l aut
horit
y co
nsid
ers
that
the
adul
t wou
ld e
xper
ienc
e su
bsta
ntia
l diff
icul
ty in
und
erst
andi
ng th
e pr
oces
ses
or
info
rmat
ion
rele
vant
to th
ose
proc
esse
s or
co
mm
unic
atin
g th
eir v
iew
s, w
ishe
s, o
r fee
lings
G
uida
nce
will
pro
vide
sup
port
to e
nabl
e th
is to
be
trans
late
d in
to p
ract
ice
whe
n th
e B
ill b
ecom
es la
w in
20
15.
7
The
Dep
artm
ent o
f Hea
lth w
ill w
ork
with
in
depe
nden
t adv
ocac
y or
gani
satio
ns to
iden
tify
the
key
fact
ors
to ta
ke a
ccou
nt o
f in
com
mis
sion
ing
advo
cacy
for p
eopl
e w
ith
lear
ning
dis
abili
ties
in h
ospi
tals
so
that
peo
ple
in h
ospi
tal g
et g
ood
acce
ss to
info
rmat
ion,
ad
vice
and
adv
ocac
y th
at s
uppo
rts th
eir
parti
cula
r nee
ds.
From
D
ec
2012
Mar
ch
2014
CO
MPL
ETE
Incl
usio
n N
orth
is w
orki
ng w
ith c
omm
issi
oner
s,
prov
ider
s, p
eopl
e &
fam
ilies
to s
hare
the
outc
omes
from
th
e N
orth
Eas
t adv
ocac
y pr
ojec
t tha
t offe
rs le
arni
ng o
n th
e br
oade
r rol
e of
adv
ocac
y &
'loo
king
out
for'
as w
ell
as a
com
mis
sion
ing
fram
ewor
k an
d ex
plor
ing
com
mis
sion
ing
advo
cacy
mod
els
that
pr
ovid
e m
ore
than
pai
d pr
ofes
sion
al a
dvoc
acy.
A
s w
ell a
s re
gion
al w
orks
hops
, all
of th
e pr
oduc
ts a
re
now
on
the
Incl
usio
n N
orth
web
site
and
ther
e ar
e re
ports
and
reso
urce
s to
hel
p pe
ople
, fam
ilies
an
d st
aff t
o th
ink
abou
t adv
ocac
y an
d lo
okin
g ou
t for
pe
ople
. ht
tp://
incl
usio
nnor
th.o
rg/p
roje
cts/
wha
t-we-
are-
doin
g-no
w/a
dvoc
acy-
proj
ect/
50
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
8
The
Dep
artm
ent o
f Hea
lth w
ill w
ork
with
in
depe
nden
t adv
ocac
y or
gani
satio
ns to
driv
e up
the
qual
ity o
f ind
epen
dent
adv
ocac
y,
thro
ugh
stre
ngth
enin
g th
e A
ctio
n fo
r Adv
ocac
y Q
ualit
y P
erfo
rman
ce M
ark
and
revi
ewin
g th
e C
ode
of P
ract
ice
for a
dvoc
ates
to c
larif
y th
eir
role
.
From
D
ec
2012
Mar
ch
2014
ON
GO
ING
A
ctio
n fo
r Adv
ocac
y ha
ve c
ease
d al
l ope
ratio
nal
activ
ity.
The
resp
onsi
bilit
y fo
r tak
ing
forw
ard
the
futu
re
of th
e Q
ualit
y P
erfo
rman
ce M
ark
(QP
M) n
atio
nal
advo
cacy
acc
redi
tatio
n sc
hem
e ha
s be
en p
asse
d to
the
Nat
iona
l Dev
elop
men
t Tea
m fo
r Inc
lusi
on (N
DTi
) in
orde
r tha
t the
com
mitm
ent g
iven
in T
rans
form
ing
Car
e ca
n be
del
iver
ed.
24
The
Nat
iona
l Qua
lity
Boa
rd w
ill s
et o
ut h
ow th
e ne
w h
ealth
sys
tem
sho
uld
oper
ate
to im
prov
e an
d m
aint
ain
qual
ity.
Aug
ust
2012
CO
MPL
ETE
The
Nat
iona
l Qua
lity
Boa
rd u
pdat
ed it
s gu
idan
ce in
Ja
nuar
y 20
13 in
the
light
of t
he W
inte
rbou
rne
Vie
w
repo
rt.
http
s://w
ww
.wp.
dh.g
ov.u
k/pu
blic
atio
ns/fi
les/
2013
/01/
Fin
al-N
QB
-rep
ort-v
4-16
0113
39
The
Dep
artm
ent o
f Hea
lth w
ill w
ork
with
the
Loca
l Gov
ernm
ent A
ssoc
iatio
n (L
GA
) and
H
ealth
wat
ch E
ngla
nd to
em
bed
the
impo
rtanc
e of
loca
l Hea
lthw
atch
invo
lvin
g pe
ople
with
le
arni
ng d
isab
ilitie
s an
d th
eir f
amili
es.
A k
ey
way
for l
ocal
Hea
lthw
atch
to b
enef
it fro
m th
e vo
ice
of p
eopl
e w
ith le
arni
ng d
isab
ilitie
s an
d fa
mili
es is
by
enga
ging
with
exi
stin
g lo
cal
Lear
ning
Dis
abili
ty P
artn
ersh
ip B
oard
s. L
INks
(lo
cal i
nvol
vem
ent n
etw
orks
) and
thos
e pr
epar
ing
for H
ealth
wat
ch c
an b
egin
to b
uild
th
ese
rela
tions
hips
with
thei
r Boa
rds
in
adva
nce
of lo
cal H
ealth
wat
ch o
rgan
isat
ions
st
artin
g up
on
1 A
pril
2013
.
From
A
pril
2013
O
ngoi
ng
ON
GO
ING
H
ealth
wat
ch E
ngla
nd h
as a
gree
d w
ith th
e N
atio
nal
Val
uing
Fam
ilies
For
um (N
VFF
) tha
t loc
al H
ealth
wat
ch
shou
ld b
e su
ppor
ted
to e
ngag
e an
d w
ork
with
peo
ple
with
lear
ning
dis
abili
ties
and
are
final
isin
g th
e ap
proa
ch
to p
rodu
cing
tool
s to
sup
port
this
. Th
is is
bei
ng g
uide
d by
the
NV
FF’s
exp
ertis
e.
51
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
43
Pro
vide
r org
anis
atio
ns w
ill s
et o
ut a
ple
dge
or
code
mod
el b
ased
on
shar
ed p
rinci
ples
- al
ong
the
lines
of t
he T
hink
Loc
al A
ct P
erso
nal
(TLA
P) M
akin
g it
Rea
l prin
cipl
es.
Dec
20
12
By
Sum
mer
20
13
CO
MPL
ETE
The
Driv
ing
Up
Qua
lity
Cod
e is
now
live
. To
sig
n up
to th
e co
de o
r get
mor
e in
form
atio
n vi
sit
http
://w
ww
.driv
ingu
pqua
lity.
org.
uk
44
The
Dep
artm
ent o
f Hea
lth, w
ith th
e N
atio
nal
Val
uing
Fam
ilies
For
um, t
he N
atio
nal F
orum
of
Peo
ple
with
Lea
rnin
g D
isab
ilitie
s, A
ssoc
iatio
n of
Dire
ctor
s of
Soc
ial S
ervi
ces
(AD
AS
S),
Loca
l G
over
nmen
t Ass
ocia
tion
(LG
A) a
nd th
e N
HS
w
ill id
entif
y an
d pr
omot
e go
od p
ract
ice
for
peop
le w
ith le
arni
ng d
isab
ilitie
s ac
ross
hea
lth
and
soci
al c
are.
Dec
20
11
By
Sum
mer
20
13
CO
MPL
ETE
Th
e fin
al re
port
can
be fo
und
here
: ht
tps:
//ww
w.g
ov.u
k/go
vern
men
t/pub
licat
ions
/lear
ning
-di
sabi
litie
s-go
od-p
ract
ice-
proj
ect-r
epor
t. Th
e ne
xt s
tep
will
be
effe
ctiv
e di
ssem
inat
ion,
incl
udin
g m
akin
g th
e rig
ht li
nks
to o
ther
goo
d pr
actic
e.
62
Nat
iona
l Ins
titut
e fo
r Hea
lth a
nd C
are
Exc
elle
nce
(NIC
E) w
ill p
ublis
h qu
ality
st
anda
rds
and
clin
ical
gui
delin
es o
n ch
alle
ngin
g be
havi
our a
nd le
arni
ng d
isab
ility
.
By
S
umm
er
2015
ON
GO
ING
W
ork
to d
evel
op a
clin
ical
gui
danc
e an
d a
qual
ity
stan
dard
for c
halle
ngin
g be
havi
our a
nd le
arni
ng
disa
bilit
y ar
e w
ell u
nder
way
; with
the
clin
ical
gui
delin
e ex
pect
ed to
be
publ
ishe
d in
May
201
5.
63
Nat
iona
l Ins
titut
e fo
r Hea
lth a
nd C
are
Exc
elle
nce
(NIC
E) w
ill p
ublis
h qu
ality
st
anda
rds
and
clin
ical
gui
delin
es o
n m
enta
l he
alth
and
lear
ning
dis
abili
ty.
By
S
umm
er
2016
ON
GO
ING
N
ICE
will
dev
elop
a c
linic
al g
uide
line
and
qual
ity
stan
dard
on
men
tal h
ealth
and
lear
ning
dis
abili
ty;
how
ever
, thi
s w
ork
is n
ot d
ue to
sta
rt ye
t.
Win
terb
ourn
e V
iew
sta
keho
lder
s, in
clud
ing
repr
esen
tativ
es o
f car
ers
and
fam
ilies
, hav
e be
en
invo
lved
, whi
le M
enca
p ar
e a
stak
ehol
der o
n N
ICE
qu
ality
sta
ndar
ds.
52
SUM
MA
RY
OF
PRO
GR
ESS
ON
AC
TIO
NS
FRO
M T
RA
NSF
OR
MIN
G C
AR
E &
CO
NC
OR
DA
T (D
ECEM
BER
201
3)
WO
RK
STR
AN
D 4
: IN
FOR
MA
TIO
N A
ND
DA
TA
Ens
ure
tran
spar
ent i
nfor
mat
ion
and
robu
st m
onito
ring
to d
eliv
er tr
ansf
orm
ed c
are
and
supp
ort a
nd to
mak
e su
re th
e pu
blic
, peo
ple
with
cha
lleng
ing
beha
viou
r an
d fa
mili
es k
now
whe
ther
we
are
mak
ing
prog
ress
. R
ef
No.
A
ctio
n St
art
Dat
e Fi
nish
D
ate
Prog
ress
C
omm
ents
4
The
cros
s-go
vern
men
t Lea
rnin
g D
isab
ility
P
rogr
amm
e B
oard
will
mea
sure
pro
gres
s ag
ains
t mile
ston
es, m
onito
r ris
ks to
del
iver
y an
d ch
alle
nge
exte
rnal
del
iver
y pa
rtner
s to
de
liver
to th
e ac
tion
plan
of a
ll co
mm
itmen
ts.
CQ
C, t
he N
HS
CB
and
the
head
of t
he L
GA
, A
DA
SS
, NH
S E
ngla
nd d
evel
opm
ent a
nd
impr
ovem
ent p
rogr
amm
e w
ill, w
ith o
ther
de
liver
y pa
rtner
s, b
e m
embe
rs o
f the
P
rogr
amm
e B
oard
, and
repo
rt on
pro
gres
s.
From
N
ov
2012
O
ngoi
ng
O
NG
OIN
G
DH
’s L
earn
ing
Dis
abili
ty P
rogr
amm
e B
oard
(LD
PB
) ov
erse
es a
ll th
e ke
y ac
tions
rela
ting
to L
earn
ing
Dis
abili
ties.
It
rece
ives
upd
ates
on
prog
ress
aga
inst
all
key
actio
ns a
nd re
ports
from
key
del
iver
y pa
rtner
s to
pr
ovid
e as
sura
nce
acro
ss p
rogr
amm
e of
act
ions
.
17
The
Dep
artm
ent o
f Hea
lth w
ill c
omm
issi
on a
n au
dit o
f cur
rent
ser
vice
s fo
r peo
ple
with
ch
alle
ngin
g be
havi
our t
o ta
ke a
sna
psho
t of
prov
isio
n, n
umbe
rs o
f out
of a
rea
plac
emen
ts
and
leng
ths
of s
tay.
The
aud
it w
ill b
e re
peat
ed
one
year
on
to e
nabl
e th
e le
arni
ng d
isab
ility
pr
ogra
mm
e bo
ard
to a
sses
s w
hat i
s ha
ppen
ing.
Feb
2013
By
Mar
ch
2013
C
OM
PLET
E Th
e Le
arni
ng D
isab
ility
Cen
sus
took
pla
ce o
n 30
S
epte
mbe
r. A
naly
sis
of th
e su
bmitt
ed d
ata
is n
ow in
pr
ogre
ss a
nd w
as p
ublis
hed
on 1
3th D
ecem
ber 2
013.
37
The
Dep
artm
ent o
f Hea
lth (D
H),
the
Hea
lth
and
Soc
ial C
are
Info
rmat
ion
Cen
tre (H
SC
IC)
and
the
NH
S E
ngla
nd w
ill d
evel
op m
easu
res
and
key
perfo
rman
ce in
dica
tors
(KP
Is) t
o su
ppor
t com
mis
sion
ers
in m
onito
ring
thei
r pr
ogre
ss.
From
A
pril
2013
O
ngoi
ng
O
NG
OIN
G
DH
, HS
CIC
and
NH
S E
ngla
nd h
ave
deve
lope
d dr
aft
KP
Is fo
r tes
ting
with
sta
keho
lder
s. T
he fi
nal K
PIs
will
be
impl
emen
ted
from
201
4.
53
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
38
The
NH
S E
ngla
nd a
nd A
DA
SS
will
impl
emen
t a
join
t hea
lth a
nd s
ocia
l car
e se
lf-as
sess
men
t fra
mew
ork
(SA
F) to
mon
itor p
rogr
ess
of k
ey
heal
th a
nd s
ocia
l car
e in
equa
litie
s fro
m A
pril
2013
. Th
e re
sults
of p
rogr
ess
from
loca
l are
as
will
be
publ
ishe
d.
From
A
pril
2013
C
OM
PLET
E Th
e 20
13/1
4 S
AF
is n
ow c
ompl
ete.
See
als
o ac
tion
18C
.
52
The
Dep
artm
ent o
f Hea
lth w
ill w
ork
with
the
impr
ovem
ent t
eam
to m
onito
r and
repo
rt on
pr
ogre
ss n
atio
nally
, inc
ludi
ng re
porti
ng
com
para
tive
info
rmat
ion
on lo
calit
ies.
We
will
pu
blis
h a
follo
w u
p re
port
by D
ecem
ber 2
013.
B
y D
ec
2013
C
OM
PLET
E Th
is is
the
prom
ised
repo
rt.
60
The
Dep
artm
ent o
f Hea
lth w
ill p
ublis
h a
seco
nd a
nnua
l rep
ort f
ollo
win
g up
pro
gres
s in
de
liver
ing
agre
ed a
ctio
ns.
B
y D
ec
2014
Fo
r nex
t yea
r
61
The
Dep
artm
ent o
f Hea
lth w
ill d
evel
op a
new
le
arni
ng d
isab
ility
min
imum
dat
a se
t to
be
colle
cted
thro
ugh
the
Hea
lth a
nd S
ocia
l Car
e In
form
atio
n C
entre
.
Feb
2013
M
arch
20
14
O
NG
OIN
G
Men
tal H
ealth
Min
imum
Dat
a S
et to
be
expa
nded
to
incl
ude
peop
le w
ith le
arni
ng d
isab
ilitie
s an
d da
ta s
et to
be
rena
med
Men
tal H
ealth
and
Lea
rnin
g D
isab
ilitie
s D
ata
Set
. Inf
orm
atio
n S
tand
ards
Boa
rd h
as a
ppro
ved
this
, how
ever
cha
nges
to in
form
atio
n sy
stem
s ar
e re
quire
d w
hich
mea
ns th
e ne
w d
ata
set i
s no
w
expe
cted
to b
e im
plem
ente
d fro
m S
epte
mbe
r 201
4.
54
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
64
The
Dep
artm
ent o
f Hea
lth w
ill c
ontin
ue to
co
llate
a s
uite
of i
nfor
mat
ion
and
evid
ence
re
latin
g to
peo
ple
with
lear
ning
dis
abili
ties
and
beha
viou
r whi
ch c
halle
nges
and
the
heal
th
ineq
ualit
ies
they
exp
erie
nce
and
repo
rt on
th
ese
to th
e Le
arni
ng D
isab
ility
Pro
gram
me
Boa
rd.
pa
rt of
ac
tion
4
A
Dat
a an
d In
form
atio
n W
orki
ng G
roup
has
bee
n se
t up
to fo
cus
and
prov
ide
tech
nica
l adv
ice
on d
ata
and
info
rmat
ion
rela
ted
com
mitm
ents
in th
e C
onco
rdat
and
al
so w
ider
lear
ning
dis
abili
ty d
ata
issu
es. T
his
grou
p re
ports
to th
e Le
arni
ng D
isab
ility
Pro
gram
me
Boa
rd
(LD
PB
). Th
e gr
oup
has
focu
sed
on th
e Le
arni
ng
Dis
abili
ty C
ensu
s, th
e de
velo
pmen
t of t
he M
enta
l H
ealth
and
Lea
rnin
g D
isab
ilitie
s D
ata
Set
, key
pe
rform
ance
indi
cato
rs, j
oint
hea
lth a
nd s
ocia
l car
e se
lf-as
sess
men
t fra
mew
ork
whi
ch a
re d
etai
led
abov
e. It
is
als
o lo
okin
g at
info
rmin
g de
velo
pmen
t of a
n in
dica
tor
on re
duci
ng p
rem
atur
e m
orta
lity
in p
eopl
e w
ith le
arni
ng
disa
bilit
ies
for t
he N
HS
Out
com
es F
ram
ewor
k. T
he li
nk
to L
DP
B p
aper
s is
: ht
tps:
//ww
w.g
ov.u
k/go
vern
men
t/pol
icy-
advi
sory
-gr
oups
/lear
ning
-dis
abilit
y-pr
ogra
mm
e-bo
ard.
All
data
and
info
rmat
ion
rela
ted
prog
ress
repo
rts a
nd
reco
mm
enda
tions
are
dis
cuss
ed b
y th
e LD
PB
.
55
SUM
MA
RY
OF
PRO
GR
ESS
ON
AC
TIO
NS
FRO
M T
RA
NSF
OR
MIN
G C
AR
E &
CO
NC
OR
DA
T (D
ECEM
BER
201
3)
WO
RK
STR
AN
D 5
: MED
ICA
TIO
N, P
OSI
TIVE
BEH
AVI
OU
R S
UPP
OR
T A
ND
PH
YSIC
AL
INTE
RVE
NTI
ON
Im
prov
e qu
ality
and
saf
ety
so th
at th
ere
is b
ette
r un
ders
tand
ing
of h
ow to
use
phy
sica
l res
trai
nt p
rope
rly a
nd g
ood
prac
tice
on p
ositi
ve b
ehav
iour
su
ppor
t and
the
envi
ronm
ent s
o th
at c
halle
ngin
g be
havi
our
is r
educ
ed. T
ackl
e ov
er-u
se o
f ant
ipsy
chot
ic a
nd a
ntid
epre
ssan
t med
icin
es to
ens
ure
the
best
cou
rse
of a
ctio
n fo
r th
e pa
tient
. R
ef
No.
A
ctio
n St
art
Dat
e Fi
nish
D
ate
Prog
ress
C
omm
ents
5
The
Dep
artm
ent o
f Hea
lth w
ill w
ork
with
the
Car
e Q
ualit
y C
omm
issi
on (C
QC
) to
agre
e ho
w
best
to ra
ise
awar
enes
s of
and
ens
ure
com
plia
nce
with
Dep
rivat
ion
of L
iber
ty
Saf
egua
rds
prov
isio
ns to
pro
tect
indi
vidu
als
and
thei
r hum
an ri
ghts
and
will
repo
rt by
S
prin
g 20
14.
From
D
ec
2012
Spr
ing
2014
O
NG
OIN
G
The
Car
e Q
ualit
y C
omm
issi
on h
as a
ppoi
nted
a M
enta
l C
apac
ity A
ct le
ad.
The
Eng
lish
Com
mun
ity C
are
Ass
ocia
tion
had
prod
uced
furth
er s
uppo
rt an
d br
iefin
g fo
r mem
bers
of
the
Dep
rivat
ion
of L
iber
ty S
afeg
uard
s an
d hu
man
righ
ts
legi
slat
ion.
6 Th
e D
epar
tmen
t of H
ealth
(DH
) will
, tog
ethe
r w
ith C
are
Qua
lity
Com
mis
sion
(CQ
C),
cons
ider
w
hat f
urth
er a
ctio
n m
ay b
e ne
eded
to c
heck
ho
w p
rovi
ders
reco
rd a
nd m
onito
r res
train
t.
From
D
ec
2012
by e
nd
2013
O
NG
OIN
G
DH
set
up
a w
orki
ng g
roup
to fi
nd li
nks
with
oth
er w
ork
on d
ata
colle
ctio
n. T
his
wor
k is
like
ly n
ow to
form
a k
ey
part
of a
muc
h w
ider
pro
gram
me
on re
duci
ng re
stra
int
and
rest
rictiv
e pr
actic
es in
lear
ning
dis
abili
ty a
nd
men
tal h
ealth
ser
vice
s.
56
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
9
A s
peci
fic w
orks
tream
has
bee
n cr
eate
d by
the
polic
e fo
rce
to id
entif
y a
proc
ess
to tr
igge
r ea
rly id
entif
icat
ion
of a
buse
. Th
e le
sson
s le
arnt
from
the
wor
k un
derta
ken
will
be
diss
emin
ated
nat
iona
lly.
All
asso
ciat
ed
lear
ning
from
the
revi
ew w
ill b
e in
corp
orat
ed
into
trai
ning
and
pra
ctic
e, in
clud
ing
Aut
horis
ed
Pro
fess
iona
l Pra
ctic
e.
From
D
ec
2012
O
ngoi
ng
O
NG
OIN
G
A s
peci
fic w
orks
tream
has
bee
n cr
eate
d by
the
Pol
ice
forc
e to
iden
tify
a pr
oces
s to
trig
ger e
arly
iden
tific
atio
n of
abu
se.
The
less
ons
lear
nt fr
om th
e w
ork
unde
rtake
n w
ill b
e di
ssem
inat
ed n
atio
nally
. A
ll as
soci
ated
lear
ning
from
the
revi
ew w
ill b
e in
corp
orat
ed in
to tr
aini
ng a
nd p
ract
ice,
incl
udin
g A
utho
rised
Pro
fess
iona
l Pra
ctic
e.
11
The
Brit
ish
Psy
chol
ogic
al S
ocie
ty (B
PS
) to
prov
ide
lead
ersh
ip to
pro
mot
e tra
inin
g in
, and
ap
prop
riate
impl
emen
tatio
n of
, Pos
itive
B
ehav
iour
al S
uppo
rt (P
BS
) acr
oss
the
full
rang
e of
car
e se
tting
s.
From
D
ec
2012
O
ngoi
ng
O
NG
OIN
G
The
Lear
ning
Dis
abili
ty fa
culty
of t
he S
ocie
ty h
as
enro
lled
thirt
een
expe
rienc
ed p
sych
olog
ists
on
the
Sou
th W
ales
Adv
ance
d P
rofe
ssio
nal D
iplo
ma
in
Pos
itive
Beh
avio
ural
Sup
port.
The
Brit
ish
Psy
chol
ogic
al S
ocie
ty h
as re
vise
d th
e ac
cred
itatio
n cr
iteria
for c
linic
al p
sych
olog
y an
d is
iden
tifyi
ng
addi
tiona
l cor
e co
mpe
tenc
ies
in th
is a
rea.
45
The
Dep
artm
ent o
f Hea
lth w
ill e
xplo
re w
ith th
e R
oyal
Col
lege
of P
sych
iatri
sts
and
othe
rs
whe
ther
ther
e is
a n
eed
to c
omm
issi
on a
n au
dit o
f use
of m
edic
atio
n fo
r thi
s gr
oup.
As
the
first
sta
ge o
f thi
s, w
e w
ill c
omm
issi
on a
w
ider
revi
ew o
f the
pre
scrib
ing
of a
ntip
sych
otic
an
d an
tidep
ress
ant m
edic
ines
for p
eopl
e w
ith
chal
leng
ing
beha
viou
r.
By
S
umm
er
2013
O
NG
OIN
G
This
act
ion
is n
ow b
eing
take
n fo
rwar
d by
NH
S
Eng
land
. Th
ree
piec
es o
f wor
k ar
e in
act
ion:
(1
) est
ablis
hing
a c
olla
bora
tive
in p
artn
ersh
ip w
ith N
HS
Im
prov
ing
Qua
lity.
The
fina
l sco
pe w
ill b
e pr
oduc
ed b
y en
d D
ecem
ber 2
013
and
it w
ill la
unch
in e
arly
201
4;
(2) w
ork
with
CQ
C o
n S
econ
d O
pini
on A
ppoi
nted
D
octo
rs (S
OA
D) d
ata
on p
resc
ribin
g fo
r ant
ipsy
chot
ic
and
antid
epre
ssan
t med
icin
es.
(3) a
naly
sis
of d
ata
held
by
Med
icin
es a
nd H
ealth
care
pr
oduc
ts R
egul
ator
y A
genc
y (M
HR
A) o
n pr
escr
ibin
g fo
r an
tipsy
chot
ic a
nd a
ntid
epre
ssan
t med
icin
es.
57
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
51
The
Roy
al C
olle
ge o
f Psy
chia
trist
s, th
e R
oyal
P
harm
aceu
tical
Soc
iety
and
oth
er p
rofe
ssio
nal
lead
ersh
ip o
rgan
isat
ions
will
wor
k w
ith A
DA
SS
an
d A
DC
S to
ens
ure
med
icin
es a
re u
sed
in a
sa
fe, a
ppro
pria
te a
nd p
ropo
rtion
ate
way
and
th
eir u
se o
ptim
ised
in th
e tre
atm
ent o
f chi
ldre
n,
youn
g pe
ople
and
adu
lts w
ith c
halle
ngin
g be
havi
our.
This
sho
uld
incl
ude
a fo
cus
on th
e sa
fe a
nd a
ppro
pria
te u
se o
f ant
ipsy
chot
ic a
nd
antid
epre
ssan
t med
icin
es.
In
201
3
See
com
men
t on
Act
ion
45
58
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
53
The
Dep
artm
ent o
f Hea
lth w
ith e
xter
nal
partn
ers
will
pub
lish
guid
ance
on
best
pra
ctic
e ar
ound
pos
itive
beh
avio
ur s
uppo
rt so
that
ph
ysic
al re
stra
int i
s on
ly e
ver u
sed
as a
last
re
sort
whe
re th
e sa
fety
of i
ndiv
idua
ls w
ould
ot
herw
ise
be a
t ris
k an
d ne
ver t
o pu
nish
or
hum
iliat
e.
Feb-
13
By
end
2013
*
O
NG
OIN
G
The
Dep
artm
ent o
f Hea
lth c
omm
issi
oned
a m
ulti-
prof
essi
onal
team
led
by th
e R
oyal
Col
lege
of N
ursi
ng
to d
evel
op n
ew g
uida
nce
on th
e us
e of
pos
itive
be
havi
our s
uppo
rt an
d th
e re
duct
ion
in th
e us
e of
re
stric
tive
prac
tices
. The
Roy
al C
olle
ge w
ill c
onsu
lt on
dr
aft g
uida
nce
on ‘T
he m
inim
isat
ion
of re
stric
tive
prac
tices
in h
ealth
and
adu
lt so
cial
car
e’ b
y th
e en
d of
D
ecem
ber 2
013
and
the
Dep
artm
ent o
f Hea
lth w
ill
publ
ish
new
gui
danc
e in
Mar
ch 2
014.
Th
e D
epar
tmen
t of H
ealth
als
o co
mm
issi
oned
Ski
lls fo
r C
are,
in c
onju
nctio
n w
ith S
kills
for H
ealth
, to
deve
lop
guid
ance
for p
rovi
der e
mpl
oyer
s on
the
com
mis
sion
ing
of tr
aini
ng a
nd w
orkf
orce
dev
elop
men
t act
iviti
es o
n ph
ysic
al in
terv
entio
ns a
s pa
rt of
a p
ositi
ve b
ehav
iour
su
ppor
t app
roac
h. S
kills
for C
are
and
Ski
lls fo
r Hea
lth
are
final
isin
g th
e dr
aft g
uida
nce
and
will
be
test
ing
it w
ith p
rovi
ders
in e
arly
201
4. T
he n
ew g
uida
nce
will
be
publ
ishe
d al
ongs
ide
the
guid
ance
dev
elop
ed b
y th
e R
oyal
Col
lege
of N
ursi
ng in
Mar
ch 2
014.
Th
e D
epar
tmen
t of H
ealth
is c
urre
ntly
wor
king
with
pa
rtner
s ac
ross
the
syst
em to
iden
tify
wha
t fur
ther
ac
tions
are
requ
ired
in o
rder
to e
mbe
d im
plem
enta
tion
of th
ese
new
pra
ctic
es a
nd e
ffect
suf
ficie
nt c
ultu
ral a
nd
lead
ersh
ip c
hang
e ac
ross
the
care
sys
tem
. * B
y en
d 20
13 (R
oyal
Col
lege
of N
ursi
ng w
ill le
ad
cons
ulta
tion
in D
ecem
ber 2
013
and
DH
will
pub
lish
new
gui
danc
e in
Mar
ch 2
014)
59
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
59
The
Dep
artm
ent o
f Hea
lth w
ill u
pdat
e th
e M
enta
l Hea
lth A
ct C
ode
of P
ract
ice
and
will
ta
ke a
ccou
nt o
f fin
ding
s fro
m th
is re
view
.
In 2
014
O
NG
OIN
G
The
Dep
artm
ent o
f Hea
lth, i
n co
njun
ctio
n w
ith th
e M
inis
try o
f Jus
tice,
the
Nat
iona
l Offe
nder
Man
agem
ent
Ser
vice
, the
Car
e Q
ualit
y C
omm
issi
on a
nd o
ther
pa
rtner
s is
cur
rent
ly re
view
ing
and
upda
ting
the
Men
tal
Hea
lth A
ct 1
983
Cod
e of
Pra
ctic
e. W
e ar
e on
trac
k to
co
nsul
t on
a re
vise
d ve
rsio
n of
the
Cod
e in
spr
ing
2014
an
d fo
r a n
ew v
ersi
on to
com
e in
to fo
rce
by th
e en
d of
20
14. T
he D
epar
tmen
t of H
ealth
is a
lso
wor
king
with
pa
rtner
s to
mak
e th
e C
ode
mor
e ac
cess
ible
and
av
aila
ble
to in
divi
dual
s su
bjec
t to
the
Act
, the
ir fa
mili
es
and
care
rs, i
nclu
ding
thos
e w
ith a
lear
ning
dis
abili
ty,
autis
m o
r whe
re E
nglis
h is
not
a fi
rst l
angu
age.
70
The
Ass
ocia
tion
of D
irect
ors
of S
ocia
l Ser
vice
s (A
DA
SS
) and
the
Ass
ocia
tion
of D
irect
ors
of
Chi
ldre
n’s
Serv
ices
(AD
CS
) will
pro
duce
gu
idan
ce n
otes
and
sim
ple
key
ques
tions
to
rais
e aw
aren
ess,
ens
ure
visi
bilit
y an
d ac
tion
at
a lo
cal l
evel
and
to e
mpo
wer
mem
bers
of
Saf
egua
rdin
g A
dults
Boa
rds,
Hea
lth a
nd
Wel
lbei
ng B
oard
s an
d Le
arni
ng D
isab
ility
P
artn
ersh
ip B
oard
s.
O
NG
OIN
G
Gui
danc
e pu
blis
hed
in D
ecem
ber 2
012
on th
e A
DA
SS
w
ebsi
te. A
vaila
ble
at:
http
://w
ww
.ada
ss.o
rg.u
k/im
ages
/sto
ries/
Pol
icy%
20N
etw
orks
/Lea
rnin
g%20
Dis
abili
ty/K
ey%
20D
ocum
ents
/Win
ter
bour
ne%
20V
iew
%20
Com
pend
ium
_Dec
12.p
df
AD
AS
S a
lso
publ
ishe
d ke
y qu
estio
ns fo
r lea
rnin
g di
sabi
lity
partn
ersh
ip b
oard
s, h
ealth
and
wel
lbei
ng
boar
ds a
nd s
afeg
uard
ing
adul
ts b
oard
s w
hich
are
bei
ng
used
, and
whi
ch A
DC
S a
re e
xplo
ring
how
bes
t to
adop
t in
rela
tion
to c
hild
ren.
The
key
prio
rity
goin
g fo
rwar
d,
for b
oth
adul
ts a
nd c
hild
ren’
s se
rvic
es, i
s to
ens
ure
that
lo
cal a
reas
use
the
guid
ance
effe
ctiv
ely.
60
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
71
The
Dep
artm
ent o
f Hea
lth h
ave
alre
ady
com
mitt
ed to
put
ting
Saf
egua
rdin
g A
dults
B
oard
s on
a s
tatu
tory
foot
ing
(sub
ject
to
parli
amen
tary
app
rova
l). D
H w
ill re
vise
st
atut
ory
guid
ance
and
goo
d pr
actic
e gu
idan
ce
to re
flect
new
legi
slat
ion
and
addr
ess
findi
ngs
from
Win
terb
ourn
e V
iew
, to
be c
ompl
eted
in
time
for t
he im
plem
enta
tion
of th
e C
are
Bill
.
O
ngoi
ng
O
NG
OIN
G
The
Dep
artm
ent o
f Hea
lth in
trodu
ced
new
dra
ft le
gisl
atio
n as
par
t of t
he C
are
Bill
201
3. T
his
has
pass
ed th
roug
h th
e Lo
rds
and
the
next
sta
ge is
2nd
R
eadi
ng in
the
Com
mon
s.
72
Saf
egua
rdin
g A
dults
Boa
rds
shou
ld re
view
th
eir a
rran
gem
ents
and
ens
ure
they
hav
e th
e rig
ht in
form
atio
n sh
arin
g pr
oces
ses
in p
lace
ac
ross
hea
lth a
nd c
are
to id
entif
y an
d de
al w
ith
safe
guar
ding
ale
rts.
O
ngoi
ng
O
NG
OIN
G
The
Car
e B
ill c
urre
ntly
in p
rogr
ess
thro
ugh
Par
liam
ent
cont
ains
a n
ew “S
uppl
y of
Info
rmat
ion”
cla
use
whi
ch
requ
ires
agen
cies
and
indi
vidu
als
to s
hare
info
rmat
ion
in o
rder
for S
afeg
uard
ing
Adu
lts B
oard
s to
be
able
to
carr
y ou
t the
ir du
ties
and
resp
onsi
bilit
ies.
Th
e A
DA
SS
Adu
lt S
afeg
uard
ing
Pol
icy
Net
wor
k ar
e fu
lly e
ngag
ed w
ith th
e im
prov
emen
t pro
gram
me
and
cont
inue
to p
rovi
de g
uida
nce
and
advi
ce to
Adu
lt S
afeg
uard
ing
lead
s.
61
SUM
MA
RY
OF
PRO
GR
ESS
ON
AC
TIO
NS
FRO
M T
RA
NSF
OR
MIN
G C
AR
E &
CO
NC
OR
DA
T (D
ECEM
BER
201
3)
W
OR
KST
RA
ND
6: W
OR
KFO
RC
E Im
prov
e qu
ality
and
saf
ety
thro
ugh
impr
ovin
g th
e ca
pabi
lity
of th
e w
orkf
orce
so
that
sta
ff ar
e pr
oper
ly tr
aine
d in
ess
entia
l ski
lls s
uppo
rted
by g
ood
clin
ical
and
man
ager
ial l
eade
rshi
p. H
ealth
and
car
e pr
ofes
sion
als
shou
ld u
nder
stan
d an
d be
sup
porte
d in
ach
ievi
ng m
inim
um s
tand
ards
and
asp
ire
to b
est p
ract
ice.
Mem
bers
of s
taff
shou
ld fe
el it
is s
afe
to ra
ise
conc
erns
whe
n th
ings
go
wro
ng a
nd b
e lis
tene
d to
. R
ef
No.
A
ctio
n St
art
Dat
e Fi
nish
D
ate
Prog
ress
C
omm
ents
10
The
Col
lege
of S
ocia
l Wor
k, w
orki
ng in
co
llabo
ratio
n w
ith B
ritis
h A
ssoc
iatio
n of
Soc
ial
Wor
kers
(BA
SW
) and
oth
er p
rofe
ssio
nal
orga
nisa
tions
and
with
ser
vice
use
r led
gro
up,
to p
rodu
ce k
ey p
oint
s gu
idan
ce fo
r soc
ial
wor
kers
on
good
pra
ctic
e in
wor
king
with
pe
ople
with
lear
ning
dis
abili
ties
who
als
o ha
ve
men
tal h
ealth
con
ditio
ns.
Apr
-13
C
OM
PLET
E A
brie
f gui
de to
goo
d pr
actic
e st
anda
rds
was
pub
lishe
d in
Aug
ust.
http
://w
ww
.tcsw
.org
.uk/
uplo
aded
File
s/Th
eCol
lege
/Soc
ial
_Wor
k_P
ract
ice/
Win
terb
ourn
eVie
wG
uida
nceA
ugus
t201
3.pd
f A
mor
e in
-dep
th g
uide
will
be
publ
ishe
d la
ter i
n 20
13/1
4.
62
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
12
The
Roy
al C
olle
ge o
f Spe
ech
and
Lang
uage
Th
erap
ists
, to
prod
uce
good
pra
ctic
e st
anda
rds
for c
omm
issi
oner
s an
d pr
ovid
ers
to p
rom
ote
reas
onab
le a
djus
tmen
ts re
quire
d to
mee
t the
sp
eech
, lan
guag
e an
d co
mm
unic
atio
n ne
eds
of p
eopl
e w
ith le
arni
ng d
isab
ilitie
s in
spe
cial
ist
lear
ning
dis
abili
ty o
r aut
ism
hos
pita
l and
re
side
ntia
l set
tings
.
Nov
-13
C
OM
PLET
E Th
ese
stan
dard
s co
ver g
ood
com
mun
icat
ion
for
com
mis
sion
ers
and
prov
ider
s to
geth
er w
ith a
gui
de to
"w
hat d
oes
good
look
like
& h
ow w
ill y
ou k
now
".
http
://w
ww
.rcsl
t.org
/new
s/go
od_c
omm
_sta
ndar
ds
14
The
prof
essi
onal
bod
ies
that
mak
e up
the
Lear
ning
Dis
abili
ty P
rofe
ssio
nal S
enat
e w
ill
refre
sh C
halle
ngin
g B
ehav
iour
: A U
nifie
d A
ppro
ach
to s
uppo
rt cl
inic
ians
in c
omm
unity
le
arni
ng d
isab
ility
team
s to
del
iver
act
ions
that
pr
ovid
e be
tter i
nteg
rate
d se
rvic
es.
By
end
Dec
20
13
O
NG
OIN
G
Eac
h of
the
sect
ions
of t
he re
port
has
been
dra
fted.
W
e ar
e no
w in
the
proc
ess
of c
onsu
lting
mor
e w
idel
y to
en
sure
that
the
vario
us s
take
hold
ers
are
sign
ed u
p to
th
e co
nten
t. Ju
ly 2
014
is th
e an
ticip
ated
dat
e fo
r the
fin
al d
raft
to b
e av
aila
ble.
15
Ski
lls fo
r Hea
lth a
nd S
kills
for C
are
will
dev
elop
na
tiona
l min
imum
trai
ning
sta
ndar
ds a
nd a
co
de o
f con
duct
for h
ealth
care
sup
port
wor
kers
an
d ad
ult s
ocia
l car
e w
orke
rs.
Thes
e ca
n be
us
ed a
s th
e ba
sis
for s
tand
ards
in th
e es
tabl
ishm
ent o
f a v
olun
tary
regi
ster
for
heal
thca
re s
uppo
rt w
orke
rs a
nd a
dult
soci
al
care
wor
kers
in E
ngla
nd.
By
Janu
ary
2013
C
OM
PLET
E S
kills
for H
ealth
and
Ski
lls fo
r Car
e ha
ve d
eliv
ered
the
min
imum
trai
ning
sta
ndar
ds a
nd c
ode
of c
ondu
ct fo
r he
alth
care
sup
port
wor
kers
and
adu
lt ca
re w
orke
rs in
E
ngla
nd. P
ublis
hed
in M
arch
to c
oinc
ide
with
the
Fran
cis
repo
rt.
http
://w
ww
.ski
llsfo
rhea
lth.o
rg.u
k/ab
out-u
s/ne
ws/
code
-of
-con
duct
-and
-nat
iona
l-min
imum
-trai
ning
-sta
ndar
ds-
for-
heal
thca
re-s
uppo
rt-w
orke
rs/
63
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
16
Ski
lls fo
r Car
e (S
fC) w
ill d
evel
op a
fram
ewor
k of
gui
danc
e an
d su
ppor
t on
com
mis
sion
ing
wor
kfor
ce s
olut
ions
to m
eet t
he n
eeds
of
peop
le w
ith c
halle
ngin
g be
havi
our.
By
Febr
uary
20
13
C
OM
PLET
E P
ublic
atio
n of
Ski
lls fo
r Car
e/N
atio
nal D
evel
opm
ent
Team
for I
nclu
sion
(ND
Ti) g
uida
nce
to ‘D
evel
op a
fra
mew
ork
of g
uida
nce
and
supp
ort o
n co
mm
issi
onin
g w
orkf
orce
sol
utio
ns to
mee
t the
nee
ds o
f peo
ple
with
ch
alle
ngin
g be
havi
our’
for e
mpl
oyer
s. P
ublis
hed
in
Febr
uary
. ht
tp://
ww
w.s
kills
forc
are.
org.
uk/c
halle
ngin
gbeh
avio
ur/
Act
ive
diss
emin
atio
n is
in p
rogr
ess
thro
ugh
SfC
and
N
DTi
. Pro
vide
r gro
ups
are
circ
ulat
ing
the
fram
ewor
k am
ongs
t mem
bers
.
21
The
Roy
al C
olle
ge o
f Psy
chia
trist
s w
ill is
sue
guid
ance
abo
ut th
e di
ffere
nt ty
pes
of in
patie
nt
serv
ices
for p
eopl
e w
ith le
arni
ng d
isab
ilitie
s an
d ho
w th
ey s
houl
d m
ost a
ppro
pria
tely
be
used
.
By
Mar
ch
2013
C
OM
PLET
E Th
e re
port
‘Peo
ple
with
lear
ning
diff
icul
ty a
nd m
enta
l he
alth
, beh
avio
ural
or f
oren
sic
prob
lem
s: th
e ro
le o
f in-
patie
nt s
ervi
ces’
was
pub
lishe
d in
Jul
y 20
13:
http
://w
ww
.rcps
ych.
ac.u
k/pd
f/FR
%20
ID%
2003
%20
for%
20w
ebsi
te.p
df
23
The
Aca
dem
y of
Med
ical
Roy
al C
olle
ges
and
the
bodi
es th
at m
ake
up th
e Le
arni
ng D
isab
ility
P
rofe
ssio
nal S
enat
e w
ill d
evel
op c
ore
prin
cipl
es o
n a
stat
emen
t of e
thic
s to
refle
ct
wid
er re
spon
sibi
litie
s in
the
heal
th a
nd c
are
syst
em.
By
1 A
pril
2013
O
NG
OIN
G
The
Aca
dem
y no
w h
as a
fram
ewor
k in
pla
ce fo
r ca
rryi
ng o
ut th
is w
ork.
A S
tate
men
t of E
thic
s is
in fi
nal
draf
t and
wid
er c
onsu
ltatio
n w
ill b
egin
ear
ly in
201
4.
64
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e Pr
ogre
ss
Com
men
ts
28
Hea
lth E
duca
tion
Eng
land
will
take
on
the
duty
fo
r edu
catio
n an
d tra
inin
g ac
ross
the
heal
th
and
care
wor
kfor
ce a
nd w
ill w
ork
with
the
Dep
artm
ent o
f Hea
lth, p
rovi
ders
, clin
ical
le
ader
s an
d ot
her p
artn
ers
to im
prov
e sk
ills
and
capa
bilit
y to
resp
ond
the
need
s of
peo
ple
with
com
plex
nee
ds
Ong
oing
O
NG
OIN
G
Pro
fess
or C
hris
Wel
sh, D
irect
or o
f Edu
catio
n an
d Q
ualit
y at
Hea
lth E
duca
tion
Eng
land
bec
ame
a m
embe
r of t
he L
earn
ing
Dis
abili
ty P
rogr
amm
e B
oard
in
June
201
3. H
ealth
Edu
catio
n E
ngla
nd’s
man
date
is
curr
ently
bei
ng re
fresh
ed a
nd th
e D
epar
tmen
t of H
ealth
is
wor
king
with
them
to e
nsur
e ap
prop
riate
incl
usio
n of
W
inte
rbou
rne
Vie
w c
omm
itmen
ts.
54
Ther
e w
ill b
e a
prog
ress
repo
rt on
act
ions
to
impl
emen
t the
reco
mm
enda
tions
in
Stre
ngth
enin
g th
e C
omm
itmen
t the
repo
rt of
th
e U
K M
oder
nisi
ng le
arni
ng d
isab
ility
Nur
sing
R
evie
w.
By
end
2013
FI
NA
LISI
NG
REP
OR
T P
rogr
ess
has
been
mad
e on
mos
t of t
he 1
7 re
com
men
datio
ns in
Stre
ngth
enin
g th
e C
omm
itmen
t th
e re
port
of th
e U
K M
oder
nisi
ng le
arni
ng d
isab
ility
N
ursi
ng R
evie
w a
nd a
full
repo
rt w
ill b
e pu
blis
hed
early
in
the
New
Yea
r.
73
Thro
ugh
the
Whi
stle
blow
ing
Hel
plin
e, th
e D
epar
tmen
t of H
ealth
aim
s to
incr
ease
aw
aren
ess
of w
hist
lebl
owin
g fo
r sta
ff w
ithin
the
heal
th a
nd s
ocia
l car
e se
ctor
s. T
he h
elpl
ine
will
adv
ise
empl
oyer
s on
em
bedd
ing
best
pr
actic
e po
licy
and
proc
edur
e an
d st
aff o
n ho
w
to ra
ise
conc
erns
and
wha
t pro
tect
ion
they
ha
ve in
law
whe
n th
ey d
o so
.
Jan-
12
C
OM
PLET
E H
elpl
ine
run
by R
oyal
Men
cap.
Hel
plin
e N
umbe
r: 08
00
0824
825
ww
w.w
bhel
plin
e.or
g.uk
en
quiri
es@
wbh
elpl
ine.
co.u
k
65
SUM
MA
RY
OF
PRO
GR
ESS
ON
AC
TIO
NS
FRO
M T
RA
NSF
OR
MIN
G C
AR
E &
CO
NC
OR
DA
T (D
ECEM
BER
201
3)
WO
RK
STR
AN
D 7
: CH
ILD
REN
AN
D T
RA
NSI
TIO
N
To d
eliv
er in
tegr
ated
sup
port
to v
ulne
rabl
e ch
ildre
n an
d yo
ung
peop
le w
ith c
halle
ngin
g be
havi
ours
. Thi
s sh
ould
incl
ude
early
and
effe
ctiv
e in
terv
entio
n w
ith c
are
co-o
rdin
ated
aro
und
and
tailo
red
to th
e ne
eds
of th
e in
divi
dual
chi
ld o
r you
ng p
erso
n.
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e P
rogr
ess
Com
men
ts
19
See
with
wor
kstra
nd 1
for C
hild
ren
and
You
ng
Peo
ple
serv
ice
spec
ifica
tion.
46
The
Dep
artm
ent o
f Hea
lth a
nd th
e D
epar
tmen
t fo
r Edu
catio
n w
ill w
ork
with
the
inde
pend
ent
expe
rts o
n th
e C
hild
ren
and
You
ng P
eopl
e’s
Hea
lth O
utco
mes
For
um to
prio
ritis
e im
prov
emen
t out
com
es fo
r chi
ldre
n an
d yo
ung
peop
le w
ith c
halle
ngin
g be
havi
our a
nd a
gree
ho
w b
est t
o su
ppor
t you
ng p
eopl
e w
ith
com
plex
nee
ds in
mak
ing
the
trans
ition
to
adul
thoo
d.
Feb
2013
B
y D
ec
2013
C
OM
PLET
E Th
e C
hild
ren
and
You
ng P
eopl
e’s
Hea
lth O
utco
mes
Fo
rum
is s
uppo
rting
this
thro
ugh
its fo
rwar
d w
ork
prog
ram
me.
G
uida
nce
on in
tegr
ated
tran
sitio
n to
adu
lthoo
d ha
s be
en d
evel
oped
for t
he F
orum
by
the
Nat
iona
l N
etw
ork
of P
aren
t Car
er F
orum
s, a
nd th
e Fo
rum
is
cons
ider
ing
addi
tiona
l rec
omm
enda
tions
in re
latio
n to
th
is.
http
://w
ww
.nnp
cf.o
rg.u
k/ne
ws-
and-
cons
ulta
tions
47
The
Dep
artm
ent o
f Hea
lth a
nd th
e D
epar
tmen
t fo
r Edu
catio
n w
ill d
evel
op a
nd is
sue
stat
utor
y gu
idan
ce o
n ch
ildre
n in
long
-term
resi
dent
ial
care
.
In
201
3
FI
NA
LISI
NG
GU
IDA
NC
E FO
R P
UB
LIC
ATI
ON
S
tatu
tory
gui
danc
e on
long
-term
resi
dent
ial c
are
has
been
sha
red
with
Sta
keho
lder
s an
d su
bjec
t to
appr
oval
; the
gui
danc
e is
exp
ecte
d to
be
publ
ishe
d in
Ja
nuar
y 20
14.
66
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e P
rogr
ess
Com
men
ts
48
The
Dep
artm
ent o
f Hea
lth a
nd th
e D
epar
tmen
t fo
r Edu
catio
n w
ill jo
intly
exp
lore
the
issu
es a
nd
oppo
rtuni
ties
for c
hild
ren
with
lear
ning
di
sabi
litie
s w
hose
beh
avio
ur is
des
crib
ed a
s ch
alle
ngin
g th
roug
h bo
th th
e S
EN
and
D
isab
ility
refo
rm p
rogr
amm
e an
d th
e w
ork
of
the
Chi
ldre
n’s
Hea
lth S
trate
gy.
S
ep-1
4
O
NG
OIN
G
The
Chi
ldre
n an
d Y
oung
Peo
ple’
s H
ealth
Out
com
es
Foru
m w
ill c
over
this
in it
s fo
rwar
d w
ork
prog
ram
me.
S
EN
refo
rms
in th
e C
hild
ren
and
Fam
ilies
Bill
are
ex
pect
ed to
gai
n R
oyal
Ass
ent i
n Sp
ring
2014
.
50
The
Dep
artm
ent f
or E
duca
tion
will
revi
se th
e st
atut
ory
guid
ance
Wor
king
toge
ther
to
safe
guar
d C
hild
ren.
In 2
013
C
OM
PLET
E Th
e gu
idan
ce, W
orki
ng to
saf
egua
rd c
hild
ren
was
pu
blis
hed
in M
arch
201
3.
http
://w
ww
.edu
catio
n.go
v.uk
/abo
utdf
e/st
atut
ory/
g002
131
60/w
orki
ng-to
geth
er-to
-saf
egua
rd-c
hild
ren
67
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e P
rogr
ess
Com
men
ts
56
The
Dep
artm
ent o
f Hea
lth w
ill w
ork
with
the
Dep
artm
ent f
or E
duca
tion
to in
trodu
ce a
new
si
ngle
ass
essm
ent p
roce
ss a
nd E
duca
tion,
H
ealth
and
Car
e P
lan
to re
plac
e th
e cu
rren
t sy
stem
of s
tate
men
ts a
nd le
arni
ng d
iffic
ulty
as
sess
men
ts fo
r chi
ldre
n an
d yo
ung
peop
le
with
spe
cial
edu
catio
nal n
eeds
; sup
porte
d by
jo
int c
omm
issi
onin
g be
twee
n lo
cal p
artn
ers
(sub
ject
to p
arlia
men
tary
app
rova
l). T
he
proc
ess
will
incl
ude
youn
g pe
ople
up
to th
e ag
e of
25,
to e
nsur
e th
ey a
re s
uppo
rted
in
mak
ing
the
trans
ition
to a
dulth
ood.
From
20
14
Ong
oing
O
NG
OIN
G
Spe
cial
Edu
catio
nal N
eeds
(SE
N) r
efor
ms
in th
e C
hild
ren
and
Fam
ilies
Bill
are
now
ent
erin
g th
e Lo
rd’s
re
port
stag
e an
d ar
e ex
pect
ed to
gai
n R
oyal
Ass
ent i
n S
prin
g 20
14.
Sig
nific
ant s
take
hold
er in
tere
st in
E
duca
tion,
Hea
lth a
nd C
are
Pla
n. T
here
is a
co
ntin
ued
need
to e
nsur
e lo
calit
ies
are
thin
king
abo
ut
this
in li
fe-c
ours
e se
rvic
e pl
anni
ng -
JIP
to le
ad.
The
You
ng P
eopl
e’s
Con
sulta
tion
on th
e S
peci
al
Edu
catio
nal N
eeds
Cod
e of
Pra
ctic
e w
as p
ublis
hed
with
a c
onsu
ltatio
n cl
osin
g da
te 2
0 D
ecem
ber 2
014.
ht
tps:
//ww
w.e
duca
tion.
gov.
uk/c
onsu
ltatio
ns/
Th
e P
athf
inde
rs a
re d
evel
opin
g ne
w a
ppro
ache
s to
S
EN
and
pro
mot
ing
them
via
Pat
hfin
der c
ham
pion
s an
d lo
cal e
ngag
emen
t. Th
ere
has
been
sig
nific
ant
stak
ehol
der e
ngag
emen
t thr
ough
targ
eted
eve
nts
with
P
athf
inde
rs, n
asen
and
the
Cou
ncil
for D
isab
led
Chi
ldre
n (C
DC
). Im
plem
enta
tion
pack
s ar
e du
e to
be
sent
out
to L
ocal
Aut
horit
ies,
Clin
ical
Com
mis
sion
ing
Gro
up’s
and
Hea
lth a
nd W
ellb
eing
Boa
rd’s
to s
uppo
rt th
eir i
mpl
emen
tatio
n of
the
upco
min
g ch
ange
s.
74
Ofs
ted,
Car
e Q
ualit
y C
omm
issi
on, H
er
Maj
esty
's In
spec
tora
te o
f Con
stab
ular
y (H
MIC
), H
er M
ajes
ty's
Insp
ecto
rate
of
Pro
batio
n an
d H
er M
ajes
ty’s
Insp
ecto
rate
of
Pris
ons
will
intro
duce
a n
ew jo
int i
nspe
ctio
n of
m
ulti-
agen
cy a
rran
gem
ents
for t
he p
rote
ctio
n of
chi
ldre
n in
Eng
land
.
From
Ju
ne
2013
O
ngoi
ng
O
NG
OIN
G
Ofs
ted
has
been
wor
king
with
HM
IC, t
he C
are
Qua
lity
Com
mis
sion
, HM
I Pro
batio
n an
d H
MI P
rison
s to
de
velo
p a
mul
ti-ag
ency
insp
ectio
n fra
mew
ork.
The
co
nsul
tatio
n fo
r thi
s cl
osed
in O
ct 2
013.
Mul
ti-ag
ency
in
spec
tions
will
take
pla
ce fr
om A
pril
2015
.
68
Ref
N
o.
Act
ion
Star
t D
ate
Fini
sh
Dat
e P
rogr
ess
Com
men
ts
75
Ofs
ted
will
mak
e ju
dgem
ents
on
the
over
all
effe
ctiv
enes
s, o
utco
mes
for c
hild
ren
and
youn
g pe
ople
, qua
lity
of c
are,
saf
egua
rdin
g as
wel
l as
lead
ersh
ip a
nd m
anag
emen
t.
O
ngoi
ng
O
NG
OIN
G
The
mul
ti-ag
ency
insp
ectio
ns fr
om A
pril
2015
will
in
clud
e ju
dgem
ents
on
lead
ersh
ip, m
anag
emen
t and
go
vern
ance
, the
qua
lity
of p
rofe
ssio
nal p
ract
ice,
the
arra
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AAPPENDIXX 2
Joint HHealthh and SSocial Care SSelf-Asssessmment Frameework 2013
Emerginng findinggs from RRespondinng Local AAuthoritiees Introducction and backgrouund This appeendix proviides a preliminary vieew of how far local Partnership Boards have been able to pprovide infoormation about their wwork for thhis year's JJoint Healthh and Sociaal Care Self-Assessmment Frameework (SAAF) exercise. The SAAF processs is a compplex local sstocktake. It covers aa wide rangge of the pphysical and mental healthcarre and the ssocial caree provided for peoplee with learnning disabilities in thee geographhic area covvered by loocal learninng disabilitty Partnersship Board. In almosst all cases Partnershiip Board areas exacttly match uupper tier LLocal Authoority areass. Followingg the actionn agreed inn Transformming Care (Action 388), this year, for the first time, the regulaar local stocktakes unndertaken by health aand social care services hhave been fully integrated. Thiss represents an amallgamation of the former Strategic Heealth Authoority Self-Asssessmentt Framewoork and thee Local Authority based Parrtnership BBoard annuual reports. The Frammework hass two partss: key numbers and qquality benchmarks. Partnership Boards arre invited tto set out nnumbers wwhich descrribe the scaale of the ttask they face in prroviding care and somme indicatoors of how well they aare performming. Thiss is followed by a selff-rating exeercise to coompare thee local perfformance wwith some nationallyy agreed yaardsticks. This part oof the exerrcise is inteended to bee undertakeen by Cliniccal Commissioning GGroup and Local Authhority officeers in collaborattion with loocal care pproviders, sself-advocaates and faamily carerrs. It is recommeended that the rating exercise should be fiinalised at a 'Big Heaalth and Social Caare Day' - aa participattory planning exercisse. This yeear the detaail of the frameworrk was developed by a group coomprising fformer Straategic Heaalth Authority learning disability leaads and members off the Assocciation of DDirectors off Adult Soccial Servicees. An independent cconsultantt facilitated the process and memberss of the Leaarning Disaabilities Obbservatory provided ttechnical aadvice. The collecction of infformation rrelating to tthe framewwork started in Augusst. The official cloosure date for submisssions wass the end oof Novembber. This reeflected partly the fact that itt involves aa great deaal of work, and partlyy the fact thhat it coincidedd with two oother natioonally inspired exercisses (the Auutism Self--Assessmeent Framework and tthe Stocktaake of locaal services led by the Winterbouurne View Joint Imprrovement PProgrammee) requiringg input larggely from the same staff. In thhe event, aas a result of techniccal difficultiees, the closure date for submissions wass extendedd to 5:00pmm on the 6tth Decembber. Thus, given the publicatioon deadlinees for this rreport theree has not bbeen time to work thrrough the data submmitted in thhe depth reequired for detailed reeporting. TThis brief ssummary focuses oon four asppects:
• The numbber of authhorities that respondeed • How mucch of the Frramework they were able to complete
DDecember 2013
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• Further detail about the responses relating to in-patient psychiatric care for people with learning disabilities and how this compares with the findings of the recent in-patient census
• The numbers of individuals on Clinical Commissioning Group registers of individuals with challenging behaviour in the context of learning disability or autism, and the progress in reviewing their care needs
Responses There are currently 152 upper tier local authorities. All of them registered to report their local conclusions. Responses reflected the geography of upper tier Local Authorities with one exception. In Lancashire Partnership Board areas were defined on the basis of former Primary Care Trust boundaries (Central, East, and North Lancashire). This year Lancashire continued to use this arrangement and produced three reports. So a total of 154 responses were received. All but 1 provided at least some details of local services.
Parts of the Framework covered This section describes the reporting of the population of people with learning disability living in Partnership Board areas and the extent to which other sections of the Framework were covered. Coverage of population figures is reported in more detail since evaluation of almost all the other sections depends on understanding the size and structure of the population served. The Framework asked about the number of people with learning disability by age group, disability and ethnic group. Age profiles could be given at three levels of detail: narrow age bands (0 to 13, 14 to 17, 18 to 34, 35 to 64 and 65 and older), broad age bands (0 to 17, 18 and older) or simply as a total figure. Respondents were asked for similar breakdowns of numbers of people with complex or profound learning disabilities (defined as learning disability complicated by severe problems of continence, mobility or behaviour, or severe repetitive behaviour with no effective speech) and with learning disabilities complicated by autism. They were also asked for numbers, aged 0 to 17 and 18 and older, of people in each of the three disability categories who are recorded as being from a minority ethnic group. Table 1 shows the numbers of respondents able to provide each set of figures.
Table 1. Numbers (and proportions) of respondents able to report figures for numbers in the population with learning disabilities (LD).
People with People with All with LD Complex or LD and
Profound LD Autism Reported in narrow age bands 111 (72.1%) 102 (66.2%) 96 (62.3%) Reported in broad age bands 28 (18.2%) 24 (15.6%) 30 (19.5%) Reported totals only 6 (3.9%) 6 (3.9%) 7 (4.5%) Respondents reporting any data 145 (94.2%) 132 (85.7%) 133 (86.4%) Reported any ethnic minority data 102 (66.2%) 77 (50.0%) 77 (50.0%)
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Table 2 gives an overview of all the sections of the Framework showing the proportion of Partnership Boards (out of the possible total of 154) responding to each. Not every Partnership Board would have people in every category in each section, so they would not necessarily be expected to respond to every question. In this table, they are scored as having responded to each Framework section if they made an entry in any part of it.
Table 2. Proportion (percentage) of respondents providing information about each section of the Framework
Framework Section Proportion of respondents providing responses
Demography Complex or profound disorder Learning Disability with Autism Screening coverage GP observations Deaths Learning Disability Health Checks General hospital use Continuing Healthcare and Mental Health Act Section 117 Local mental health in-patients Specialist commissioned mental health in-patients Stay legth of current mental health in-patients Challenging Behaviour registers and reviews Social Care statistics Employment and voluntary work Accommodation arrangements Adult safeguarding Mental Capacity Act / Deprivation of Liberty SafeguardsNumbers with relevant Special Educational Needs in schools Staying Healthy ratings Being Safe ratings Living Well ratings
94% 86%86%87%77%67%
97%77%
95%88%
92%90%90%84%84%82%98%
99%
97%95%96%95%
The parts of the Framework with the weakest coverage were the number of deaths of people with learning disabilities (67%), the various GP-based observations, including blood pressure, body mass index, diabetes, epilepsy, asthma, dysphagia (difficulty swallowing) and coronary heart disease (77%), and the use of local general hospital care (77%). 87% of respondents were able to report to some extent about screening coverage, although only 80% reported about all three types. There were some parts of the Framework where it was a surprise that coverage was so low. These described issues which have been reported in national statistical returns for many years. They are the provision of social care packages (84%), work status (84%) and housing status (82%).
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In-patient care for mental health problems or challenging behaviour Respondents were asked to report the numbers of people in mental hospital in-patient care as at 31st March 2013. They were asked to break this down by commissioner type, location, primary reason for admission and broad length of stay. Table 3 shows the numbers of respondents (out of the possible total of 154) providing information about the numbers of patients in locally commissioned and specialised commissioned services.
Table 3. Respondents providing numbers of mental hospital in-patients at 31st March by age band, commissioning arrangements and primary reason for admission
Age 18 or Age 0 to 17 Primary reason for admission older Locally commissioned services
Challenging behaviour 103 (66.9%) 130 (84.4%) Mental health problem 101 (65.6%) 131 (85.1%) Complex physical 100 (64.9%) 119 (77.3%) health needs
Specialised commissioned - located locally Challenging behaviour 105 (68.2%) 132 (85.7%) Mental health problem 107 (69.5%) 130 (84.4%) Complex physical 106 (68.8%) 127 (82.5%) health needs Specialised commissioned - distant Challenging behaviour 104 (67.5%) 133 (86.4%) Mental health problem 101 (65.6%) 131 (85.1%) Complex physical 103 (66.9%) 120 (77.9%) health needs
From table 3 it is clear that the overall numbers obtained give an incomplete picture of the numbers of in-patients Partnership Boards are aware are receiving mental hospital in-patient care. However some patterns emerge. A total of 3,213 people in hospital were reported. 6% of these were younger than 18, 94% were aged 18 or older. 45% of those reported were in local services, 57% in specialised commissioned services. Of those in specialised commissioned services, 67% were described as being in placements within the Partnership Board area or a neighbouring Clinical Commissioning Group. 31% of all patients were reported as being in hospital primarily because of challenging behaviour, 65% because of a mental health problem and 3% because of complex physical health problems. 56% of the people primarily in hospital because of challenging behaviour were in ordinary local services, as were 65% of those primarily in hospital because of complex physical health needs. In contrast only 39% of those primarily in hospital for mental health problems were in ordinary services whilst 61% were in specialised commissioned provision.
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Respondents were asked how many of those currently in hospital at the end of March 2013 had been in-patients continuously for more than 3 months and more than two years. These responses were harder to analyse. 111 (72.1%) Partnership Boards provided a total year-end figure, but a larger number (120 (77.9%)) provided a three month figure. There was also evident inconsistency in how these data were recorded indicating that further consultation with sites submitting them will be needed before they can be reported in detail. 101 (65.6%) reported numbers in hospital two years or longer. The figures reported in the SAF would not be expected to agree exactly with the findings of the recent Learning Disabilities Census7 since only around 85% of SAF respondents reported in-patient numbers. Despite this the totals are strikingly similar The total number of in-patients reported in the SAF was 3,123, 99% of the census figure of 3,250. The split between local in-patients (SAF 1,441, census 1,470) and specialised commissioned patients (SAF 1,772, census 1,780) was also very close. In the SAF, 39 Partnership Boards did not provide local in-patient numbers and 28 did not provide specialised commissioned numbers. The census identified roughly 650 patients from these Local Authority areas; however the tabulation in the census report (table 10) is not sufficiently detailed to give a precise figure). This would suggest that the figures reported in the SAF are roughly 25% higher than the census findings. There is a further clear discrepancy in the proportion of in-patients reported as having been in hospital for two years or more. SAF respondents reported only 587 patients (18%) as having stayed this long. The census identified 1,363 (42%) patients in this position.
Challenging Behaviour Care Registers In Transforming Care NHS England agreed to ensure that all Primary Care Trusts would set up registers of people with learning disability or autism who presented challenging behaviour for which they were receiving NHS-funded care, by 1st April 2013 (Action 22). Registers would be transferred to successor Clinical Commissioning Groups who would subsequently maintain them. Clinical Commissioning Groups were asked to ensure that all those registered had a review of their care by 1st June, with these reviews leading to a personal care plan agreed with the individual and based around their and their families’ needs and agreed outcomes (Action 26). The Framework asked about numbers on the register at the handover point and at the end of June, and the number of these who had had a care review as specified by June 1st. Numbers were to be divided into those currently in hospital and those not. 123 (79.9%) Partnership Boards reported the number of patients in the registers handed over to Clinical Commissioning Groups at the start of April. 123 (79.9%) reported the number registered at 30th June, and a larger number (130 (84.4%)) reported the number whose care had been reviewed. Table 4 shows figures for the 115 Partnership Board areas answering all three questions.
7 http://www.hscic.gov.uk/ldcensus
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Table 4. Total number of patients reported by 115 respondents providing figures for all three questions (percentages are by row).
Measure In hospital at index date
Not in hospital at index date
Total patients
On the PCT register at 31st March 1,156 (37.1%) 3,112 (72.9%) 4,268
On the CCG register at 30th June 1,124 (40.2%) 2,796 (71.3%) 3,920
Number whose care was reviewed by 1st June 1,163 (37.4%) 3,112 (72.8%) 4,275
The numbers reported as being on challenging behaviour care registers and those reported as in-patients in the previous section differed somewhat. Only 80 Partnership Boards answered all the questions reported in table 4 as well as all the questions about numbers of in-patients by primary cause and commissioner type described above. This group of respondents reported a total of 894 in-patients on their registers at the end of March and 865 at the end of June. They reported having done care reviews for 905. However the numbers of in-patients they reported in response to the earlier questions, whose primary reason for being in hospital was challenging behaviour, were substantially lower: 346 in locally commissioned services and 271 in specialised commissioned services, a total of 617.
Conclusion These are inevitably preliminary observations since data collection was only closed to entry on 6th December. This overview is intended mainly to indicate the extent to which the commitment to undertake self-assessment has been fulfilled.
The SAF is primarily intended to provide impetus, structure and comparative benchmarks for a local process of review and service improvement. A more detailed report on all of the findings of the exercise will be published by Public Health England early in the new year. This will be based on a thorough check and exploration of all the data from the SAF. It will include thematic analysis of the comments made in relation to the local quality ratings. Full responses from Partnership Boards and a summary spreadsheet designed to facilitate comparative study will be published alongside the final report.
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APPENDIX 3 INVESTMENT SUMMARY
JOINT IMPROVEMENT PROGRAMME 2013/2014 Figures include apportioned staff costs
Budget
Expenditure to date (as at
Dec. 2013)
Balance
1 Involvement and engagement work
£128,000 £61,962 £66,038
2 Communications activity
£56,000 £30,101 £25,899
3 Improvement projects and activity
£1,144,000 £125,672 £1,018,328
4 Programme support costs
£640,000 £143,590 £496,410
5
Other costs, including medication collaborative
£400,000 n/a £400,000
6 VAT
£492,000 £36,906 £455,094
TOTAL EXPENDITURE TO DATE £2,860,000
£398,231 £2,461,769
Staff costs (total figure). These are included in the figures above apportioned across relevant activities
£229,917
Notes Figures include apportioned staff costs 1 Including events, consultation etc. 2 Publication costs, including easy read materials, briefings etc. 3 Improvement programme/support to local areas, including resource development 4 Including support to Joint Improvement Board activity & LGA charge 5 Medication collaborative and CQC research project on medication data Nb. Costs are profiled to increase substantially during 2013/14 and 2014/15. Some costs have been committed but not yet spent and are therefore not included in expenditure to date.
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