Crisis Houses

Wednesday 22nd May 2024 Westminster Hall

10:56

[Yvonne Fovargue (in the Chair)]

I will call Bambos Charalambous to move the motion and then call the Minister to respond. As is the convention for 30-minute debates, there will not be an opportunity for the Member in charge to wind up.

[Bambos Charalambous (Enfield, Southgate) (Lab)]

I beg to move,

That this House has considered crisis houses.

Until October 2021, I had never heard of a crisis house and did not know what one was, but that all changed when one of my constituents got in touch to tell me about the tragic circumstances of her daughter’s death in a crisis house, following a referral there from the local clinical commissioning group.

What is a crisis house? Crisis houses are broadly defined as community-based residential settings that give clinical and social support to people during a crisis. The emphasis is on providing a safe alternative to hospital admission when an individual is undergoing a mental health crisis. Some crisis houses are staffed by volunteers, while others are staffed by medical professionals. The level of support can vary greatly, from accommodation and emotional support to acute mental health support. Despite the varying degrees of support that they provide, crisis houses are not regulated. I will explain why that is a problem by speaking about the tragic case of my constituent’s daughter, Jess. The details of Jess’s case, which I will draw on in my speech, were reported at her inquest and are publicly available online.

In 2020, 27-year-old Jess Durdy entered Link House, a crisis house in Bristol. Link House is run by a charity and was commissioned by the local care commissioning group to provide mental health support. It was not registered with the NHS or the Care Quality Commission. Jess was moved from regulated NHS care to a service that was unregulated, where her care co-ordinator was not a registered practitioner. Five days later, she took her own life.

Jess’s death was almost certainly preventable. She died because staff at Link House were entirely lacking in the training necessary to deal with patients suffering from severe mental ill health. They failed to take seriously or act on Jess’s repeated warnings that she was having intrusive suicidal thoughts; they used unsafe door locks that prevented them or paramedics from reaching her quickly; and they were unable to provide emergency services with the information necessary to arrive on time to save Jess’s life. For Jess’s family, there were and there remain many questions. Could Jess’s death have been prevented? Was the crisis house that Jess entered a safe alternative to hospital care? How could they raise their concerns about the care provided to their daughter?

Despite growing numbers of crisis houses dealing with some of the most vulnerable in society, the regulatory oversight of these organisations is a complex patchwork of different regulators and regimes, including the CQC, the Charity Commission, local authorities and so on. The CQC can only regulate providers of certain regulated activities, including in such areas as accommodation for nursing or personal care and family planning. In Jess’s case, the CQC had no oversight of the care and treatment provided by Link House. It could only examine the procedures of the commissioning Avon and Wiltshire Mental Health Partnership NHS Trust in ensuring patient safety. Without proper regulation and oversight, there is always the risk that other vulnerable people will take their lives. For that reason, the Government must introduce regulation for the sector to ensure basic standards of care before another tragedy occurs.

I pay tribute to Jess and her family. Jess’s mother Moira Durdy is my constituent, and I have been supporting her attempts to get justice for Jess to ensure that no other family has to experience the terrible loss of a loved one in similar circumstances. Jess was originally from north London. Her family describe her as a dearly loved, bright and caring child. They are hugely proud of the kind, loving, generous and loyal person she was and of her intelligent and inquiring mind. After spending time in Bangladesh working for Engineers Without Borders, Jess returned to her university town of Bristol to live and work in 2016. Jess had struggled with mental health since her teens, and had been diagnosed with anxiety, depressive disorder and bulimia. Despite this, her family say that she always had a smile and often hid her struggles.

Jess approached her GP for additional support in June 2020 and was under the care of Avon and Wiltshire Mental Health Partnership NHS Trust. She struggled with the medication provided, and by October 2020 her health had further declined. She was referred by the trust to Link House, which is run by the housing association Missing Link. Places at Link House were commissioned by the local clinical commissioning group. It provides care to patients with mental ill health who need more support than can be given in their homes. Despite this, its staff are support workers and not qualified medical professionals.

In the three days before she died, Jess disclosed to Link House staff that she felt suicidal and wanted to end her life. However, staff lacked the training necessary to understand how seriously to take Jess’s reports. They simply made phone calls to the recovery team and failed to follow up on those calls when there was no response. They did not make calls to the crisis team because, as Jess had not been admitted under the crisis team, they mistakenly assumed that it would not respond to calls. They failed to remove the ligature from Jess’s room that she ultimately used to take her life. There was a lack of clarity in the pathway for the escalation of risk and an assumption that the welfare checks that they were doing were sufficient.

On the morning of Jess’s death, when staff found that she was not responding to the morning check-up, they were unable to enter her room, because the doors at Link House were locked from the inside. The door closure inside the room was a readily available ligature point, and an inward opening door is contrary to the usual standard in mental health facilities. Staff did not know how to communicate the seriousness of the issue to paramedics, such that the emergency call was made a category 3 welfare check call. The result was that Link House staff stood helpless outside Jess’s door for 30 minutes before paramedics arrived. The paramedics were eventually able to break down the door, by which time Jess could not be saved. Had the call been made to the fire brigade, which has specialist equipment for breaking down doors, the outcome might well have been different.

The lack of clinical oversight and regulation at Link House meant that it was not a safe place for Jess to be housed. Jess was continually and graphically describing how she would ligature, and it is clear that the welfare checks and her environment were not suitable for her. Patients like Jess are extremely vulnerable and require specialised care and support, which was lacking in this case.

This is a tragedy that unfolded at one crisis house, but this is not just about one crisis house. In response to my written parliamentary question in June 2023, the Minister informed me that there were “around 70 crisis houses” around the country, with the number continuing to rise. However, I was concerned that figures for the number of crisis houses that were NHS-commissioned but not managed by NHS staff were not available. In September 2023, the Minister confirmed to me that the Government are committed to expanding mental health crisis services as alternatives to emergency hospital admission, and that they are investing over £140 million to expand the provision of emergency care options such as crisis houses.

The existing regulation in this space is complex. If providers offer regulated activities, they must register with the CQC as a provider of health or care services. That requires certain basic standards of training and care, but in many cases what crisis houses offer is outside the scope of those regulated activities, so there is no requirement to meet those standards despite crisis houses dealing with a patient population with complex needs. In the case of Link House, for example, the housing association Missing Link is regulated only by the Charity Commission, which is not an appropriate oversight body for ensuring proper standards of healthcare.

With all NHS services struggling after more than a decade of under-investment, crisis houses may be commissioned as a low-cost option and staffed by support workers without sufficient training for the task that they are asked to undertake, creating a potentially dangerous environment for patients. Consistent and appropriate standards are needed as a matter of urgency to ensure that as more vulnerable patients enter crisis houses, they get the care that they need to be safe and to recover.

I ask the Minister again: when will the Government bring forward legislation to harmonise regulation across the sector, bringing all crisis houses under the same regulatory oversight? If the aim is to use an increasing number of crisis houses to provide a safe alternative to hospital in which to recover from mental health crises, where is the oversight to ensure that those environments are safe? Regulation is essential to ensure both appropriate and consistent standards of care and training for staff at all crisis houses and to create an effective and transparent mechanism for residents or their families to raise concerns, and complaints where standards of care fall short.

There is a long list of regulated activities, including treatment of those being treated for substance misuse or detained under the Mental Health Act 1983, that, if provided, require organisations to register with the CQC. It is regrettable that the Government are declining to expand the list, which would require crisis houses supporting those going through a mental health crisis also to register with the CQC, rather than relying on local integrated care boards and local authorities to provide oversight.

The Minister wrote to me that there were no plans to change the national definition of a crisis house, but added:

“We do however expect crisis house services to be designed in a way that aligns with national requirements, guidance and local structures, to ensure that appropriate safeguarding processes are in place, including enabling the escalation of risks.”

But where is the mechanism to ensure that crisis houses meet those expectations? Where does a bereaved family turn when standards fall tragically short? I hope that, following today’s debate, the Minister will consider all the points that I have raised and will give a commitment to regulating crisis houses to help to prevent any future tragedies.

11:08

[The Parliamentary Under-Secretary of State for Health and Social Care (Maria Caulfield)]

It is a pleasure to serve under your chairmanship, Ms Fovargue. I thank the hon. Member for Enfield, Southgate (Bambos Charalambous) for bringing forward the issue. I offer my deepest condolences to his constituents on the loss of their daughter Jess.

Improving mental health crisis services has been a key priority for the Government for the past few years. We very much recognise that we need to support people better in their communities, rather than wait for someone to go into crisis when the only option is admission into a mental health in-patient unit. If we can get to people earlier, the outcomes are better, particularly for certain groups, depending on age, gender and ethnicity. We know that recovery is possible if the right treatment and early intervention can be given. That is why we have invested heavily in crisis services over the past few years. We see the difference that that can make, with people not ending up in detention in police cells, A&E or other inappropriate settings.

Before I touch on crisis houses specifically, I want to mention the range of crisis support available. We have provided more than £150 million of capital investment in urgent and emergency care infrastructure, £7 million of which has gone into new specialist mental health ambulances, which have mental health teams on board, rather than a traditional ambulance crew. Also, £143 million has gone into a range of alternatives—crisis houses are one of them, but we also have crisis cafés, step-down services and other crisis centres—which provide healthcare for people at a difficult time. More than 160 projects have been allocated funding and 137 of them are completed. We now have our crisis 24/7 helplines, so that around the country, in every area, a call will go through to the local crisis team. They are now linked through the NHS 111 service to provide a consistent route, so if a person is not aware of their crisis helpline number, dialling 111 will get them to that crisis line and their local mental health crisis team.

Crisis houses are a key part of that provision, and the early evidence shows that even crisis cafés can be associated with an 8% lower admission rate to hospital. Telephone services are associated with about a 12% lower admission rate. Overall, there is a 15% lower rate for detention under the Mental Health Act, which is all to the benefit of patients going into crisis. Crisis houses specifically are part of that crisis support team, and they provide accommodation for those who need such help and support, perhaps as a step towards more intensive crisis support, although sometimes that is just enough that someone is able to return home.

The hon. Gentleman is right that there is a mix in the provision of crisis houses. Some provide specialist care and regulated activity, including for those going through drug and alcohol addiction, some of whom might need their medication assessed and changed. Those crisis houses that do not provide such activities are not regulated by the CQC—he is absolutely right about that—and, to date, there have been no plans to expand the list of CQC-regulated activities to capture crisis centres that do not provide the more intense support. I hear his concerns, however, and as part of our work on the suicide prevention strategy, through which we are trying to reduce the number of suicides in England, we know that those suffering with pre-existing mental health illnesses are a high-risk group. I hear his concerns about Jess and the fact that she was in a place of safety that did not safeguard her needs, in particular as a vulnerable woman needing that help.

Crisis houses play an important role. They help mental health support teams, allowing them to deal with the most serious cases. They can also become a familiar setting for those patients who may use them regularly if they are going into crisis; they will know that that is a place where they can get help and support. Through our work on the suicide prevention strategy, in all the accommodation that people come into—crisis houses, police cells, prison cells, A&E or mental health in-patient settings—a key piece of work is on trying to eradicate ligature points, so that if someone is thinking of such a method of suicide, we have made it as difficult as possible for them to do that.

I am also concerned by the hon. Gentleman’s point about staff training. These staff members are looking after very vulnerable patients and they need training to know to whom they can signpost more quickly, whether that is the crisis team or other support avenues. Crisis houses are about more than just accommodation. Although they are not a regulated activity, they are more than just a roof over someone’s head. They are about assessing someone and getting them more intensive support if needed or getting them back home if possible.

Although I cannot commit today to including crisis houses as a regulated activity, I want them to meet the same standards as other places in which people going into crisis are often accommodated. Our motto for the suicide prevention strategy is “Suicide is everyone’s business”, so if crisis houses are not going to be a regulated activity and therefore not the business of the CQC, there must be more safeguards in place to ensure that they are as safe as possible, particularly for those at risk of suicide and for the staff, who have a difficult enough job at the best of times without having to deal with the fallout of a young person taking their own life under their care.

What I can commit to today is discussing the issue of crisis houses with Professor Louis Appleby, the Government’s adviser on suicide prevention, with whom I am working on the suicide prevention strategy and the suicide prevention oversight group. I am not sure whether regulation falling under the CQC is the answer, but I agree with the hon. Gentleman that there are clearly some gaps in training and development for staff. They must be able to better assess risk. There is also the issue of ligature points in crisis houses and gaps in their assessment as a place of safety for those staying in them.

I commit to following up on Jess’s case. We are going to get those suicide rates down. It is no one’s fault, but if there is extra work we can do to make crisis houses not just places of crisis, but places of safety, we should leave no stone unturned in doing that. I am very grateful to the hon. Gentleman for raising his constituent’s case as an example of what can happen. Crisis houses are not a regulated activity at the moment, but I am sure that there is more we can do to improve the safeguards that are in place. Following the debate I will speak to Professor Louis Appleby to see what more we can do for crisis houses to ensure that when a person going into crisis reaches out to get the help they need, they are as safe as they can be.

Question put and agreed to.

11:16

Sitting suspended.