Section three The NPM in 2016–17 in this area in March 2017.139 The CI also commenced an inspection focus in two further areas: dementia in care homes for older people in order to support scrutiny of the National Dementia Strategy; and child sexual exploitation to ensure staff working in residential care are able to recognise and respond appropriately to support vulnerable children and young people who may be at risk. The Care Quality Commission (CQC) inspected the three high secure hospitals in England between November 2016 and March 2017, serving a warning notice on the NHS trust that manages Broadmoor Hospital following the inspection there. In addition to its inspections of high secure hospitals, CQC continued with its programme of comprehensive inspections of all specialist mental health services in England, work which began in 2014. The CQC undertook a national review of the way the NHS trusts identify, report, investigate and learn from the deaths of people using their services in 2016. The report, Learning, candour and accountability, published in December 2016, identified missed opportunities to learn from patient deaths and that too many families are not included or listened to when investigations are carried out. The report has informed a programme of work across the country to improve the action taken following a death and to improve care for future patients and their families, including patients who die while detained by the state. The Children’s Commissioner for England (CCE) continued to conduct announced and unannounced visits to children’s custodial settings. During 2016–17, this work focused on secure children’s homes in order to understand the vulnerabilities of children in this type of setting, and how their needs were being met. The CCE also expanded the focus of its visits to places of detention, piloting visits to the six medium secure and forensic child and adolescent mental health service units in order to better understand the children who are detained in these settings, how the units function and their interaction with the youth justice sector. In addition, the CCE conducted research on the provision of non-familial appropriate adults to children in police custody to ascertain whether and to what extent this contributes unnecessarily to the period of time children spend in police detention, and how that period might be reduced. The CCE continued to participate in the National Care Leavers Forum coordinated by Her Majesty’s Prison and Probation Service, the work of which focuses on improving the identification of young people in custody who have previous care experience and enhancing their access to entitlements. Criminal Justice Inspection Northern Ireland (CJINI) continued its programme of inspection work and also commenced a thematic inspection of prisoner resettlement in the Northern Ireland Prison Service, on which it will conclude in late 2017. 139. Care Inspectorate, 2017, THE KEYS TO LIFE: Report of the Care Inspectorate’s Inspection Focus Area 2014–2016, http://www.careinspectorate.com/images/documents/3741/Keys%20to%20life%20report.pdf [accessed 13/11/17]. 59