By Richard Johnstone | 7 August 2012
The Care Quality Commission has admitted ‘failing’ in its response to concerns about abuse at the Winterbourne View home, after an independent review called for better monitoring of services for vulnerable adults.
The review, published today, was ordered by South Gloucestershire Council’s Safeguarding Adults Board after 11 former members of staff at the home admitted offences against patients.Abuses at the home, near Bristol, were revealed by a BBC Panorama programme in May last year. Undercover filming showed residents with learning disabilities and autism being slapped and restrained under chairs, having their hair pulled, and being held down.
Adult safeguarding expert Margaret Flynn, who carried out the review, found the abuse resulted from ‘serious and sustained failings’ in the management procedures of the owner and operator of the home, Castlebeck.
However, her report also concluded that other organisations’ systems and procedures ‘fell short in commissioning patient care, and in reviewing and safeguarding the wellbeing of patients before and during their stay’.
Recommendations included more investment in community-based care to reduce the need for in-patient admissions at assessment, treatment and rehabilitation units such as Winterbourne View.
It also called for the systems set up to deal with concerns, including safeguarding alerts, to be better co-ordinated to allow earlier identification of potential problems and quicker action by regulators.
Following the publication of the report, CQC chair Dame Jo Williams said the abuse represented ‘a watershed moment’ for the watchdog, which regulates health and social care services in England.
‘We did not respond as we should have and we have offered our apologies to the patients and their families,’ she said.
‘We have been honest about our limitations at the time and willing to learn from them. We carried out an urgent and thorough internal review to strengthen our processes and to ensure that we are better placed to play our part in protecting people in vulnerable care situations.’
Chief executive David Behan added: ‘There is much for all the organisations involved with Winterbourne View to consider… I will ensure that the Care Quality Commission responds fully to all the recommendations. We will continue to work with other organisations to improve communications and sharing of information to ensure we all protect those who are most vulnerable.’
Council safeguarding board chair Peter Murphy said the organisations that make up the board, which also include the NHS and Avon & Somerset Police, ‘deeply regret the shocking events’ at Winterbourne View.
He added: ‘We fully accept the findings and recommendations of the report, and are determined to work together to ensure that events such as this never again occur in South Gloucestershire.’
Castlebeck said it hoped ‘the lessons learned and the actions that flow from this rigorous report will mark the start of a new chapter for care in our sector’.A statement by the residential home group added: ‘The criticisms that have been directed at the health and social care sector in general, and particularly those that were directed at our organisation and are highlighted in this report, have been listened to and are actively being addressed.
‘We believe we have responded in a way that demonstrates our resolve to ensure that the events of Winterbourne View will not be repeated.’
The care home closed in June 2011.
