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CQC publishes critical report of Castlebeck abuse failings

There was a “systemic failure to protect people” by the owners of a Bristol hospital at the centre of abuse allegations involving vulnerable adults, care watchdogs have said.

The Care Quality Commission has published its findings following an inspection of services provided at Winterbourne View, owned by Castlebeck Care Ltd, in Bristol.

The report comes after the BBC’s Panorama filmed patients being pinned down, slapped, doused in cold water and repeatedly taunted and teased despite warnings by whistleblower Terry Bryan.

Mr Bryan, a senior nurse, had alerted the care home’s management and the CQC on several occasions, but his concerns failed to be followed up.

After considering a range of evidence, CQC inspectors found Castlebeck Care had failed to ensure that people living at Winterbourne View were adequately protected from risk, including the risks of unsafe practices by its own staff.

It said: “There was a systemic failure to protect people or to investigate allegations of abuse.

“The provider had failed in its legal duty to notify the Care Quality Commission of serious incidents including injuries to patients or occasions when they had gone missing.”

It added that staff did not appear to understand the needs of the people in their care and said “some staff were too ready to use methods of restraint without considering alternatives”.

The watchdog said the review began as soon as it found out Panorama had gathered evidence, including secret filming, to show the serious abuse of patients at the centre.

Inspectors said they found people who had no background in care services had been working at the centre, references were not always checked and staff were not trained or supervised properly.

They added Castlebeck failed to meet essential standards, required by law, including:

  • The managers did not ensure that major incidents were reported to the Care Quality Commission as required;
  • Planning and delivery of care did not meet people’s individual needs;
  • They did not have robust systems to assess and monitor the quality of services;
  • They did not identify, and manage, risks relating to the health, welfare and safety of patients;
  • They had not responded to or considered complaints and views of people about the service;
  • Investigations into the conduct of staff were not robust and had not safeguarded people;
  • They did not take reasonable steps to identify the possibility of abuse and prevent it before it occurred;
  • They did not respond appropriately to allegations of abuse;
  • They did not have arrangements in place to protect the people against unlawful or excessive use of restraint;
  • They did not operate effective recruitment procedures or take appropriate steps in relation to persons who were not fit to work in care settings;
  • They failed in their responsibilities to provide appropriate training and supervision to staff.

Winterbourne View, which had 24 patients, was closed down last month.

Readers' comments (22)

  • tinkerbell

    After considering a range of evidence, CQC inspectors found Castlebeck Care had failed to ensure that people living at Winterbourne View were adequately protected from risk, including the risks of unsafe practices by its own staff

    Maybe I'm a bit dim but didn't the CQC fail to do that also as they had been alerted to the abuse on at least 2 occasions by ex employees.

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  • “systemic failure to protect people”

    if the CQC did not act on information of abuse, which was reported to them by Mr. Bryan, a senior nurse (although it what rank the complainant held is immaterial, whether patient, visitor, qualified or untrained staff), and it needed a TV report before the so-called 'Care Quality' commission took any action, is this not also a "systemic failure to protect people" on the part of the CQC and its questionable ability to to carry out its functions?

    Doesn't 'Care Quality' also include safety of the individuals being cared for?

    What recommendations and preventative actions are being made for the future so that this or similar cases do not occur? Or is this merely another costly investigation with a report for the archives?!!!!!!!!!

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  • tinkerbell

    and just swept under the carpet without anything being achieved so that it all happens again.

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  • "CQC publishes critical report..."

    no mention of their recommendations or further actions.

    "The watchdog said the review began as soon as it found out Panorama had gathered evidence, including secret filming, to show the serious abuse of patients at the centre."

    why did they wait all this time. after a tv documentary shown to the public they were forced to act and carry out a 'review'!

    why did they not act as soon as the first complaints were made? what is this complacency of this organisation all about?

    why are there no appropriate measures in place to deal with and act on serious complaints?

    "Winterbourne View, which had 24 patients, was closed down last month."

    after the damage was done but if there are no recommendations for action and action actually taken when serious complaints are made what is to stop a similar scenario elsewhere with other vulnerable groups of individuals?


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  • tinkerbell

    SOS..............and what's been exposed is probably just the tip of the iceberg. Poor people if action to abuse is so delayed that they have to suffer it day in and day out and no one to effectively go in and help them with a RAPID response. Disgrace and every other adjective that can be used to sum up abuse to the vulnerable. Shame on you CQC.

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  • CQC report on Winterbourne View confirms its owners failed to protect people from abuse
    18 July 201
    1
    http://www.cqc.org.uk/newsandevents/pressreleases.cfm?cit_id=37463&FAArea1=customWidgets.content_view_1&usecache=false

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  • michael stone

    Anonymous | 19-Jul-2011 11:59 am

    I am pretty sure, I heard (Radio 4)someone from the CQC say that the problems shown by Panorama, were more serious than those Mr Bryan originally raised with the CQC - the comment was along the lines of 'The whistle-blower was as shocked as we were, by the TV programme'.
    This does not excuse the CQC, and other people and bodies, from not acting before Panorama got involved, but perhaps the full nature of the abuse, was not made clear to the CQC until after it had seen the Panorama stuff ?
    This always comes back to the same thing - good staff on the ground behave well, but it is possible to have a group of staff and mamagers who behave very badly, and self regulation within a 'bad group' will fail. And bad managers, allied with bad staff, can effectively intimidate those staff who are good, into keeping quiet (sometimes).
    And it is about 'so what do you plan to change ?'. Saying that people did not follow existing guidelines, tends to prove that something in the existing system needs to be improved - just saying 'everything would be fine, if people followed the guidance' is pathetic, if the evidence is that some people don't follow the existing guidance !

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  • michael stone

    tinkerbell | 19-Jul-2011 12:10 pm

    I fully agree about the 'it is shameful and should not happen' points you make.
    But the staff on the frontline, who see these abuses, should be the 'first resort' for the solutions. It must be made impossible to 'bully' whistleblowers !

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  • Michael Stone

    n answer to another of your ramblings, you seem to be obsessed by 'guidelines' but please note that all qualified nurses have professional autonomy and are capable of, and do work with their knowledge and experience as well as guidelines. we are not robots. guidelines are there for advice on applying 'best practice' to care based on evidence based practice and constructed by a panel of experts which any registered nurse can join if it is in their field but at the end of the day they can be subjective, can get quickly out of date by the time they are published and do not apply to every single situation. Also they are only as good as the panel of people who made them.

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  • Anonymous | 19-Jul-2011 2:05 pm

    Michael Stone

    further to your comment above, I posted the reference to the report from the CQC site above yours.

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  • And what has happened to the CQC members who have failed so spectactularly? Have they not been subject to the same accountability as us? If not then why not?

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  • above. I have just been looking at their website to see if I can throw further light on that. their own report is quite revealing.

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  • i agree - this report doesn't tell us a great deal . When is the report into the failings of CQC due out?

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  • From the CQC website:

    “...it is incorrect that CQC had failed to act on warnings by the whistleblower. Our internal investigation has confirmed that while we were aware of those concerns, our inspector believed they were being dealt with through the local safeguarding process involving a number of agencies. We should have contacted the whistleblower directly – and this will be one of the issues which will be addressed by the independently-led serious case review."

    This is to be chaired by Margaret Flynn, who I think produced the review on the murder of Steven Hoskin in Cornwall.

    So we'll just have to wait and see, but it looks like they are getting their defence in early.

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  • A complete whiewash by the CQC. A quango if ever there was one.

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  • tinkerbell

    We should have contacted the whistleblower directly – and this will be one of the issues which will be addressed by the independently-led serious case review

    the independently led serious case review my derriere!

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  • tinkerbell

    maybe there should be a comma between review and my derriere, I am not suggesting they should seriously review my derriere, but you get my drift.

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  • tinkerbell | 19-Jul-2011 9:39 pm

    The Hoskin Review (summary available online) seems to me to have been able to point the finger at all the relevant mistakes and failures by all agencies involved. So unless you know that this lady's independence is compromised in some way, I think it's a bit previous to prejudge the results of that.

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  • tinkerbell

    Nick just read it. So what changes came out of that? Unless the CQC are brought to trial for their failings to protect vulnerable people, this time in care homes, but regardless of any environment, and with reports made by staff who worked there to the CQC directly, what changes to ensure that these tragedies don't keep recurring? No matter how seriously deadly a report they do if nothing changes then it is of no consequence. If the CQC are let off the hook on this one and do not have to face any consequences for their own negligence in failing to protect the vulnerable which is supposedly what they are put in post to do, what does it matter if all the recommendations are put in place but no one actually adheres to them. They always talk about 'lessons being learned' but isn't that supposed to mean that these tragedies, therefore, should not keep being repeated. Recommendations and guidelines are not enough on their own if reports of abuse are not taken seriously and acted upon. It took an undercover investigation to bring about change in this instance.

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  • tinkerbell, it's a good point you make about the 'learning the lessons' cliche. In this instance the agencies are quite positive about their responses to the review (this is the transcript):

    http://www.scie.org.uk/socialcaretv/transcripts/002001.pdf

    Of course you never know if this is just flannel, and I noticed that it was glossed over that No Secrets (2000) had covered the inter-agency communication already.

    From my own experience where I worked just after training, the Trust had gone through a Homicide Inquiry which actually meant that our risk assessment and management strategy was well-considered, organised and useful. So these things can be helpful.

    Saying that (and obviously now pre-judging the results) it seems clear that the CQC have significantly failed around this case. It is shameful that it requires undercover exposure whilst the CQC languishes in myopic content.

    It's interesting though that they refer to the local safeguarding process and agencies, so there's some extra information to come out of that too.

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