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.