Winterbourne View was a private independently run hospital by Castlebeck Care (Teesdale) Ltd. Opening in December 2006 the hospital was a 24 bed unit providing treatment, care and support for adults with autism, learning disabilities and challenging behaviour. The hospital had 2 floors each with 12 beds, the ground floor contained the offices, kitchen, laundry and meetings rooms. The second floor was a 12 bed unit providing support to rehabilitate service users towards independent living. The third floor again was a 12 bed unit providing more intensive treatment for service users with more complex needs.
The hospital provided commissioners, service users and their families with a ‘statement of purpose’ of what would be provided. This boasted a quality service providing high quality specialist healthcare, treatment and support, based on the needs of the individual to achieve their full potential. Through the recruitment, development and retention of well trained and dedicated staff, including registered nurses and psychiatrists. Each service user benefitting from appropriately registered staff and a multi-disciplinary team approach.
It came into the spotlight following the BBC programme Panorama secretly filming within the hospital, and raised much concern about the abuse that was taking place. Terry Bryan a senior nurse working at Winterbourne View reported his concerns firstly to management at the hospital and then to The Care Quality Commission (CQC). His concerns of abuse were not listened to in both cases, and decided to approach the BBC.
BBC Panorama Undercover Care The abuse Exposed
Aired 31st May 2011, Panorama’s programme exposed the disturbing levels of abuse taking place. An undercover reporter Jo Casey gained employment as a support worker and secretly filmed within the hospital for 5 weeks. Before he went undercover the BBC sent Jo on a private training course on ways to best care for people with learning disabilities. Following this he fully understood restraint should be a last resort, and all other attempts should be made before using such methods.
Whilst filming there were several incidents of extreme abuse witnessed, a service user was doused with water fully clothed, left outside on a cold March day and left shivering on the ground. This person was then taken to their bedroom had a vase of water poured over them whilst lying on the floor screaming, which was a gift from their parents. The patient was then taken to the bathroom for a second shower fully clothed, where workers poured mouthwash over them.
On another occasion a worker repeatedly poked a client in the eye. The same client was later pushed to the floor by a different worker and told to ‘suffocate on your own fat’. Another service user was repeatedly bullied by staff, this person was slapped, held down for no reason and threatened to have their head put down the toilet. He witnessed most of the staff were using physical restraint as a first resort, and little evidence of other techniques being used.
Jo witnessed the services users experiencing abuse practically daily, mostly taking place on the 3rd floor of the hospital. He found the level of activity and engagement with the service users was very poor. He felt an air of boredom within the staff and service users, days consisted of watching television in the lounge or service users sleeping in their rooms. One activity that took place whilst secretly filming was a member of staff reading from a general knowledge textbook.
Jo found the experience difficult, saying what he witnessed horrific and struggled not to intervene and stop abuse happening. He knew he needed to get the abuse on film to expose the abuse and protect vulnerable people in the future. The programme sparked serious concerns about the whistle blowing and safeguarding procedures in place to prevent abuse taking place failing. As well as the role of the CQC to inspect services and ensure standards are being met, once notified by the BBC CQC began an immediate inspection of Winterbourne View. The Department Of Health, Care Service Minister Paul Burstow, called for urgent reviews of services for adults with learning disabilities. By 10th June 2011 Avon and Somerset Police had arrested a total of 11 employees.
An Adult Protection Expert Margaret Flynn was appointed to chair the serious case review, commissioned by South Gloucestershire Safeguarding Adults Board. Margaret Flynn is leading the examination into what lessons are to be learnt from the agencies failures to protect vulnerable adults from abuse. She had chaired an investigation of the murder of disabled man Steve Hoskin in 2006, which made far reaching recommendations to reform adult protection, including raising awareness and tightening up multi-agency working. She is also the chair for Lancashire Safeguarding Adults Board and joint editor of the Journal of Adult Protection.
Winterbourne View has been one of the most public and worst abuse cases in many years, the procedures in place to prevent this failed. The senior nurse Terry Bryan reported concerns to the management of Winterbourne View, which were ignored. He later reported these to the CQC and again these were not acknowledged and action not taken. There is clear evidence of safeguarding concerns reported to South Gloucester Council Safeguarding Adults Board and shows policies and procedures were ineffective. The first safeguarding concern raised was in 2008, and continued up until 2011 and were not fully investigated by the governing bodies responsible.
The Care Quality Commissions Actions
CQC began an immediate investigation, admissions into Winterbourne View were stopped, and alternative placements sought for patients. Extra staff were brought in to ensure patients were protected until they could be moved. Once these actions were finalised Winetbourne View had its registration removed and closed by CQC in June 2011. A statement published by CQC in July 2011 which detailed the enforcement actions taken above, it details the failures of Castlebeck Care to meet 10 essential standards required by law and misled CQC by not reporting incidents to them as required by law. CQC acknowledged action should have been taken sooner, had they been aware of incidents action would have been taken sooner.
CQC also explained action would have happened sooner had evidence from the TV programme had been available sooner. CQC responded to the concerns raised by Terry Bryan stating it was incorrect they had failed to act on his warnings. CQC explain they had been made aware by the whistle-blower, however the inspector assumed these were being dealt with by local safeguarding procedures. CQC acknowledge Terry Bryans complaint should have been contacted directly, and will be addressed by an independent serious case review. CQC released its review of compliance report in July 2011. It details the failings in the 10 essential standards Winterbourne View (Castlebeck Care LTD) were responsible to meet by law. There were serious and massive failings which were widespread across the service and company.
The standards not met being and findings by CQC – Outcome 4 – People should get safe and appropriate care that meets their needs and supports their rights. PAGE 6 Care plans were poor, lacking information and were not person centred. Records lacked understanding of the complex needs of the clients, planning and delivery of the care and treatment provided did not ensure their safety and welfare. Incidents and accidents were not followed up, prompt medical attention and wound management were lacking. Interventions and support to prevent and manage self-harm and suicide were also poor.
The service did not ensure users were protected from care and treatment that was inappropriate or unsafe. Care, treatment and risk plans were often out of date, not reviewed and contained poor use of language and little information. They showed little respect or understanding for the service users and that staff were using a controlling approach. Records for one service user showed persistent self-harm and suicide, plans to monitor this were lacking details on methods, and safety measures were not put in place. Plans for this person did not include supportive action to prevent harm or wound management following harm. There was reactive action of administering first aid, however only 9 of 53 staff had been trained in emergency first aid.
The care plan dated 29/05/2009 stated the person had an objective of learning relaxation techniques and good night time routine, this contained no details of what these were or the benefits for person. Another person’s records were checked, self-harm was often reported to staff by the service user. Again plans were lacking details of preventative or risk minimising measures. There were also no wound management plans in place, despite the person’s records showing repetitive harm using the same methods. An incident report dated 20/09/2012 detailed a service user who was on frequent observations had self-harmed causing serious injury to themselves. Medical treatment had not been sought until the next day, the person required 19 stiches.
The risk assessment was not reviewed, and accident report was completed 10 days later, and both contained conflicting information. An incident dated 03/03/2011 staff recorded and person’s behaviour as not being helpful, was on the floor and not moving. The situation was handled by a further 2 staff applying physical restraint, and staff document the behaviour became more problematic. More staff members joined to manage the person, all using restraint totalling 7 members of staff who were de-escalating the situation.
Outcome 7 – People should be protected from abuse and staff should respect their human rights. PAGE 6 -7 There were not suitable and effective arrangements to identify and prevent abuse. Allegations or risks of abuse were not managed or responded to appropriately, therefore service did not protect people using the service from abuse. Records checked show staff were willing to use restraint rather than de-escalation techniques. They also show how management were lacking in effectively reviewing this, other serious incidents and completing necessary reports and ensuring actions to prevent and improve standards were implemented.
Winterbourne View was visited by Mental Health Act Commissioner between 18/06/2009 and 25/09/2010, reviewing the safety and vulnerability of service users. They observed a service users arm was in plaster, the commissioner was told by the person the injury had happened when restrained on 23/07/2010. The commissioner reported that all necessary action was taken immediately to deal with the incident, but the service user was not offered any legal or advocacy services.
The commissioner checked the mini root cause analysis completed by the manager and deputy manager following the incident, the quality was poor and showed a lack of recommendations or lessons to be learnt. The commissioner requested the independent review report, which should have been carried out following such an incident. This was not provided, and was requested again by CQC on 19/05/2011, the report was dated 20/05/2011. CQC reviewed all the documentation for the above incident.
The incident report had not been dated, three statements from employees were dated 22/07/2010, an accident report dated 223/07/2010, a female body map dated 29/07/2010 and the mini root cause analysis dated 29/07/2010. This showed clear inconsistencies with how incidents were dealt with, the mini root cause analysis did not identify these and no lessons were learnt. It was reported to the health and safety executive as required by reporting of injuries, diseases, and dangerous occurrences (RIDDOR) regulations.
The manager stated the incident happened 29/07/2010, six days after the incident, it also conflicted with the details in statements from staff on location of the incident. The notification CQC received was very limited in detail and stated ‘was being restrained on the floor’. Another incident dated 14/10/2010, detailed the service user was removed during the incident. The service user continued to fight, spit, scream, scratch, bit and pull hair. The staff restrained the person with a pillowcase over there mouth for 20 minutes, and involved 6 members of staff. CQC also noted in the daily notes of a service user on 24/02/2011, they were restrained under a duvet for 15 minutes.
