Winterbourne View provider failed ten standards required by law, says CQC

The registered provider that ran the Winterbourne View assessment and treatment centre near Bristol failed to comply with ten essential standards required by law – including the requirement to report serious incidents, the Care Quality Commission has said.

Winterbourne View was shut in June after a Panorama programme exposed serious abuse of patients at the centre.

According to the watchdog, the ten standards failed by Castlebeck Care (Teesdale) Ltd were:

  • “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.”

The report concluded that there was “a systemic failure to protect people or to investigate allegations of abuse”. It said the provider had failed to notify the CQC of serious incidents including injuries to patients or occasions when they had gone missing.

Inspectors decided that the centre’s staff did not appear to understand the needs of the people in their care –adults with learning disabilities, complex needs and challenging behaviour. “People who had no background in care services had been recruited, references were not always checked and staff were not trained or supervised properly,” the Commission said. “Some staff were too ready to use methods of restraint without considering alternatives.”

Amanda Sherlock, the CQC’s Director of Operations, said: “This report is a damning indictment of the regime at Winterbourne View and its systemic failings to protect the vulnerable people in its care.

“It is now clear that the problems at Winterbourne View were far worse than were initially indicated by the whistleblower. He has stated that he was not aware of the level of abuse until he saw the footage from the secret filming.”

Sherlock said the CQC now knew that the provider had effectively misled it by not keeping it informed about incidents as required by the law. “Had we been told about all these things, we could have taken action earlier,” she said. The CQC will now consider whether it is appropriate to take further legal action.

However, Sherlock insisted that it was “incorrect” that the 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,” she said.

“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. Immediately we were aware of the extent of the problem, we took the action which is detailed in this report. Although Winterbourne View is now closed, we will continue to monitor Castlebeck's other services closely.”

The CQC will publish the outcome of its review of all of Castlebeck Care (Teesdale) Ltd’s 24 locations at the end of July.