An independent report into abuse at a private hospital where care staff have been found guilty of abusing vulnerable people has revealed that its owners took “financial reward without responsibility”.
The serious case review into events at Winterbourne View near Bristol which was owned by private company Castlebeck Ltd, comes after 11 former staff members admitted offences against patients. The abuse came to light following undercover filming by the BBC Panorama programme.
But the report's author Margaret Flynn revealed that concerns were raised before the Panorama report. She discovered that the safety of dozens of patients was raised but the NHS was only told about a handful. She calls for a fundamental review of how care for people with learning disabilities is commissioned, provided and checked.
From the opening of the hospital in 2006 until 2011, her report reveals that there were 38 safeguarding alerts raised about 20 patients from the unit. Only one in five of those was reported to the NHS.
In three alert cases - an allegation of abuse by staff, concerns about the attitude of some staff, and an allegation of assault by a member of staff – she said the NHS does not appear to have been notified in any way.
Ms Flynn, who chairs Lancashire Council’s Adult Safeguarding Board, said Castlebeck had "promoted an unworkable management structure" and relied on "poorly paid and untrained staff". She added the firm did not "act on the concerns, complaints of Winterbourne View visitors or patients".
The report also states that “there were echoes of ‘out of sight, out of mind’ commissioning at Winterbourne View Hospital and evidence of uncertainty about which agency was responsible for commissioning services.”
Peter Murphy, the head of South Gloucestershire Safeguarding Adults Board, said he wanted to convey his "deep regret" for what had happened at the hospital.
Dame Jo Williams, the chair of the Care Quality Commission said Winterbourne View was a “watershed moment”. She conceded the CQC “did not respond as we should have and we have taken steps to put things right”.
Now the CQC has set up a specialist team to deal with whistleblowers and systems to make sure every such contact is followed up. “Before Winterbourne View we were receiving about 50 whistleblower contacts a month; now we get more than 500. This information is vitally important in helping us to identify poor care.”
Since the Panorama revelations the CQC has carried out 150 unannounced inspections of 150 services for people with learning disabilities which she said showed up serious concerns about the nature of services for people with learning disabilities, but no evidence of abuse on the scale at Winterbourne View.
The CQC has inspected all of Castlebeck’s 23 registered locations and three of the services, including Winterbourne View, were closed as a result of CQC’s actions.
The Department of Health allowed CQC to appoint another 250 inspectors, which means that most hospitals, care homes and home care services can now be inspected at least once a year.