Jef Smith considers the implications of the Care Quality Commission’s (CQC’s) alarming report on learning disability services following the Winterbourne View affair.
Reading the summary of the CQC’s inspections of a selection of learning disability services, published in June, it would be easy to allow one’s sense of déjà vu to deepen into disillusionment. We have been along this well-trodden and depressing path many times before. For those whose memories extend for even only a few years, the words Ely Hospital, Longcare, Cornwall, and Sutton and Merton will readily come to mind. All were associated with previous scandals involving people with learning disabilities, and recall only the most notorious of a much longer list.
In each instance, seriously poor practice in the care of intensely vulnerable people was revealed and the press and public were mightily outraged. Ministers too expressed anger and official enquiries in varying forms were set up. Some months later, the publication of a report briefly reignited concern and changes were promised. However, a year or two passed and the process, with small variations, repeated itself.
The most recent example of this cycle started when, in May 2011, the BBC’s Panorama team exposed serious malpractice at an establishment in South Gloucestershire called Winterbourne View. The fact that it was variously described as a home and a hospital reveals a significant ambiguity about its purpose.
Shock at the truly dreadful revelations — not just negligence but actively sadistic bullying, which led to the criminal conviction of 11 members of staff in the summer of 2012 — was compounded by the fact that the abuse had been drawn to the notice of the CQC as the responsible regulator, but had been ignored.
Nevertheless, it was a duly repentant CQC that was given the task of inspecting a sample of facilities to see whether Winterbourne View was a one-off or whether there is a deeper malaise within the learning disability sector.
The Winterbourne View exposure set off or significantly contributed to not just one but a whole series of reviews and investigations. It led directly to an Internal Management Review of how the CQC had responded to the incident, producing a report in October 2011 which focused on the relationship between inspection, abuse and whistleblowing.
It hung over the Department of Health’s Performance and Capability Review (published on 23 February 2012) of the CQC’s first four years of operation and surely played a part in the resignation of its chief executive Cynthia Bower on the same day. Dame Jo Williams, the CQC’s chair, for whom the affair was even more embarrassing as she was at one time chief executive of Mencap, survived to pick up the pieces.
As a result of the performance review, the Department of Health implicitly acknowledged that regulation had been under-resourced and the CQC admitted that its inspections needed to be much more regular and rigorous. A further management review was published by the CQC on 7 August, coinciding with the publication by South Gloucestershire Adult Safeguarding Board of the serious case review into Winterbourne View.
The CQC therefore set about the task of carrying out unannounced inspections of 150 residential facilities. It produced reports in batches and consolidated all except those relating to five pilot projects into a comprehensive overview which appeared in June. The Department of Health simultaneously put out an “interim Winterbourne report” containing its response and plans for a series of immediate steps, and promising both a further report once criminal proceedings were concluded and a follow-up report to assess progress a year later. Whether this well-intentioned paper will produce commensurate changes in the quality of services, however, remains doubtful.
The CQC’s individual inspection reports and the consolidated summary broadly make the case that the Winterbourne staff were rare bad apples, and not representative of care workers generally. One would hardly have expected a different finding, since even unannounced inspections will not reach the truths about day-to-day treatment which hidden cameras reveal. But even if one accepts that the horrible abuses which went on at Winterbourne are not widely replicated, the apparent ease with which staff behaviour at a so-called caring establishment can degenerate into callous cruelty is an object lesson in the pervading power of group culture in residential care.
Bad practice quickly spreads through a staff community, leading the South Gloucestershire serious case review to describe the Winterbourne saga as “a case study in institutional abuse”. A few bad apples, it should be remembered, can quickly contaminate a whole barrel. In fact, many staff, not just one or two, were involved, supervision was lax and management was totally ineffective in its first responsibility — to safeguard residents from harm.
The failure of either commissioners or regulators to intervene, even when alerted to concerns, compounded the tragedy.
What the CQC did witness and report on, even if not the whole truth, is that more than half of the services reviewed failed to meet nationally set standards. If that sounds worrying, remember also that these visits came in the wake of a widely reported set of incidents — managers were well warned of likely scrutiny and most had seen the early reports in the series so knew the drift of the findings, so there was therefore both incentive and opportunity to put right any glaring defects.
But are improvements to services made in the run-up to an inspection always maintained long-term? Anecdotal evidence suggests not. Castlebeck, the company which owned Winterbourne View, closed not only the home where the abuse had first been revealed but two others where the level of care was clearly beyond rescuing.
The standards referred to by the CQC are in fact “essential”, not simply desirable, ideal or aspirational, and of 28 required outcomes, inspectors on this exercise tested only two. Admittedly, these were the very important indicators relating to care and welfare and safety from abuse, but subjects featured in the Essential Standards that were not covered by this exercise include respect, the involvement of users in service planning, nutrition and medicine management. In short, the total picture is probably much more serious than even these highly critical reports have demonstrated.
Partial as the picture is, the sample of care surveyed reveals several worrying trends. Many of the placements were supposed to be for assessment but, once admitted, a service user could be left without review or further action for a year or more. That is not sensible purchasing, rather manifest — and very expensive — incompetence.
Local authority commissioners should also note and act on the fact that independent sector providers were twice as likely to be quality non-compliant as NHS trusts; advocates of further health and social care privatisation in other areas should also have cause for concern in this finding.
Of clear relevance to the abuse which launched this exercise, many homes and hospitals still have to learn critical lessons about the uses and misuses of restraint. In 25% of settings, instances of restraint were not recorded or monitored appropriately and there were no systematic review processes in place. Concerns sufficiently serious to be referred to local authority safeguarding teams were noted at an astonishing 27 locations. Other similar findings in the reports make it clear that for people with learning disability in institutional care, the risk of physical mistreatment remains alarmingly high.
One brave whistleblower
Winterbourne View only came to public attention through the disclosures of one brave decent man among a staff team where at least 11 others were engaged in vicious abuse. With so much poor practice around, it is worrying that so few staff feel able to speak out, and the deafness of managers and regulators on this occasion, whatever their subsequent expressions of regret, is hardly likely to encourage further whistleblowing.
Terry Bryan, the Winterbourne informant, although ultimately vindicated, had a harrowing ordeal in the process of trying to alert the authorities. Will others be willing to follow such an obviously perilous path?
Care Minister Paul Burstow, who commissioned the CQC review, simultaneously published the Department of Health’s reaction. This document is remarkable for its complacency, opening with the statement that in the establishments visited by the CQC “no abuse on the scale of Winterbourne was found” and proceeding to a bland list of proposed “national actions”. For example, open access to services for users’ families and friends is to be promoted, unannounced inspection by the CQC will be encouraged, and a “national public commitment to deliver the right care” will be made soon. Predictably, the Government’s statement does not mention additional resources.
Activists immediately criticised this feeble lack of serious initiatives. Ron Greig, Chief Executive of the National Development Team for Inclusion and formerly the Government’s National Director for Learning Disabilities, dismissed the report as “extremely disappointing”. His call for radical improvements in local services so that remote assessment and treatment centres like Winterbourne View would simply cease to be needed received a telling echo in August when Mencap and the Challenging Behaviour Foundation published Out of Sight.
The charities stated that since the Panorama programme, 260 families had been in touch to express concern that loved ones with a learning disability were being neglected or abused in institutional-style care. A large number of serious incidents were reported, including physical assault, sexual abuse, withdrawal of food and water and the overuse of restraint.
Far from being a unique case, Winterbourne View is typical of many so-called assessment and treatment units intended to provide short-term specialist care. Astonishingly, more than half of residents in such places remain for two years or more, and nearly a third stay for over five years.
In contrast to Mr Burstow’s complacency, Mark Goldring, Mencap’s chief executive, warned that “unless the Government commits to a strong action plan to close large institutions ... there is a very real risk that another Winterbourne View will come to light”.
So the depressing chain of learning disability scandals, followed by much rhetoric but little action, takes another turn. Within days of the flurry of post-Winterbourne reports, it was announced that four staff at a Doncaster hospital were to be charged with offences against several learning disabled patients. This begs the question: is the cycle of abuse behind closed institutional doors unstoppable or can we trust that, moving forward, those who are skilled and well-trained for their demanding task of caring for those with learning disabilities will receive the right support in the most appropriate environments?
Last reviewed 15 November 2012