Last reviewed 18 January 2013

The Government has published its final report into Winterbourne View, the private hospital for people with learning disabilities where abuse was exposed in an undercover BBC Panorama programme aired in May 2011. Martin Hodgson looks at what happened there and the Government’s plan of action.

The report, Transforming Care: A National Response to Winterbourne View Hospital, follows a Serious Case Review which described numerous examples of ill-treatment and abuse at the hospital, as well as a repeated failure of management and other authorities to intervene.

It sets out the actions that the Government believes now need to be taken to ensure that people with learning disabilities get the high-quality support they need. The actions have been laid out in a “Concordat”, which organisations with a role to play have been asked to sign.

Previous Winterbourne View reports

Transforming Care is the last in a series of reports on Winterbourne View.

The first was an “interim” report written while the police investigated the serious allegations made in the Panorama programme. As the criminal investigation was ongoing the interim report did not cover what happened at the hospital itself but responded to public concern that the health and social care system was failing to meet the needs of people with learning disabilities.

This report prompted a programme of unannounced CQC inspections. It also triggered work with the NHS Commissioning Board Authority and the Association of Directors of Adult Social Care to develop a clear description of all the essential components of a model service for people with learning disabilities.

To comply with the requirements of the report, the CQC carried out inspections of 145 services. Its report did not identify further abuse of the type found at Winterbourne View but showed that half of all services were not meeting acceptable standards around care and welfare and protecting people from abuse.

The interim report was followed in August 2012 by a Serious Case Review commissioned by South Gloucestershire Council Adult Safeguarding Board. This report, written by Margaret Flynn, gives a comprehensive analysis of events at the hospital.

The final report draws on evidence from the interim report, the Serious Case Review, the police prosecutions and the CQC inspections.

What happened at Winterbourne View?

The Winterbourne View case came to the attention of the public after the broadcast of a BBC Panorama programme in May 2011. The documentary contained shocking undercover footage of abuse and humiliation carried out by a team of support workers who were supposed to be safeguarding service users. Staff were shown repeatedly abusing service users, including:

  • humiliating patients

  • restraining patients under chairs

  • giving cold punishment showers

  • leaving patients outside in cold weather

  • pouring mouthwash into patients’ eyes

  • pulling patients’ hair

  • forcing medication into patients’ mouths.

Victims were shown screaming and shaking. One was seen trying to jump out of a second-floor window and being mocked by staff.

The abuse revealed at Winterbourne View hospital was criminal and was subject to a lengthy police investigation, which resulted in a number of prosecutions. Eleven individuals were sentenced, six receiving custodial sentences. The offences were treated as disability hate crimes based on ignorance and prejudice.

Systemic failings

The Serious Case Review concluded that there were systemic failings which allowed ill-trained and poorly supervised staff to mistreat those in their care. It also revealed a history of previous incidents at the hospital and missed warnings.

Opened in December 2006, Winterbourne View was a private hospital owned and operated by Castlebeck Care Ltd. It was designed to accommodate 24 patients in two wards and was registered as a hospital with the stated purpose of providing assessment, treatment and rehabilitation for people with learning disabilities.

Admissions to units such as Winterbourne View were supposed to be short-term but the average length of stay at the hospital was reported to be around 19 months. Some patients had been there more than three years when the hospital closed and there was little evidence of discharge and move-on plans for patients.

The final report states that one of the most striking issues was the high number of recorded physical interventions at Winterbourne View. The Serious Case Review notes that Castlebeck Care Ltd recorded a total of 558 physical interventions between 2010 and the first quarter of 2011, an average of over 1.2 per day. One family provided evidence that their son was restrained 45 times in five months, and on one occasion was restrained “on and off” all day.

The Review points out that opportunities to identify the poor quality of care and abuse were repeatedly missed by multiple agencies and by Castlebeck, citing these examples.

  • Winterbourne View patients attended NHS Accident and Emergency services on 78 occasions but there was no process in place for linking these so that an overall picture emerged.

  • Between January 2008 and May 2011 police were involved in 29 incidents concerning Winterbourne View patients and 40 safeguarding alerts were made to South Gloucestershire Council; 27 were allegations of staff-to-patient assaults, 10 were patient-on-patient assaults and three were family-related incidents.

The hospital was also the subject of whistleblowing alerts to the CQC which were ignored and it is likely that were it not for the Panorama report the abuse would have gone on for longer.

The Serious Case Review identified many areas of poor care and management practice, including the following.

  • Routine healthcare needs were not attended to; there were widespread dental problems and “most patients were plagued by constipation”.

  • Many patients were given anti-psychotic drugs without a consistent prescribing policy.

  • Families and visitors were not allowed access to the wards or individual patients’ bedrooms which meant there was very little opportunity for outsiders to observe daily living in the hospital. This enabled a closed and punitive culture to develop on the top floor of the hospital.

  • Patients had limited access to advocacy and complaints were not dealt with.

  • For much of the period in which Winterbourne View operated, there was no Registered Manager and approaches to staff recruitment and training did not demonstrate a strong focus on quality.

  • There was little evidence of staff training in anything other than in restraint practices.

  • The hospital was “dominated to all intents and purposes by support workers rather than nurses”.

  • There was very high staff turnover and sickness absence among the staff.

The final report states that the high number of recorded restraints, high staff turnover, low levels of training, high number of safeguarding incidents and allegations of abuse by staff all should have been identified as pointing to something seriously wrong at the hospital. The failure by the provider, Castlebeck Care Ltd, to identify these problems or to “focus on clinical governance or key quality markers” is striking and displayed a critical breakdown in management and oversight within the company.

It was equally striking that adult safeguarding systems failed to link together. For instance, those responsible for commissioning care were not always told about safeguarding alerts.

Commissioners themselves were admonished for failing to focus on quality or to monitor whether the hospital was providing services in line with its registered purpose, ie assessing the needs of individuals and promoting their rehabilitation back home. The report identifies this as a “serious failure of commissioning”.

Whistleblowing failures

As well as failures within the hospital itself, and within Castlebeck, attempts to alert others about the state of care at Winterbourne View also identified failures in the whistleblowing system.

Whistleblowing — reporting failures of care to outside agencies — is a vital part of safeguarding and indeed it is part of a nurse’s code of conduct to make such an alert in cases of abuse. However, in this case the CQC — the official regulator — has acknowledged that it did not respond to a Winterbourne View hospital whistleblower. Neither did the CQC follow up on the outcomes of statutory notifications, clearly failing to enforce the requirement for there to be a Registered Manager.

The Mental Health Act Commissioner also failed to follow up incidents, as did the police, who are reported to have acknowledged that they took explanations from staff at face value.

Whistleblowing arrangements within the CQC have since been strengthened.

The wider picture

The criminal activities and mismanagement at Winterbourne View sparked a wider review of the situation in learning disabilities services across the country.

While abuse of the type found at Winterbourne View was not seen elsewhere, the picture from the inspections and reviews conducted by the CQC is of good services in some places but poor services in others. The final report finds “widespread poor service design, failure of commissioning, failure to transform services in line with established good practice, and failure to develop local services and expertise to provide a person-centred and multidisciplinary approach to care and support”.

Quite simply, the model of care where vulnerable adults were taken from their homes and placed miles away in an assessment centre for long periods has long been outdated and should not have been commissioned at Winterbourne View. Modern models of care stress the need for local, non-institutional community care. Where specialist support is needed the default position should be to put this support into the person’s home through specialist community teams and services, including crisis support.

The actions announced in the final report are therefore designed to address these issues and transform the way services are commissioned and delivered so that another Winterbourne View can never happen.

The report admits that such service redesign will not be easy but points out that best practice guidance has been available for many years and that there are no excuses for commissioners failing to commission services that will enable most people to live safely with support in their communities and prevent unnecessary admissions to hospital.

Key actions in the report

The final report outlines 60 actions to transform services to ensure that people with learning disabilities no longer live inappropriately in hospitals, but are cared for in line with best practice based on their individual needs, and with their wishes and those of their families listened to and at the heart of planning and delivering their care.

Key actions emerging from the report can be summarised as follows.

  • The report commits the Government to a programme of change, which will be led by a new NHS and local government-led joint improvement team. The Department of Health will report on progress by December 2013.

  • The programme will aim to reduce the number of people with a learning disability being sent away to assessment and treatment units and to move anyone inappropriately being cared for in a hospital to community-based support by June 2014. The report states that all current placements will be reviewed by 1 June 2013, and everyone inappropriately in hospital will move to community-based support as quickly as possible.

  • High-quality care and support services will be introduced in all areas by 2014, including production of joint plans to ensure all people with learning and behaviour challenges receive care and support that meets best practice.

  • Plans will be brought forward to hold the senior managers, directors and board members of care organisations to account for the safety and quality of care that their organisation provides by spring 2013.

  • New guidance will be issued on the use of restraint.

  • People with a learning disability and their families will be more involved in decisions about care and support.

  • The CQC will strengthen inspections and regulation of hospitals and care homes for this group of service users, including unannounced inspections involving people who use services, and their families.

There are currently an estimated 3400 people in NHS-funded learning disability inpatient beds of which around 1200 are in assessment and treatment units.

Alongside the final report, the Department of Health has also published a Concordat agreed with key external partners. This sets out a shared commitment to transform services and includes details of specific actions which individual partners will deliver to make the changes outlined in the report real.

Reactions to the report

The report has been welcomed by the families of those involved at Winterbourne View and by organisations that have long campaigned for the closure of such units.

Mencap, the most influential charity for people with learning disabilities, welcomed the fact that the Government had listened to families and campaigners but warned that “words are not enough” and called for action. In particular it has asked for commissioners in local government and the health service to take urgent, joint action to develop better local services. It called for the many hundreds of people with a learning disability still “far from home” in institutions like Winterbourne View to be enabled to quickly return to their communities and be close to their loved ones. Mencap maintains that the Government will be judged on whether effective change takes place right across the country and has launched its own campaign in collaboration with the Challenging Behaviour Foundation, Out of Sight, calling for more high-quality local services.

Others have called for a new offence of “corporate wilful neglect” to prosecute care home-owners for allowing abuse to go on.

Winterbourne View’s former owner Castlebeck has issued a statement welcoming the Serious Case Review’s findings. It states that its operational management structures have been revised and that it has made significant changes within the organisation to provide safe, high-quality, person-centred care.