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Care watchdog defends failure to uncover abuse evidence

The care regulator has defended the failure of its own inspectors to uncover evidence of serious abuse at a private “hospital” for people with learning difficulties.

The Care Quality Commission (CQC) faced serious questions this week after it published its report into alleged abuse at Winterbourne View, near Bristol.

The report includes evidence of concerns about care standards at the hospital that pre-dates CQC’s previous inspection of Winterbourne View in December 2009, which failed to uncover the alleged abuse.

Instead, action was only taken by the authorities after detailed evidence was aired in a BBC Panorama investigation in May this year.

Until this week, CQC has been criticised for failing to follow-up concerns expressed by a whistleblower but not for its failure to uncover the alleged abuse through its inspection process.

The new report details the findings of CQC’s in-depth review of care at Winterbourne View, undertaken after it was told about Panorama’s investigation.

The CQC report says Winterbourne View failed to “protect people or to investigate allegations of abuse”, while the company that ran the hospital, Castlebeck, failed in its legal duty to notify CQC of serious incidents including injuries to patients or occasions when they had gone missing. 

The CQC concluded that Winterbourne View had breached 10 legal care standards, and said the report was a “damning indictment of the regime” and its “systemic failings” to protect the people in its care.

But the report crucially reveals that documentary evidence of concerns about standards at Winterbourne View appears to date back to at least 2006 and seems to have been overlooked by the previous CQC inspection in December 2009. 

The new report also reveals that a Mental Health Act commissioner who visited Winterbourne View for the CQC in September 2010 asked the hospital for a copy of an independent review of an incident in which a patient had received a broken wrist after being restrained by a staff member.

But CQC failed to follow-up on its request and did not receive any paperwork about the incident from Winterbourne View – documents which were to show a string of inconsistencies – until it made a new request after the Panorama revelations.

Although there are substantial parts of the new CQC report where dates are unclear, among the evidence that pre-dates December 2009 are:

  • Records that show a staff member was employed for more than three months in 2008 before their Criminal Records Bureau check was completed. There was only one employment reference for this member of staff.
  • The employment of a member of staff in 2006 relied on two telephone references from friends of the applicant.
  • A support worker wrote in their appraisal in April 2009 that they were “struggling to follow senior support worker directions due to shortage of staff”.

A CQC spokesman said that the December 2009 inspection was carried out under previous legislation, in which inspections concentrated on “issues of concern” raised by the service’s own self-assessment.

He said: “There is no evidence that abuse was taking place at that time, although our latest report has uncovered concerns that date from then.”

He added: “A range of professionals from a range of organisations had contact with Winterbourne View. None of them uncovered this serious abuse.

“The whistleblower who did contact us had not seen this level of abuse. It took secret filming to find out what was going on at Winterbourne View.  

“No system of inspection, however regular, is guaranteed to expose criminal abuse if the perpetrators are determined to keep it secret.” 

When asked whether he believed CQC could have uncovered the alleged abuse in December 2009 if it had inspected Winterbourne View more thoroughly, he said: “I can’t add to my earlier replies except to say that it is a matter for the serious case review [commissioned by South Gloucestershire council] chaired by Margaret Flynn to look at the actions of the regulator, and others.

“She’ll draw conclusions – and it’s not appropriate for us to pre-empt them.”

He was also unable to clarify why CQC failed to follow-up the missing independent review of the incident in which a patient received a broken wrist.

CQC admitted this week that it wants to increase the frequency of inspections of care and health services, in a reversal of its previous “proportionate, risk-based, light-touch” policy. 

CQC reports on Castlebeck’s other 23 facilities for people with learning difficulties in England are to be published by the end of this month.

Winterbourne View has already closed, and nine men and three women have been arrested and released on police bail in connection with allegations of abuse.

News provided by John Pring at