Yesterday the Serious Case Review written by Margaret Flynn about Winterbourne View Hospital was published. It catalogues the series of circumstances which led to those scenes seen on BBC’s Panorama programme and it makes important and salutary lessons for everyone involved in health and social care.
It is a well-written, detailed report which catalogues a series of holes in the process of provisioning, commissioning, managing and monitoring a long stay hospital for people with learning disabilities but the most important lessons can easily be extrapolated out to many other areas of residential, nursing and long stay hospital care.
In summarising my own reading of the report, I have added some of my own thoughts as I go but I do recommend going to read the full version. No doubt I’ll be reflecting on it more over the next few days/weeks.
This sets out the background to the airing of the programme on 31 May 2011 and the scope of the serious care review (SCR) which covers the period between January 2008 – when South Gloucestershire Council received their first safeguarding referral to 31st May 2011 when the Panorama programme was aired. It explains the terms of reference of the report and some of the specific incidents seen on Panorama which caused concern. This included illegal restraints procedures and
‘notions of a hospital, nursing, assessment, treatment, rehabilitation and support were emptied of meaning and credibility’
The Place and the Personnel
Winterbourne View opened in December 2006 after a ‘feasibility’ study by Castlebeck Ltd which had assessed that there was a need in that particular geographic location for this kind of service. As seen in the programme the placement of a hospital on a business park seems unbelievable but according to the ‘Statement of Purpose’ quoted in the report, there was local access to ‘amenities and a main bus route’ – one does wonder how much this was important to those in the hospital as opposed to those working at the hospital.
Families were not allowed into the bedrooms of those living there which rings many alarm bells to those of us in the sector but may not have been seen as something unusual if you don’t know how these things should operate.
Learning disability nursing and psychiatry were the only disciplines employed in the so-called ‘multi-disciplinary’ teams. The report explains the structure of the service and staffing which was heavy on support workers, which in itself isn’t surprising however a ‘hospital’ employing no occupational therapy, for example, is particularly surprising. There was a very high turnover and sickness rate among staff which in itself is a sign of there being something particularly wrong in the structures. 12 hour shifts were the norm which may have suited the service and staff more than those who use the service and there was certainly a lack of detail regarding day time activities and timetables for those who lived in Winterbourne View.
I do wonder where the input from care managers/care co-ordinators were in terms of monitoring care plans and ensuring their were adhered to. My gut feeling is that with out of area placements, there was less impetus to be able to monitor these. Commissioners didn’t seem to make many demands that the operating guidelines for Winterbourne were met in terms of providing a therapeutic and rehabilitative environment.
This section details the concerns raised and is an analysis of what was actually happening at Winterbourne along a timeline. Unsurprisingly there are a string of concerns raised that when seen along a timeline can build a picture of a hospital and an organisation that is not fit for purpose.
Part of the concern as a whole is that the dots were not connected in terms of the series of incidents and concerns to build a coherent picture of what was happening. Whilst it’s ‘easy to be wise with hindsight’ it’s important to remember that we have systems which are supposed to protect vulnerable adults which should include collating and using information, concerns and reports to build cohesive pictures of what is going on – that’s even without the whistleblowing which took place.
It makes very difficult reading – all the more so in the context that it was not sufficiently investigated, not internally, not locally and not by the regulator nor police. The key worry that ran through my head is that this may have continued had it not been for both the intervention of determined ‘whistleblowers’ and the involvement of a BBC journalist. That’s a very very worrying lesson that needs to be acted on.
The Experiences and Perspectives of Patients and their Families
The author of the report spoke to six families in particular and explains their perceptions, experiences and understanding of what was happening at Winterbourne View. The report gives life to some of those who lived at Winterbourne View and humanises them in a way, it seems that the service itself never did – with hopes, aspirations, character and personality.
One patient said
he had been in ‘loads of worse places than them, all over the country’ and that he had been abused in lots of care homes
And if there’s a key lesson to learn it is that Winterbourne View is not an anomaly and shouldn’t be seen as such.
The patient recollections of abuse and treatment at Winterbourne is very powerful. It evidences the importance both of listening and humanising approaches within residential care and hospital care. The importance of being near families and the disruptions of constantly changing placements seems to be the nature of life for some groups of people who have particular care needs and I wonder where the power in commissioning is coming from to look at different models.
When families raised concerns that their children had brought to them these reports were often disbelieved or families were not given the full details of what was going on. It also raises the importance of visiting and monitoring – particularly for those who may not have families.
Importantly the report says
A family expressed anger that service commissioners making spot purchases to meet the needs of individuals do not know what they want to buy; they do not seek assurance that the service they believe they are buying is delivered; and they do not follow up on what is being provided.
Perhaps more importantly in terms of lessons to be learnt globally
‘As families recalled some of their distressing experiences, it was clear that they had no collective experience of being regarded as partners deserving of trust and respect or even of collaborating with paid carers.
There has to be a shift in the conceit of ‘paid professionals’ or ‘paid support workers’. We have to work with, alongside and for those whom we support and their families as otherwise we should be nowhere even close to a position in social care. Respect, listening and remembering whom we are serving is the crux of the profession and that seems to have been lost somewhere.
Castlebeck Ltd seemed to have a ‘limited executive oversight’ of Winterbourne View with the geographical distance from their head office in Darlington providing significant lapse in responsiveness when concerns were raised.
Interestingly they seem to place some of the blame directly on the CQC and problems with the transition from the Healthcare Commission to the CQC. While no CQC apologist this seems to be a very complacent and worrying dereliction of duty from the organisation that was paid to provide a service which should include self-monitoring. The SCR looks at Castlebeck’s own analysis of their failings but finds it lacking with attempts to discharge responsibility for the things that went wrong. As it says
Overall Castlebeck Ltd’s appreciation of events leading up to transmission of Panorama is limited, not least because they took financial rewards without any apparent responsibility. The recommendations fail to address corporate responsibility at the highest level
Which is sad, but unsurprising.
NHS South of England also produced a report about commissioning of care and treatment at Winterbourne View. Out of the 48 referrals made to Winterbourne View, 13 came from commissioners located less than 20 miles away and 9 of those 13 were from commissioners less than 10 miles away.
Worrying is that there were some placements made with few checks and some not even reading the most recent inspection reports. Interesting that of the 48 English patients (the experiences of Welsh patients – not being the responsibility of the NHS in England were not counted in these figures) 35 were admitted under a section of the Mental Health Act, 13 were admitted informally and 6 were detained after being admitted informally. Unfortunately there are no details regarding the Deprivation of Liberty Safeguards but it would be interesting to know more about those ‘informal’ admissions legally.
NHS South Gloucestershire PCT was the ‘coordinating’ commissioner being where Winterbourne View is located. They produced another report. Hospital records were also accessed but there seemed to be no linking of information together and agencies not speaking to each other seems to be a major problem and continuing concern.
South Gloucestershire Council also provided a Safeguarding Review. South Gloucestershire received 40 safeguarding alerts between October 2007 and April 2011. The system locally to follow up some safeguarding alerts seemed to be flawed in terms of not receiving relevant and necessary information requested back from Winterbourne View. Many of the alerts ‘tail off inconclusively with no clear decisions and no rationale for decisions’. Each alert was dealt with discretely and the pattern was not allowed to emerge.
Avon and Somerset Constabulary were also involved as there were a number of assaults reported and they also provided a report. There were some flaws in the sharing of information between the police and the local council.
CQC also compiled a report. The SCR picks up on some confusion in language in terms of the CQC and notes the importance to note that Winterbourne View is not a care home but is a hospital. The CQC admits that it’s creation has had a significant impact on inspection of services – something we all knew – but it’s good to see them acknowledge this finally rather than paint the biased hue of everything ‘being better’ under the new regime.
The lack of specialist inspectors is a particular factor that the new systems of regulation have lost. Apparently ‘professional regulators’ is a better way of doing things rather than those with specific knowledge of particular service areas. Perhaps this isn’t quite the right way to develop regulatory services.
Findings and Recommendations
The report finishes with a summary that is robust. Winterbourne View is a particular snapshot which has been able to take place due to a series of circumstances that put the spotlight on the services. These spotlights aren’t often shined into the world of long stay hospitals and residential care. But for a BBC programme, it might never have been picked up. That’s a lesson in itself.
Castlebeck Ltd didn’t provide a poor service because it had no money. It provided a poor service because it didn’t see any reason not to. There were no reasons to question itself or what it was doing. Those questions weren’t being asked by any of the agencies responsible for protecting those who lived in Winterbourne View.
The recommendations are that the Clinical Commissioning Groups, Local authorities and NHS Commissioning Board should be looking more closely at the services they commission, where they are commissioning them and aim to cut down in-patient services.
The report emphasises
‘Commissioning is a professional activity that should be led by trained specialists who know and develop the market according to public policy’
This made me sigh as it seems in my own experience that we are moving backwards on this. I see fewer specialist commissioners who know their areas and more general commissioners who come from non-health or care related backgrounds and with little understanding of the sector or the needs locally of those who use the services they commission.
The report strongly criticises the commissioning of long stay hospitals for people with learning disabilities as perpetuating the ‘out of sight, out of mind’ type modelling for care services.
Recommendations include a more robust use of the Mental Capacity Act 2005 and particularly that
‘The Department of Health should assure itself that CQC’s current legal responsibility to monitor and report on the use of Deprivation of Liberty Safeguards provide sufficient scrutiny of the use of DoLS’
There was a lesson in poor multi-agency working which needs to be worked on actively and there is a recommendation that those who are subject to provisions of the Mental Health Act or Deprivation of Liberty Safeguards as well as all who make a complaint have access to independent professionals, whether social workers, Best Interests Assessors, IMCAs or IMHAs or more than one. Advocacy is crucial to prevent abuses.
As far as the CQC is concerned, the report explains that the ‘light touch’ regulation, enamoured by the CQC doesn’t work with settings like Winterbourne View. The CQC has been too reliant on self-reporting and trusting providers are complying.
There’s a recommendation that the ‘
Mental Health arm of the CQC should have characteristics akin to HM Inspectorate of Prisons in terms of standards’
That would be an interesting and useful development but I doubt the current CQC is set up to provide a robust monitoring procedure.
I haven’t been able to cover all the points of the SCR. It is worth reading in its entirety. It concludes by emphasising that services like Winterbourne View should not exist as they create no aspirations and hope.
They are not therapeutic environments and were created to provide a funding stream to the private company rather than to improve the quality of treatment and care to those who need them.
Commissioning should look at what exactly is being commissioned and what is needed to achieve the end result of an improvement of quality of life.
I look at this report and it is an excellent report, and I despair. I recognise parts of it but it is a particularly appalling litany of pain, distress and human suffering that could have been identified earlier. We relied on a television programme to identify these issues when there were so many people who should have identified this sooner.
No one comes out of this well apart from the whistle blowers who tried to make a difference.
Good services can and do exist but we need to be very clear about expectations of services and what we expect a hospital built on an industrial estate and factoring in amounts of income possible can achieve as opposed to services which truly exist in local communities.
It’s an awful situation but the SCR offers an opportunity to learn and do things differently. Let’s listen more and better across the whole sector and remember that this job is always a matter of partnership and never should be one of dictation. We have to do things better.