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Issues for the CQC from Winterbourne View

David Behan.jpg

The Care Quality Commission’s failure to respond to whistleblowing nurse Terry Bryan’s reports of abusive practice at Winterbourne View will haunt the regulator for the foreseeable future. However, the CQC’s review into its role in the case – published alongside the serious case review on Tuesday – makes clear that there are a number of other lessons for the regulator to learn from Winterbourne. These will be among many things sitting in the in-tray of incoming chief executive David Behan (pictured above).

Failure to follow-up on statutory notifications and action plans

Like other regulated services, Winterbourne was obliged to report certain matters, including abuse allegations or serious injuries, to the CQC, both under the current regulatory regime, which came into force in October 2010, and the previous one.

However, on a number of occasions, the CQC failed to follow-up with the hospital or South Gloucestershire adult safeguarding team on the outcomes of investigations – whether by the hospital, police or safeguarding team. These covered incidents including alleged staff assaults on patients.

On other occasions, the CQC failed to monitor Winterbourne View’s progress against action plans submitted in response to problems identified in regulatory inspections.

  • Inspectors should record the outcome of investigations arising from safeguarding alerts and their managers should sign off the agreed actions from the investigations. Where CQC cannot agree these actions, this should be communicated to the council adult safeguarding team.
  • Follow-ups on investigations of incidents should be recorded in the service’s Quality and Risk Profile and, where there is limited progress, inspectors should report this to their managers.

Failure to share information internally

When it was formed in April 2009, the CQC brought together two organisations with a watching brief over Winterbourne View: the Healthcare Commission, as regulator of independent healthcare, and the Mental Health Act Commission (MHAC), as the watchdog for patients detained under the Mental Health Act. 

Both these functions involved conducting site visits to Winterbourne and reporting on them. However, the CQC review found a lack of information sharing between the staff who carried out these visits, Mental Health Act commissioners and inspectors. 

For instance, in a visit to Winterbourne in July 2010, a MHA commissioner found that a patient had fractured their wrist during a restraint procedure and that an internal review of the incident had been poor. The commissioner told Winterbourne that it needed to provide evidence to the CQC about their procedures for investigating serious incidents. But there is no evidence that the commissioner reported their observations to the compliance inspector.

  • The CQC should evaluate and embed the process for information sharing between compliance inspectors and MHA commissioners, through supervision of both staff groups.
  • When MHA commissioners set out suggestions for improvement to a provider these should be monitored through an action plan submitted to the CQC.
Sharing information with safeguarding agencies

That the individual bits of the safeguarding system – NHS commissioners, council safeguarding staff and the regulator – failed to piece together their separate bits of intelligence on Winterbourne to form a picture of concern was one of the chief failings detected by the serious case review.

The CQC review identified a lack of routine sharing information of its findings – and those of the the Healthcare Commission and MHAC - with the council adult safeguarding team and commissioners.

This culminated in the lack of response to Terry Bryan when he blew the whistle on 11 October 2010 in an email to managers, which was passed to the adult safeguarding team on 28 October, who then passed it to the CQC on 29 November. This prompted discussions between the CQC and the safeguarding team about what to do next. However, each of the CQC, South Gloucestershire safeguarding adult team and Winterbourne View assumed the other had replied to Bryan about his concerns but none had done so.

  • The CQC should build new protocols about working with local adult safeguarding teams and safeguarding adult boards to ensure timely investigation of alerts and that all relevant parties are involved in investigations.
  • The CQC should immediately audit the interaction it has with safeguarding adult teams and boards across England, focusing on CQC attendance at multi-agency safeugarding meetings and how it signs off on actions agreed at them.

What progress?

It’s worth pointing out that the CQC review was completed in October 2011, so there should be some idea of progress on its recommendations by now. I will ask them if any progress report has been done.

Mithran Samuel

About Mithran Samuel

Mithran Samuel is adults' editor at Community Care.

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2 Responses to Issues for the CQC from Winterbourne View

  1. Alan Rosenbach 12 April , 2013 at 3:20 am #

    Mithran I refer you to the SCR pp 120 paragraph 6.14. Dr Flynn notes the “regulators self scrutiny is refreshingly honest”.
    We have long since begun and in some cases completed the implementation of the recommendations in our own internal management review. We will be content to share the detail if you want these. These were all processes and actions we recognised needed change long before the SCR was published. I have one more comment which is not to be defensive but just to put the record straight. The detailed concerns of Terry Bryan were known to the Castlebeck Management and Safeguarding Adults for many weeks before we knew about them. We were not the first port of call for his concerns.We did respond as soon as we knew of his concerns by contacting the safeguarding adults team. We always acknowledged that we should have contacted Terry Bryan as well.

  2. Mithran Samuel
    Mithran Samuel 12 April , 2013 at 3:20 am #

    Thanks for that Alan, that’s helpful. I’ve revised the sentence about contacting Terry Bryan to make it clear that the CQC heard about it weeks after the safeguarding team (and Castlebeck). Yes, we’d be very keen to hear about progress since last autumn, particularly on the issues highlighted.