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Practice lessons for social workers from Winterbourne View


So the verdict on what happened at Winterbourne View has been delivered through the serious case review (SCR) published on Tuesday, alongside separate reviews on the roles of NHS commissioners and the Care Quality Commission. But what were the chief practice lessons for social workers?

Where was the social work?

Social workers performed two key roles in the Winterbourne View story:
  • As care co-ordinators working under the Care Programme Approach (CPA) to monitor the care and progress of people placed at Winterbourne, on behalf of primary care trusts (in some cases commissioning with local authorities). Though most co-ordinators were nurses, a substantial minority were social workers.
  • As safeguarding staff from South Gloucestershire Council responding to some 40 alerts relating to Winterbourne View from October 2007-April 2011.
These were fundamentally oversight roles. However, a strong point from the SCR was that people at Winterbourne View – 95% of whom had a learning disability, 73% of whom were sectioned under the Mental Health Act on admission and a number of whom had histories of abuse or self-harm - should have been benefiting from social work as part of their core support package. Instead, professional input, outside of CPA reviews, was largely confined to psychiatry and learning disability nursing, the two professions employed at Winterbourne. To quote the SCR:

“The long-stay hospitals demonstrated that medicalising people’s lives under the supervision of nurses and psychiatrists produces poor physical and mental health outcomes.”

So what went wrong in the social work practice that was present?

1) A lack of challenge

One of the strongest themes to emerge from the SCR is that social workers and other professionals failed to challenge Winterbourne View, and each other, about the quality of care received by patients and the level of and response to serious incidents, including staff on patient assaults. This applied to both safeguarding staff and care co-ordinators. 

Council safeguarding staff were too deferential to the police, failing to follow up cases – including of alleged staff on patient assaults – when the police had declined to investigate. They also relied on the hospital for patient information when alerts were raised and failed to follow up on cases where Winterbourne did not produce required reports from internal investigations of alerts (SCR, p107-108).

There was also a lack of challenge from care co-ordinators to Winterbourne staff during CPA reviews. Reviews were typically arranged and chaired by Winterbourne, not held in response to incidents or concerns and there was an over-reliance on information provided by Winterbourne about patients (NHS review, p44-47).

Crucially, this lack of challenge concerned an institution that was failing to provide full and accurate information, notably about the physical restraint and injury of patients by staff.

  • When a hospital fails to produce a credible safeguarding investigation report within an agreed timeframe, the host safeguarding adult board should identify remedies (SCR, p131).
  • Care co-ordinators must have the right mix of skills to challenge providers or should be adequately supported to do so. This should include not taking explanations and reassurances at face value and following up information of concern far more robustly (NHS review, p66).

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2) Failure of safeguarding agencies to piece together a pattern of risk from discrete cases

Adult safeguarding received 40 alerts from October 2007-April 2011; the police had 29 contacts with Winterbourne from January 2008-May 2011; over the same period patients attended A&E 76 times and care co-ordinators picked up on several other serious incidents.

Yet agencies were unable to piece these together into a coherent picture; significantly because of Castlebeck’s lack of disclosure, but also because of an ineffective multi-agency safeguarding response.

For instance, the council was unaware of the number of police attendances at Winterbourne (SCR, 130) and commissioners were only informed about one-fifth of safeguarding alerts, either by care co-ordinators (who knew about them in most cases) or adult safeguarding (NHS review, p55).

Also, the fact that placements were commissioned by multiple primary care trusts in isolation meant intelligence was not shared between them about what was going on at Winterbourne (NHS review, p59).

Key recommendation
  • Agencies must have a shared safeguarding objective and effectively share information (SCR, p130)

3) Lack of experience of independent hospitals

“Most local authorities are not responsible for, and have no experience of co-ordinating safeguarding activities at an independent hospital. Consequently, as South Gloucestershire Council acknowledges, there was a markedly different safeguarding response to Winterbourne View Hospital to their responses to other services.” (SCR, p131)

South Gloucestershire’s management review found safeguarding practice was stronger in relation to a sample of other cases was good: decision-making was appropriate and evidenced, casework was sensitive and plans were clear and detailed. 

Apart from a lack of experience of such establishments, suggested reasons for the difference in quality included lower expectations of conduct and practice in hospitals catering for people detained under the Mental Health Act.

However, the review made clear that such “closed establishments” were inherently risky and required a more concerted safeguarding approach than other services.

Key recommendation
  • Hospitals for adults with learning disabilities and autism require frequent, more thorough unannounced inspections, more probing criminal investigations and exacting safeguarding investigations (SCR, p136)
4) Lack of clarity of roles 

There was a lack of clarity in the roles of care co-ordinators and the expectations placed on them by commissioners funding placements at Winterbourne. Because of the lack of direct involvement from commissioners in monitoring patients, co-ordinators had to both provide challenge and hold the provider to account and build a long-term relationship with a vulnerable person – very different skills. The NHS review said this “contributed to the lack of robust challenge” ( p47). 

Another consequence was a lack of clarity over the threshold at which the care co-ordinator should have raised issues of concern with the commissioner over quality of care – meaning crucial information was not shared (NHS review, p28)

Key recommendation
  • Commissioners should clarify the roles of care co-ordinators in mental health and learning disability specialist placements and ensure there are consistent thresholds for communicating information from care co-ordination teams to the commissioner (NHS review, p68)
  • Commissioners should ensure that clinical commissioning teams have access to clinical expertise (p69)

See for yourself

Please do read the reviews for yourselves if you have time as your insights into them will carry far greater value; also the British Association of Social Workers and The College of Social Work have already had their say on what Winterbourne means for the profession and will, I think, be seeking feedback from members on the same.

Pic credit: Image Source/Rex Features

Mithran Samuel

About Mithran Samuel

Mithran Samuel is adults' editor at Community Care.

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