A report into the abuse of 19 people with severe disabilities at a Doncaster day centre has criticised the delay in investigating the incidents and highlighted a “gap in regulation” of the facilities.
Last year two people were jailed for assaulting service users at the Solar Centre between 2005 and 2007. The serious case review, which was commissioned in July 2013 and published last week, found agencies had “lost sight” of the victims.
The review also highlighted the fact that day centres are not currently regulated by care inspectorate the Care Quality Commission. It recommended that Doncaster Safeguarding Adults Partnership Board (DSAPB) should write to the Department of Health and the CQC highlighting this lack of oversight.
DSAPB apologised to families for the time taken for the review to be published. A spokeswoman for DSAPB said it had written to the Department of Health to raise the issue of day centre regulation but not yet had a response.
A spokeswoman for the Department of Health said it had replied to a letter from DSAPB but she could not comment on the contents.
The Department of Health decided in 2009 to exclude day care from regulation on the basis that it was relatively low risk.The Solar Centre is run by Rotherham, Doncaster and South Humber NHS Foundation Trust.
A spokeswoman for the CQC said: “At present the regulations do not require day care services to be registered with the CQC, however all registered locations of Rotherham Doncaster and South Humber NHS Foundation Trust providing learning disabilities services have been inspected since the trust was registered under the Health and Social Care Act 2008 in June 2010.
“We last inspected the trust on 21 and 22 October 2013 and this included an inspection of trust headquarters location, in Doncaster. Although the Solar Centre falls outside our direct regulatory remit, we spoke to three members of staff who work in the centre as part of our overall assessment across the trust of staff understanding about training, induction, supervision and safeguarding of people who are made vulnerable.
“It is the Department of Health who have responsibility for setting the regulations and not within our power to make direct changes, however CQC would seek to work with the Department of Health if they make the decision to include day services within the scope of regulation.”
Roger Thompson, chair of the safeguarding board, said: “First of all and most importantly, I would like to sincerely apologise on behalf of the Doncaster Safeguarding Adults Partnership Board to the victims and families in this case for the amount of time it has taken to reach this point and for this report to be concluded.
“There are lessons to be learned from this case and agencies should have worked better together at the time. It will be little comfort to those victims and families to hear that in Doncaster, things have changed for the better since this case and we do work more effectively together and have people at the heart of what we do especially in safeguarding. I do want to stress that. That said, the report does recognise that agencies could have done things more expediently and in a more coordinated way. The independent author has made recommendations and we will ensure they are actioned.”
A Department of Health spokeswoman said poor care was “utterly unacceptable”. She said: “NHS staff recruited to work with vulnerable people are subject to appropriate checks, which have been made more robust since the time of this abuse. Checks are no substitute for on-going management and supervision of staff once in post. Where there are failings by an NHS service, we expect immediate action to be taken by the trust.”
What the review found
Victims hit in the face and locked in a cupboard
The victims of abuse at the Solar Centre had profound, multiple disabilities including communication, learning and physical disabilities. One was locked in a cupboard and a chair was put behind the door, several were hit in the face or around the head, and one had cushions thrown at him as “target practice”. Several flinched or appeared frightened near certain staff, and another was not changed or given a drink. A staff member boasted of beating up a service user in a minibus and offered to “sort people out”.
The serious case review comes seven years after a staff member revealed the abuse at the day centre when asking for a transfer.
Investigations took “too long” and agencies “lost sight of victims”
The report said the investigations into the abuse had taken “too long”. The agencies involved “did not effectively engage the victims or their families” and “seem to have lost sight of the 19 individuals who were abused; and the impact that the abuse and subsequent investigations have had on the victims and their families”, the report said.
The serious case review was not commissioned until July 2013 and the disciplinary and safeguarding reviews were halted during the police investigation in the belief that the police case had priority.
The case did not make it to court until June 2013 when James Hinds, then 59, and Susan Murphy, then 43, were each sentenced to two years and nine months in prison for ill-treating outpatients. Two other staff were cleared.
For four years the police said the Crown Prosecution Service (CPS) advised them that the case could not be prosecuted.
Crown Prosecution Service rejects case for four years
But following pressure from the families of the victims, the case was eventually referred to CPS Yorkshire and Humberside Complex Casework Unit for a review which said in July 2012 that the defendants could be charged under the Mental Health Act 1983.
The report said the safeguarding board should “seek assurance” from the CPS that practice has changed nationally as a result of the case. It should also write to the Department of Health, Home Office and Association of Directors of Adult Social Services network to “seek clarity in relation to the supremacy of police investigations and the interface with all other investigations”.
No analysis of impact of abuse
Three families of victims were interviewed for the report and they said communication with them had been poor and the issue of confidentiality could be used “to hide things”. The report said there was “little evidence” that lessons had been learned from concerns they had raised in meetings in 2010 and 2011.
The report said: “There has been no analysis of the impact of the abuse on the individuals and their families. All individuals and families should be approached by DSAPB, on behalf of the partnership, and asked if there are any on-going needs which could be addressed. The impact for the victims and families of the abuse at the Solar Centre may have been exacerbated by the length of time it took to for the various investigations to conclude.”
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If this facility had been privately operated, as in the Winterbourne case it would have been closed down years ago, why is there one rule for the Private Sector and another for the NHS ? why doesn’t the BBC Panorama program carry out unbiased surveys ? why are cover ups etc? not dealt with more strenously .
Mid Staffs Hospita all over again
The Public is getting a raw deal from the NHS and “Safeguarding” doesn’t seem to apply to the NHS. Tank goodness that the CQC seem to be getting a more aggressive attitude towards the NHS now that they have got new Management.