A review into the abuse of adults with autism at a home in Somerset run by the National Autistic Society (NAS) has called for an overhaul of the monitoring of out-of-area care placements.
Mendip House, which closed in October 2016 following a highly critical inspection, was part of an NAS ‘campus’ home to adults with severe autism placed by 30 local authorities and clinical commissioning groups from across the UK.
The review by the Somerset Safeguarding Adults Board (SSAB) said Somerset County Council (SCC) “had to invest in an expensive and labour-intensive enquiry because of the lack of rigor and failures of judgement of commissioning professionals”.
“Had the National Autistic Society addressed long standing concerns and the commissioners undertaken essential reviewing and monitoring, the workload of SCC and the Enquiry Team would not have been as extensive,” it added.
The review criticised the failure of the Care Quality Commission (CQC) to identify problems at the home earlier through its inspections.
It drew comparisons between Mendip House and Winterbourne View, the private hospital near Bristol where BBC Panorama exposed abuse of people with autism and learning disabilities.
It said: “There were over 30 different placement authorities across Somerset Court and although concerns were raised with SCC’s safeguarding team about other Somerset Court dwellings on at least four occasions between 2014-2016, not one identified concerns about Mendip House. Five years after the scandal of Winterbourne View Hospital this is remarkable.”
The review said commissioners continued to “act as place-hunters rather than agents of individuals with autism or stewards of the public purse with the means to control fee levels”.
It recommended that the Department of Health and Social Care, NHS England and the Local Government Association consult on the regulation of commissioning, including the “expectation that commissioners must notify the host authority of prospective placements”.
The consultation should look at the role of a ‘lead commissioner’ to “assume responsibility for coordination when there are multiple commissioning bodies of a single service”, and “assert a new requirement to discontinue commissioning and registering ‘campus’ models of service provision”.
Somerset council plans to require commissioners of services in the county to fund “essential monitoring and reviewing processes”, fund residents’ access to local health services, particularly community health services, and to identify a lead commissioner.
History of concerns
The review criticised the NAS for failing to share findings from its own investigations with the CQC.
The CQC and a senior NAS manager received allegations of abuse at Mendip House from whistleblowers in November 2014. The outcome of the NAS investigation raised concerns about the staff culture in the home.
In addition, a provider audit in October 2015 identified 43 areas for improvement but this was not reported to the CQC at the time.
The review also said the CQC should have been more proactive in identifying problems at Mendip House through inspections.
“The regulator acted once the harm was alleged to have occurred – without reference to the history of inspecting Somerset Court dwellings. The CQC’s decision to act after the whistleblowing is not good enough.”
The CQC eventually acted in May 2016 after two staff members raised concerns about unacceptable staff behaviour. It carried out an urgent focused inspection at Mendip House and was “satisfied that the staffing arrangements were adequate to keep people safe and ensure continuity of the service”.
It then decided to carry out comprehensive inspections of all Somerset Court locations in June and rated Mendip House ‘inadequate’ in all of its inspection criteria.
The CQC proposed to cancel the home’s registration, but the NAS decided to close the service of its own accord.
Reported incidents of mistreatment included an employee making one resident crawl around on all fours, while staff threw cake at the head of another.
Almost £10,000 was reimbursed to Mendip House’s six residents after an audit of case files found residents had been funding meals of staff accompanying them during outings since 2014.
The review was particularly critical of practice in staff supervision sessions, stating it “beggars belief that staff were asked to sign a declaration each time they had a formal supervision session to confirm they had not witnessed any abuse”.
“There was recorded evidence that often a whistle-blower would themselves resign, while the alleged perpetrators were given warnings following disciplinaries and retained or recycled within the service,” it added.
Councillor David Huxtable, Somerset council’s cabinet member for adult services, said: “The report makes important recommendations for change that would bring more clarity on the responsibility for placing authorities to monitor the care being provided to the people they place.”
NAS chief executive Mark Lever said: “We want to run the best possible residential services for autistic people, where they are safe and can thrive. We are very sorry that in May 2016 it became clear that we had failed to achieve this for the people living at our Mendip House care service, who were not shown proper care and respect and were mistreated by a group of our staff.
“We welcome the SAR report’s recommendations addressed to national agencies aimed at improving and monitoring the safety and quality of care placements. All of us who provide and commission care services need to make sure we have the right staff and robust systems in place as well as being prepared to take swift action if there are any signs that standards are dropping.”
Andrea Sutcliffe, the CQC’s chief inspector of adult social care, said: “We share the [safeguarding adults] board’s concerns over the outdated design of services like Mendip House: these days we would be unlikely to register a new service like this, and we are monitoring those services that already exist ever more closely.
“I am sorry that we did not do more when concerns were first raised with us instead of accepting assurances from the council and the NAS that those concerns had been dealt with.”