Review condemns out-of-area commissioning that left adults with learning disabilities in abusive home

A safeguarding adult review (SAR) has slammed “ineffective and inefficient” commissioning arrangements that saw people with learning disabilities sent away from their local authority areas to care homes in Devon where they were abused.

The investigation into systemic cruelty almost a decade ago at two facilities run by Atlas Project Team Limited drew heavily on the testimony of victims’ relatives, which it said delivered a “bracing indictment” of out-of-area placements.

The families had also been failed by the criminal justice system, which left them feeling the humanity of their loved ones had not been recognised, the review concluded.

Trials in 2016 saw 13 care workers, managers and directors convicted over the routine false imprisonment of residents. “[But] it was harmful for families to hear the behaviour of their distressed and traumatised relatives presented as the rationale for the criminal behaviour of Atlas directors and employees,” the SAR report said.

Systemic neglect and isolation

The abuse took place in the Veilstone and Gatooma homes, which along with Atlas’ other facilities were closed down in 2012 following inspections by the Care Quality Commission (CQC).

The 2016 trials heard that residents of the homes were subjected to systemic neglect, isolation in unheated rooms with no access to food, drink or a toilet, assaults and ‘compliance tests’ from staff.

In all, Devon and Cornwall police identified that 2,600 incidents of seclusion had taken place, with some residents imprisoned up to 400 times.

Most had been placed there by authorities other than Devon, including Wiltshire, Bath and North East Somerset and Plymouth councils. Resistance by Atlas to family contact prevented any “significant role” in reviewing relatives’ care, the SAR report observed.

A serious case review (SCR) completed in 2013 but not published due to ongoing legal proceedings, which the SAR sought to update, found commissioning bodies had considered Atlas a “service of last resort” for adults with challenging behaviours and complex needs.

“People placed out of area were disadvantaged because their circumstances did not feature in commissioning strategies,” the SAR said. “There was no guarantee the host authority would be informed of their arrival; and because reviewing processes were underdeveloped there was no agreed means of determining the quality of specialist services.”

The Care Quality Commission (CQC), which was heavily criticised by victims’ relatives interviewed by the SAR, was described as being “in transition” between 2010 and 2012 – though the report noted it had since made considerable improvements.

“It accepted that its inspections and monitoring had no knowledge of the potential risks such as Atlas’ inattention to Deprivation of Liberty Safeguards (DoLS) across its homes, or the implications of registered managers being registered for more than one site,” the report said.

The SAR noted that many of the learning points from the 2013 SCR – including around commissioning arrangements and scrutiny of providers – mirrored those identified in the wake of the Winterbourne View scandal exposed in 2011. The 2012 SCR into Winterbourne was written by the same author as the Atlas SAR, adult safeguarding consultant Margaret Flynn.

‘Urgent need’ to reconsider out-of-area placements

The SAR found that, since the implementation of the Care Act 2014 in 2015, all former commissioners of Atlas claimed to have put in place procedures that would be more responsive to safeguarding concerns regarding people placed out of area.

“All commissioning bodies are immersed in efforts to ‘shape’ the market to reduce the likelihood of people… being moved away from their areas of origin,” it said. “These are significant developments.”

Nonetheless, the review said processes and reporting systems would offer greater reassurance if commissioning authorities could demonstrate they had involved families affected by safeguarding concerns in their development, and that systems were “reducing variability” between providers.

There remains an “urgent need” to reconsider out-of-area placements in locations where commissioning bodies outsource reviews to host authorities, where hosts’ ability to hold providers to account was in doubt or where families may struggle to stay in touch with relatives, it added.

“Many developments and considerations are now brought to bear on re-commissioning support,” the SAR report said. “However, these must be viewed against an enduring backdrop of insufficient (i) local provision for adults with complex support needs and (ii) accommodation and support.”

The review concluded that Devon’s safeguarding adults board should recommend that the Department of Health, NHS England and Local Government Association:

• Incentivise commissioners to engage in ‘close to home’ arrangements for adults with learning disabilities, autism and mental health problems.
• Make mandatory notifications by commissioning authorities of prospective placements to a host authority.
• Assert a requirement for specific funding for monitoring, reviewing and safeguarding as necessary, and for residents’ access to local health services.
• Assert a requirement that placements be discontinued should they ‘take anyone’, or would not be registered by the CQC in line with its Registering the Right Support policy for services for people with learning disabilities and/or autism.

It also said the board should propose replacing episodic/once a year reviews with “continuing, complex case management with a strong advocacy role”, starting with all ex-Atlas residents. It should also incentivise the creation of an “intelligence repository” for commissioners about providers, including information on responses to complaints and inspections.

‘We must all remain vigilant’

Responding to the SAR’s findings, families of people abused in Atlas homes issued a statement saying they welcomed its publication but that it was “long overdue”.

“We have been waiting almost eight years for its publication and for an explanation of the failings that led to the horrific abuse of our relatives,” the statement added. “We and our loved ones continue to suffer the trauma inflicted in Atlas care homes.”

Julie Ogley, president of the Association of Directors of Adult Social Services, said the organisation was “shocked and appalled by the terrible failings and their implications for the people affected and their families”.

“Our shared priority must be to ensure that everyone has the right to high quality support and care and, where possible, in proximity to where to their loved ones live,” Ogley said. “This is an important reminder that we all must remain vigilant to protect vulnerable people and support them in living their lives fully, with dignity and respect.”

Deborah Ivanova, the CQC’s deputy chief inspector of adult social care in the South of England, said the regulator welcomed the report but that much had since changed.

“When these abusive practices were discovered, CQC took decisive action but we should have responded more quickly to the concerns raised,” she added. “Since then we have overhauled our regulatory approach; improved the monitoring of services and the way we respond to safeguarding concerns; introduced a new and more thorough inspection process; increased the numbers of people with learning disabilities involved in our inspections; and strengthened our enforcement processes.”

A Department of Health and Social Care spokesperson said that abuse of any kind was “abhorrent and will not be tolerated”.

“The abuse uncovered at Atlas Project Ltd homes is deeply shocking and has rightly led to criminal convictions,” the spokesperson added. “The government is committed to preventing and reducing the risk of harm to vulnerable people – we want to see a focused and effective safeguarding system, where harm or risk of harm is identified, acted upon effectively and ultimately prevented.

“The publication of this safeguarding adult review offers an opportunity to learn for the future and we will carefully consider its recommendations,” the spokesperson said.

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