Residential care services provider Castlebeck failed to comply with 10 essential standards at its Winterbourne View care home in Bristol - subject of a recent Panorama expose - according to a report by regulator the Care Quality Commission (CQC).
The CQC's report found a systemic failure to protect people or to investigate allegations of abuse, and that the provider had failed in its legal duty to notify the CQC of serious incidents including injuries to patients or occasions when they had gone missing.
Inspectors said that staff did not appear to understand the needs of the people in their care. People who had no background in care services had been recruited, references were not always checked and staff were not trained or supervised properly. Some staff were too ready to use methods of restraint without considering alternatives. They also found that planning and delivery of care did not meet people's individual needs. This review was initiated immediately after the BBC Panorama programme was broadcast on May 31. The programme contained undercover footage showing alleged abuse of residents.
Since the programme went out, Winterbourne View has been closed and its residents found alternative accommodation.
Amanda Sherlock, CQC's director of operations said: "This report is a damning indictment of the regime at Winterbourne View and its systemic failings to protect the vulnerable people in its care. "It is now clear that the problems at Winterbourne View were far worse than were initially indicated by the whistleblower. He has stated that he was not aware of the level of abuse until he saw the footage from the secret filming. "We now know that the provider had effectively misled us by not keeping us informed about incidents as required by the law. Had we been told about all these things, we could have taken action earlier. We will now consider whether it would be appropriate to take further legal action. "CQC has already acknowledged that we would have acted earlier if the evidence from the television report had been made available to us. "However it is incorrect that CQC had failed to act on warnings by the whistleblower. Our internal investigation has confirmed that while we were aware of those concerns, our inspector believed they were being dealt with through the local safeguarding process involving a number of agencies. We should have contacted the whistleblower directly - and this will be one of the issues which will be addressed by the independently-led serious case review." Sherlock added that the CQC's plans for a programme of random, unannounced inspections of hospitals providing care for people with learning disabilities are well underway.
In response, Castlebeck's chief executive, Lee Reed said: "We are truly sorry for the failures which led to the terrible mistreatment suffered by patients at Winterbourne View. "As soon as the company was made aware of the appalling misconduct of staff at Winterbourne View, we alerted the police and other relevant authorities. We then took immediate remedial steps to safeguard the welfare of all our service users. This work is ongoing, and is our absolute priority. "Castlebeck is determined that its safeguarding and welfare procedures should be the best in the care industry. We therefore welcome the report from the Care Quality Commission, which sets out a number of concerns in relation to the service at Winterbourne View. We are also looking forward to the findings of the independent inquiry by PricewaterhouseCoopers into Castlebeck's policies and procedures company-wide, which will report this month. "We are expecting further CQC reports over next few weeks and will pursue any defects equally vigorously."