This week we feature a guest blog by CareKnowledge editor Jim Kennedy on the Care Quality Commission’s post-Winterbourne View internal review…


The Care Quality Commission undertook an internal management review on their involvement in Winterbourne View, as their contribution to the Serious Case Review that was held by South Gloucestershire’s Adult Safeguarding Board.


The Review was written in October of last year. Its publication was delayed until last week, when the trial of those accused of offences at Winterbourne View was concluded. This means that CQC has had some time to digest and act on the findings of the review, but there will still be a range of lessons arising from it, that the new Chief Executive, David Behan will want to ensure have been properly learned.


Since the review’s completion, CQC says that it has inspected all of Castlebeck’s 23 registered locations resulting in the closure of two (in addition to Winterbourne View), and completed a programme of 150 unannounced inspections of hospitals and homes for people with learning disabilities.


CQC also says that they have set up a specialist team to deal with whistleblowers and have appointed 250 additional inspectors so that most services can now be inspected at least once a year.


CQC has already accepted that there were practice failures in relation to Winterbourne View – particularly in relation to the way they responded to the whistleblower, Terry Bryan. However the Review also concludes that there was nothing in the pattern of notifiable incidents that would have led CQC to make different regulatory judgments.


So what lessons remain to be more fully addressed?



  • The need to share information across agencies and regulators to enable a complete picture to be gained of how a service is performing, and of the pressures it is under
  • This can then be used to ensure that there is an accurate assessment of the risks concerned – and that a strengthened inspection approach is adopted where necessary
  • The need for inspectors and their managers to fully record concerns notified to them and agree actions
  • The need to ensure follow up on action plans for improvement agreed with providers  
  • The need for new agreements covering CQC’s work with local Safeguarding Adults Teams and Safeguarding Adult Boards



And, I think two further issues identified in the Review are particularly worth noting – one for CQC and one for the NHS.


The first of these is that the Review shows that failures in information sharing and communication were not restricted to work across agencies. It also recognises that CQC itself still has work to do to ensure better performance across its own internal structures.


The second thing worth emphasising is that the Review is crystal clear that national guidance, both on the preferred models of community-based provision and on the dangers of larger institutions had been in place for some time – yet NHS commissioners continued to use and develop such provision. Turning that ship around is the real challenge for the future…


Terry Bryan, the man who blew the whistle at Winterbourne View, spoke at the Learning the Lessons from Winterbourne View conference. You can watch his talk here.