This week we feature a guest blog by CareKnowledge editor Jim Kennedy on the implications and recommendations made by the Winterbourne View Serious Case Review and Mencap’s Out of Sight report… 

The publication of Mencap’s national report on the institutional abuse of people with a learning disability – and the release of the Serious Case Review on Winterbourne View – should mark an important stage in the development of better, and safer, services for some of the most vulnerable people in the care system. But will these publications have the impact their authors hope for? 

The Panorama programme on Winterbourne View was undoubtedly a wake-up call – not only for the way it exposed abuse so directly, and painfully, but also because it drew attention to the re-growth in institutional care – particularly for people with learning disabilities, who challenge services.

What was also remarkable about the Panorama programme was that many of the Winterbourne residents filmed did not, in truth, seem to display the kind of high levels of challenging behaviour that might demand the most intensive ( and expensive, in this case) care. It was staff behaviour that was shown to magnify and in some cases create the apparently maladaptive behaviour of those they were meant to be caring for.

The Mencap Report and the Serious Case Review share many conclusions about what went wrong at Winterbourne View and what is similarly going wrong in the wider health and care system.

Between them they point to serious failures in commissioning, in regulation, in management, in safeguarding practices and in the provision of advocacy. Some broader themes also come through: there is concern that, nationally, we seem to have re-invested in institutional care – and expensive institutional care that neither cares for nor safeguards resident; and that staff and managers in many cases seem to have lost complete sight of the values that are central to the caring role.

Recommendations made across both reports include the need to: 


  • ensure the early closure (within 3 years) of all large assessment and treatment units
  • make greater investment in community alternatives and ensure that small local units – integrated with other services – are available instead
  • direct commissioners to develop local services that can meet the needs of people who challenge; and which will prevent them being placed at a distance from their homes
  • direct the CQC only to accept registration of units which meet the criteria set out in the Mansell report
  • strengthen the law on safeguarding and ensure that CQC acts quickly to de-register or enforce recommendations
  • cease the use of ‘t-supine’ restraint – in which patients are laid on the ground with staff using their body weight to restrain them
  • establish registered managers as a profession with a code of ethics and an effective regulatory body 


Affecting the necessary change sought by these reports will be extraordinarily difficult.

The reports identify such serious and such widespread problems in institutional care that improvement can only be made on a system-wide basis, and in concert with a wider drive to improve services for people with learning disabilities. I think some of the changes required, in the real world, will need national leadership and a level of drive and determination that is hard to see emerging in current circumstances.

After all, we’ve been here before. We’ve already identified the risk and harm associated with large institutions. We’ve already been through a closure programme. We’ve had, for a considerable period of time, policy approaches that emphasised local and community-based care. Yet establishments like Winterbourne View grew up again.

And, like it or not, they currently meet a need – however inappropriately – that will somehow have to met in other ways, and quickly – if Mencap’s recommendations are to be acted on. As we can all recognise this is a pretty hard time to be starting on a drive that will demand new resources – at least initially – and however more cost-effective the eventual alternatives may prove to be.

The Government has just failed to identify what it can do to meet current adult social care need, never mind rise to a major challenge like re-energising our national approach to learning disability services.

But the pressure for change is great. I don’t know how many of these larger units there are nationally, or what the costs and time-frames for replacing them will be, but to have allowed a system to grow up where such placements are even relatively common, seems amazing – especially with their innate tendency to be at considerable geographic remove from families and carers. Although, here, the parallels with what has happened in specialist child care are striking.So, improvement will mean confronting some pretty tough realities, and will challenge some current policy thinking – particularly in relation to the hands-off role of government. Are the leadership and the resources necessary to drive such momentous change in place? I worry that they’re not and that Winterbourne View could quickly slip from the public, policy and professional memory… 

 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.