winterbourne view care home case study

CQC report on Winterbourne View confirms its owners failed to protect people from abuse

18 july 2011.

The Care Quality Commission has published details of the enforcement action it has taken against Castlebeck Care (Teesdale) Ltd which failed to protect the safety and welfare of patients at Winterbourne View. The effect of this action is that the assessment and treatment centre near Bristol has been closed.

Today CQC publishes the findings following an inspection of services provided at Winterbourne View. After considering a range of evidence inspectors conclude that the registered provider, Castlebeck Care (Teesdale) Ltd, had failed to ensure that people living at Winterbourne View were adequately protected from risk, including the risks of unsafe practices by its own staff.

The report concludes that there was a systemic failure to protect people or to investigate allegations of abuse. The provider had failed in its legal duty to notify the Care Quality Commission 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, adults with learning disabilities, complex needs and challenging behaviour. 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.

The review began immediately after CQC was informed that the BBC television programme Panorama had gathered evidence over several months including secret filming to show serious abuse of patients at the centre.

Inspectors who visited Winterbourne View considered taking urgent action to close the centre, but decided that it was in the best interests of the patients to allow NHS and local authority commissioners further time to find alternative placements.

CQC ensured that there would be an immediate stop on admissions and that extra staff would be brought in to protect patients until they could be moved.

When they were satisfied that those arrangements were in place, CQC took enforcement action to remove the registration of Winterbourne View, the legal process to close a location. The hospital closed in June.

The report which is published today finds that Castlebeck Care Ltd (Teesdale) was not compliant with 10 of the essential standards which the law requires providers must meet. CQC’s findings can be found below.

• The managers did not ensure that major incidents were reported to the Care Quality Commission as required.
• Planning and delivery of care did not meet people's individual needs.
• They did not have robust systems to assess and monitor the quality of services.
• They did not identify, and manage, risks relating to the health, welfare and safety of patients.
• They had not responded to or considered complaints and views of people about the service.
• Investigations into the conduct of staff were not robust and had not safeguarded people.
• They did not take reasonable steps to identify the possibility of abuse and prevent it before it occurred.
• They did not respond appropriately to allegations of abuse.
• They did not have arrangements in place to protect the people against unlawful or excessive use of restraint.
• They did not operate effective recruitment procedures or take appropriate steps in relation to persons who were not fit to work in care settings.
• They failed in their responsibilities to provide appropriate training and supervision to staff.

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.

“Immediately we were aware of the extent of the problem, we took the action which is detailed in this report. Although Winterbourne View is now closed, we will continue to monitor Castlebeck's other services closely.

“The most important outcome of all this is that the people who had been living at Winterbourne View are no longer subject to this culture of abuse.

”Our plans for a programme of random, unannounced inspections of hospitals providing care for people with learning disabilities are well underway and we will report back in due course."

Over the last four months CQC has reviewed and inspected all the services provided by Castlebeck Care (Teesdale) Ltd at its 24 locations. We will publish the results of this review, including reports on all locations, at the end of July. Where we have identified concerns, measures are in place to address the problems and to ensure the safety of people using services.

For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

Notes to editors

Below is CQC’s response to the abuse at Winterbourne View hospital.

• A review of all Castlebeck services. Full details of the inspection of 23 locations will be published later this summer.
• A review of learning disability services involving the inspection of 150 services for people with learning disabilities which have the same or similar characteristics as Winterbourne View.
• An internal management review. The first stage of CQC’s internal management review of our actions in relation to Winterbourne View is complete. The final report will make recommendations relating to how CQC ensures that safeguarding alerts and whistle blowing information are handled.
• A serious case review: CQC's internal report will feed into a serious case review being led by an independent chair, Margaret Flynn, which will examine the role of all the responsible agencies.

Read the report

Review of compliance: Winterbourne View - July 2011

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.

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10 years on from Winterbourne View: lessons for social workers

Professional curiosity, legal literacy and a human rights focus are key to social workers enabling better lives, and ending institutionalised care, for people with learning disabilities, say jack skinner and claire webster.

By Jack Skinner and Claire Webster

Ten years ago, BBC Panorama exposed the horrific abuse that staff at Winterbourne View hospital had inflicted on people with learning disabilities who were supposed to be receiving assessment, treatment and rehabilitation. A police investigation lead to 11 criminal convictions, a national outcry and a formal government response on the serious failings highlighted.

A series of investigations found that:

• More than half of the people there were over 40 miles away from where their families lived.
• There were over 500 reports of restraint used in a 15-month period.
• Patients at Winterbourne had informal hospital stays inappropriately converted into formal detentions under the Mental Health Act.

In 2012, the government launched the Transforming Care programme , which aimed to significantly reduce the number of people with a learning disability or autism in hospitals and assessment and treatment units (ATUs), and ensure they received good-quality care and support in their own communities instead.

Have we made progress?

Ten years on, have we made any progress in improving the support available to people with learning disabilities, reducing risk of abuse and, ultimately, moving away from large institutionalised settings as a go-to support mechanism?

Tragically, there have been further, and recent, cases of abuse of people with learning disabilities or autism in settings similar to Winterbourne View, such as Yew Trees (2020) and Whorlton Hall (2019) . NHS figures state there are still over 2,000 people waiting to be moved . There also remains a question about a general dependence on institutionalised care that is far from family and support networks.

Hearing about some of the successful moves out of hospital, like that of Beth , goes to show the night-and-day difference that can be made when people work together to achieve a common aim.

Social workers’ key role

The key to getting it right often lies with the social worker

Socal work works brilliantly when we build relationships with people. We love this quote from Professor Sara Ryan, a disability studies academic who has become a leading campaigner for the rights of people with learning disabilities after her son, Connor, died, entirely preventably, in a hospital in 2013 “… what do health and social care professionals and students need to know about our families? The answer is: we are all human” (Love, Learning Disabilities and Pockets of Brilliance, 2020).

With a human rights focus, social work can ensure that home, family, happiness and love are central to decisions made in a person’s life.

Challenges in practice

However, this can be very challenging, in our experience. When people are placed in hospitals far away from the local authority it’s harder to build that fundamental relationship with the person and discover first-hand how best to build the right support around them to live the life they want.

When the Court of Protection is involved, proceedings can sometimes go on for months and years rather than days and weeks. All the while, the person is still in a place they don’t call home.

There are always resource implications for working with people in hospital settings, and because there is often no discharge date it can often be drawn out as the person is seen to be ‘safe’.

When the risks are perceived as high, and the multidisciplinary team are conveying the severity of what might happen if they are discharged, it takes a strong-willed social worker to advocate for lessening of restrictive practices.

It’s sometimes the case that skilled support is hard to come by. A good support agency can be the difference between a plan for community-based support working flawlessly or failing, for example, if the agency pulls out with very little notice.

Maintaining a human rights focus

Throughout the academic journey of social work, you will be introduced to the idea of the profession as a vehicle for social change and the need to critically analyse and reflect on your practice experiences.

A strong team – one that encourages innovation and promotes social justice – can nurture the requisite ethos to improve support for people with learning disabilities or autism.

In some teams, you quickly become familiar with a transactional approach of: referral received, visit, complete assessment, complete support plan, set up a service to support a person, plan a review date.

In order to maintain a human rights focus, you almost need to memorise the sequence required to ‘complete’ a process but have that in the background while making sure, in the foreground, you are listening, observing and building trust, and working to ensure the person is at the centre and forefront of the process.

The challenge that arises is securing the right support, at the time someone requires it, at likely the most difficult point in their life. Balancing the wishes and feelings of the individual and their families with available resources can be a challenge, but the skill really lies with a social worker’s ability to work through it with the person, working together to find solutions.

Health and employment inequalities

People with learning disabilities or autism continue to experience inequalities in both access to healthcare and employment, two huge factors that affect their socio-economic experience and lead to much lower life expectancy than the general population.

It is often the case that regular appointments are not followed up, either because things were not considered as urgent or because it was deemed in the person’s ‘best interests’ not to pursue further medical intervention.

The pandemic has further highlighted this, with the blanket applications of DNACPR (do not attempt cardio-pulmonary resuscitation) orders and a high rate of Covid-related deaths, owing to a delay in prioritising vaccinations. Couple this with minimal oversight due to visiting restrictions, and you find a perfect storm of increased risk of abuse and deterioration, both on a physical and an emotional level.

Although we have made some progress in the availability of community support for people with learning disabilities and autism, it has not yet gone far enough to make sure that opportunities are available for a person to live in their own home with the care and support that enables them to live flourishing lives.

Practice tips

Our top tips, based on our experience are:

• Don’t be afraid of the law  – the laws that govern these situations are primarily there to protect and empower people, but ensuring that you are up to date with legislation and guidance, and acting within the spirit of the law, is so important in ensuring people have the intended support and scrutiny over decisions that are made.
• Strong advocacy –  having great advocates can be indispensable. Build and nurture relationships with advocates. Make them your critical friend.
• Working in partnership with health colleagues –  have good conversations about rights and risk enablement. Those honest conversations are absolutely essential in order to work towards achieving what the person wants. There is no one size fits all. Labels are for clothes, not people
• Professional curiosity – always look past the task in hand. You may be the only visitor a person has, and the only opportunity to raise concerns about their care.
• Use your leadership skills  – this is not about management skills, this is about challenging situations that may not appear to be in a person’s best interests and use it to promote human rights-based practice.
• Review your decisions  – there will inevitably be situations where an urgent placement may need to be made (say for hospital discharge purposes). Review any temporary arrangements as soon as possible and don’t forget to refer to an independent mental capacity advocate if the person lacks capacity to make a decision about their arrangements and the arrangements are likely to be longer than eight weeks.

Further advice is available from a set of resources recently released by BASW,  Homes not hospitals , designed primarily to support practitioners in navigating the complex decisions that sometimes present in trying to facilitate a move out of a hospital setting.

Ultimately, this quote from campaign group #SocialCareFuture sums it up “We all want to live in the place we call home with the people and things that we love, in communities where we look out for one another, doing things that matter to us.”

Jack Skinner is a team manager in a community learning disabilities team in Bradford

Claire Webster is a team manager for the Mental Capacity Act team in North Yorkshire

More from Community Care

Related articles:, 8 responses to 10 years on from winterbourne view: lessons for social workers.

I ran an assessment, respite and training toward independence service for many years for adults with learning disabilities. It was apparent that many ‘ behaviours that challenge’ were, and are created by constraining, denying risk taking and fear by multidisciplinary teams of getting it wrong. Of course one size doesn’t fit all, some people will need differing levels of support including full residential care, but by then we knew what spectrum- so this all feels very familiar and sad. There was an insightful director called Richard Evans who wrote ‘A Life of My Own’ and was instrumental in setting up three hostels on this model of a core hostel with a more independent house attached, prior to moving on, one of which I ran. Best bit ? A 24 hour back up for when things went wrong, CSVs so people didn’t get lonely and staff to monitor and support as outreach and practically. The snag for the service I ran was that it outgrew the support network available, and with competing demands was closed and handed over to home care. I was told there wasn’t the ‘ political will’ to invest in it, but can honestly say we saw very little of behaviours that required intervention, and knew our service users on a level that only sharing a bit of their lives could bring. Sadly I doubt the ‘political will’ exists now to introduce such services but as a cost exercise far far cheaper than what is used now, let alone the cost of such frankly dreadful accommodation as Winterbourne View et al. Of course it was a LA service so not concerned with profit, rather best value….. Best wishes from an old dinosaur sw!

I always say believe the people who live in these institutions. They’re the ones re-living constant abuse that they’re too afraid to tell anyone about, because these patients recieving institutional abuse by staff, are worried that no-one will believe them. So how are patients or care home residents meant to just suddenly open up to staff they can’t trust? Even if they could, it would fall on deaf ears. As is always the case. A problem shared isn’t always a problem halved. I have aspergers and I’ve experienced “most things” that these articlesention about institutions. If you tell a care worker who just takes the pi$$ out of you, then i doubt you’re going to bother telling that certain care worker.

The legal literacy also needs to extend to the duties and obligations under the NHS Acts for this population group (CHC) and the commodification of care- the NHS has been effectively privatised for many years in its response to this population …The EHRC could be an excellent tool to challenge the rights to have the millions the NHS spends on propping up failed systems into excellent community resources- where Social Workers can work in collaboration …

Once again the assumption is made that social workers do not work in either the NHS nor hospitals.

Or that registered social workers also work at the CQC.

It interests me that little mention is made of NHS commissioning in this are that remains woeful when it comes to hospital admissions. I know one wants people with LD and ASDs admitted to hospitals, but it happens and subject to MHA reform is likely to continue to happen. NHS E&I for under 18s and CCGs for the majority of over 18 provision appear to have not grasped the specialist needs of people on the autistic spectrum. This goes especially for young women/ teenage girls.

I get a little frustrated having been a social worker for 20 years that it is primarily expected that it is only social workers that can embody human rights approaches. Why? The HRA 1998 applies to all public authorities.

So some of this isn’t actually about what social worker’s need to do. It is about what the whole of the system needs to do.

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Winterbourne View scandal and government response

On 31 May 2011, a BBC Panorama programme exposed serious failings and abuse of people with learning disabilities and autism at the Winterbourne View care home. Owned by Castlebeck Care Ltd, Winterbourne View was an independent sector hospital that took NHS-funded patients.

While the majority of patients’ places had been ‘purchased’ by NHS organisations (as opposed to local authorities), the events at Winterbourne View were of significant relevance to the social care sector.

The Care Quality Commission (CQC) carried out a review of Winterbourne View in June 2011. The CQC found serious concerns about the quality of services and took enforcement action to close the hospital. The regulator then inspected 150 services as part of a focused programme to review care provided by similar hospitals and care homes for people with learning disabilities.

Interim government report

The government set up a departmental review of Winterbourne View in the aftermath of the scandal and published an interim report in June 2012. The interim report was unable to comment specifically on the scandal due to the ongoing legal proceedings.

The report focused on wider issues relating to the care system and the quality of care for people with learning disabilities and autism in hospital services for assessment and treatment.

The interim report concluded that:

• too many people had been placed in inpatient services for assessment and treatment and had stayed there for too long
• there was evidence of poor quality of care and care planning and an over-reliance on restraint techniques.

In the report, Minister of State for Care Services Paul Burstow stated: 'There is compelling evidence that some people with learning disabilities and autism are being failed by health and care. Around the country there are excellent examples of personalised care, focused on supporting people in their community. But that excellence is not universal. There is insufficient focus on personalised care planning. And too often the care which people receive is poor quality. This is not good enough.'

Final government report

The Department of Health published Transforming care: A national response to Winterbourne View Hospital , the final report of its review into the Winterbourne View scandal, in December 2012. The response stated that the scandal had exposed the flaws in the wider system's ability to hold the leaders of care organisations to account.

Winterbourne View, along with the CQC's inspections of 150 care homes and hospitals, had highlighted that many people with learning disabilities or autism had been placed into residential care or hospitals, when they should not have been there or had been there for too long. The report also found that there had been widespread 'failure' in the commissioning, planning and delivery of services in the health and care system.

The report established the ‘Transforming Care’ programme of action to 'transform services for people with learning disabilities, autism, mental health problems, or behaviours described as challenging'. It set out the following actions:

• there would be a review of all current hospital placements for those with learning disabilities or autism by 1 June 2013. Those found to be inappropriately placed in hospital care would be moved to receive community-based support by no later than 1 June 2014
• each area was to have a locally agreed and joint plan to ensure the planning, commissioning and delivery of high quality services
• a joint improvement team led by the NHS and local government would be established to lead and support service transformation
• boards of directors and managers would have increased accountability for safety and quality of care
• the CQC would strengthen its inspections of hospitals and care homes
• the government would monitor and report on progress nationally.

As a result of these actions, it was anticipated that there would be a significant reduction in hospital placements for people with learning disabilities. However, it did not fulfil its promise to enable people to live in their own homes, where possible, by June 2014.

Department of Health. Winterbourne View Hospital: Interim Report. Department of Health; 2012.

Department of Health. Transforming care: A national response to Winterbourne View Hospital Department of Health Review; Final Report. Department of Health; 2012.

Department of Health. Update on CQC learning disability review. Department of Health; 2011.

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