The first event of the Social Care Support Network, Managing Risk in a Person-Centred Way, was opened by Birmingham City Council’s Strategic Director of Adult Services Peter Hay. Both personalisation and risk involved standing in others’ shoes and seeing the world from their perspective, he said. The main speaker was Margaret Flynn, chair of Lancashire’s Adult Safeguarding Panel, who chaired the Winterbourne Serious Case Review. She described the failings which led to the scandal revealed by Panorama in 2011.
Rosemary Trustam reports
Castlebeck which ran the now infamous private hospital Winterbourne View, was owned by CB Care Ltd, which itself was owned by the Jersey limited partnership, Lydian Capital Partners LP, acquired in 2006 by the Swiss-based private equity group Lydian and backed by a group of Irish millionaires (Private Eye, Nov 2012).
Margaret Flynn cited this report in describing the circumstances that led to the abuse. No one asked why, when NHS commissioners sought placements on Friday afternoons, Winterbourne always had vacancies. Nor did they enquire into the cost at an average of £3,500 a week, one woman costing £10,000 a week.
Distant localities
The hospital held patient review meetings without relevant professionals from distant localities.
How could a unit be built on an out of the way business park, nowhere near public transport, when it was not required by local services and was completely against national policy? she asked.
Margaret detailed the failings leading up to the scandal.
- CQC inspectors relied too much on self-reporting and paperwork;
- An acting registered manager was in post for two years;
- Recommendations made by the Mental Health Tribunal, including on the use of restraint, were not followed up;
- Health & Safety Executive received reports; Adult Safeguarding treated any reports as isolated incidents
- There was no pulling together of reports (reports indicated there were no complaints but the police found stacks in the manager’s drawer);
- Turnover of staff was 400 in the five years since it opened;
- Some staff were homeless and were not CRB-checked;
There was dangerous and illegal use of restraint which necessitated accident and emergency visits – with at least one reported concern from a consultant who told staff that the injuries didn’t match the explanation.
The whistle-blower, a fairly new member of staff, initially went to the manager, then to the regional manager twice, then to CQC three times (they say twice) before going to the BBC.
Systems and processes don’t protect people. “It is people who keep people safe,” Margaret said. “When people are locked away in a remote place, they are only likely to be honest with people they trust – and the people who knew them were far away”.
Services which pose high risk to residents and staff need strong governance. Winterbourne View just presented a business opportunity for investors. The Social Care Support Network (SSCN) is open free to anyone supporting its aims.
