A damning report into abuse at the Winterbourne View care home in South Gloucestershire has been highly critical of local health services and police.
The owners of the home, health regulators, local health services and police were all criticised for failing to act on increasing warning signs of institutional abuse by staff at the care home.
The 150-page South Gloucestershire Safeguarding Adults Board report into the scandal was carried out by an independent expert in adult safeguarding, Margaret Flynn, who is chair of the Lancashire Safeguarding Adults Board.
The main findings of the report were:
- Highly critical of agencies
- Multi agency response ineffective
- No overall leadership among commissioners
- The whistleblowing notification was not addressed by Winterbourne View Hospital or Castlebeck Ltd
- Castlebeck primarily responsible and accountable for neglect. They put money over care
- Care Quality Commission (CQC) should carry out more frequent and unannounced inspections
The report also found that Avon and Somerset Police were aware of 29 incidents at the home between 2008 and 2011.
It calls for notifications of concern, including safeguarding alerts and police attendances, to be better coordinated and shared amongst safeguarding organisations, which would allow earlier identification of potential problems and earlier action taken.
It recommends the Department of Health should consider banning the 't-supine restraint' - this is where patients are laid on the floor and restrained by a staff member's body weight.
According to the report, the hospital was not based on a local population needs assessment. Castlebeck Ltd spotted a business opportunity and were not discouraged by NHS commissioners. They had indicated their willingness to buy its services irrespective of national policy and guidance.
The review concluded that 'oversight across sectors was unequal to the task of uncovering the fact and extent of abuses and crimes at the hospital'.