Staff at a home for people with autism in Somerset 'bullied' residents by making them crawl on the floor on all fours and throwing cake at them.
The findings of a Somerset Safeguarding Adults Board review describe the behaviour at Mendip House near Brent Knoll as “cruel and disrespectful”. It also draws comparisons with the Winterbourne View hospital scandal in South Gloucestershire.
The report also called for a nationwide change in the way patients are placed in care.
Mendip House was home to six people with autism and complex support needs. It was one of seven separate dwellings on a residential care home campus, called Somerset Court, for adults with autism run by the National Autistic Society.
For around eighteen months Mendip House, part of the National Autistic Society’s Somerset Court, was dominated by what was described in the report as a “gang” of controlling male staff.
- Patient was 'made to crawl on the floor', another was given an onion to eat instead of a biscuit
The report found the staff at Mendip House engaged in behaviour that was "cruel" and "far below the standard expected".
The incidents of 'bullying' and disrespectful behaviour included a patient being made to crawl on the floor on all fours. Staff threw cake at another resident's head and when one man asked for a biscuit he was given an onion to eat instead.
- Numerous counts of residents buying food for staff
The report also found medication had gone missing and numerous counts of vulnerable residents buying food for staff - amounting to thousands of pounds.
Roy Franklin worked at Somerset Court during the 1990s. He’s blown the whistle on abuse at other homes but says he is shocked as he only saw good care at Mendip House.
Mark Lever, Chief Executive of the National Autistic Society, says:
“We want to run the best possible residential services for autistic people, where they are safe and can thrive. We are very sorry that in May 2016 it became clear that we had failed to achieve this for the people living at our Mendip House care service, who were not shown proper care and respect and were mistreated by a group of our staff.
“When people raised the alarm to our charity and to other agencies, we took immediate action to make sure residents were safe and to investigate what went wrong. We brought in different staff, who knew the people living in the house, to ensure they were well supported. We also disciplined and then dismissed staff. After deciding to close the service, we supported families and their home local authorities while they found the six residents alternative places to live, helping them through what could have been a difficult transition to their new homes in October 2016".
Mr Lever goes on to say that work has taken place to ensure the situation is never repeated.
- Apology for the distress experienced by residents and families
The Chief Executive of the National Autistic Society continues:
“We want to take this opportunity to repeat our previous apologies to the residents at Mendip House and to their families for the distress they experienced.
"We want to reassure them that we share fully the commitment of the Somerset Safeguarding Adults Board to making sure that the lessons are learned and that improvements continue to be made across the country.”
The report refers to the Winterbourne View hospital scandal in South Gloucestershire – where abuse by staff towards patients was caught on hidden cameras. It says concerns were raised by Somerset County Council’s safeguarding team about other dwellings at Somerset Court but not once about Mendip House when it’s now known this bullying was happening. It says "five years after Winterbourne View – this is remarkable"
Several staff members were dismissed and the review highlights weaknesses in the system by which authorities making care placements outside of their local area monitor the care being provided.
All the residents have been found new placements in Somerset or further afield.
The Somerset Safeguarding Adults Board requested the review to identify lessons that could be learned from the case and the report calls for change at national level. Its recommendations include:
- The Department of Health and Social Care, NHS England and the Local Government Association carry out a national consultation on steps to regulate the commissioning of care placements. The aim being to make sure there is clear responsibility for local authorities and clinical commissioning groups to actively monitor the quality of care provided for the people they place.
- The Care Quality Commission (CQC) makes clear in its inspection reports that it will no longer register ‘campus’ model care arrangements.
- Commissioners should be required to notify the local authority in the area where a placement is being made.
- The Care Provider Alliance issues its members with guidance about roles and responsibilities in quality assurance and safeguarding.
- A way of working be agreed by which information about grievances, disciplinaries and complaints can be shared with the CQC and pooled with local authority safeguarding referrals and intelligence from police and others.
Richard Crompton, independent Chair of the Somerset Safeguarding Adults Board, says:
“These reviews are not about apportioning blame, they are about making sure lessons are learned and improvements made.
"This happened to be in Somerset, but the weaknesses in the system are nationwide and must be considered at that level. That is why some of our key recommendations are addressed to the Department of Health and Social Care and national bodies.
“This board exists to protect vulnerable people and reduce the risk of incidents like those at Mendip House happening again. This will have been tremendously upsetting for the victims and their families and the board very much thanks them for the support they gave the investigation.
“I know that the agencies involved it have learned lessons and I hope that they can be learned nationally too”.