Investigation finds widespread institutional abuse of people with learning disabilities at an NHS trust in Cornwall
5 July 2006
Commissions recommend special measures to protect people
who use services after findings show significant failings in local
procedures
Widespread institutional abuse of people with learning
disabilities at an NHS Trust in Cornwall is revealed today in a
report published by the Healthcare Commission and the Commission
for Social Care Inspection (CSCI).
The report details the findings of a joint investigation into
services for people with learning disabilities at Cornwall
Partnership NHS Trust.
The services investigated were the Budock Hospital near
Falmouth, which is a treatment centre for 18 inpatients.
The investigation also looked at two other treatment centres, 4
children’s units and 46 houses occupied by groups of up to four
people with learning disabilities.
The report describes many years of abusive practices at the
trust and the failure of senior trust executives to tackle this.
Examples of abuse included physical abuse and misuse of people’s
money.
The Healthcare Commission has today written to the Secretary of
State for Health to advise that she place the trust under special
measures.
This will involve an external review of the trust’s board by the
strategic health authority.
The Commission also recommends retaining the external team,
which was brought in last October after the Commission highlighted
that the trust had “significant failings”.
Investigators found evidence of institutional abuse including
some staff hitting, pushing, and dragging people. Some staff were
also reported to have withheld food and given people cold
showers.
A number of staff working in the homes were found to be caring
and well intended. However, they were not working in accordance
with best practice.
The investigation team also found an over-reliance on medication
to control behaviour, as well as illegal and prolonged use of
restraint. One person spent 16 hours a day tied to their bed or
wheelchair for what staff wrongly believed was for that person’s
own protection.
The investigation revealed serious and wide-reaching flaws in
the local NHS Trust’s procedures for protecting adults. Senior
managers failed to identify and correct situations involving
physical, emotional and environmental abuse.
As a result of the investigation 40 people were referred to
Cornwall County Council under the procedure for the protection of
vulnerable adults (POVA).
Despite the seriousness of the evidence presented, Cornwall
Partnership NHS Trust and Cornwall County Council failed to
adequately coordinate inter-agency arrangements in accordance with
the Government’s guidance “No Secrets”* (*see notes for editors
below).
More than two thirds of the 46 supported living houses visited
by the investigation team placed unacceptable restrictions to the
people living there.
For example, investigators found that some internal doors were
kept locked by staff to restrict the movement of people who live
there as a method of dealing with challenging behaviour.
Investigators also found that the houses were run as
unregistered care homes, which did not meet accepted standards.
The Healthcare Commission and CSCI have also referred
allegations about inappropriate use and control of personal
finances of those living in supported living houses to the NHS
Counter Fraud and Security Management Service.
Since the investigation Cornwall Partnership NHS Trust has taken
disciplinary action against a number of staff. It has also taken
action to address the concerns of the investigation team that the
model of care administered at the trust is both outdated and
inappropriate.
The leadership of the trust has been strengthened with the
appointment of a new chief executive. Staff have received training
and the investigation team have also observed improvements in the
interaction between staff and people who use services.
One ward at Budock has been closed, and the environments of the
two other wards have been improved through refurbishment and the
introduction of a sensory room for patients.
The environment of the supported living houses has also
improved. A number of the locked doors observed have been removed
and action has been taken to address the unacceptable levels of
physical restraint.
The Commission and CSCI have recommended that special measures
be put in place to safeguard people who use services. These state
that:
- the external team should remain in place for at least 12
months, in order to oversee the quality of the services provided to
people with learning disabilities;
- the external team must work with the Southwest Peninsular
Strategic Health Authority (the SHA) to ensure that the action plan
agreed between the trust, Cornwall County Council Social Services
Department and the local primary care trusts to redesign services
is properly implemented, in line with agreed time scales; and the
external team ensure that sufficient transitional funding, both
from health and social services bodies, is made available so that
changes and improvements are sustainable.
- there needs to be an external review of the performance and
membership of the trust’s board to ensure that it is able to
discharge its responsibilities to an acceptable standard.
In addition, the Commission and CSCI also state that:
- services for people with learning disabilities must be
redesigned by the local health and social care organisations,
taking into account the individual needs assessments of every
learning disability service user
- all providers of personal care, including the NHS, must
register those services with the CSCI in accordance with the Care
Standards Act 2000.
- best practice in medical, nursing and therapeutic care must be
provided throughout learning disability services
- regular reports on all matters relating to the protection of
adults with learning disabilities must be provided to the learning
disability partnership board and the strategic health authority to
ensure that sufficient action is taken to address individual and
systemic problems
- interagency arrangements and planning for learning disabled
people must be clearly identified in the local development
plan
- nationally, the Department of Health should strengthen
processes for protecting adults, in accordance with the provisions
of the Safeguarding Vulnerable Groups Bill currently before
Parliament.
- all local authorities, in their role as lead agency for the
protection of vulnerable adults, must ensure that arrangements for
investigating allegations of abuse are robust.
Full details of the recommendations can be found in the
report.
The official investigation into learning disability services
provided by Cornwall Partnership NHS Trust began in May 2005 and
was sparked by concerns raised by East Cornwall Mencap Society.
Last October, the Healthcare Commission notified the Secretary
of State for Health that the early stages of the investigation had
found “significant failings” in services. As a result, an outside
team was brought in to urgently address these concerns while the
investigation continued.
The outside team has been working with the trust, the local
council, and the two Commissions’ since last October. Improvements
made since that time include: community care assessments by the
council of all people using the trust’s services; the appointment
of an expert in the protection of vulnerable adults; the
development of action plans for all the trust’s learning
disabilities services; and improved environments in Budock
hospital.
Ends
Notes
- Although some media coverage has suggested that the national
audit referred to in the Commissions' joint
statement would involve all care homes in England, it is
important to clarify that it is in fact an audit by the Healthcare
Commission of all NHS services for people with a learning
disability, involving CSCI where appropriate.
- A local help-line has been set up by NHS Direct, tel: 0845 850
980 50
- If people have general concerns regarding services for people
with learning disabilities contact:
- The Healthcare Commission help-line on: 0845 601 3012
- The Commission for Social Care Inspection help-line on: 0845
015 0120
* In March 2000, the Department of Health published No Secrets:
Guidance on Developing Multi-agencies Policies and Procedures to
Protect Vulnerable Adults from Abuse. The guidance sets out an
inter-agency policy on how allegation of abuse should be
investigated, how actions plans should be developed and how to
monitor outcomes.
Special measures
The Healthcare Commission has a legal obligation under the
Health and Social Care Act 2003 to report significant failings to
the Secretary of State, and as part of this may include
recommendations for special measures. Special Measures are designed
to generate improvement where other methods have failed, or are
considered likely to do so. Full details of the special measures
recommended by the Commission on Cornwall Partnership NHS Trust can
be found in the report.
Further information on the Healthcare Commission is available on
www.healthcarecommission.org.uk
Further information on the Commission for Social Care Inspection
is available on www.csci.org.uk
For media enquiries or to arrange an interview, contact:
The Healthcare Commission press office – Donna Watson or Alero
Harrison, tel 020 7448 9210, out of office hours, 0777 999
0845.
The Commission for Social Care Inspection press office – Andy
Keast Marriott, 020 7979 2093.
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