CQC took enforcement

After considering a range of evidence inspectors conclude that the registered provider, Castles Care (Tessellated) Ltd, had failed to ensure that people living at Wintergreen 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 behavior. People who had no background in care services had been recruited, references were not always checked and staff were to trained or supervised properly. Some staff were too ready to use methods of restraint without considering alternatives. The review began immediately after ICQ was informed that the BBC television programmer Panorama had gathered evidence over several months including secret filming to show serious abuse of patients at the centre.

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Inspectors who visited Wintergreen View considered taking urgent action to close the centre, but decided that it was in the best interests of the patients to allow NASH and local authority commissioner’s further time to find alternative placements. ICQ ensured that there would be n 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, ICQ took enforcement action to remove the registration of Wintergreen View, the legal process to close a location.

The hospital closed in June. The report is full of unsafe practices such as; ‘The providers 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. ‘ ‘Staff did not appear to understand the needs of the people in their are, adults with learning disabilities, complex needs and challenging behavior. ‘ Wintergreen view was not ‘compliant with 10 of the essential standards which the law requires providers must meet. ‘ ‘People who had no background in care not trained or supervised properly. ‘Some staff were too ready to use methods of restraint without considering alternatives. ‘ REPORT 2 ‘In July 2006, Steven Hooking was found dead at the bottom of a 100-foot railway viaduct in SST Austral, Cornwall. He had been tortured for hours before his death, suffering various injuries inflicted upon him by a number of perpetrators. He had been tied up, dragged round by a lead, imprisoned, burnt with cigarettes, humiliated and repeatedly violently abused in his own home over a period of time. He had been forced to make a false confession that he was a photocopied and coerced into taking a lethal dose of perpetrator tablets.

Finally he was taken to the viaduct and forced over the railings before one of the perpetrators stamped on his fingers until he let go. Steven was a 38-year-old man with learning disabilities. His murder was the culmination of ongoing abuse. Five people were involved on the night of his death. The ringleader was Darrel Stewart, 29, who had moved into Stevens flat along with his girlfriend. The other perpetrators were Martin Pollard, 21, Steward’s girlfriend Sarah Bullock, 16, and two male teenagers, who cannot be named for legal reasons.

The two male teenagers took part in the torture and humiliation of Steven but left before he was forced to take the tablets and taken to the viaduct. Stevens death followed a series of abusive incidents occurring over a period of months that a number of agencies, including police, health services, housing and social services, had en alerted to at some stage. Opportunities to intervene to halt the abuse were missed. Steven had been identified as having learning disabilities as a child and numerous agencies and organizations came into contact with him throughout his lifetime.

He attended an NASH Assessment and Treatment Unit for persons with learning disabilities and mental health issues. He was assessed by Adult Social Care as having ‘substantial need’ and allotted weekly visits. Social services did not conduct a risk assessment when agreeing to stop these weekly visits at Stevens quest, after he was befriended by Stewart. Various healthcare visits, including an emergency ambulance call after Steven had been assaulted, were not reported to the police or adult protection.

Once the Adult Care support ceased, Steven contacted the police on a number of occasions, without ongoing follow up taking place. There were numerous 999 calls to the property but these were treated as individual events and not linked. His greatly increased contact with police and health services in the period following the cessation of weekly visits did not trigger a safeguarding referral. Stevens landlord, Ocean Housing Group, was aware that he was a ‘vulnerable adult’, that young people were always hanging around his bed-sit and that he had a lodger who was ‘dangerous’ and officials should not visit the accommodation alone.

They did not intervene to address why Steven became the subject of frequent neighbor complaints after Stewart moved in with him or contact adult protection to alert them to their concerns. ‘ The unsafe practices in this report are clear such as; ‘Stevens death followed a series of abusive incidents occurring over a period of months that a number of agencies, including police, health services, housing and social services, had been alerted to at some stage. ‘ ‘He was assessed by Adult Social Care as having ‘substantial need’ and allotted weekly visits.

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