Published: 12 July 2006
‘Significant failings’ call for special measures
The Healthcare Commissions has recommended special measures to protect people who use services after widespread institutional abuse of people with learning disabilities was discovered at a NHS Trust in Cornwall.
A report published by the Healthcare Commission and the Commission for Social Care Inspection (CSCI) details 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 wrote to the Secretary of State for Health to advise that she place the trust under special measures, which will involve an external review of the trust’s board by the Strategic Health Authority (SHA).
The Commission also recommends retaining the external team, which the SHA agreed to bring 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’.
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.
A new chief executive has been appointed in an effort to strengthen the leadership of the trust.
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 special measures recommended by the Commission and CSCI include:
· 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 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.
· Inter-agency 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
Further information
Healthcare Commission
Commission for Social Care Inspection (CSCI)
Cornwall Partnership NHS Trust
Protection of vulnerable adults (POVA)
No secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse
NHS Counter Fraud and Security Management Service
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