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Our action since Winterbourne View

  • Public,
  • Care homes with nursing

Panorama provided a shocking illustration of the vulnerability of people in hospitals like Winterbourne View. 

As the serious case review (published by South Gloucestershire Council) made clear, care services and staff, commissioners, local authorities and regulators must work together to prevent abuse from happening.

You can read the serious case review on South Gloucestershire Council's website.

Good care starts with providers and their staff, it relies on effective commissioning and safeguarding procedures, and is informed by the views of people who use services and their families. We must all work better to ensure people are protected from abuse.

We cannot guarantee that abuse like that uncovered in Winterbourne View will never take place, but we now have more people and better systems and new ways of working that make us much stronger. In addition, we were able to recruit an extra 229 inspectors so that we can check services more frequently.

We have already done a lot to make sure we spot poor care and abuse in the future.  

Our own internal review demonstrated very clearly where our systems needed to be stronger. Our actions since then have shown how seriously we have taken our responsibilities to improve.

A specialist team in CQC now take whistleblowing calls to ensure each one is tracked and chased until it is resolved. We now receive 500 calls a month – up from an average of 50 before the events at Winterbourne View were uncovered.

We now carry out more unannounced inspections of high risk services similar to Winterbourne View. We carried out an extra 150 inspections of similar services and found that almost half didn’t meet national standards and needed to improve the care they provide. Read more in Review of learning disability services.

Find out more about Winterbourne View

Review of compliance: Winterbourne View - July 2011 PDF | 357.57 KB

Easy read: What we think about Winterbourne View PDF | 429.75 KB

Read our press release on Winterbourne View

Castlebeck review

On 28 July 2011 we published the results of our review of all services run by the Castlebeck Group. We produced an overview of the review and individual reports for each service.

Read our press release about the results of the review:
CQC calls on Castlebeck to make root-and-branch improvements

CQC review of Castlebeck Group Services Word | 327.46 KBCQC review of Castlebeck Group Services (Easy to read) Word | 2.88 MB

Learning disability inspections

We have now completed and published the results of our review of services for people with learning disabilities.

Visit Review of learning disability services to find out about the inspections and our findings.

Alternatively, you can read our press release about the review:
National report finds half of learning disability services did not meet standards.

If you want to give us feedback on your experiences of care, download the document below for easy to read instructions on how to do it on our website.


The allegations of abuse at Winterbourne View only came to light when concerns were raised by a former charge nurse, Terry Bryan. We have acknowledged that his intervention has led to this close examination of services for people with learning disabilities.

If you work in a health or adult social care service and want to highlight abuse or raise concerns then you can contact us.

Whistleblowing: Guidance for providers PDF | 566.29 KB

Serious case review

South Gloucestershire Council has now published its serious case review in to the events at Winterbourne View.

The review looks at our role and that of Castlebeck Ltd, NHS South Gloucestershire, NHS South West, South Gloucestershire Council and Avon and Somerset Police.

Read the serious case review on South Gloucestershire Council's website.

We have already made significant changes to various areas of our work to ensure that we are better placed to respond to concerns of whistleblowers in order to protect vulnerable people.

Other changes relate to the way we:

  • follow-up on action plans when services aren’t meeting national standards
  • build new ways to work with local safeguarding teams
  • develop the way we analyse safeguarding alerts so we can spot trends in care.

Our role in Winterbourne View: Internal management review PDF | 346.72 KBOur role in Winterbourne View: Internal management review (Easy to read) PDF | 443.41 KB


Last updated:
13 May 2014