CQC publishes report of investigation into concerns raised by Winterbourne View

Published: 7 August 2012 Page last updated: 3 November 2022

7 August 2012

Regulator strengthens systems to respond to whistleblowers and to monitor services for vulnerable people.

The Care Quality Commission has welcomed the report of the serious case review into events leading to the abuse of patients at the former Winterbourne View Hospital, near Bristol.

At the same time CQC has published an internal management review which sets out the results of its own investigation into its role as regulator.  CQC has already made significant changes to its systems and processes to ensure that it is better placed to respond to concerns of whistleblowers in order to protect vulnerable people.

The serious case review which is published by South Gloucestershire Adult Safeguarding Board draws on reports produced by five organisations including the provider Castlebeck Ltd, NHS South Gloucestershire, South Gloucestershire Council, Avon and Somerset Police, and CQC.

Dame Jo Williams, CQC chair, said:

“Winterbourne View was a watershed moment for CQC. We did not respond as we should have and we have taken steps to put things right. Among other things, we set up a specialist team to deal with whistleblowers and systems to make sure every such contact is followed up. Before Winterbourne View we were receiving about 50 whistleblower contacts a month; now we get more than 500.  This information is vitally important in helping us to identify poor care.

"This Serious Case Review sets out failings across a number of organisations at individual or organisational level that contributed to the events at Winterbourne View. As Margaret Flynn notes, we have been honest about the areas where the CQC fell short, and have made changes as a result. We carried out an urgent and thorough internal review to strengthen our processes and to ensure that we are better placed to play our part in protecting people in vulnerable care situations. Following this review, we have adopted 13 recommendations for improvements to systems and working practices.

“We also carried out a programme of unannounced inspections of 150 services for people with learning disabilities.  While the findings showed up serious concerns about the nature of services for people with learning disabilities, there was no evidence that points to abuse on the scale which was uncovered at Winterbourne View.

“But a recurring theme running through all these reports is that the important job of preventing abuse is not just a matter for CQC; good care starts with providers and their staff, 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.”

CQC Chief Executive David Behan said: “There is much for all the organisations involved with Winterbourne View to consider in Margaret Flynn’s thorough and comprehensive report. I will ensure that the Care Quality Commission responds fully to all the recommendations for CQC.  We will continue to work with other organisations to improve communications and sharing of information to ensure we all protect those who are most vulnerable.”

Since Winterbourne View:

  • CQC has inspected all of Castlebeck’s 23 registered locations. Three of the services, including Winterbourne View, were closed as a result of CQC’s actions.
  • Inspectors have made unannounced inspections of 150 hospitals and homes for people with learning disabilities and where they found concerns, they have already taken action.  
  • Inspectors have continued to monitor the safety and quality of care for the former patients of Winterbourne View, with follow up inspections at 12 locations which took them after the hospital closed.
  • CQC set up a dedicated team to deal with whistleblowers and to ensure that all calls are followed up. 
  • CQC has introduced a new inspection regime, which recognises that hospitals like Winterbourne View are high risk institutions.  
  • The Department of Health allowed CQC to appoint another 250 inspectors, which means that most hospitals, care homes and home care services can now be inspected at least once a year.


For media enquiries call the CQC press office on 0207 448 9401     For general enquiries call 03000 616161

Notes to editors

Publication of both reports had been delayed until the outcome of the criminal proceedings against 11 care workers.

The internal management review was set up to identify recommendations for improvement to regulatory systems and practice following the abuse uncovered by Panorama.  The full report is available below.

Our role in Winterbourne View: Internal management review

The internal CQC review formed part of the serious case review, which was commissioned by South Gloucestershire Safeguarding Adults Board.  The serious case review report is available here.

In June, CQC published the findings from a national review of 150 services for people with learning disabilities. Inspection teams were led by CQC inspectors,  joined by professional advisors and ‘experts by experience’ -  people who have experience of using services, either first hand or as a family carer and who can provide the patient perspective.

Further information

There is information on CQC’s web site about how to share concerns and complaints about a social care service, a council, independent healthcare services, the NHS or CQC. http://www.cqc.org.uk/contactus/howtoraiseaconcernorcomplaint.cfm

People can telephone concerns to CQC on 03000 616161

Find out more

The Challenging Behaviour Foundation has provided this list of organisations providing independent support to families with disabled relatives

Support for families

Families provide long term love, care and support for their disabled relatives, and speak up for them. Even when people leave home, they do not leave the family. Families continue to offer a lifetime of involvement and support, and know a great deal about their relative’s needs and wishes, likes and dislikes.

When the services and support for a relative go wrong it can be very difficult for families to deal with. They may be faced with a barrage of information and decisions to take, as well as coming to terms with what has happened. It is important that families know where they can get impartial information, and find out what support is available to them. There is a list below of organisations which you may find useful.

It is important to note that family carers must be consulted and involved in keydecisions about the care and support of a relative who is unable to make these decisions (unless you have specifically asked not to be involved). There is a proper legal process that must be followed, under the Mental Capacity Act 2005. For example, your relative cannot be moved to another service without involving you, and others who know your relative well, in the decision-making process. For more information about this, see “Making Decisions: A guide for family, friends and other unpaid carers” Copies available by phoning 0300 456 0300 or download from www.justice.gov.uk/guidance/protecting-the-vulnerable/mental-capacityact/index.htm

Organisations providing independent support

Ann Craft Trust: Provides advice to anyone who has a query about the protection of vulnerable children and adults, including professionals, parents, carers and family members.

Tel: 0115 9515400 (Mon-Thurs 9am-5pm, Fri 9am – 4.30pm) or

email: ann-craft-trust@nottingham.ac.uk

The Challenging Behaviour Foundation: Provides telephone and email support from a Family Support Worker on challenging behaviour associated with severe learning disabilities and related issues. Tel. 0845 6027885 or email: info@thecbf.org.uk

Free information sheets and DVDs about good support for people who have a learning disability and behaviour described as challenging. www.challengingbehaviour.org.uk

Disability Law Service: Provides telephone or email advice on community care law. Free to disabled people and their family carers www.dls.org.uk Tel: 020 77919800 e-mail: advice@dls.org.uk

Mencap Learning Disability Helpline: Provides advice and information on all issues relevant to people with learning disabilities and their families in England, Wales & Northern Ireland.

England: Telephone: 0808 808 1111
Email: help@mencap.org.uk

Northern Ireland: 0808 808 1111
Email: mencapni@mencap.org.uk

Wales: 0808 808 1111
Email: information.wales@mencap.org.uk

National Autistic Society: If your relative has an Autistic Spectrum Condition you can contact the National Autistic Society which offers advice and information to people on the autism spectrum and their families: Mon-Fri, 10am – 4pm.www.autism.org.uk Tel: 0808 8004104 or email: autismhelpline@nas.org.uk

Hft Family Carer Support Service (FCSS): provides free information and support to all family carers of people with learning disabilities. For help or more information call 0117 9061751; email familycarersupport@hft.org.uk; write to FCSS at Hft, 5 – 6 Brook Office Park, Emersons Green, Bristol BS16 7FL and see www.hft.org.uk/family_carer_support

Respond: works with children and adults with learning disabilities who have experienced abuse or trauma, as well as those who have abused others, through psychotherapy, advocacy, campaigning and other support. Respond also runs a free helpline: 0808 808 0700. If you call outside opening hours leave a message and someone will get back to you. For more info see their website: www.respond.org.uk/

Voice UK: are a national charity supporting people with learning disabilities and other vulnerable people who have experienced crime or abuse. They have a helpline for carers, parents and professionals on 080 8802 8686 (Mon-Fri, 9am – 5pm) or email helpline@voiceuk.org.uk

Other useful contacts

Samaritans: Confidential emotional support 24 hours a day, 7 days a week to those experiencing despair, distress or suicidal feelings. Tel: 08457 909090. Email: jo@samaritans.org 

Find out more

Our internal management review sets out the results of our investigation in to our role in the Winterbourne View case and the changes we have made to our systems and processes to ensure we are better placed to respond to concerns.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.