CQC report on Winterbourne View confirms its owners failed to protect people from abuse

Published: 18 July 2011 Page last updated: 12 May 2022

18 July 2011

The Care Quality Commission has published details of the enforcement action it has taken against Castlebeck Care (Teesdale) Ltd which failed to protect the safety and welfare of patients at Winterbourne View. The effect of this action is that the assessment and treatment centre near Bristol has been closed.

Today CQC publishes the findings following an inspection of services provided at Winterbourne View. After considering a range of evidence inspectors conclude that the registered provider, Castlebeck Care (Teesdale) Ltd, had failed to ensure that people living at Winterbourne 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 behaviour. People who had no background in care services had been recruited, references were not always checked and staff were not trained or supervised properly. Some staff were too ready to use methods of restraint without considering alternatives.

The review began immediately after CQC was informed that the BBC television programme Panorama had gathered evidence over several months including secret filming to show serious abuse of patients at the centre.

Inspectors who visited Winterbourne View considered taking urgent action to close the centre, but decided that it was in the best interests of the patients to allow NHS and local authority commissioners further time to find alternative placements.

CQC ensured that there would be an 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, CQC took enforcement action to remove the registration of Winterbourne View, the legal process to close a location. The hospital closed in June.

The report which is published today finds that Castlebeck Care Ltd (Teesdale) was not compliant with 10 of the essential standards which the law requires providers must meet. CQC’s findings can be found below.

  • The managers did not ensure that major incidents were reported to the Care Quality Commission as required.
  • Planning and delivery of care did not meet people's individual needs.
  • They did not have robust systems to assess and monitor the quality of services.
  • They did not identify, and manage, risks relating to the health, welfare and safety of patients.
  • They had not responded to or considered complaints and views of people about the service.
  • Investigations into the conduct of staff were not robust and had not safeguarded people.
  • They did not take reasonable steps to identify the possibility of abuse and prevent it before it occurred.
  • They did not respond appropriately to allegations of abuse.
  • They did not have arrangements in place to protect the people against unlawful or excessive use of restraint.
  • They did not operate effective recruitment procedures or take appropriate steps in relation to persons who were not fit to work in care settings.
  • They failed in their responsibilities to provide appropriate training and supervision to staff.

Amanda Sherlock, CQC’s Director of Operations said: “This report is a damning indictment of the regime at Winterbourne View and its systemic failings to protect the vulnerable people in its care.

“It is now clear that the problems at Winterbourne View were far worse than were initially indicated by the whistleblower. He has stated that he was not aware of the level of abuse until he saw the footage from the secret filming.

“We now know that the provider had effectively misled us by not keeping us informed about incidents as required by the law. Had we been told about all these things, we could have taken action earlier. We will now consider whether it would be appropriate to take further legal action.

“CQC has already acknowledged that we would have acted earlier if the evidence from the television report had been made available to us.

“However it is incorrect that CQC had failed to act on warnings by the whistleblower. Our internal investigation has confirmed that while we were aware of those concerns, our inspector believed they were being dealt with through the local safeguarding process involving a number of agencies. We should have contacted the whistleblower directly – and this will be one of the issues which will be addressed by the independently-led serious case review.

“Immediately we were aware of the extent of the problem, we took the action which is detailed in this report. Although Winterbourne View is now closed, we will continue to monitor Castlebeck's other services closely.

“The most important outcome of all this is that the people who had been living at Winterbourne View are no longer subject to this culture of abuse.

”Our plans for a programme of random, unannounced inspections of hospitals providing care for people with learning disabilities are well underway and we will report back in due course."

Over the last four months CQC has reviewed and inspected all the services provided by Castlebeck Care (Teesdale) Ltd at its 24 locations. We will publish the results of this review, including reports on all locations, at the end of July. Where we have identified concerns, measures are in place to address the problems and to ensure the safety of people using services.


For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

Notes to editors

Below is CQC’s response to the abuse at Winterbourne View hospital.

  • A review of all Castlebeck services. Full details of the inspection of 23 locations will be published later this summer.
  • A review of learning disability services involving the inspection of 150 services for people with learning disabilities which have the same or similar characteristics as Winterbourne View.
  • An internal management review. The first stage of CQC’s internal management review of our actions in relation to Winterbourne View is complete. The final report will make recommendations relating to how CQC ensures that safeguarding alerts and whistle blowing information are handled.
  • A serious case review: CQC's internal report will feed into a serious case review being led by an independent chair, Margaret Flynn, which will examine the role of all the responsible agencies.

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.