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CQC publishes first reports from its review of services for people with learning disabilities

8 December 2011
  • Public

The Care Quality Commission (CQC) today publishes the first five reports from a targeted programme of 150 inspections of hospitals and care homes that care for people with learning disabilities.

The programme is looking at whether people experience safe and appropriate care, treatment and support and whether they are protected from abuse. A national report into the findings of the programme will be published in the Spring.

These first five reports are from the ‘pilot’ inspections carried out to help test and refine the inspection approach. The five inspections were of hospitals that provide assessment services.

Although it is too early to draw universal conclusions, the indications from these and other completed inspections from the programme is that leadership and governance needs to be stronger to ensure that services are safe and meet essential standards. Findings so far suggest a lack of understanding about what safe, person-centred care looks like.

Only one of the five services inspected was found to be fully compliant with the government’s essential standards of quality and safety required by law.

Commenting on the publication of the first reports, Dame Jo Williams, Chair of the CQC, said:

“These inspections are the first of many, but already we can see the effects of a lack of strong leadership and governance. Where we have found problems, they can often be traced back to poor procedures or poor understanding of procedures.

“Another recurring issue in the first inspections is a lack of person-centred care. It is especially important that services make sure that the care of people using these services, many of whom have extremely complex and individual needs, is tailored to their needs. 

“CQC inspectors have been joined by ‘experts by experience’ – people who have first hand experience of care or as a family carer and who can provide the patient perspective as well as professional experts in our learning disability inspections. This has been invaluable to help us build a detailed picture of the care that people are receiving from these services.”

Terry Bryan, the nurse who drew attention to the abuse at Winterbourne View, and who is now one of the professional experts working with CQC’s inspection teams said:

“After Winterbourne View, there was a consensus that the inspection processes at the time did not always stand up to close scrutiny. The current unannounced inspection programme has been slimmed down sufficiently to obtain honest ’snapshots’ of daily life for people who live in services, together with ’gut feelings‘ about the services themselves.

“By using people who have either worked extensively in the care sector, or who have experience of that support first hand, we are now managing to obtain more substantial and qualitative results. However, the Commission should not be expected to work in isolation, as there is also wide consensus that providers' local governance procedures be sufficiently robust, because ultimately, that is where the real daily safeguarding operates.”

Where we identified concerns, we raised these immediately with the providers and managers of services. In the case of two services, Kent House and Townend Court, our inspectors sought assurances that the providers would take prompt action to ensure the safety of people using services. In both cases, the major concerns were in relation to safeguarding people who use services from abuse.

  • At Kent House in Wirral, inspectors found staff were not following agreed safeguarding procedures, which was putting patients at risk. In addition, systems to check that staff were competent in, and understood, their safeguarding roles were not strong enough.
  • At Townend Court in Hull, inspectors found that suitable arrangements were not in place to safeguard patients against the risk of abuse because of failings in patient records and because the trust had not recognised that use of restraint may amount to abuse. Nor had the trust responded appropriately to allegations of abuse made by patients.

All the services where concerns are identified must tell the CQC how and when they will improve. Those failing to meet essential standards could face enforcement action by the regulator if improvements are not made.

Our inspectors have already returned to check progress at Townend and found improvements. Other services will be re-inspected shortly.

Inspection teams also observed examples of good practice. For example, at Rose Lodge in Tyne and Wear inspectors found that decisions about how behaviours that challenged were managed were based on the individual’s needs, and support plans were comprehensive to ensure that responses to behaviour that challenges were appropriate, reasonable and proportionate and justifiable to that individual.

All the reports relating to these inspections will be published over the coming months. The national report due to be published in the Spring will draw conclusions about the overall state of this type of service.

The reports will be published on CQC’s website at 12 noon on Thursday, 8 December

Inspection teams are making unannounced visits to 150 services. More than 100 are NHS and independent services that provide assessment and treatment services for people with learning disabilities.  The others will be adult social care locations.

They are checking two outcomes:

  • Outcome 4 Care and welfare
  • Outcome 7 Safeguarding adults from abuse.

But where our inspectors find problems with other outcomes, they will report on these.

Our inspection teams are led by CQC inspectors joined by two ‘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 and a professional advisor.

More than half of the inspections have been carried out. Reports will be published in due course. Although reports are not published immediately after inspections because they have to be written and checked, including checks by the provider for factual accuracy, inspectors give immediate feedback on their findings so that providers can take appropriate action. Where inspectors identify major concerns they can take enforcement action to require compliance.

We set up an advisory group to help us plan the programme. CQC’s Chair, Dame Jo Williams, chairs the group. The members come from a range of voluntary, charitable and other organisations that work with or represent people with learning disabilities and their families.

The learning disability inspection programme was launched in response to the abuse revealed by undercover filming by the BBC Panorama programme. CQC apologised for failing to respond to warnings of abuse at Winterbourne View. Matters concerning Winterbourne view are the subject of serious case review.

The first five reports relate to the following providers

  • Cheshire and Wirral Partnership NHS Foundation Trust – Kent House
  • Four Seasons (Granby One) Limited – James House
  • Humber NHS Foundation Trust – Townend Court
  • Modus Care Limited – Westbrook Grange
  • Northumberland Tyne and Wear Foundation Trust – Rose Lodge

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.

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

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)


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 602 7885


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

Disability Law Service

Provides telephone or email advice on community care law. Free to disabled people and their family carers.


Tel: 020 7791 9800


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: Tel: 0808 808 1111 Email:

Northern Ireland: 0808 808 1111 Email:

Wales: 0808 808 1111 Email:

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.


Tel: 0808 800 4104



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.


Voice UK

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.

Tel: 080 8802 8686 (Mon-Fri, 9am – 5pm)


Other useful contacts


Confidential emotional support 24 hours a day, seven days a week to those experiencing despair, distress or suicidal feelings.

Tel: 08457 909090


Last updated:
29 May 2017