The care regulator is facing fresh questions over its inspection failings after it emerged that it delivered glowing reports on standards at a dozen care homes, less than two years before abusive regimes were exposed at all 12 institutions.
The Devon care home at the centre of the scandal, Veilstone, had not been visited by inspectors from the Care Quality Commission (CQC) for three-and-a-half years by the time the abuse was finally exposed six years ago.
CQC had even failed to order an inspection of Veilstone after receiving allegations of abuse from a resident in August 2010, even though it was by then three years since its previous inspection.
Instead, it passed the allegations to Devon County Council to investigate, while also notifying the home and the police, but did not inspect the home until April 2011 – more than three-and-half years after Veilstone’s previous inspection by CQC’s predecessor, the Commission for Social Care Inspection.
Even then it failed to uncover the abusive regime.
It was not until a second whistleblower came forward in July 2011 and made similar allegations to the police, and CQC ordered another inspection of Veilstone as well as examinations of the other 14 Atlas homes, that the regime was finally exposed.
Last week, reporting restrictions on the case were finally lifted following a lengthy series of criminal trials and hearings that led to the conviction of 13 company directors and employees of Atlas Project Team, which provided residential care for people with learning difficulties and challenging behaviour.
Bristol Crown Court had heard how managers and staff at two of the homes locked residents in bare, freezing seclusion rooms with no heating or toilet facilities as a punishment.
Devon and Cornwall police worked with prosecutors to establish a pattern which showed how staff used “excessive and inappropriate seclusion” as a result of training provided by senior Atlas figures.
The Crown Prosecution Service said this had led to a “culture of abuse – unlawfully detaining residents in very poor conditions for long periods of time”.
But Judge William Hart jailed only one of the 13 people convicted, Atlas director Jolyon Marshall, with others receiving suspended prison sentences, conditional discharges, or in the case of Atlas founder and director Paul Hewitt, a £12,500 fine and prosecution costs of £105,000.
One of the Atlas residents had also been abused at the notorious Winterbourne View private hospital, a regime which was exposed by the BBC’s Panorama in 2011 – at about the same time that the regulator was being warned about the Atlas homes – and also led to criticism of CQC.
In the Winterbourne View case, CQC admitted mistakes after failing to follow up a whistleblower’s allegations (it failed three times to respond to his evidence, according to a serious case review) because it believed the local council was doing so.
The Atlas trials and hearings focused mainly on charges of false imprisonment and conspiracy to falsely imprison residents at two of the company’s homes in Devon, but CQC documents show the abusive regime extended far beyond false imprisonment and spread across many of its 15 properties.
Analysis by Disability News Service (DNS) of inspection reports published by CQC show that less than two years before the abusive regimes were finally exposed, the watchdog had branded 12 of the Atlas homes “good” or “excellent”.
Inspection reports from 2009 and 2010 showed CQC repeatedly congratulating Atlas for the quality of the service it provided at 12 care homes across Devon, Hampshire and Berkshire.
The following year, in 2011, when CQC finally launched urgent inspections of all of Atlas’s homes, it found breaches of care standards in every one of the 12, as well as three others that had opened since 2010.
The CQC reports also show that the regulator failed to carry out a full inspection in 2010 of Veilstone, in Bideford, as it had promised it would the previous year.
The CQC reports which followed the 2011 inspections, and were published in early 2012, show disturbing levels of abuse across the institutions.
In one Devon home, Gatooma – the other home where allegations were dealt with in court – residents’ telephone calls to their relatives were listened to and recorded by staff.
In another home, Santa Maria, in Wokingham, Berkshire, records showed that one resident had been “sent to their room” 58 times in December 2010; in July 2011, the same resident was sent to his room 208 times, and by October 2011 he was being sent to his room 438 times.
In Santosa, a care home in Holsworthy, Devon, the inspectors found the behaviour of two residents was “being managed through the giving or removal of food”, while residents were paid a tiny amount of money to carry out a series of daily tasks.
The previous year, CQC had described Santosa as an “excellent” service.
In another Devon home, Teignmead, written information showed staff were attempting to manage one resident’s behaviour by the use of what they called a “time out protocol”, while there were reports of residents being physically restrained.
The records showed how one resident (X) “was observed through the crack in the door (lounge) to of been crying for 1 minute – [X] was directed to his room as per his time out policy”.
Another Teignmead incident report stated: “Due to [X] not listening to staff, [X] was directed to his room as per time out policy.”
That report also stated that, because X had not complied with the time out policy, he had been physically restrained twice for a total of eight minutes.
Two years before, CQC had described Teignmead as a “two star good service”.
All 15 homes had their registrations cancelled by CQC in August 2012.
CQC said this week that its “inspection methodology” in 2010 was that “unless information of concern raised with us indicated that we needed to make an additional visit, we would inspect two-star services every two years”.
But CQC had been warned repeatedly that its approach to inspection – which focused on homes submitting written self-assessments – could lead to some institutions avoiding inspections for up to five years.
In his book on another major abuse scandal* involving adults with learning difficulties, at the Longcare homes in Buckinghamshire, experts interviewed by DNS editor John Pring warned in 2011 about the “diluted” protection offered by CQC’s new inspection system.
One told Pring: “They say they have a focus on poor performing homes, but my view is that this realignment has just been done to save money.
“There are just not the inspectors walking through the door like there used to be on a regular basis. It’s a paper assessment and I do not think that is wholly effective.”
Another warned that CQC resources were “thin and getting thinner” and that abusive regimes were slipping through the CQC net.
Dr Noelle Blackman, chief executive of the charity Respond, which has provided years of advocacy, emotional support and psychotherapy and counselling to victims of the abuse, and their families – and which also supported some of the survivors of the Longcare abuse – said this week that the Atlas regime had spread throughout its homes.
She said: “They all lived in fear as they witnessed their fellow residents going through the abuse, even if they didn’t witness it themselves.”
She said the abuse went far wider than was exposed by the trial, which focused on the use of solitary confinement punishment rooms.
Many residents were forced to carry out work, such as scrubbing the floors.
She said: “It was a huge part of the culture that the residents had to do a lot of the manual tasks and it was seen as a way of civilising these people who were seen by the managers and staff as being not quite human.”
If they refused to carry out the work, they were punished, by being deprived of food or being locked in a punishment room.
She added: “Part of the regime of coming out of isolation was that they had to carry out tasks to prove they deserved their freedom again.”
Five years after the abuse was finally halted, she believes CQC still has lessons to learn.
She believes the regulator needs to be far more “curious” about the services it inspects and not allow itself to be “fobbed off” by the “glossiness” presented by some of the care businesses it inspects.
One improvement in recent years has been the use of Experts by Experience, often disabled people themselves, who have experience of using services and accompany CQC inspectors on their inspections.
Blackman said: “They are curious, they ask the key questions, they instinctively know what is right.”
But all too often, she said, that information is not captured by CQC’s reports because the criteria they use are too narrow.
Asked about its failings, CQC insisted that its procedures had changed in the years since the abuse was exposed.
A CQC spokesman said the events took place “six or seven years ago when CQC was a different organisation, using previous methodology.
“When these abusive practices were discovered, CQC took action although we acknowledge that we should have responded more quickly to the concerns raised.
“Much has changed since 2011. Since then we have overhauled our regulatory approach; improved the monitoring of services and the way we respond to safeguarding concerns; introduced a new and more thorough inspection process; increased the numbers of people with learning disabilities involved in our inspections; and strengthened our enforcement processes.
“We have also worked with The Challenging Behaviour Foundation on the issue of restraint and we now subject services where staff frequently resort to restrictive interventions to much tougher scrutiny than we did five years ago.”
Asked if CQC believed there should be an independent investigation into its failings, he said: “CQC did carry out its own review at the time and we would of course contribute to any serious case review, along with all the agencies who were involved at the time.”
But he said the responsibility for preventing abuse “rests with the providers who must be held accountable for delivering on that quality”.
He said: “We will take action if we find that a provider is failing – first to protect people in their care, and also to hold them to account through using our enforcement powers.”
He said CQC now had “a new, more thorough inspection process”, introduced three years ago, and “will never rely solely on the assertions of a provider about the quality of their care without crossing the threshold to check”.
And he said there were now systems in place “to ensure that safeguarding processes are not closed without the outcome of the investigations being recorded”.