Reflective_Account_Shipmam._Level_3_Diploma

A Reflective Briefing: The Care Quality Commission’s (CQC) review at Winter Bourne View. By Senior Relief Care Worker. How the CQC; the UK’s Independent Regulator for the Health and Social Care, failed to act in response to poor performance data or how any one in authority at Winterbourne View; at Castlebeck Care Limited, the NHS or local Commissioners apparently failed to notice or let alone failed to take effective action and allow time to find alternative providers demonstrates a clear serious system failure to address a poor service and in particular address identified known concerns. Local safeguarding process’s within the NHS and local authority commissioners failed to act on the CQC Inspectors concerns, and how the CQC’s own inability to act on or follow up identified poor performance identified by its Inspector and demonstrates poor internal communication and poor joint working, particularly the concerns raised by a whistle blower in the BBC television programme Panorama and which had gathered evidence over several months including secret filming which showed serious abuse of patients and evidenced the poor service at Winterbourne View. Following the TV programme the resulting detailed investigation by the CQC concluded that Winterbourne View was not compliant with 10 of the essential standards which the law requires providers must meet and closed the centre due to its failure to protect the safety and welfare of patients. The TV programme and the resulting CQC’s report was a damning indictment of the regime and systemic failings at Winterbourne View in Bristol. The CQC report concluded there was a systematic failure to protect individuals or investigate allegations of abuse. ThE CQC failed its responsibilities to patients and initial concerns should have triggered a more detailed inspection. Amanda Sherlock, CQC’s Director of Operations stated “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” this raises concerns over the quality of inspections by the regulator and its own monitoring/reporting systems. The decision by CQC not to take action because its Inspector informed that concerns were being dealt with through the local safeguarding process by NHS and local authority commissioners needs to be reviewed and improvements made to ensure that referrals are followed up to prevent further system failures. Further, how the CQC’s failed to interview the whistle blower only compounded the systematic failure and the importance of learning from and sharing information. Castlebeck Care Managers had failed to report major incidents to the CQC; care did not match individual needs, there was poor service monitoring, they did not respond to or consider peoples views about services and had not investigated complaints, investigations into the conduct of staff were not robust, and they did not make an appropriate response into allegations of abuse. Behaviours need to change and there is a need to ensure the use of more robust appointment, screening processes and improvements made to training and learning needs; there is a need to develop regular shared and standardised reporting and feedback systems with clear roles and responsibilities transparent to all in particular what is to happen in the event clients are at risk. Improvements need to be made to performance monitoring and information sharing. The improved sharing of performance data on routine monitoring would assist all in detecting many apparent failures in organisational/individual performance. The sharing of information from different sources including CQC’s internal management review and improved utilisation of information from complaints together with robust standards would improve future ability to deal with poor performance and behavioural issues. This review prompted an inspection of all Castlebeck services, a review of learning disability services involving 150 services, an internal review at CQC and an independent review to examine all responsible agencies.