The CQC has published its Independent Review by David Noble QSO into the regulation of Whorlton Hall (full report here). The review examined why a 2015 inspection report which rated the service as ‘requires improvement’ was not published. It also covers the treatment of key whistle-blowers (including the chief inspector of the 2015 inspection) who raised concerns before the May 2019 Panorama documentary (https://bbc.in/2NL0QR1); and how the CQC deals with inspection complaints from providers.
The report concluded that the CQC’s decision not to publish the 2015 report was wrong, and made the following recommendations:
- Improve security and availability of notes and evidence gathered during inspections
- Improve the information provided to inspectors about services
- Re-examine the report quality assurance process to ensure it is providing valuable ‘quality assurance’ at the right points in the process
- Produce legal advice about the Commission’s duty under the Health and Social Care Act 2008 to publish a report
- Review how to process complaints made by providers following an inspection (including using this to inform the current CQC review into assessing mental health hospitals)
- Implement results of the 2016 whistle-blowing complaint
- Ensure that reports of action planned or taken are fed back to the complainant as part of the CQC’s ‘Speak Up’ policy
The Transforming Care programme was meant to address the systemic issues that the abuse at Winterbourne View Hospital uncovered in 2011. Children and adults with learning disabilities and/or autism are entitled to receive the right support, provided by the right services by staff with the right skills. For this to become a reality, all parts of the system need to work well – commissioners who buy places in services and monitor the outcomes for individuals, the service providers and the regulators.
This review focusses on the regulator and identifies significant failings in an organisation that should be, and needs to be, robust, rigorous and efficient. It is always the people with learning disabilities and/or autism and their families who feel and live with the direct impact and consequences of these failures. Another failing, another review, another report.
This week, the Minister for Social Care confirmed that there are currently 350 people with learning disabilities and/or autism in services rated as ‘requires improvement’ or ‘inadequate’ across the country. Yet again, we all call for action by those who have the power to make the changes we all know are needed. Yet again we are dismayed by the inertia and lack of urgency, which will be followed by another failing, another review and another report.
The CQC has an opportunity now to demonstrate leadership, address the underlying causes of its failures, to work with people with learning disabilities and/or autism, their families and other stakeholders to tackle the root causes within CQC and in the wider system, and to enable people with learning disabilities and/or autism to get the support they have a right to.