This slideshow was used for a presentation to the National Registered Managers Conferences in 2012

1. In the eye of the storm
Debra Moore
Director of Nursing & Patient Safety
Castlebeck

2. Aim of the session
Transforming The Workplace Culture – including
findings from the external review of the culture
Learning And Implications For Other Learning
Disability Providers

3. Do we use this a chance to do something
different? Can we take stock and rebuild?
“Her death has become one of those major modern occasions where
there seems to have been a collective sense of empathy for a
stranger’s fate. She has become an embodiment of the betrayal,
vulnerability and public abandonment of children.
The inquiry must mark the end of child protection policy built on a
hopeless process of child care tragedy, scandal, inquiry, findings, brief
media interest and ad hoc political response. There is now a rare
chance to take stock and rebuild”
Peter Beresford
Professor of Social Policy, Brunel University

4. Personal and professional

5. What do I know?

6. How did I become involved? –
my response to Winterbourne View
“You have many choices. You can choose forgiveness over
revenge, joy over despair. You can choose action over
apathy.”
Stephanie Marston

7. Abuse - is anyone, anywhere safe?
For 10 years, Gordon Rowe raped, kicked, punched, drugged, starved and
neglected the adults with learning difficulties who lived in his residential homes in
South Buckinghamshire. (Longcare Inquiry)
One on occasion she attended the hospital at around 6 am to find her mother in a
side room calling ‘please help me, please help me’. The patient was covered in
dried faeces and was completely naked. She ran down the ward to find the staff
‘chatting and laughing’. She assisted in washing her mother and it was ‘awful’.
Her ‘hands were absolutely caked’ and it ‘was dried and it was up her arms and it
was round her neck’. The patient died later that night. (Mid Staffordshire)
One person interviewed was raped, age 7, by a family friend; then abused, aged
10, by her foster brother who had Downs Syndrome; and then, at age 14,
sexually abused by her cousin. (Lemos & Crane)
In October 2007, Pilkington, then 38, drove herself and her 18-year-old daughter,
Francesca Hardwick, to a layby …the then set the Austin Maestro on fire, killing
them both…an inquest heard how the family had been kept virtual prisoners in
their own homes by youths who threw stones, flour and other objects and kept up
a relentless stream of abuse

8. Abuse - is anyone, anywhere safe?
“appalling examples of discrimination, abuse and neglect across the range
of health services” Death by Indifference
“People with dementia are the most vulnerable in society and it is shocking
that this study has found that they are being subjected to abuse in their own
home” Alzheimers Society
Inspectors for the Care Quality Commission - which regulates home care in
England - found that 217 companies were employing workers who were not
properly qualified. One company in Birmingham employed 23 carers with
criminal convictions for offences including theft and assault. One carer in
Coventry locked a vulnerable person out in the garden while another put a
carrier bag over a care user's head.
Scotland Yard, which is co-ordinating the investigation into Savile's alleged
offences, says it is following up 340 lines of inquiry, following complaints of
abuse and sexual assault by him. It is also in contact with 14 other police
forces. In total, officers are in contact with 40 potential victims.

9. In Winterbourne View
What do all these scandals tell us about the setting conditions for
abuse?
What is the recipe for disaster?
Lack of voice in terms of service users/families/advocacy
Lack of respect for the individuals and their families
Unclear purpose and values
Mix of service users with widely differing needs
Boredom – lack of activities
Institutional and impoverished environments
Geographically isolated services
Low staffing levels and high use of bank/agency staff
Poor training and staff development
Lack of management supervision and appraisal
Closed inward looking culture
Poor incident reporting systems and low level governance
Weak management and low visibility
Lack of clinical/nursing leadership
Poor whistleblowing procedures
Failure to act on complaints/concerns
Poor intra-agency reporting and liaison
Where could we see all this happening?

10. Methodology of the review
 Site visits to 12 hospitals between June and August 2011
 Winterbourne View not included as subject to on-going police investigation
 Assessment of services against Confirm & Challenge Outcomes Framework
 Review of literature and government policy
 Interviews and observations with people who use services and their families
 Observation of key meetings – service user forum and staff meeting
 Confidential Interviews with staff across all departments including
housekeeping, administration, nursing, clinical and training
 Confidential Interviews with Executive Team
 Analysis of documentary evidence – rota’s, MDT and CPA minutes and
notes, nursing and clinical notes
 Summit with key stakeholders to inform recommendations (Sept 2011)

11. Findings and recommendations
9 key areas
1. Assessment, care planning and therapeutic
interventions
2. Multi-disciplinary team working
3. Planning and delivering person centred care
4. A meaningful day
5. Environment and facilities
6. Workforce and staff training
7. Organisational structure and culture
8. Commissioning
9. Clinical governance and patient safety

12. Assessment, care planning and
therapeutic interventions
– key lessons
 Ensure a clear purpose and focus for in-patient provision
– ‘short term psychiatric assessment & treatment’ with the
aim of returning people to the community
 Agree admission criteria and a proper care pathways with
individual outcome measures and discharge planning
from the start
 Ensure there are the resources and expertise to deliver
specialist interventions – therapies and programmes
 Create a meaningful day – combat boredom!
 Promote healthy lifestyles
 Invest in person centred care planning – INVOLVING
PEOPLE & FAMILIES!

13. Multi-disciplinary team working
– key lessons
 Be clear about the role of each person and
support activities that bring them different
professional groups together such as training
 Ensure that the MDT is visible within services
and spend time with direct care staff –
accountability
 The role of named nurse & key worker need to
be defined and accountable
 Listen and respond to the views of people and
families – don’t confuse!

14. Planning & delivering person
centred care – key lessons
Really connect with PEOPLE AND FAMILIES
 Increase opportunities to hear the voice of people
who use services and their families
 Support people and families with knowledge and
information - expert patient/expert carer skills
 Ensure materials are accessible and enable people
and families to engage fully in assessment and care
planning processes
 Ensure people know their rights!

15. A meaningful day – key lessons
Building skills
Person centred active support
Positive Behavioural Support
Intensive interaction
Communication
Meaningful occupation and
employment opportunities

16. Environment and facilities
- key lessons
 Smaller environments – better
compatibility
 Involve service users and families in
setting and monitoring environmental
standards
 Remember the ‘healing’ aspect of the
environment
 Space for therapeutic activity

17. Workforce and staff training
- key lessons
 Induction – first point of contact – emphasis on
values, rights and safeguarding
 Robust preceptorship, induction and clinical
supervision
 Rolling programme of training prioritising
person centred thinking and approaches, care
planning and HAP as well as clinical skills
 Training needs analysis and effective staff
matching vital – KSF linked to appraisal
 Involve people and families at every stage
 Look outwards – network, network, network

18. Organisational structure and culture
- key lessons
 Patient care and outcomes must be focus of
Board level discussion and communication
 Robust management supervision and clear
accountability
 Staff who are related should not work in the
same team
 Managers need development and training
 All meetings need to be purposeful,
strengths based and appreciative
 High visibility - Management by
wandering about!

19. Commissioning - Key lessons
 Focus on patient experience and quality
of care
 Use of multi-media to see what the life
of the person is like e.g. video diaries
 Undertaking regular population needs
analysis aggregated information from
care plans, HAPs, patient exit
interviews, family carer surveys etc.
 Ensuring manager understand
commissioning landscape and
expectations and work in partnership

20. Clinical governance and patient safety
- Key lessons
 Be clear about expectations – agree
the Quality Strategy – clear outcomes
and accountability
 Weave achievement of quality targets
into appraisals of all staff
 Ensure people and families are
involved in all aspects of setting and
monitoring standards
 Robust governance systems and data
 Board reporting
 ZERO TOLERANCE

21. In summary
 My report contains nothing new – it is,
sadly, an echo of other reports
detailing failings across the NHS,
Social Care, Independent Sector and
in people’s own homes
 How many times do we have to say
it?
 We need to stop blaming each other
and get on with changing things…!
 We need to create the conditions for
person centred care to flourish

22. A personal ‘call to action’
“It is all built on trust, so I
trust you to look after my
son”