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Winterbourne View Care Home Failures

Info: 3682 words (15 pages) Nursing Assignment
Published: 25th Aug 2020

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Tagged: residential care

Winterbourne View Review

This report will be exploring the failures, rules, laws and policies, that were not adhered to and what could have been done to ensure that such failings do not occur again. This report will be looking more at the laws that were broken during the 5week period shown on the Panorama undercover investigation.

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Winterbourne view was a residential hospital based in Bristol owned by Castlebeck care, that at full capacity housed 24 patients with learning disabilities and Autism many with the mental capacity of very young children as young as 4 years old, the hospital at the time was also costing the tax payer around 4 million a year to run. In 2011 a senior nurse (Terry Brian) that worked in Winterbourne view contacted BBC’s Panorama after he had made several complaints to he’s Senior bosses and to the CQC’ about many acts of abuse that were being perpetrated on the patients in there care, but nothing was done about it and the abuse continued. Panorama sent in an undercover carer/Support worker (Joe Casey) and after 1 weeks training Joe was sent in to work as a Carer, over the 5week period he was able to film the abuse that occurred on the grounds of Winterbourne view.

Joe Casey Undercover Carer

QCQ are the governing body that determines the standards of care that is provided in England, policies are set also as guidance mainly by a group of politicians to ensure that laws like the Mental Health act 2014 and the Care Act 2014 are upheld.  Since the Winterbourne view video was aired a full review of events has taken place in May 2011 and it was found that there were major failing to report incidents, and even worst when they were reported there was a delay in responding to these reports meant the abuse continued.

Laws Breached

     Humans rights act 1998

  • Article 3 (prohibition of torture)
  • Article 5 (right to liberty and security)
  • Article 8 (right to your private and family life)
  • Article 10 (freedom of expression)
  • Article 14 (prohibition of discrimination)
  • Mental Health Act 2014
  • Offences against the person act 1861 (ABH section 47)
  • Abuse
  • Neglect

Systematic Failings

  • Report incidents
  • Act on incidents that were reported

The first incident that stands out for me is 10 minutes into the video you will see a woman in her 40’s is in the corridor,  as 3 of the carers/support workers are walking passed her, she throws something at one of them and straight away they jump on her using and illegal choke hold, this is never acceptable the necessary training should have been provided to deal with a situation like this, policy also states that restraining a patient should be the last resort when all options have been exhausted as restraints can not only cause injury but also cause a lot of distress.

The patients at Winterbourne view were placed there under the Mental Health Act 1983 which states that a person can be removed from the home if they are deemed unsafe to themselves or the people around them,  and then placed in a facility like Winterbourne view in which they would be assessed and then rehomed in appropriate accommodation to facilitate their needs, which could take up to 6 months under section 3 of the Mental health act 1983. As a care provider there is a Duty of Care which means we have a duty to provide the best care we can to ensure that any individual we are caring for is able to live a happy and comfortable life. Even though many acts of abuse occurred on the premises I believe that many things were not addressed, the fact the assessments were not done in the allotted time and social services had not done follow ups to ascertain why these assessments had not been done meaning that patients were living at the hospital for much longer than 6 months some up to 3 years making it impossible for them to have any quality of life or receive the necessary care they needed.

Simon was a patient at Winterbourne that was placed there for assessment, he was a high profile patient as he was determined by the carers there as over friendly and liked to give hugs which the carers did not like, he was the focus of a lot of their abuse and seemed to be targeted, also Simone an 18 year old girl with a personality disorder, that had been living there for 4 months. Simone and Simon both go through continued abuse which go’s as far as ABH (Actual Bodily Harm) which is an offence on section 47 which covers assaults that cause injury that aren’t serious. In addition offences under the Human rights act 1998 that covers 16 human rights were perpetrated.

Codes of Conduct forexample Promote and uphold the privacy, dignity, rights health and wellbeing of people in care, also communicate in an open and effective way to promote health   determines the way that a patient is treated while in care they may not be set by law but when upheld they ensure that we are providing the best care we can at many stages in the video you will see none of these codes are being upheld there is an incident with a young lady that doesn’t want to get out of bed firstly, policy states that when dealing with a female patient a female should always be present if a male carer or support worker is attending you will see a Support worker/manager (Wayne Rogers) burst into the room and demand she gets up and have a bath, when she refuses Wayne then escalates the situation by threatening to drag her out of bed and force her to have a shower under the Human Rights Act 1998 Article 3,10 & 14 this patient has a right to refuse a bath if she doesn’t want one and not to be force to do anything that she doesn’t want do, in addition when this incident occurs policy and code of conduct states that a full log of events should be written so as events can then be investigated to determine if your action were necessary, or to be held accountable for your actions, this was not the case at Winterbourne view Wayne did not follow this policy and nobody came forward to dispute his account either.

There is a point in the documentary when you will see Simone subjected to a planned assault committed by more than one support worker, several cups of water are thrown all over her to control her behaviour as it is determined she is having a bad day and unable to control, this is not the correct way to resolve a situation like this as care workers you are trained to stay calm in situations like this and as a result of their conduct Simone ended up being restrained even though she hadn’t really done anything wrong. This could also be deemed as assault and an offense under the Mental Health Act  3 that determine your rights against Torture and Inhumane Treatment should it be in the workplace or in your place of residence. 

CQC ( Care Quality Commission the regulatory body that determines the quality of care that is provided in England by Health care professionals, support workers and anyone that works in a healthcare setting) they also played a massive role in allowing the continued abuse to go on, and were found to have known about the abuse to as far back as in 2008. As a result of the Panoroma being video was aired, a full review of the company Castlebeck Care that owned Winterbourne view and all the other hospitals owned by them were given a full review and 3 other hospitals owned by Castlebeck Care   also were shut down, but addition there was a nationwide review of all institutional hospitals. Also new legislation and policies were put in place to ensure that the rights of patients that are place in hospitals under the mental health act are treated more humanly.  Also put in place as a policy, was the care plan to ensure that every patient is treated to their individual needs, also policies that give patients more rights over the care that they receive.

In addition to this report the Department of Health (DOH) did a report about the staff mistreatment and the abuse of the patients at the winterbourne hospital. The 24 patients that resided at winterbourne view were relocated to appropriate accommodation to assist their needs. Six out of 11 care workers who admitted a total of 38 charges of neglect or abuse of patients at a private hospital have been jailed.

  • Wayne Rogers, 32,  jailed for two years
  • Alison Dove, 25, jailed for 20 months
  • Graham Doyle, 26, jailed for 20 months
  • Nurse Sookalingum Appoo, 59, jailed for six months
  • Nurse Kelvin Fore, 33,  also jailed for six months
  • Holly Laura Draper , 24, jailed for 12 months;
  • Daniel Brake, 27, six month jail sentence suspended for two years and ordered to carry out 200 hours of unpaid work;
  • Charlotte Cotterall , 22, was given a four-month jail term suspended for two years. Cotterell was ordered to do 150 hours of unpaid work
  • Michael  Ezneagu, 29, was given a six month jail sentence suspended for two years and ordered to carry out 200 hours of unpaid work;
  • Neil Ferguson, 28, was given a sixmonth jail term was suspended for two years and ordered to carry out 200 hours of unpaid work;
  • Jason Gardiner, 43, was given a four month jail term was suspended for two years and ordered to carry out 200 hours of unpaid work.

The Burns Group Home Care

Welcome to The Burns Group Home Care, this brochure will give you some guidance and a brief recap on some of the information on the regulations and policies, also what is expected of you and of us to ensure we are providing continuous good care, and to keep your journey with us a comfortable and happy one. Most of the information on this brochure you would have received in training but take the time to read over it again as there is some further information that will be useful to you.


Main office contact: 0208 345 8822 Head office contact: 01753 555 1876

Address:  17 Crescent road                     Address: Peabody House

  Crouch end  London N8 8AL                      Middlesex   L23 8BB

When providing care, we need to take in to account the dignity and respect of our clients and work following statutory guidance/policies as these are set out to ensure we are providing a service that involves the client in every step we take as the guidelines of the government request we do.  The Executive and legislature branches make up the government, the legislative part within a government is who sets the laws, the executives initiate the policies and put the laws that are set by the legislature into practice. The only time the Judiciary will come into play is to resolve any disputes between parties in a legal setting by relaying the laws that are put in place by the legislative branch. So a bill cant be passed until the legislature has looked over the proposed terms.

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Policies and Regulations

Even though policies are not laws, they are clear guidance that is set out by governing bodies to ensure that legislations/laws such as the Care Act 2014 andthe Mental Health Act 2014 are followed correctly. The relationship between Laws/Legislation and policies are very important, policies are put in place to ensure that laws are upheld and more importantly, to ensure that every individual is treated like an individual, so understanding that everybody’s individual needs are different, this is for example why we have a care plan, to promote person centred care, to promote wellbeing, it is important that we read the clients care plan and understand every clients personal needs because something that may be good for one client may not be good for another.

Ethical practice

As a care workers/assistants you are expected to respect your clients privacy and dignity and keep confidentiality, but in some instances you WILL need to breach policy and report to the office. Example: you are with a client and you notice the client is extremely depressed every time that you attend, while talking to the client they tell you that they are having suicidal thoughts we expect you to report something  like this to the office we do not expect you to keep anything like this to yourself.  Contact your coordinator, do not write in your MARS chart and report straight away if your client does act on how they feel and you have not reported it not only can you be held responsible but your future as a care assistant could also be in jeopardy as this is a major safeguarding issue.   

Personal Care

Whenproviding personal care you are expected to respect your client’s needs, ask questions to determine what your client wants and needs actually are. Make sure dignity is kept by making sure all windows and doors are closed when providing any form of personal care and always ensure that your client is happy with you and whatever task you are attending to.


Every clientyou attend will have a Care Plan in the care plan you will findthe MARS Chart (medication administration records chart) you are expected to give a full account of any medication given to clients and follow codes in your MARS chart, if client refuses medication that is to be marked clearly in your chart. If at any time a client refuses medication that you feel can be dangerous to there wellbeing you NEED TO mark it clearly on the chart in addition give a full account in your care plan and contact your local office to make a report of it also so we can determine if its something we need to report ourselves. If at any time you have any confusion remember your five rights: Right person, Right drug, Right dose Right Route and Right time.

Health and safety

When attending a client’s home, if you are using equipment you are expected to make sure that the equipment that you are using is safe and all maintenance of equipment is up to date. Check your equipment before using it, check the dates of the last time the equipment had any maintenance and make sure all fixtures are safe and in place if you see any issues contact your local office Do not attempt to use this equipment as may there be any injuries to your client you may be held responsible please follow LOLER regulations when using any equipment to ensure the safety of you and your client, and please remember no lifting and handling equipment should be used singled handed, you will always have a second staff member attending never attempt to use any equipment singled handed at any time.

Attending a client’s home

When attending a client’s home we ask that you show the upmost respect, if you are doing any task for your client that you gain consent before doing anything you ensure that your client is happy with you doing it. Example: if you attend a lunch call and your client asks for something eat and you find that the food requested is out of date, we ask that you do not just throw it in the bin get consent from your client and explain to your client why you think it may not be safe to eat, that is the approach we expect you to have when doing any task at a client’s home.

All the information provided in this brochure is to guide into a comfortable and happy future with our company, but we need you to keep in mind that these are requirements of the government and the legislations and policies set out are a legal requirement, when laws like the Care act 2014 and the Mental health act 2014 are set out they go through a process to ensure that it will be effective nationwide. The Government of the United Kingdom formally referred as Her Majesty’s Government is led by the Prime Minister who selects all remaining ministers known as Senior Ministers they are the supreme decision makers known as the Cabinet. Government ministers all sit in parliament and are accountable to it, the government is dependent on parliament to make primary legislation, but before any of these laws can be passed a request to the queen must be made and she will make the final decision on all bills are passed.

Important information for you

In this brochure we have covered many rights for our clients, but we would also like you to know your rights, and what they mean for you as an employee of our company.

Refresher training

Every year we a required to offer you a refresher course as the care industry is ever changing and new a more innovative equipment and techniques are being run out we know the only way to keep at the top of our game is to ensure our employees are equipped with all the knowledge, but this is also a requirement by law, you will be paid at the hourly rate on your day of training but it is expected that you attend, any employee that does not attend the refresher course will be removed from rota until they attend, in addition to that we also run additional courses throughout the year so you apply to do a Level 2 NVQ or your Level 3 NVQ if you have you level 2 already. We do also run additional sort courses if you wish to advance in your particular area of interest, you will find all notifications of any courses running in the notice board of your office please feel free to apply if you are interested.

You would have already signed your contract we suggest you read through this as it will give a full breakdown of a lot of the information we will cover, on your signed contract if you are a full time employee we would require a minimum of 36 hours, but if you wish to do more you are welcomed to request, part time requirement of 15 hours that will be paid at the national rate of £9.23 p/h.  This rate can also raise to £12.00p/h after 6 months additional training is required.

Annual leave 

As a full time employee, you will acquire 28 days of paid annual leave every year, part employees receive 14 days paid annual leave which is paid at a calculated rate, meaning we will use your pay from the past 3 months to calculate your rate of pay. Annual leave is renewed every year in January on the 1st of the month, so we do suggest you use these days as we are not required to roll over any unused days we may do so in exceptional circumstances, but you will lose them if unused.

Sick Pay

As an employee of our company you are entitled to Statutory sick pay, this will be paid if you find yourself sick for more than 4 days, but a signed and dated sick note from your doctor will be needed before we can make any payments for sick leave and that will be paid for up to 6 months at the national rate of £94.25 p/w    

 As a company we pride ourselves on providing high standards of care and a safe and friendly environment for our staff, but we know that everything does not always run smoothly 100% of the time, we are here to help resolve any problems you may have client or personal, but if you find that you’re not getting the right support or an issue is not being resolved in the right way a list of numbers are below, we will try to resolve any issues professionally and respectfully, once again we would like to welcome you to our family, we hope that you enjoy working here as much as we do, everyday making people’s lives that little bit easier by providing quality care.


  • Copyright © 2019 Citizens Advice [online]citizenadvice.org.uk/rightsatwork  citizen advice
  • Library + learning commons https//:bowvalleycollege.libguides.com 22 Feb 2019
  • BBC news Winterbourne view: careworkers jailed for abuse [online]https://www.bbc.co.uk/news/uk-england-bristol-20092894  26 oct 2012


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