The abuse of patients with learning disabilities and autism at Whorlton Hall, reported in the recent Panorama programme, raises a whole host of questions. Many of these must surely revolve around the attitude and mindset of those who perpetrated such actions, and whether the abuse was feeding some form of underlying psychopathology in them. There is also the question of the underlying culture of the service which appeared to ‘normalise’ such behaviour. And where was the management in all this, both in the service itself, and at provider level? Were they aware of what was happening, and if so, why did they apparently do nothing to stop it? Finally, although the CQC did find problems in their March 2018 inspection, their previous one in September 2017 rated it as ‘Good’, so this must raise some serious questions regarding the inspection team at the time, and, quite possibly, the inspection regime itself.
As far as the question of the mindset and attitude of individual staff members goes, and the wider service culture, this is far more complex than it might first appear. In its response to the revelations, Dr Paul Lelliott, Deputy Chief Inspector of Hospitals at the CQC, makes reference to the findings of the March 2018 inspection (which did not give a rating to the service but was in response to whistleblowing concerns):
It is clear now that we missed what was really going on at Whorlton Hall, and we are sorry. The patients we spoke to during this inspection told us they felt safe and had not experienced aggression towards them. We also spoke to health care professionals who had formal caring roles for patients at the hospital, but who were independent to the hospital; they did not raise any concerns. This illustrates how difficult it is to get under the skin of this type of ‘closed culture’ where people are placed for long periods of time in care settings far away from their communities, weakening their support networks and making it more difficult for their families to visit them and to spot problems. When you add staff who are deliberately concealing abusive behaviour, it has the potential to create a toxic environment.
Although the CQC’s response has been generally ridiculed, especially in the light of their 2017 ‘Good’ report, Lelliott has (perhaps for the wrong reason) put his finger on a real problem here regarding the issue of ‘closed cultures’ and how an external inspection team is supposed to ‘penetrate’ such a culture.
Environments such as Whorlton Hall are in many ways closed communities, and tend to create very insular cultures. Staff and patients (service users) live and interact very closely together, often over long periods of time, with little ‘interference’ from the outside world. The dynamics of such relationships are often very complex, and in many cases the staff members involved, who often have minimal knowledge and training in such matters, fail to recognise that they are starting to ‘mirror’ the behaviour of the people they are supposed to be supporting. To put it another way, the underlying culture in such environments can quickly become quite pathological and, in some ways, quite incestuous.
None of this excuses what went on at Whorlton Hall, but the question I want raise here is how would a CQC inspection actually recognise such a ‘toxic’ environment in the first place, especially when most of its inspectors probably have little or any training in this field?
The inspection in September 2017 was conducted over two days and the inspection team comprised two CQC inspectors and one learning disability nurse adviser. The inspection was part of the CQC’s ongoing mental health inspection programme, and as with all CQC inspections, aimed to address the five key questions regarding the service: is it safe, effective, caring, responsive and well-led? Although the service had a capacity for 19 patients at the time of the inspection there were only nine patients in residence.
According the report, the inspection team:
- looked at the quality of the ward environment and observed how staff were caring for patients;
- sampled the food provided to patients to assess its quality;
- spoke with seven patients and carers;
- spoke with the service and deputy managers of the service;
- spoke with nine other staff members; including nurses, a doctor, an occupational therapist, sports co-ordinator and activities co-ordinator;
- spoke with a pharmacist from the external pharmacy service used by Whorlton Hall;
- spoke with two care commissioning groups about their relationship with Whorlton Hall;
- observed a team meeting and multi-disciplinary meeting; looked at six patients’ care and treatment records:
- carried out a specific check of the service’s medication management;
- looked at a range of policies, procedures and other documents relating to the running of the service.
Prior to the inspection the team reviewed the information they already held about the service.
The only problems highlighted in the report were issues with curtain and shower rails in the patients’ rooms; a smell of urine in one of the male bedroom areas; and a door being slammed shut which caused alarm to a patient.
In the March 2018 inspection, which was in response to concerns raised by a whistleblower regarding staffing and patient safety, culture and incident monitoring, the inspection team was as before (two CQC inspectors and one specialist advisor) and again took place over two days. As I mentioned earlier, the team did not rate the service this time, but did raise the following issues:
- There were no processes in place to assess and monitor the impact of staff working excessive hours;
- Managers knew that staff were working up to 24 hour shifts and had no system in place to assess and mitigate the risk and impact of this on patients or staff;
- The service relied heavily on the use of bank and agency staff;
- Not all agency staff were up to date with mandatory training, and there was no internal system in place to review the training compliance of agency staff;
- Individual staff supervision was not taking place in line with Danshell’s (the previous provider) policy and supervisory bodies.
The provider was instructed to come up with an action plan to address these issues.
I’ve covered the inspection process in some detail in order to highlight some of the difficulties in trying to ‘penetrate’ a service’s culture in such a short period of time and with only limited resources (three people). As far as the September 2017 inspection went, there appears to be no reference in the report to service culture at all. With regards to the March 2018 inspection the report states that it had received concerns regarding low staff morale and a culture of bullying within the service. However, according to the report:
The staff we spoke to said that morale was positive in the team and they were happy in their roles. All of the staff we spoke to felt supported, respected and valued by management and peers and felt that they worked well as a team. Staff told us that there was a culture of openness within the service and the wider Danshell group and managers empowered and actively encouraged staff to raise any issues or concerns and make suggestions to improve service delivery (p.13).
Clearly in this case a staff member did take the provider at their word and reported their concerns to the CQC. One has to wonder, however, why the inspection team took the staff team at their word, rather than probing deeper. And this goes back the question of time, resources (and proper training for inspectors) that I touched on above. Organisational culture and team dynamics are complex issues, and cannot be understood in a couple of days. In fact, even those who work in and manage services for many years often have no real understanding of their underlying cultures.
So what’s the answer? Can we realistically expect CQC inspectors to become experts in discerning a wide range of service cultures and understanding the complexities of staff-service user dynamics overnight? No, probably not! However, I would suggest there might be a compromise solution, which would not involve ditching the whole CQC inspection regime and starting from scratch (tempting though this might seem).
And this starts with the CQC’s own inspection data. Every month the CQC publishes its latest rating data, and with some careful analysis, and a bit of tidying up of the data, it is not too difficult to work out that there is a very strong correlation between the ratings for ‘Well-led’ and the overall ratings for each service. In other words, services that are, for example, rated ‘Good’ or ‘Outstanding’ for ‘well-led’ tend to be rated likewise overall. Now I say ‘tend to’, and it could be argued that this is just common sense anyway, but actually the correlation can be measured fairly accurately. For those who trust statistics more than intuition, the correlation coefficient is 0.85 for the May 2019 data, which is very strong (1.00 is perfect correlation, 0.00 is no correlation, and –1.00 is a perfectly inverse correlation).
This figure of 0.85 is for all four ratings taken together, but things get even more interesting when you split the data between those services which are rated negatively (‘Inadequate’ and ‘Requires Improvement’) and those that are rated positively (‘Good’ and ‘Outstanding’). For the negatively rated services the correlation is only 0.5, whereas for the positively rated ones the correlation is 0.79. In other words, there is a much stronger correlation between those services which are rated ‘Good’ or ‘Outstanding’ for ‘well-led’ and their overall rating, than there is between those which are rated ‘Inadequate’ or ‘Requires Improvement’. The message here is clear: if you want to improve your chances of getting an overall positive rating for your service, you need to ensure it is well-led!
To put it another way, and this is something the CQC have been aware of for ages, good leadership and robust governance (which is essentially what the ‘well-led’ domain is looking at) is the key to a high quality service. In their latest State of Care report the CQC make this very same point.
Bearing in mind that the CQC’s five ‘well-led’ Key Lines of Enquiry (KLOEs) cover a whole range of leadership and governance issues, including culture, quality assurance, joint working, stakeholder engagement, organisational learning, and partnership working, I would suggest that this is where the initial focus of any inspection should be. This could either involve using the existing ‘well-led’ KLOEs or amending/extending them in order to allow inspectors to probe more deeply into the leadership and governance of the service.
Now, one obvious problem with this approach is that if the inspection team were to focus all their attention on the ‘well-led’ domain then they would not be in a position to look at the other four domains (‘safe’, ‘effective’, ‘caring’ and ‘responsive’). However, if both intuition and the statistics are to be believed, there is a high probability that any problems in these other domains are rooted in the ‘well-led’ one. In an ideal world, of course, such an initial inspection, focusing on ‘Well-led’, would then be followed up by a more general assessment of the service, which could indeed look at the other four domains. And bearing in mind that many inspections of services now take at least two days, or even longer in the case of larger, more complex facilities, this is still, in principle, feasible within the current framework. What I’m suggesting here is that at least one day should be totally focused on leadership and governance (the ‘well-led’ domain) and another day could then be used for looking at the other domains. If my argument regarding the strong correlation between ‘Well-led’ and the overall quality of the service is correct, then the broader assessment would not need to be so elaborate (and bureaucratic) as it is at present.
Another option would be to bring in someone else from the outside to conduct an initial review of ‘well-led’ in order to identify any serious issues in this area (and by extrapolation, in other aspects of the service as well), prior to the actual CQC inspection.
I would like to conclude by coming back to the basic problem with the current CQC inspection regime that I highlighted earlier. It is trying to do too much with too little. It has neither the time or the resources to carry out proper, thorough and in-depth explorations of the services that it regulates, and the results are Whorlton Hall, Winterbourne View and who knows how many other disasters lurking just around the corner?