Devon abuse case concludes that inspections on their own “cannot improve care”

The role of the CQC and how local intelligence information is shared should be reviewed, a report by the Devon Safeguarding Adults Board has concluded following a review of the abuse suffered by residents at Atlas care homes in Devon.

The report calls for a new repository of “intelligence”  about providers which is accessible to commissioning bodies and the development of a tool to measure indicators of harm in an organisation. The DSAB concludes: “There remains a reliance on CQC reports. However, inspections on their own cannot improve care; it can only tell us what it is measuring.”

The report by the DSAB comes two years after 12 former staff members were convicted over the “systematic neglect” of residents at care homes in Devon operated by the now defunct Atlas Project Team. The homes were commissioned to provide specialist care to individuals with a learning disability at a cost of up to £4,000 per week. However, criminal court proceedings revealed that residents suffered systemic neglect, seclusion in rooms without food, drinks, heating or access to toilets, and physical assaults.

A key theme in the DSAB report is that there was a lack of oversight by commissioners of the quality of care delivered by Atlas and a fundamental lack of challenge to its services provided by Atlas. There is also acknowledgement that the expertise of families was not recognised.  

Other recommendations include:

  • A new specificity in contracting most particularly in re-contracting services for people with learning disabilities and autism. It is said that it is during the post-award period that poor contract performance is likely to emerge.
  • Ongoing scoping of existing provision, future demand and supply of care provision to support people in local area/reduce out of area placements.
  • Commissioning bodies should allow families to challenge the care being provided and there should be “professional curiosity” in all activities
  • Unannounced visits to placements by parents, carers and social services
  • Care managers/those reviewing how care and support needs are met must have clear goals which hinge on understanding the aspirations of people with learning disabilities and their families for ordinary lives.

The report concludes: “There was an absence of relationship with and a lack of understanding of family involvement and each family’s context. Their views relating to how they perceived their loved one to be at his placement were not actively sought. Their expertise was not recognised.”  

Law firm Leigh Day represents a number of former residents of Atlas care homes Veilstone and Gatooma, and their families, who are bringing civil cases for redress. The civil claims argue that the mistreatment and abuse that residents were subjected to was akin to torture, and a breach of their human rights.

Alison Millar, head of the abuse team at Leigh Day, said: 

“Seven years after the Atlas homes were closed, too many people continue to live in placements where the overuse of restraint and seclusion of residents is the norm. These outdated models of care create environments where individual human rights are too easily breached.”

The Challenging Behaviour Foundation, which supports people with severe learning disabilities and their families, said: “There is a significant body of evidence about how to provide good support for people with learning disabilities and learning from previous abuse scandals about how to safeguard vulnerable adults.  The recommendations from this report and others must be prioritised by those commissioning and providing care to people with learning disabilities.  People with learning disabilities have a right to feel valued and safe, wherever they live.”

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