Last week, we released a statement regarding the abuse at Mendip House. At the time, we said we had approached NAS for an update on what they had done to learn from events and make sure they could not happen again. Below is Carol Povey’s response in full.
Many thanks for your e mail following the Safeguarding Adults review into the horrific events which happened in Mendip House in 2016.
We had correspondence in August 16, and in November 2016, we closed Mendip House. I think, when we spoke, we had taken that decision, and were in the process of working with families and the people who were living there, to find alternative accommodation and support which would meet their needs.
We want to reiterate how appalled we were by the cruel behaviour towards the people we supported at Mendip House by some staff there. And we apologise without reservation for the failures at Mendip House and for not spotting them and putting them right as quickly as we should have. We have since done all we can to ensure this cannot happen again.
The timeline can be difficult to follow, because the Safeguarding Adults Report into Mendip House draws on a range of minutes and reports from other enquiries by Somerset County Council, the Care Quality Commission and the NAS, rather than being based on a single, stand-alone investigation, but the following gives an account of what happened and when:
• In May 2016, a member of staff alerted us and the CQC to abusive behaviour by some members of staff towards the people we supported at Mendip House. These are the extremely distressing accounts of abuse detailed in the SAR report.
• In May 2016, we immediately made sure everyone living at Mendip House was safe and properly supported by staff who knew them and their needs well. The staff responsible for the abuse were immediately suspended and disciplinary investigation started, which resulted in their dismissal.
• In May 2016, we undertook a full review of all previous safeguarding alerts and supplied this to the CQC. The CQC inspected Mendip House. Somerset County Council, as the agency responsible for safeguarding in the area, started a safeguarding inquiry process, including placing a team at Somerset Court for several months.
• In June 2016, we calculated then repaid the money taken from the people who lived at Mendip House by staff who had been getting them to pay for their meals.
• In July 2016, we took the difficult decision to close Mendip House because of the depth of the problems we had discovered there.
• In August 2016, the CQC published their report, which found the service inadequate in all areas. We apologised publicly and acknowledged that we’d ‘failed badly’ at Mendip House
• In early November 2016, Mendip House closed, after the last of the people who had been living there moved to their new home.
• In March 2017 the Somerset Adult Safeguarding Board started the Safeguarding Adults Review (SAR). We worked with the review author, council staff, the Care Quality Commission, the Clinical Commissioning Group and the police to contribute to lessons learnt about what went wrong at Mendip House.
• On 8 February 2018 The Safeguarding Adults Board published the SAR report.
From when the situation at Mendip House first came fully to light in early May 2016, we’ve worked to understand what went wrong and introduce the necessary changes to stop the combination of cruel and unprofessional staff practice and a failure to quickly spot this and put it right.
We don’t believe that what happened at Mendip House represents the experience of the people we support in our other services, nor the attitudes or practice of our staff. Our adult social care services are rated above the national average. But, we need to make sure that we do everything we can to prevent any abusive behaviour like this happening again. In my last letter to you, I said we would be reviewing all our policies and procedures. We have done this and made the following changes to the way we work. We have:
• Put in an independent whistleblowing line so that staff can confidently report any concerns. We’ve seen a significant increase of 14% in staff awareness of how to whistleblow in our independent staff survey, putting us 7% ahead of similar care providers. We will continue to promote this to staff.
• Increased proactive contact with family members of people we support so that we can pick up on even minor concerns that otherwise
• Started more in-depth data analysis so that we look at data on safeguarding, staff retention, complaints, disciplinaries and other indicators in the round and report on trends in services so we can pick up on minor changes and intervene early if there are any concerns.
• Introduced a new quality assurance process – we will commission an independent evaluation of this after 6 months to be sure that it is working
• Co-opted independent, experienced safeguarding professionals (including a Local Authority ex-director of Adult Services) onto our Services Quality and Development committee
• Begun the process of creating an independent safeguarding panel, in addition to our Services Quality and Development committee, to make sure that all safeguarding issues get properly scrutinised and dealt with
• Introduced a ‘lessons from Mendip House workshop’ for frontline staff and managers from Autumn 2016. It shows what can go wrong and brings starkly to life the necessity of all staff and managers taking responsibility and acting when they see practice deteriorating as it did at Mendip.
• Strengthened our quality improvement teams in each area of the country– these now include autism practice facilitators, positive behaviour support co-ordinators, learning and development staff, behaviour support and health and safety trainers).
• Improved our culture and worked to embed our values in our workforce, for example through values-based recruitment and reflective supervision. Although this will take time, we’ve already seen in our Oct 2017 independent staff survey a 13% increase year-on-year in those agreeing that: ‘Our charity has strong values which are put into practice’.
• Audited all our policies so that they are clearer and are more closely monitored.
• Improved investigations training so that managers are better able to conduct good quality investigations if there are any concerns about our practice.
We have subscribed to the Driving up Quality Initiative, and to STOMP, and these are both integrated into our way of working. Throughout this time, we have been working closely with the Somerset Adult Safeguarding board to ensure we have learnt from these terrible events, and can make sure they never happened again, not only in NAS services, but across the social care sector. We will be participating in the Somerset Adult safeguarding conference to share what we’ve learnt, and will continue to talk about both what we got wrong, and what we’ve done to change things.
Contrary to some of the reports in the media, we have not covered up anything that happened at Mendip House, or our actions in response to those events.
When we last spoke, I said our Chief Executive, Mark Lever, was hoping to hold a roundtable to look at how we, and other organisations, can and should respond to when things go wrong to ensure events done repeat themselves. This has taken longer that we had hoped, but we still intend doing this, and will invite representatives from Learning Disability England.
I’d also like to reiterate the offer I made in August 2016. I am more than happy to join you in any forum which can enable us, as a group of organisations providing services to people with learning disabilities and/ or autism to use our learning to improve services or our responses to poor practice and other service failings.
With best regards
Director of the Centre for Autism
The National Autistic Society