Learning from Somerset

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During March 2018, Somerset’s Safeguarding Adults Board hosted a conference at which a Safeguarding Adults Review was considered. The review concerned Mendip House, a National Autistic Society (NAS) home based within a campus service.[1] The NAS apologised for the treatment of Mendip House residents and apologised for the failure of its managers and systems to identify abusive practices. The review identified three lessons which have implications for practice in Somerset and elsewhere.

1. Noticing a problem, asking questions and pooling information:

  • allows for early intervention and support,

  • sorts out real warnings from background noise,

  • reduces the surprise effect

“The closure of Mendip House may be traced to May 2016when incidents were revealed to Somerset’s Safeguarding personnel by NAS whistle blowers, one of which was reported via the Care Quality Commission. The scattered knowledge arising from previous incidents was collated and an incubation of failures and harmful practices became apparent…Somerset’s Safeguarding Adults personnel were faced with reports concerning the poor oversight of staff and a sustained failure to address the taunting, mistreatment and humiliation of residents” (SAR pages 3, 5-6).

  • The National Autistic Society is primarily responsible and accountable for the practices revealed at Somerset Court
  • The unprofessional behaviour of a “gang” of male employees did not suddenly occur
  • The biggest challenge is how we [Somerset Safeguarding practitioners]engage with 30 different placement authorities [from three UK countries], 26 being local authorities and four CCGs
  • The Council involved itself in the NAS’ responses to events at Mendip House by creating and funding an operational Enquiry Team (three social workers and a learning disability nurse) in a process of scrutiny and review
  • Neither the history of safeguarding referrals nor CQC inspections at Mendip House revealed the cruelty of employees or the failures of management oversight. The CQC identified multiple breaches of the Health and Social Care Act (2008) (Regulated Activities) Regulations 2014 once it was alerted to the poor oversight of practice at Somerset Court
  • Residents’ care plans were wanting and yet there was no remedial action


2. The commissioning task is more than that of place-hunting: commissioners are the agents of people with autism and stewards of the public purse

  • Somerset Court is a dated, single-site “campus” model of service provision which sources residents with diverse support needs from around the UK
  • Decisions about continuing placements were not based on data such as what was being achieved with and on behalf of individual residents
  • It does not appear that the placing authorities asked searching questions about the benefits of residents being placed at Mendip House or receive detailed accounts of how fees were being spent on their behalf
  • Somerset County Council had to invest in an expensive and labour-intensive enquiry because of the lack of rigor and failures of judgement of commissioning professionals
  • In parallel with Somerset County Council’s lead with local authorities responsible for commissioning places at Somerset Court, NHS Somerset CCG assumed the lead as the coordinating Commissioner, negotiating with the five health bodies (in addition to itself), responsible for jointly commissioned placements
  • Social care and health care commissioners were broadly responsive to Somerset County Council’s steps to ensure the safety of Mendip House residents when it was revealed that the NAS was not delivering what commissioners believed they were purchasing. However, within six months of the whistle-blowing notification, commissioners decided that three Mendip House residents could remain on the campus
  • There can be no confidence that there is sufficient capacity in Speech and Language, psychology, behaviour support, learning disability nursing and psychiatry services to meet the needs of unknown numbers of adults who are placed outside their own localities. Thus far, there has been no conversation concerning the implications for local services


3. It is better to have a working knowledge of the remit, powers and enforcement resources of residential services, the local authority, the Care Quality Commission, Clinical Commissioning Groups and the police in advance of crises, however…

  • Two out of seven of the lead placing commissioners at Mendip House attended the learning event
  • There is a persuasive case for the regulation of commissioning
  • When there are multiple bodies commissioning a single service, a lead commissioner should assume responsibility for ensuring that individual resident reviews start with principles and make the uniqueness of each person the focus for designing and delivering credible and valued support
  • Commissioners should be required to notify the host authority of prospective placements
  • A new requirement to discontinue commissioning and registering “campus” models of service provision remains to be asserted by the regulator, and in the interim, there is a case for the Care Quality Commission to (a) make this fact explicit in its inspection reports; (b) undertake more searching inspections of such services; and (c) cease to register “satellite” units which are functionally linked to “campus” models of service provision
  • Since the “search costs” of information seeking, negotiating access, processing and storing are excessive, a means must be identified of aggregating information about provider services which is shared with the CQC and pooled with the host authority’s safeguarding referrals
  • The role of responsible or nominated individual in supervising the management of the regulated activityin respect of quality assurance and safeguarding remains to be set out for all provider services