Impact Training

"Hidden in Plain Sight"

Inquiry into disability-related harassment, published by the Equality & Human Rights Commission, 12th September 2011

"Several serious cases of abuse of disabled people - such as Fiona Pilkington and her daughter Francecca, who died in 2007 after suffering years of harassment - have been reported in the media over the last few years. Our inquiry shows that harassment of disabled people is a serious problem which needs to be better understood".

The inquiry looked in particular into ten cases in which disabled people have died or been seriously injured.

Click here to see the full report.

Key findings from the inquiry

• Public authorities were often aware of earlier, less serious incidents but had taken little action to bring the harassment to an end
• Many of the victims were socially isolated which put them at greater risk of harassment and violence
• Left unmanaged, non-criminal behaviour and "petty" crime has the potential to escalate into more extreme behaviour
• Public authorities sometimes focussed how the victim could avoid being harassed, rather than how the perpetrator could be made to stop harassing them
• There was often a failure to share intelligence and co-ordinate responses across different services
• Disability is rarely considered a possible motivating factor in crime and anti-social behaviour

Seven core recommendations

• There should be real ownership of the issue in organisations critical to dealing with harassment
• Definitive data should be available which spells out the scale, severity and nature of disability harassment
• The criminal justice system should be more responsive to victims and disabled people
• We should have a better understanding of the motivations and circumstances of the perpetrators
• The wider community should have a more positive attitude towards disabled people
• Promising approaches to preventing and responding to harassment should be evaluated and shared
• All frontline staff who may be required to recognise and respond to issues of disabled-related harassment should receive effective guidance and training

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CQC investigation of Castlebeck Care Group

Investigation of 23 services run by Castlebeck. Report published by the Care Quality Commission on 28th July 2011.

The CQC found serious concerns at four services, whilst a further seven services were failing to comply with one or more essential standards.

Click here to see the full report.

Main failings

• Lack of training for staff
• Inadequate staffing levels
• Poor care planning
• Failure to notify relevant authorities of safeguarding incidents
• Failure to involve people in decisions about their care

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CQC report into Winterbourne View Care Home

Investigation by the Care Quality Commission following undercover filming on the BBC's Panorama programme which showed residents being verbally and physically abused by members of staff. The report was published on 18th July 2011.

"The report concludes that there was a systemic failure to protect people or to investigate allegations of abuse. The provider (Castlebeck) had failed in its legal duty to notify the Care Quality Commission of serious incidents including injuries to patients or occasions when they had gone missing".

The result of the report was that Winterbourne View was closed down with immediate effect.

Click here to read the full report.

The main findings of the report

• The managers did not ensure that major incidents were reported to the Care Quality Commission as required.
• Planning and delivery of care did not meet people's individual needs.
• They did not have robust systems to assess and monitor the quality of services.
• They did not identify, and manage, risks relating to the health, welfare and safety of patients.
• They had not responded to or considered complaints and views of people about the service. 
• Investigations into the conduct of staff were not robust and had not safeguarded people.
• They did not take reasonable steps to identify the possibility of abuse and prevent it before it occurred.
• They did not respond appropriately to allegations of abuse.
• They did not have arrangements in place to protect the people against unlawful or excessive use of restraint.
• They did not operate effective recruitment procedures or take appropriate steps in relation to persons who were not fit to work in care settings.
• They failed in their responsibilities to provide appropriate training and supervision to staff.