CALLS for national change to the way patients are placed in care have been made following the publication of a damning report which highlights a culture of abuse at a Somerset care home.

The Somerset Safeguarding Adults Board will lobby the Government after the director of the National Autistic Society said he is 'desperately sorry' for the torment residents at Mendip House, in Brent Knoll, Highbridge, have been subjected to.

Mendip House was closed down by the society, which ran it, in 2016 after whistle-blowers reported a shocking catalogue of mistreatment of six vulnerable residents.

RELATED LINK: SHOCKING ABUSE: Somerset care home staff made residents crawl, threw food at them and made them pay for staff meals

A review by Somerset Safeguarding Adults Board into the goings-on at Mendip House revealed residents were forced to crawl around on all fours, pay for staff meals, had cake thrown at them and were bullied by a group of male carers.

At a media briefing today (February 8) led by Richard Crompton, chairman of SSAB, said the abuse of the residents was 'completely unacceptable' and said 'change needs to be made' across the country to the way patients are placed in care.

He said: "There was unprofessional and cruel behaviour from what is described as a gang of male employees. Action should have been taken by the National Autistic Society earlier.

"I see no way this will change without national action. I will be writing to the Department of Health and Social Care NHS England and other relevant authorities with the SSAB's recommendations to address abuse on a national level.

"Somerset County Council intends to take local action. "

RELATED LINK: No charges against care home staff after autistic resident was 'ridden like a horse', police say

The SSAB's recommendations to The Department of Health, NHS England and the Local Government Association are:

  • Prepare consultations to regulate commissioning; n include in those consultations the role of ‘lead commissioner’ who will assume responsibility for coordination when there are multiple commissioning bodies of a single service and 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;
  • Include in those consultations the expectation that commissioners must notify the host authority of prospective placements; n set out in guidance the remit, powers, structure and enforcement resources of all agencies immersed in the task of achieving better lives for adults with autism;
  • Assert a new requirement to discontinue commissioning and registering “campus” models of service provision
  • Assert a new requirement for (a) formal consultation with Local Authorities with Social Services responsibilities and Clinical Commissioning Groups regarding all planning applications for building residential services that would require registration with the Care Quality Commission to operate, and (b) to decline planning permission for types of service provision for which there is no local demand and which fail to “think small” and “think community.”
  • Fund essential monitoring and reviewing processes;
  • Fund residents’ access to local health services, most particularly community health services;
  • Identify a lead commissioner.

The Department of Health, NHS England and the Local Government Association be advised of the actions that Somerset County Council intends to take to address the detrimental persistence of “place hunting” by commissioners.

That is to require commissioners to:

  • Since it is unlikely that the Care Quality Commission would register this model of service now, Somerset Safeguarding Adults’ Board should write to the Care Quality Commission requesting that it (a) makes this fact explicit in its inspection reports; (b) undertakes more searching inspections of such services; and (c) does not register “satellite” units which are functionally linked to “campus” models of service provision
  • A Memorandum of Understanding is negotiated by Somerset County Council whereby the aggregate-level information concerning grievances, disciplinaries and complaints, for example, gathered by providers is shared with the Care Quality Commission and pooled with that of local authorities’ safeguarding referrals, the “soft intelligence” of Clinical Commissioning Groups, the police and prospective commissioners.
  • The “search costs” of information seeking, negotiating access, processing and storing are excessive – this is most particularly the case where Section 42 inquiries are invoked
  • The Care Provider Alliance, with the support of the Care Quality Commission and Skills for Care, issue its members with guidance on how the role of responsible or nominated individual in supervising the management of the regulated activity83 should be performed in respect of quality assurance and safeguarding.

In addition to the recommendations made by the report author the Somerset Safeguarding Adults Board has also agreed:

  • For the Somerset Safeguarding Adults Board to review assurance arrangements for all people currently placed outside of Somerset, and to monitor the implementation of any actions identified through this work.

Speaking to the County Gazette Mark Lever, director of the National Autistic Society, apologised to the residents and families affected by the abuse.

"I am desperately sorry, sorry doesn't seem to be a big enough word to explain how I feel," Mr Lever said.

"What the residents who abused went through affected was unacceptable and I would like to repeat my apologies to the residents and families affected by the abuse at Mendip House for the distress they have experienced.

"We want to reassure them that we share fully the commitment of the Somerset Safeguarding Adults Board to making sure that the lessons are learned and that improvements continue to be made across the country."

Mr Lever said he welcomed calls for national action to be taken.

"We welcome the SAR report’s recommendations addressed to national agencies aimed at improving and monitoring the safety and quality of care placements.

"All of us who provide and commission care services need to make sure we have the right staff and robust systems in place as well as being prepared to take swift action if there are any signs that standards are dropping."

Stephen Chandler, director of Adult Services at Somerset County Council, said he had a 'collection of emotions' after hearing about the abuse at Mendip House.

"I am really sorry that residents at Mendip House experienced the abuse they did and all the stress that comes with that," Mr Chandler said.

"I believe that the county council responded quickly so that an investigation was opened quickly into the abuse and alternative arrangements were made.

"I had a collection of emotions when I first heard about the abuse from anger and sadness but my first priority was making sure that the right action was taken to make sure the residents were safe.

"At the county council we are taking action locally to ensure patients not only in but outside of Somerset are reviewed to make sure they are getting the right care and are not overlooked.

"We welcome the recommendations put forward by SSAB."

Apologising to clients and their families on behalf of Somerset Clinical Commissioning Group, Deborah Rigby, acting director of quality and patient safety, said Somerset Clinical Commissioning Group (CCG) would like to apologise for “contributing to a failure to deliver” the necessary oversight of the health care provided to the residents of Mendip House in 2016.

She said: “The National Autistic Society recognised that failings in care were neither effectively dealt with nor escalated to the national regulator, the Care Quality Commission (CQC), or to commissioning organisations and as a consequence an 'uncaring environment' was able to develop.

“It is to Somerset CCG’s regret that false assumptions about the quality of care and specialist expertise being offered to residents contributed to a lack of scrutiny and delayed opportunities to safeguard residents from the uncaring behaviour of five NAS employees.

“The CCG has since acted on the key recommendations of the Somerset Safeguarding Adults Board and believes that standards of health care and safeguarding have significantly reduced the risk of such a situation occurring again.

“We would also like to commend the two staff members employed by the NAS who alerted national inspectors of the poor care of residents at Mendip House and prompted the 2016 investigation.”