Action taken by CQC to protect people being cared for at 'Westgate College for Deaf People and the Road Project' in Margate

The Care Quality Commission (CQC) has set out the steps it has taken to protect the safety and welfare of young adults who were living at 'Westgate College for Deaf People and the Road Project' in Margate.

CQC took action to prevent John Townsend Trust from providing care at this location in response to significant concerns about the culture of this service, backed by evidence of people in vulnerable circumstances experiencing serious harm, identified by our inspectors, Kent County Council, and the police.

Since November 2014, CQC has been involved in regulatory and legal action aimed initially at securing improvement, and later in preventing the trust from providing accommodation, personal care and support at this location. This process was significantly complicated by the fact that the young people being cared for there had complex and profound disabilities which meant that they could not easily be moved, or cared for elsewhere.

Until now, CQC could not legally disclose the details of what we found, what actions we took and what prompted them. On 16 February 2016 – three months after we had taken legal action requiring residents to be moved for their own protection – the John Townsend Trust’s appeal was ‘struck-out’ by the First-tier Tribunal. This lifted the restrictions placed on us to share our reasons for taking this action. Now that the legal process has completed and following discussion with our partners we are now able to give details about our involvement and are duty bound to explain the reasons for the action we took.

CQC’s action was in relation to the trust’s provision of accommodation, personal care and support at ‘Westgate College for Deaf People and the Road Project’. It did not prevent the John Townsend Trust from continuing to provide services as a school, or from providing care from its other registered locations (St Gabriel’s House – Apartments and Dane End’ and ‘Westcliffe House’).

The Care Quality Commission’s Chief Inspector of Adult Social Care, Andrea Sutcliffe, said: "What we saw at ‘Westgate College for Deaf People and the Road Project’ – and what was reported to us – were shocking examples of institutionalised failings and abuse. Residents were physically harmed by the very people who should have been caring for them, and the leadership within the John Townsend Trust did not take sufficient steps to prevent this, or to tackle a culture where people in vulnerable circumstances were not protected.

"At the point we first took action against the John Townsend Trust - in November 2014 – we made it clear that their service was not meeting the needs of the young people that they were responsible for caring for. The fact that these young people had complex and profound disabilities meant that our decision about whether to start the process which would lead to the urgent closure of the service had to be balanced against the difficulties involved in finding alternative placements for them at short notice.

"The provider initially seemed to respond to our serious concerns and showed some improvement. However, as time went on, it became increasingly clear that its leadership was incapable of sustaining this improvement and providing safe, effective and compassionate care. The culture in the service was one of staff being in control and people being contained. Staff felt that since they were in charge, people using the service would have to fit in with what the staff wanted rather than people having a say and developing the support they needed to lead fulfilling, meaningful lives.

"While I can understand how distressing the closure was for the former residents and their families, I hope they can now see that their safety and wellbeing were what drove our actions at all times. The John Townsend Trust was given every opportunity and support to improve but failed to do so and it seriously let down the people in its care. We eventually concluded that the care at the college was so poor that it was essential to use our enforcement powers to the full so that people could be protected from harm given that its leadership was incapable of making the rapid and substantial changes required. I am sorry for the impact this had on the lives of the young people there and their families. They, and CQC, should never have been put into this position.

"Whenever we take action leading to the closure of any service, we always take into account the needs of the people who use the service but when we find such poor care and abuse which is not being tackled, as we did there, we have no choice but to act to protect the safety and welfare of people. Everyone who uses services has the right to expect safe, high-quality and compassionate care and we will do everything we can to make sure that happens."

Background to CQC’s involvement with Westgate College for deaf people and the Road Project

‘Westgate College for Deaf People and the Road Project’ was registered with CQC to provide accommodation with personal care and support in a further education setting for up to 55 people who had hearing, communication physical or learning disabilities. Separate to this, the college was also registered with Ofsted as a school, responsible for providing specialist education for deaf children.

CQC carried out inspections in March 2013 and March 2014, where the service was found to be meeting the standards it was inspected against. In June 2014, CQC began receiving safeguarding alerts regarding the service.

On 2 October 2014, CQC carried out an unannounced inspection in response to these safeguarding alerts. During this inspection, inspectors found evidence of abuse, including services being withdrawn from people to punish them for exhibiting challenging behaviours. It was reported that, when a resident ripped their t-shirt, a member of staff hit the resident with this, while reprimanding them for their behaviour and telling them that their activities would be withdrawn. We met with Kent County Council and the police to discuss our concerns.

Four staff members were suspended and subsequently dismissed after admitting to poor practice and abuse. The police investigated and presented a case to the Crown Prosecution Service, which concluded there was not enough evidence to bring charges against the staff. This case was also further reviewed after a complaint was made to the Independent Police Complaints Commission. No further charges were brought and this case was closed in December 2015.

CQC then made another unannounced inspection of ‘Westgate College for Deaf People and the Road Project’ on 14 November 2014. Inspectors found that the provider had taken little action since the last visit and that the action plan submitted was unreliable. Again, inspectors found evidence of abuse – including residents being ridiculed for their physical and learning disabilities. As a result, a number of staff members were suspended and some were later dismissed.

CQC alerted a number of other agencies to its serious concerns, and discussed the possibility of taking urgent action to immediately prevent the John Townsend Trust from providing personal care, accommodation and support at its Westgate College location. However, due to the complex and profound nature of the disabilities of the 52 residents, it decided to serve a Notice of Proposal (a longer route to cancel or amend a provider’s registration) instead, in order to allow the 21 placing authorities involved time to find alternative placements for the residents.

On 21 November 2014, CQC met with the John Townsend Trust’s leadership team to discuss the severity of the concerns. The trust did not dispute these concerns.

CQC served a Notice of Proposal to prevent the trust from providing regulated activities from this location on 2 December 2014. The John Townsend Trust then made representations about this Notice, and whilst these were being considered, new regulations were introduced by the Government which required CQC to re-register the John Townsend Trust so that it remained within the scope of regulation.

In April 2015 local authorities alerted CQC to concerns about staffing levels. In May 2015, CQC inspectors visited and found that some improvements had been made to ensure that people were safe.

However from July 2015, CQC was alerted to further safeguarding concerns and allegations of a very serious nature, which worryingly, the John Townsend Trust had not made CQC aware of. These included an allegation that a resident had had a hot cup of tea placed on their arm and was then goaded by a staff member: CQC understands this was the subject of a police investigation. Also, there was a separate allegation that a staff member had grabbed a resident around the neck and pushed their head down: CQC understands that a staff member was suspended and interviewed by police regarding this allegation but no prosecution was pursued due to lack of evidence.

In response to these safeguarding concerns CQC visited the location again on 5 November 2015 and found that:

• Vulnerable residents were not being supervised in a swimming pool (which was open to the public) and no lifeguard was on duty.
• The key to a fire exit had been lost, meaning that it could not be used.
• A cupboard which contained bleach and other hazardous chemicals had not been secured, making it accessible to residents.
• Serious medication errors had occurred, and had not been reported to CQC in line with requirements of the registration regulations, including a person being given too much insulin and a person given a double dose of sedative.
• There was no evidence that incidents were being recorded appropriately and being learnt from.
• Staff did not have an understanding of fundamental safeguarding procedures and when concerns should be escalated to the local authority.

Following this inspection, CQC met with representatives of the John Townsend Trust, including its Chairman and members of the Board of Trustees, to discuss its findings and its concerns. The Board did not accept the feedback or agree with the extent of the concerns and the risk these presented to people.

CQC wrote to all of the placing authorities and formally notified John Townsend Trust of its decision to amend its registration by removing ‘Westgate College for Deaf People and the Road Project’ on 19 November 2015.

CQC met with the families of those living there to explain this decision. However, as the John Townsend Trust was in the process of appealing CQC’s decision, CQC was limited in what it was legally able to disclose at this time with regards to what prompted its inspection and what it then found. A number of families expressed disappointment that the service would be closing.

On 20 November 2015, the 38 residents began to be moved from ‘Westgate College for Deaf People and the Road Project’ to alternative facilities, although some could not be moved immediately due to their complex needs. CQC ensured local authorities had time to make alternative arrangements due to the impact this would have on residents and their families.

On 7 December 2015, it was reported that the John Townsend Trust went into administration.

On 16 February 2016, the trust’s appeal against CQC’s decision to prevent it providing care and accommodation at ‘Westgate College for Deaf People and the Road Project’ was ‘struck-out’ by the First-tier Tribunal – meaning that CQC’s decision stands.