Our role in Winterbourne View and the changes we will make to protect people from abuse

Published: 7 August 2012 Page last updated: 3 November 2022
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7 August 2012

Our role and that of five other organisations involved in the events at Winterbourne View have been drawn together in the serious case review published today.

The serious case review looks at our role and that of Castlebeck Ltd, NHS South Gloucestershire, NHS South West, South Gloucestershire Council and Avon and Somerset Police during the events at Winterbourne View.

You can find the serious case review on South Gloucestershire Council's website.

After the events of Winterbourne View, we carried out a full review of our systems and processes that showed failings in the way we involved whistleblowers and processed the information they gave us.

We have already made significant changes to various areas of our work to ensure that we are better placed to respond to concerns of whistleblowers in order to protect vulnerable people.

Other changes relate to the way we:

  • follow-up on action plans when services aren’t meeting national standards.
  • build new ways to work with local safeguarding teams.
  • develop the way we analyse safeguarding alerts so we can spot trends in care.

Our role in Winterbourne View: Internal management review

Dame Jo Williams, CQC chair, said,  “Winterbourne View was a watershed moment for CQC.  We did not respond as we should have and we have offered our apologies to the patients and their families.

“We have been honest about our limitations at the time and willing to learn from them.  We carried out an urgent and thorough internal review to strengthen our processes and to ensure that we are better placed to play our part in protecting people in vulnerable care situations.”

Chief Executive David Behan said, “There is much for all the organisations involved with Winterbourne View to consider…I will ensure that the Care Quality Commission responds fully to all the recommendations for CQC. We will continue to work with other organisations to improve communications and sharing of information to ensure we all protect those who are most vulnerable.”

Find out more

Our internal management review sets out the results of our investigation in to our role in the Winterbourne View case and the changes we have made to our systems and processes to ensure we are better placed to respond to concerns.

Read the full press release:

CQC publishes report of investigation into concerns raised by Winterbourne View