Castlebeck

The people who used the service at Winterbourne View did not receive effective, safe and appropriate care, treatment and support that meet their needs and protected their rights. This is because the quality of information recorded within care plans was poor, and was not person-centred. There was a lack of understanding of the complex needs of people and the planning and delivery of care and treatment did not ensure the welfare and safety of people.
Injuries to people who used the service and subsequent accidents and reports were not followed up. Records evidenced a lack of prompt medical attention, including a lack of wound management and a lack of support and intervention to prevent self-harming or attempts by people to take their own life. Proper steps were not taken to ensure each service user was protected against the risks of receiving care or treatment that was inappropriate.
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