I don’t have any inside knowledge about whether there was a “cover up” at Care Quality Commission, but I note the reference to an internal report that was apparently suppressed because it would show the organisation in a bad light.

‘No one could be released for staff development because they were so short staffed’

I do however have experience of internal management reports which are not for public consumption, where managers say the unsayable with reference to cuts and closures, where managers make proposals for achieving savings they know the politicians will not entertain because they are too controversial, unpopular or embarrassing.

I also have experience of being told my report identifying serious concerns could not be made public because it would show senior managers in a very bad light and undermine the credibility of the organisation.

A leaderless organisation

The report identified a catalogue of service issues at a home for adults with learning difficulties. The manager had been suspended for over a year while police investigated allegations of inappropriate and sexual exploitation. The police investigation concluded there was insufficient evidence for a successful prosecution, mainly because they considered people with a learning disability to be unreliable witness. The home was subject to a staffing review which meant all staffing vacancies were frozen until it’s future was decided.

‘Incident reports showed almost daily incidents of aggression and violence towards staff’

The deputy was on long term sick leave and a number of inexperienced staff were acting up to cover. Vacancies in care posts meant that the home was only able to operate by excessive use of casual staff and overtime. Staff absenteeism levels were extremely high and morale was extremely low. To top it all one of the casual staff had blown the whistle on care practices, particularly around one of the more dependent residents.

The staff felt abandoned and leaderless and were criticised for their care of what they believed were aggressive and often difficult residents. They were unqualified and untrained. No one could be released for staff development because they were so short staffed.

Closure recommended

Incident reports showed almost daily incidents of aggression and violence towards staff. The reports had been diligently completed as staff were under the impression this was the only way certain residents would be transferred. The building was totally inappropriate for people with multiple disabilities: it had a split level ground floor and was a maze of extensions, making it very difficult to use staff appropriately and efficiently. Staff often worked alone in isolated parts of the building. Hence a lot of unorthodox and unauthorised methods used in the care and control of residents.

My report was made to the senior management team with a recommendation that the home be closed immediately and all the residents transferred. The staff to be offered redeployment or redundancy.

‘What were you thinking? No way could this report go to the board and become a public document’

To their credit that team accepted there had been a failure of leadership which had allowed a very unsatisfactory situation to drift and escalate. They accepted the recommendations. Any closure and subsequent transfer of residents had to be agreed by the board. So I was asked to write the report for the next board meeting.

I assumed that this was simply a case of a change to title, from “report to senior management team” to “report to board meeting”, and changing the formating to the standard style for such reports.

Politically sensitive

Two days later when I submitted my report to be signed off by the director before being circulated to board members I was surprised to be called in and asked: “What were you thinking? No way could this report go to the board and become a public document. You can’t criticise senior managers in this way, you would totally undermine the credibility of the department and publicly embarrass the board.”

I totally rewrote the report emphasising the unsuitability of the building for people with physical disabilities and challenging behaviour. The board accepted the recommendation to close. I don’t know how I would have responded if they hadn’t .

I learnt a valuable lesson about getting things done in the public sector.

I know it is not the same as what we are told happened at CQC − no one died in this instance − but it does illustrate how things work in a politically sensitive environment.