• Review of Whorlton Hall care scandal says CQC “wrong” not to publish critical 2015 inspection
  • Decision was “missed opportunity” to highlight failings at the now-closed hospital
  • Whistleblowing processes among seven changes recommended by review

The Care Quality Commission has pledged to overhaul its whistleblowing procedures after a report described as “wrong” its decision not to publish a critical inspection report about Whorlton Hall — years before alleged abuse was revealed there.

An inquiry has found the CQC’s decision not to publish the 2015 report was a “missed opportunity” to record serious failings at the County Durham hospital four years before a BBC Panorama investigation appeared to show patients with learning disabilities being abused.

The independent review by David Noble QSO — published on Wednesday — has told the care watchdog to make sure its internal investigation procedures are “truly transparent” by reporting any changes made back to complainants.

The review said people who had not raised their concerns through the CQC’s ‘Speak Up’ internal review process had frequently told Mr Noble they had a “lack of confidence in actual change happening”.

It comes after former inspector Barry Stanley-Wilkinson resigned in 2016 after raising concerns that his original report, which rated Whorlton Hall as “requires improvement”, was not published.

The CQC has also been told to improve its systems which pull together information about a service, consider producing legal advice on publishing reports, and to review its quality and assurance processes and its approach to handling complaints by providers.

Ted Baker, chief inspector of hospitals, said the CQC will implement recommendations of the report in full.

He told a board meeting on 22 January: “We are determined to improve the way we regulate, inspect and identify poor care and abuse in these closed environments.

“It’s important we remember that the model of care is fundamentally something that needs to be addressed.

“[This] model of care [has] been allowed to last for too long in the system.”

The original report did not find evidence of abuse of patients at Whorlton Hall, but did identify failings by the provider to properly manage the care and safety of people admitted to the hospital.

Peter Wyman, chair of the CQC’s board, said the report “makes pretty uncomfortable reading”.

He said: “It’s clear that although abuse was not identified in 2015, we let people down in Whorlton Hall by not understanding sufficiently the environment was such that abuse could happen.”

The Noble report said the decision not to publish Mr Stanley-Wilkinson’s original report was compounded “by the failure to then publish the report as recommended by the (CQC’s) internal reviewer”.

“Those decisions were a missed opportunity for CQC to publicise that the care and safety of patients at Whorlton Hall were indeed, not good,” Mr Noble said.

The CQC rated Whorlton Hall “good” following an inspection in March 2016. At the time, the CQC explained “there was concern about the August 2015 inspection and not enough evidence was gathered”.

But the Noble review said: “I have not had explained to me, in any satisfactory and documented way, a detailed and persuasive justification for that decision not to publish (the original report).

“Nor have I received any clear and detailed analysis of the faults in that draft inspection report which were considered so fundamental that they justified the decision not to publish it.”

The draft report was eventually published in June 2019 — a month after the Panorama documentary was first aired.

A separate report on the CQC’s regulation of Whorlton Hall between 2015 and 2019 — being undertaken by clinical psychologist Professor Glynis Murphy — is due to be published later this year.