A serious case review carried out after a whistleblower alerted Cornwall Council to problems at the John Daniel Centre in Penzance has highlighted a raft of failings.

The review says that "multiple serious concerns" were raised by a whistle blower and others, warning of alleged substandard care at the day care facility.

These concerns ranged from alleged incidents of physical and wilful neglect, to incidents of humiliation, ostracising, favouritism, inappropriate communication, rough handling and also a deliberate exposure to a service user to an item of which he was known to be phobic.

There were also allegations around the service being run for the staff at the day centre rather than being person centred toward those using the day centre.

The information was reviewed by senior managers in HR and senior management in commissioning and there were thirteen immediate suspensions of staff . Two further suspensions followed. Five of those suspended were later arrested and released on bail. 

The review says that the sequence of events from allegations being made by the whistle blower and then to suspension and an internal investigation did not follow the correct procedure and contravened the Council’s own policy for managing serious concerns around staff.

The police became aware of staff suspensions through the media and the safeguarding concerns were not raised as a priority. 

The "gist of the concerns" involved allegations of wilful neglect; an unsafe environment; lack of effective care planning and care delivery resulting in poor and unsafe service delivery; lack of sound management and supervision; disrespectful communications towards those who use the service; poor or no choices offered for activities and running the service to suit staff.

Senior management did raise a safeguarding alert when informed of these allegations but not immediately as is should be the case. 

The review adds that the state of the buildings and environment at the centre shocked the interim management staff. with here was damage to the internal and external aspect of the building, the windows looking into the office were boarded up so no one could see into the office.

The building was in a state of disrepair, toilets were broken, there was dried faeces on one of the toilet walls, and old, used incontinence pads piled in a corner in one toilet area, supplies piled up in various places and precariously placed on high shelves.

The kitchen was dirty and unhygienic and some way off being fit for purpose on health and safety grounds. Some of the furnishings in the communal areas were stained and worn and the whole day centre was reported to be darkly lit and in serious need of maintenance and decoration. 

The police did charge three members of staff in relation to events but the criminal proceedings were halted after a decision was made that the evidence would not be sufficient to meet the criminal burden of proof. All three denied ill-treating people in their care.

 Jack Cordery, Cornwall Council’s lead for safeguarding, said: “We have already learnt important lessons from the events of 2011 and, since then, staff have worked extremely hard to improve the quality of practice and the experience of people using the John Daniel Centre.  The managers and staff who have stayed with us and those who have joined the team have much to be proud of.

“We have looked at the findings of this review as part of our ongoing efforts to keep learning and to improve the quality of the services we provide and outcomes for service users, both at the John Daniel Centre and the other Council run day centres in Cornwall. In our response to the review findings we are taking a number of additional actions to further improve the quality of services.  These have been shared and agreed with the Safeguarding Adults Board. 

“Service users and their families and carers, as well as other stakeholders, will all be involved in any future review of services provided by the Council and we look forward to working with all partners to ensure that we provide the best possible care and support.”