They stated that: * There was a systematic failure to protect people in their care. * Castlebeck had failed it’s legal duty to notify the CQC of serious incidents including injuries and patients going missing. * Staff didn’t appear to understand the needs of the people in their care and some staff were too ready to use restraint without considering alternatives. * Background checks on staff weren’t carried out * Planning and delivery of care did not meet individual needs * They didn’t have good enough systems in place 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 ignored their own complaints procedures * Staff investigations were not robust * They didn’t have agreements in place to protect people against unlawful or excessive use of restraints.
The patient’s autonomy was in violation because he was not informed and has risked making a healthcare choice not reflective of his values or wishes. Contextual
Mr Bryan, a senior nurse, had alerted the care home’s management and the CQC on several occasions, but his concerns failed to be followed up. After considering a range of evidence, CQC inspectors found Castlebeck Care had failed to ensure That people living at Winterbourne View were adequately protected from risk, including the risks of unsafe practices by its own staff. It said: “There was a systemic failure to protect people or to investigate allegations of abuse. “The provider had failed in its legal duty to notify the Care Quality Commission of serious incidents including injuries to patients or occasions when they had gone missing.” It added that staff did not appear to understand the needs of the people in their care and said “some staff were too ready to use methods of restraint without considering alternatives”. The watchdog said the review began as soon as it found out Panorama had gathered evidence, including secret filming, to show the serious abuse of patients at the centre.
There was a failure of consideration when Proudfoot did not devise a system that would work and save money. Because of this failure of the consideration for the promise of Sanitary Linen to pay money, there was no basis for having made those payments. Consequently, Sanitary Linen was entitled to get its payments back. This can be seen by assuming that the service company had not paid anything and that instead of suing to recover payments it had made, Sanitary Linen was suing for breach of the contract to provide a better system. Here, it would be affirming that there was a binding contract, but insisting that the obligation of Proudfoot had not been performed.
When beginning the project, an Implementation plan was not made, and followed through. The change in leadership further effected the project success. The leadership that was chosen to finish caring out the project was not supportive, or inspiring of the team. This caused the development of the project to fail. The progress reports were not accurate, so rebuilding of the project was not
It also showed emotional and verbal abuse in the form of name calling. This was an inhumane and diabolic mistreatment of vulnerable individuals unable to defend themselves. Winterbourne appears to have made decisions based on profits and returns, over and above decisions about the effective and humane delivery of assessments and treatments. Where were the staff who should have been reporting these crimes to management , if management was not listening then they should have been reported to the authorities and organisations, such as social services and CQC that is what they are there for. Staff who had no involvement in the actions taken towards the residents, but failed to comply with the agreed ways of working and report what they knew was wrong is just as much to blame as those who were involved.
Ethical Issue: Before even beginning the project, Mr. Allison couldn’t keep his commitment in regards to meeting the temperature requirement. Mr. Allison was dishonest and to make matters worse he failed to voice his concerns. It was apparent that Gary was not truly on board with the project plans from the beginning and lack confidence to get the job done. Everyone on the team also did not communicate these issues with the client or stakeholders of the organization. Legal and Contractual Issues: SEC is guilty of legal and contractual issues in regards to the Orion Shield Project.
It was found that the sling loop fixings were wrongly adjusted and a safety pommel was not used. In this report the carers were
This directly resulted in lack of leadership and poor communication. Because we did not plan for such a disaster, roles and responsibilities were not clear, so response times were extremely poor. Local authorities did not prepare how they would get personnel and other resources out to vulnerable locations. Authorities waiting too long, planning on the spot, before taking decisive action. In the future, they must learn to proactively address critical needs.
The Department of Veterans Affairsfailed to handle the situation by not bringing in some of the world’s best information system personnel or qualified security personnel. The Department of Veterans Affairssecurity plan did not comply with the agency's own rules for securing data, and it improperly allowed the IT Specialist and contractor access to databases beyond the requirements of his job and the scope of his background check. It also concluded that the VA had failed to adequately supervise the IT Specialist and the contractor, whose actions had violated the Privacy Act as well as the Health Insurance Portability and Accountability Act of