We are deeply sorry for the appalling and cruel behaviour of our former staff at Mendip House, a residential service – now closed – run by the National Autistic Society in the South West.

We apologise without reservation for the failures at Mendip House and for not spotting them and putting them right as quickly as we should have. We have since done all we can to ensure this cannot happen again.

We know many of you have questions about how this situation occurred and what we have done. Here you can find:

• Our Chief Executive, Mark Lever’s apology to the people living at Mendip House and their families
• Frequently asked questions, including why no one was prosecuted
• A timeline of events
• An explanation of what we have done since closing Mendip House
• Mendip House: Learning the lessons – report of a consultation event to discuss the actions our charity had taken and what else we and other providers could do

You can also go to other pages to find out about: 

Details of the action CQC took in March 2019

Details of the CQC report on Mendip House, published in August 2016

If you have questions that aren’t answered here, please contact us on nas@nas.org.uk.

Our Chief Executive has apologised unreservedly for what we allowed to happen at Mendip House: 

Mark Lever, CEO at the National Autistic Society said, “We want to run the best possible residential services for autistic people, where they are safe and can thrive. We are very sorry that in May 2016 it became clear that we had failed to achieve this for the people living at our Mendip House care service, who were not shown proper care and respect and were mistreated by a group of our staff.

“When people raised the alarm to our charity and to other agencies, we took immediate action to make sure residents were safe and to investigate what went wrong. We brought in different staff, who knew the people living in the house, to ensure they were well supported. We also disciplined and then dismissed staff. After deciding to close the service, we supported families and their home local authorities while they found the six residents alternative places to live, helping them through what could have been a difficult transition to their new homes when Mendip House closed at the end of October 2016. 

“All the agencies involved have worked hard to prevent this happening again. Since this situation first came to light almost two years ago, we have continued to examine and improve our own practice. Somerset County Council set up an intensive enquiry to investigate what had happened which, alongside our and other agencies’ input, has fed into the Somerset Safeguarding Adults Board (SSAB) Safeguarding Adults Review (SAR). 

“We welcome the SAR report’s recommendations addressed to national agencies aimed at improving and monitoring the safety and quality of care placements. All of us who provide and commission care services need to make sure we have the right staff and robust systems in place as well as being prepared to take swift action if there are any signs that standards are dropping.

“We want to take this opportunity to repeat our previous apologies to the residents at Mendip House and to their families for the distress they experienced. We want to reassure them that we share fully the commitment of the Somerset Safeguarding Adults Board to making sure that the lessons are learned and that improvements continue to be made across the country.”

Frequently asked questions

Why was no one prosecuted?

• The decision to prosecute rests with the police and the Crown Prosecution Service. We co-operated fully and shared all relevant information with a lengthy police investigation. The police in the end took the decision not to prosecute. Avon and Somerset Police Service have explained: “Allegations of abuse against vulnerable people are always considered against the highest public interest threshold, but on this occasion the evidential test required to bring criminal charges was not met.”
• We supported multiple investigations into Mendip House by the Care Quality Commission, police and other agencies. This included a criminal investigation the CQC rightly initiated in June 2018 into financial abuse at Mendip House, where staff had got the people they were supporting to pay for meals when out on trips. 
• In January this year, the CQC took action against our charity by issuing us with a Fixed Penalty Notice of £4000 because of the failure to comply with regulations which ‘ensure systems and processes must be established and operated effectively to prevent financial abuse of service users’. We have accepted and paid this penalty notice.
• At the time when the allegations were first raised at a national level, we reported the staff involved in these investigations to the Disclosure and Barring Service (DBS) as unfit to work with children or vulnerable adults. The DBS decide whether they are added to their ‘barred’ list.
• Further, anyone applying to work with children and vulnerable adults has to have an ‘enhanced’ DBS check, where checks include any additional information held by local police that they decide ought to be disclosed.
• There is more information about DBS checks on the GOV.UK website. 

Was there a cover up?

• There has been no cover up or attempt by our charity to hide what happened at Mendip House.
• Since the situation first came to light at a national level in May 2016, we have publicly apologised and taken responsibility for what happened.
• At every stage we have supported the investigations into Mendip House by the Care Quality Commission, the police, the Somerset Safeguarding Adults Board throughout their Safeguarding Adults Review (SAR) and other agencies.
• As the appalling situation and subsequent investigations developed, we have always aimed to be as open as possible with the people we support and their families.  
• The SAR report rightly identifies failures of local staff and managers to follow proper practice and procedures, including ensuring they report incidents consistently and follow up on action plans. This was an important failure but it does not amount to a cover up.
• We have since tightened up how these systems work and this would not be allowed to happen now.

What about your other services?

• Our adult social care services are rated above the national average by the Care Quality Commission.

83.79% good    (71% nationally)
13.51% requires improvement  (21% nationally)
0% inadequate  (2.9 % nationally)
2.70%  not yet inspected

• We want all of our services to be good or outstanding and have action plans in place for all services that are rated anything below ‘good'.

Why do you run campus-style services?

• We wouldn’t set up campus-based provision now. Mendip House was part of Somerset Court, which was one of the first residential services for autistic adults in the UK and was set up in the 1970s.
• There is no evidence that the problems at Mendip House were linked to it being a campus-style service. Many of the risks around campus provision aren’t necessarily related to the scale of the service – it’s often more about issues of isolation from care managers, family and the community, which can happen in any setting.
• There are many separate homes at Somerset Court, rather than any single large-scale dwelling. For people living there, it is not an institution but their home, where their individual needs and wants should be properly considered. Six people or fewer live in each house. We make sure that we provide the support those people need as individuals, with individual support, communication and behaviour plans.

Shouldn't you install CCTV?

• The decision whether to use surveillance is for care providers, like us, to make in consultation with the people who use our services, their families or carers and with staff.
• The legal framework requires that any use of surveillance in care services must be lawful, fair and proportionate – and used for purposes that support the delivery of safe, effective, compassionate and high-quality care.
• There are other, less intrusive steps that we can take to make sure that care is high quality and safe. We believe these are more appropriate given that the services we provide are people’s homes. Instead of CCTV, we are focusing on:
  • Making sure we have capable and confident staff on duty with the right mix of skills.
  • Encouraging an open culture, where staff and the people who use our services are able to raise any concerns, and ensuring that those concerns are addressed.
  • Ensuring supervision and appraisal are used to develop and motivate staff and, where required, review their practice or behaviour. 

Timeline of events at Mendip House

May 2016 onwards

• In May 2016, a member of staff alerted us and, a few days later a second member of staff informed the CQC (Care Quality Commission), about abusive and unprofessional behaviour by members of staff towards the people we supported at Mendip House. These are the extremely distressing accounts of abuse which were later detailed in the Safeguarding Adults Review report (initiated in March 2017 and published February 2018).
• In May 2016, we immediately made sure everyone living at Mendip House was safe and properly supported by staff who knew them and their needs well. We reported the allegations to the CQC, Somerset County Council, and the police. The staff responsible for the abuse were immediately suspended and a disciplinary investigation started, which resulted in their dismissal.
• In May 2016, we undertook a full review of all previous safeguarding alerts and supplied this to the CQC. The CQC inspected Mendip House. Somerset County Council, as the agency responsible for safeguarding in the area, started a safeguarding inquiry process, including placing a team at Somerset Court for several months.
• In June 2016, we calculated then repaid the money taken from the people who lived at Mendip House by staff who had been getting them to pay for their meals.
• In July 2016, we took the difficult decision to close Mendip House because of the depth of the problems we had discovered there.
• In August 2016, the CQC published their report, which found the service inadequate in all areas. We apologised publicly and acknowledged that we’d 'failed badly’ at Mendip House.
• In early November 2016, Mendip House closed, after the last of the people who had been living there moved to their new home. 
• In March 2017, the Somerset Adult Safeguarding Board commissioned the Safeguarding Adults Review (SAR). We worked with the review author, council staff, the Care Quality Commission, the Clinical Commissioning Group and the police to contribute to lessons learnt from what had gone wrong at Mendip House.
• In February 2018, The Safeguarding Adults Board published the SAR report.
• In January 2019, the CQC served our charity with a Fixed Penalty Notice, following an investigation into the financial abuse at Mendip House.

Before May 2016

• All the incidents at Mendip House going back to 2014 had been reported locally. All but one incident had also been reported to Safeguarding at the Council and/or to the Care Quality Commission. However, they should often have been reported to both, and incidents were not reported as they should have been to all external agencies.
• There was a serious incident in November 2014, comparable to the kind of abuse that prompted the whistleblowing in May 2016. This was fully reported, and our investigation and response shared and agreed with other agencies.
• What happened to the people at Mendip House showed our reporting and monitoring systems weren't good enough.
• Also, the quality of our own investigations was not good enough, and each allegation was taken separately and not followed up nationally. Neither our charity nor external agencies joined up the separate incidents to get the full picture.
• That is why we now: collate and cross check different reports on staff and service performance; ensure all concerns are reported externally; produce more robust action plans; and escalate concerns rapidly to a national level in the charity if they aren’t dealt with in the appropriate timeframe.

What we have done since closing Mendip House

• From when the situation at Mendip House first came fully to light in early May 2016, we’ve worked to understand what went wrong and introduce the necessary changes to stop this happening again.
• We don’t believe that what happened at Mendip House represents the experience of the people we support in our other services, nor the attitudes or practice of our staff. Our adult social care services are already rated above the national average for services, and we want them to be even better.
• What happened at Mendip House was a combination of cruel and unprofessional staff practice and a failure to spot this and put it right quickly. To prevent this happening again we have:
  • Put in an independent whistleblowing line so that staff can confidently report any concerns, even where they don’t feel they can report it within the service. We’ve seen a significant increase in staff awareness of how to whistleblow in our independent staff survey. We continue to prioritise to all our staff their responsibility and the vital importance of reporting any concerns.
  • Increased proactive contact with family members of the people we support so that we can pick up on even minor concerns.
  • Started more in-depth data analysis so that we look at data on safeguarding, staff retention, complaints, disciplinaries and other indicators in the round and report on trends in services. In this way, we can pick up on minor changes and intervene early if there are any concerns.
  • Co-opted independent, experienced safeguarding professionals (including an ex-director of adult social services) onto our Services Quality and Development committee.
  • Begun the process of creating an independent safeguarding panel, in addition to our Services Quality and Development committee, to make sure that all safeguarding issues get properly scrutinised and dealt with.
  • From the autumn of 2016, introduced a ‘lessons from Mendip House workshop’ for frontline staff and managers. It shows what can go wrong and brings starkly to life the necessity of all staff and managers taking responsibility and acting when they see practice deteriorating as it did at Mendip.
  • Strengthened our quality improvement teams in each area of the country– these now include autism practice facilitators, positive behaviour support co-ordinators, learning and development staff, and health and safety trainers.
  • Improved our culture and worked to embed our values in our workforce, for example through values-based recruitment and reflective supervision. Although this will take time, we’ve already seen in our Oct 2017 independent staff survey a 13% increase year-on-year in those agreeing that: ‘Our charity has strong values which are put into practice’.
  • Audited all our policies so that they are clearer and are more closely monitored.
  • Improved investigations training so that managers are better able to conduct rigorous investigations if there are any concerns about our practice.

Mendip House: Learning the lessons (added 16 October 2019)

We organised a consultation event to talk about what actions we had taken, what else we could do and the principles that participants thought all social care providers should follow. The event was attended by autistic people, family members, other providers, representatives of the statutory sector and other autism professionals. You can download and read a report of discussions at the event in online and printed format here:

• Read the report online
• Read the print-friendly report