We carried out this investigation into Sutton and Merton Primary Care Trust, after the trust contacted us about a number of serious incidents in its service for people with learning disabilities.

We found that, in most cases, the trust had followed the correct procedures for protecting vulnerable adults when responding to these serious incidents.

However, the investigation found that some of the environments in which people lived were impoverished and completely unsatisfactory. Staff were not properly trained or supported to provide an acceptable level of care, and inadequate levels of staff meant that people were often left each day with little to occupy their time. There were failures in management and leadership at all levels.

Our follow-up report in June 2008 showed that the trust had made considerable strides in modernising its services. It had improved the safety for its service users and strengthened its senior management team.

More information

Further information on the investigation is available in the publications listed below:

• Investigation into the service for people with learning disabilities provided by Sutton and Merton Primary Care Trust
• Summary: Investigation into the service for people with learning disabilities provided by Sutton and Merton Primary Care Trust
• Easy read summary: Investigation into the service for people with learning disabilities provided by Sutton and Merton Primary Care Trust
• Action plan Sutton and Merton PCT response to Healthcare Commission investigation
• Sutton and Merton Primary Care Trust: Review of progress
• Sutton and Merton Primary Care Trust: Review of progress (Easy read summary)