Orchid View care home review makes 30 recommendations to prevent future abuse

The Serious Case Review into the abuse and neglect that contributed to the deaths of five elderly people at the Sussex care home, has made 30 recommendations to prevent a repeat of what the Department of Health called ‘truly appalling’ care.

At an inquest last year into the deaths of 19 former Orchid View residents, a coroner described a culture of ‘institutionalised abuse’.

West Sussex coroner Penelope Schofield concluded five deaths at the care home were contributed to by neglect and in all 19 cases examined, the care residents were given, was described as ‘suboptimal’.

Nick Georgiou, former director for adult services of Hampshire County Council, was commissioned by West Sussex Adult Safeguarding Board to chair a Serious Case Review into the abuse and neglect at the care home.

He said: “Undertaking this Serious Case Review into what happened and how to guard against future failings was complex. It was not designed to place blame on any organisation or individual. However, it does not shy away from criticising organisations that could and should have done better.

“The report’s recommendations are intended to promote service quality and improved information to the public and stronger accountability drawing on the practice, management and scrutiny of Orchid View to improve such services into the future.”

Residents given wrong doses of medication, left soiled and unattended

The five-week inquest which concluded on October 18 last year heard from witnesses who described scenes of patients being underfed and locked in their rooms, unsafe staffing levels and medical records being changed to cover up medication errors at the Copthorne home, which was run by Southern Cross and closed down in October 2011.

Residents were given wrong doses of medication, left soiled and unattended due to staff shortages and there was a lack of management. Call bells were often not answered for long periods or could not be reached by elderly people, and the home was deemed "an accident waiting to happen".

The 30 recommendations, which have been welcomed by West Sussex County Council, include the Care Quality Commission (CQC) making it public on its website if a care home has no registered manager.

Providers should also have to demonstrate to the CQC that they have established training, appraisal and supervision processes in place and NHS England should issue GPs with clear guidance on their responsibilities to care homes.

Care providers should also hold regular open meetings with relatives of residents to discuss any concerns and relatives should always have a named point of contact within homes and concerns relating to safeguarding issues should be escalated outside the home if they are not dealt with promptly and properly.

West Sussex County Council calls abuse 'harrowing'

Peter Catchpole, West Sussex County Council’s Cabinet Member for Adult Social Care and Health, called the abuse and neglect at Orchid View “harrowing”.

He said: “There is nothing more important than looking after the most vulnerable people in our society and in this respect Southern Cross Healthcare has been judged to have failed. Statutory agencies such as West Sussex County Council had no choice but to take action to investigate and ultimately move people from the home to protect them.

“Nothing will help ease the pain of the families who were affected by these terrible events and who lost loved ones. I want to offer them my condolences and assure them that we will act on the recommendations made in this report and do all we can to ensure that the other agencies involved in managing and regulating the care of our elderly relatives do the same.”

Judith Wright, chairman of the West Sussex Adult’s Safeguarding Board, said in response to the report.

“We welcome this report and its recommendations. We know that, for the families of residents in the home, nothing can bring back the people they loved and lost. However, we will work with other organisations to ensure that the recommendations outlined in this report are adopted.”

CQC admits it did not act on early warning signs

Andrea Sutcliffe, the Care Quality Commission’s chief inspector of adult social care, admitted that the CQC “did not fulfil our purpose of making sure Orchid View provided services to people that were safe, compassionate and high quality.

“The way we worked when these serious incidents happened meant we did not respond to early warning signs, we were too easily reassured by the responses of Southern Cross and the people who worked there – and we did not take appropriate enforcement action quickly or strongly enough.

“Since then, a great deal of work has been done to drive forward significant and sustained improvements on many issues we identified as areas of concern – and we are changing for the better.

“CQC is now more responsive to safeguarding and other notifications of risk; our inspection techniques have improved; we have additional money which we are using to appoint more inspectors and better training has been provided in relevant areas.”

However, she added: “There is more we can and should do, and our new approach to the regulation and inspection of Adult Social Care is designed to do just that.”

The families of some of the residents who died have spoken out in the wake of the Serious Case Review.

Care home appeared to be one of the best yet was one of the worst

Ian Jerome, whose uncle Bertram died as a resident at Orchid View, said: “The key question we still have is why Orchid View could appear from the outside to be one of the best care homes in the country, when in fact it was clearly one of the worst. There needs to be a much better system for sharing information about care home standards and about the people who are working in and running them.

“It is really important to us that the recommendations revealed today become reality as soon as possible so that care homes can be improved across the country.”

Linzi Collings whose mother Jean Halfpenny died in 2010 after being administered three times her regular dose of the blood thinning drug Warfarin over the course of 17 days at Orchid View, said: “We welcome the Review’s findings and recommendations but still feel frustrated that there is still a lack of accountability for how severe the problems became before action was taken.”

Laura Barlow, a specialist medical negligence lawyer at Irwin Mitchell representing the families of Jean Halfpenny, Jean Leatherbarrow, Doris Fielding, Enid Trodden, Bertram Jerome, Wilfred Gardner and John Holmes, said: “The recommendations in the Review are comprehensive and apply to many different organisations both locally and nationally, but for real change to occur they must be delivered and there are questions over who will now drive these improvements and who is ultimately accountable not only for the neglect at Orchid View but at other care homes across the country.

“We still believe the horrific scale of neglect warrants a completely independent inquiry which would take into account this Review as well as pulling together all the organisations involved in safeguarding care to provide a true blueprint for change in reforming the whole care industry – this must be the lasting legacy of the Orchid View scandal.”

To read the full report go to www.westsussex.gov.uk/your_council/news_and_events/news/2014_archive/june_2014/orchid_view_serious_case_revie.aspx