The serious case review (SCR) into a Southern Cross nursing home where a coroner identified “institutional abuse” may uncover concerns about other homes run by the former provider giant.
That was the message from Nick Georgiou, who will chair the SCR into the Orchid View home near Crawley, West Sussex, where neglectful care led to the deaths of five residents, an inquest that concluded last week.
The coroner, Penelope Schofield, said she would have considered calling for a public inquiry into the case if not for the SCR, but said she would observe what happens with the case review and keep the option of requesting an inquiry “under constant review”.
Georgiou said that his review, commissioned by West Sussex Adult Safeguarding Board, could not examine whether Southern Cross was a “competent organisation” or whether anything in the running of the organisation contributed to the neglect uncovered at Orchid View.
But he said that the SCR may receive “bits of intelligence that are gained from other homes that Southern Cross was operating at the time if there was something serious going on”.
Georgiou said he was in no position to know whether that would occur but said he would discuss the possibility with the Care Quality Commission.
Collapse of Southern Cross
Southern Cross, which ran 752 care homes, collapsed in 2011 after it became unable to meet rental payments to the landlords who owned the homes it operated. Orchid View closed in October of that year after a CQC inspection uncovered significant care and safeguarding failings.
Given Southern Cross’s collapse, the review will receive no information or evidence from the provider responsible for running Orchid View. However, Care UK, which took over the home and reopened it last year as Francis Court, has indicated it would take part in the review. Francis Court is fully compliant with all standards the CQC has inspected it against.
Georgiou said the review would also examine concerns raised by Schofield that “many of those involved [in running Orchid View] are still working in similar roles in the industry. Georgiou said this part of the SCR would examine the role of nursing regulator the Nursing and Midwifery Council, the Disclosure and Barring Service (DBS), which can bar individuals from working with vulnerable adults, and its predecessor, the Independent Safeguarding Authority.
An issue raised by the inquest is how action can be taken against people not registered with a professional regulator like the NMC, not in a direct care role covered by the DBS and not registered with the CQC as either the registered manager or nominated individual responsible for the service.
Managers left company following review
Sarah O’Mara, the Southern Cross area manager who oversaw Orchid View, and Mark Cash, the company’s regional director for the South East at the time, were both subsequently taken on by Care UK. The company said both had now left Care UK after it initiated a review following the conclusion of the inquest “to address…any observations by the coroner that concern the conduct of any of Care UK’s current employees who were previously involved in the Southern Cross management structure responsible for the Orchid View home”.
Georgiou also said he would seek to speak to Lisa Martin, the Southern Cross business manager who blew the whistle on what happened at Orchid View, and who was strongly praised by the coroner. Schofield said: “I have to commend Lisa Martin for the courage in speaking out. Had she not done so then I really believe that what went on in Orchid View would have been swept under the carpet once the home had closed.”
Schofield criticised the role of the CQC, questioning how it gave Orchid View a ‘good’ rating in January 2010, shortly after it opened, and saying it should have taken tougher action after finding the home non-compliant with six standards at an inspection in June 2011. Witnesses told the inquest that Orchid View continued to deteriorate until a subsequent CQC probe – in September that year – forced its closure.
SCR will tie in with CQC review
The regulator’s chief inspector for adult social care, Andrea Sutcliffe, has announced a “thoroughgoing review” into its handling of the case.
Georgiou said “there would need to be a connection” between his review and Sutcliffe’s and would discuss with the regulator how this could be arranged.
The CQC is one of the organisations sitting on the SCR panel, alongside West Sussex council, Sussex Police, NHS commissioners and providers and the probation service. There is no organisation representing the independent care sector on the panel but Georgiou said he would be “more than happy to speak to any such organisation”.
Georgiou said he could not predict whether the review would uncover lessons for other care homes but there would “undoubtedly be common themes” in what it found that would resonate with the wider sector.
The formal terms of reference for the review would be released in the next few days, he said. It is due to report by next April.
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