Serious case review to commence into neglect that contributed to care home deaths

Care Quality Commission chief inspector Andrea Sutcliffe launches separate inquiry into regulator's monitoring of Orchid View care home in West Sussex

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A serious case review (SCR) will be launched into agencies’ role in safeguarding residents at Orchid View nursing home, after a coroner ruled that neglect had contributed to five deaths there.

The terms of reference for the SCR – which will be commissioned by West Sussex Adult Safeguarding Board – are due to be decided today.

The Care Quality Commission has also launched its own review into its monitoring of Orchid View, was run by Southern Cross, closed in 2011 and has since reopened under the management of Care UK.

The inquest examined 19 deaths at the home and West Sussex coroner Penelope Schofield found that neglect had contributed to five of these:

  • Wilfred Gardner, about whom the coroner found that the home failed to provide for his nutritional needs and failed to prevent his necrotic wounds from becoming infected;
  • John Homes, whose nutrition, hydration and medication needs were not managed by the home;
  • Enid Trodden, whose medication needs, dehydration and weight loss were not properly managed by the home;
  • Margaret Tucker, whose medication needs and pain relief were not well managed;
  • Jean Halfpenny, who died after overdosing on the blood-thinning drug, warfarin.

Schofield found that staff at Orchid View fabricated the medication administration record sheet to cover up the error.

West Sussex council’s director of adults’ services, Amanda Rogers, said: “This was a shocking example of poor care and West Sussex County Council is pleased that it has been exposed. As the inquest has made clear these were serious cases and families had every reason to expect better.”

She said the council, in its safeguarding role, took “all possible measures” to rectify what happened at the care home in Crawley as soon as it became aware of the severity of the problem.

Southern Cross opened the 87-bed home in 2009 and it was given a ‘good’ rating by the CQC in January 2010, after an inspection described it as being a a “well-maintained home”, where staff were knowledgeable about residents and complaints responded to promptly.

A subsequent inspection in June 2011 found the home was not complying with six standards – including on levels of staffing, medication management and meeting nutritional needs – but did not cover serious failings. The CQC returned to inspect the home later that year and found major failings against eight standards, with residents left at risk of serious neglect due to poor continence care and pain management, and failure to tackle the risk of choking. It found there were not enough staff on duty to meet residents’ needs and inadequate training and management. The home closed in October of that year, shortly after the publication of the last inspection report.

CQC chief inspector of adult social care Andrea Sutcliffe said: “We need to learn lessons from what happened at Orchid View, which closed in 2011. I will personally oversee a thorough review of our actions in relation to Orchid View to make sure we learn from it and build any findings into our new way of inspecting.”

The home, now named Francis Court, was given a clean bill of health at its last inspection in May, meeting all five standards that it was inspected against, including on safeguarding.

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