Orchid View serious case review calls for more scrutiny of private care homes

Independent care home providers should subjected to much greater scrutiny, the serious case review into the Orchid View nursing home has recommended.

The review, launched in October after an inquest found that neglect at the West Sussex home had contributed to the deaths of five residents and that a further 14 had received ‘sub-optimal’ care, makes more than 30 recommendations including private homes being required to provide they can sustain a skilled workforce.

“It is right that the scrutiny and demands for improvement in the NHS are also expected from the independent sector,” said review author Nick Georgiou, the independent chairman at West Sussex Adult Safeguarding Board.

“As the role of independent sector care businesses has grown, the number, frailty and vulnerability of people dependent on their care has increased. It is critically important that these services demonstrate that they can provide the quality of care necessary. In this case the provider failed.”

It says that care providers should be required to demonstrate that they have robust plans for recruiting and sustaining a skilled workforce to the Care Quality Commission (CQC).

It recommends that West Sussex Adult Safeguarding Board creates a threshold and a system for alerting relatives about safeguarding concerns at homes so that they can make “informed choices” about where to place their loved ones.

The review also says the CQC should name homes that lack a registered manager on its website. “There was too much tolerance given to Orchid View as they operated without a registered manager for most of the time they were open,” says the review.

Georgiou added: “People were making crucial decisions about their care, or that of their relative, and did so without full information about the home, and were largely dependent on the services and self-proclaimed quality described in Southern Cross Healthcare’s own publicity.

“They were also ill-informed by the information on the CQC website and unaware of the concerns that the statutory sector had about the home. This was a particular problem for people paying for their own care.”

The serious case review also calls on the CQC to do more to get the views of relatives in its inspections, including providing them with the opportunity for private discussions about any safeguarding concerns they may have.

Council backs recommendations

The review also called on coroners who have concerns about deaths at care homes should report this formally to the police and inform adult social care departments of any safeguarding concerns they have.

Care homes should also be contractually obliged to display complaints procedures and information about neutral agencies like the local Healthwatch in prominent locations within homes, it added.

Councillor Peter Catchpole, the cabinet member for adult social care and health at West Sussex County Council, said: “We wholeheartedly support the recommendations made in this serious case review and want to see them acted upon so that individuals, private businesses and companies can be held to account when it comes to failings in care.”

Andrea Sutcliffe, chief inspector of adult social care at CQC, said: “We know from our own review that we 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.

“We will keep working hard to make further improvements in partnership with people running care services, local authorities and other agencies to ensure the recommendations of the serious case review are implemented.”

Families urge public inquiry

Irwin Mitchell, the law firm which is representing the families of seven former Orchid View residents, said the recommendations in the serious case review were welcomed but said a public inquiry was still necessary.

Laura Barlow, specialist medical negligence lawyer at Irwin Mitchell, 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.”

Linzi Collings, whose mother died in 2010 after being given an overdose of the blood-thinning drug warfarin while 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.

“That is why we support our lawyers in their calls for a public inquiry so that all organisations involved, including previous owners of Southern Cross, can be brought together in one place.”

Southern Cross opened Orchid View in 2009. It was rated as good by the CQC the following year but closed in October 2012, shortly after an inspection report found residents were at risk of serious neglect.