Following a Serious Case Review in relation to Orchid View carried out by West Sussex Adults Safeguarding Board, the Care Quality Commission (CQC) has today published its own report.
The reports follow an inquest into the deaths of 19 people living at Orchid View care home last year. The coroner found that neglect had contributed to the deaths of five residents with other residents suffering ‘sub-optimal’ care.
Andrea Sutcliffe, the Care Quality Commission’s Chief Inspector of Adult Social Care, said: “I was appalled by the descriptions of what had happened at Orchid View.
“Today’s Serious Case Review once again shows what a truly tragic situation this was and my thoughts remain with the people who suffered such awful care and with their families. The Serious Case Review shows the primary responsibility for these failings rests with the people providing services at Orchid View, together with their owners Southern Cross.
“When things go wrong in health or social care services, families affected want to make sure that others do not have the same experience. To do this, we need to be honest about our mistakes, be clear about changes that are needed and then make sure they happen.
“At CQC we made a commitment to take a long, hard look at our role, make sure lessons were learned – and most importantly – turn those lessons into action. 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.
“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, 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.”
