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9 June 2014, 17:13 | Updated: 9 June 2014, 17:14
More than 30 recommendations have been made in a Serious Case Review (SCR) in a bid to prevent a repeat of the "institutionalised abuse'' which led to the death of five elderly people at a scandal-hit care home.
The inquiry was launched following an inquest held last year which found serious failings at the now-defunct Orchid View, labelled "Britain's worst care home''.
West Sussex coroner Penelope Schofield heavily criticised the quality of care at the Southern Cross-run home in Copthorne and identified failings such as a lack of respect for the dignity of residents, poor nutrition and hydration, mismanagement of medication and a lack of staff, she said.
Call bells were often not answered for long periods or could not be reached, and the home was deemed "an accident waiting to happen'', the inquest heard.
Ms Schofield said at the inquest's conclusion: "There was institutionalised abuse throughout the home and it started, in my view, at a very early stage, and nobody did anything about it.''
The SCR, commissioned by West Sussex Adult Safeguarding Board, has now made 34 recommendations in its answers to a series of questions asked by the family members of those who died at Orchid View on how care homes and their regulations can be improved.
One of the main recommendations is that it should be a requirement for care businesses to prove that they can recruit and sustain a trained and skilled workforce and that they can prove this to the Care Quality Commission (CQC) - the care watchdog and regulator.
Another states that relatives should always have a named point of contact within homes and that concerns relating to safeguarding issues should be escalated outside the home if they are not dealt with promptly and properly. And also the emergency services should have named contacts so that they easier access to care homes, particularly at night time.
Other recommendations include a call for care providers to be contractually required to hold open meetings with residents and their relatives on a regular basis to discuss issues of general concern and to make relatives aware of any significant safeguarding concerns in their home. The local authority should be invited to this and the minutes should be shared, the report states.
And it calls for residents to be involved in CQC inspections with opportunities for their relatives to meet and discuss the care home with the inspection team.
Also, the report makes the recommendation that West Sussex Adult Safeguarding Board should develop a threshold for informing the public about significant safeguarding issues and concerns that have been raised at homes. This would help people make informed choices about the homes they choose for their loved ones. The report states that organisations should make it very clear where and how this information can be accessed, known as a duty of candour.
Nick Georgiou, independent chairman of the SCR, said that he supported calls for the independent care home sector to be placed under the same scrutiny as care under the NHS.
Highlighting three main issues, he said: "Firstly, a number of the concerns identified in the recent past with hospital services in the NHS have been echoed at Orchid View and it is right that the scrutiny and demands for improvement in the NHS are also expected from the independent sector.
"As a result of the concerns about the NHS there have been recent government consultations relating to a duty of candour, the fit and proper person test, and a new offence of wilful neglect where people have mental capacity. This Serious Case Review wholeheartedly supports them being applied to independent sector businesses and organisations.
"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 service provider failed. A number of these recommendations are intended to promote strengthened scrutiny of organisations, and the services they provide.
"Secondly, 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.
"Thirdly, a great deal of work has gone into building this picture of the care at Orchid View and the volume of problems in the home. With the benefit of hindsight the pattern of safeguarding concerns is now clear, for example in regard to medication, and consistent failures by the people working in the home, and the senior management of Southern Cross Healthcare, to provide positive management and leadership. This was not the case for the social work and nursing staff involved at the time. Firm evidence and information about concerns, and the inability of Southern Cross Healthcare to follow through on remedial actions emerged piecemeal and as the safeguarding investigations ended Orchid View was closed.''
He added: "I want to acknowledge the information and understanding I gained from the families of former residents at Orchid View. I hope this report goes some way to addressing the serious and thoughtful questions they put to me based on their direct experience of the poor care their relatives endured.
"Finally, I want to say that it is not possible to say that this report or any other will prevent all future safeguarding alerts. It will not do that, but acting on the recommendations will lessen the risk to other residents in other settings. They also promote actions to support the statutory services and the service provider to respond constructively when there are safeguarding concerns to ensure safe and better quality services for people dependent on nursing care.''
Responding to the SCR, Peter Catchpole, West Sussex County Council's cabinet member for adult social care and health, said: "What happened at Orchid View was harrowing. We welcome this report and its recommendations. 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.''
At last year's inquest, the coroner questioned whether a CQC inspection which gave Orchid View a "good'' rating in 2010 - a year before it shut - was ``fit for purpose''.
And the coroner expressed incredulity that many staff were still working in the care industry, and that "there could be another Orchid View operating somewhere else''.
The inquest looked at the deaths of 19 pensioners at Orchid View after whistleblower Lisa Martin, an administrator at the home, contacted police to raise concerns about the standard of care.
The coroner ruled that all of these residents suffered "sub-optimal'' care. But five of the residents - Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77 - died from natural causes ``which had been attributed to neglect''.
The multimillion-pound home was said to have had a "five-star'' feel when it opened in September 2009 which ``seduced'' families into believing it was well run.
But one staff member at the #3,000-a-month home said: "It was like a car that looked good from the outside but it was knackered.''
Residents were left soiled and unattended due to staff shortages, while in a single night shift staff made 28 drug errors.
It was shut down in late 2011 after an investigation by the CQC. Bereaved relatives called on the Government to usher in "dramatic changes'' to improve care standards.
Linzi Collings, Mrs Halfpenny's daughter, said: "How the corporate failings of Southern Cross could create these events and how such terrible standards could go unnoticed by the authorities for so long has left us baffled.
"In this day and age you expect measures to be in place to protect vulnerable members of society from being subjected to such horrendously poor care.
"We believe dramatic changes are needed to the current care system, starting firstly with greater accountability for care home owners if they are found to be making unnecessary mistakes and offering substandard services.''
Judith Charatan, whose dementia-suffering mother Doris Fielding died, said: "The Government needs to wake up and take heed. More funding, resources, better training and increased standards amongst those that work in this industry are the only ways to truly tackle the crisis.''