At an inquest into 19 deaths at Orchid View care home , the coroner described a culture of institutionalised abuse. The coroner concluded that five deaths were contributed by neglect. He also said that the care given in all 19 cases was suboptimal.
The inquest which lasted for five weeks was told that residents were being underfed and locked in their rooms, and that medication records were altered to cover up that residents were given wrong medicines and doses. Orchid view did not have a manager in place and staff left residents in soiled continence pads and clothing for long periods as call bells were either not answered or were placed out of reach for residents to make it difficult for them to call for help.
Thirty recommendations were made by the review which was welcomed by West Sussex County Council, one of which was that the Care Quality Commission should make it public on its website if a care home has no manager in place . The CQC also said that care providers have to put in place Training, supervision and appraisal processes. Care providers should also hold regular meetings with relatives to discuss any issues arising with care and that safeguarding issues should be escalated outside the home if not dealt with promptly and properly.
The CQC has admitted that it did not respond robustly enough to complaints about the Southern Cross owned care home. A CQC spokesperson said,” We did not respond to early warning signs and were put off by reassurances from Southern cross and people that worked at Orchid view we did not take appropriate enforcement action early enough” The CQC added “ We are now more responsive to safeguarding and other notifications of risk , more inspectors and better training have now been put in place”
Other recommendations from the serious case review are as follows:-
That care providers recruit and sustain a trained workforce to meet the needs of the people in their care, and they should nurture the