A Serious Case Review (SCR) will be published today after five elderly people died after suffering neglect at a scandal-hit care home riddled with “institutionalised abuse”.
A press conference this afternoon at County Hall, Chichester, West Sussex, will highlight the findings at the now-defunct Orchid View, labelled “Britain’s worst care home”.
Following a five-week inquest last October, West Sussex coroner Penelope Schofield heavily criticised the quality of care at the Southern Cross-run home in Copthorne.
Failings included 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.
“This, to me, was from the top down. It was completely mismanaged and understaffed and failed to provide a safe environment for residents.
“Those who did nothing or turned a blind eye should be ashamed. It is disgraceful that this home was allowed to be run in the way it did and run for nearly two years.”
Ms Schofield questioned whether a Care Quality Commission (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 by 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.”
Last week medical law experts at Irwin Mitchell, representing seven family members, said a SCR was only the first step and they called for a public inquiry into the regulation of the care industry.
The call follows further high-profile care home exposes including undercover footage of abuse at The Old Deanery Care Home in Essex in April, as well as a CQC report into standards at Francis Court, which re-opened on the same site as Orchid View following its closure, having “serious failures” in staffing levels and resource during an inspection in October 2013.
A spokeswoman for Irwin Mitchell said: “A public inquiry must consider Orchid View and other care homes that have been found to provide exceptionally poor care, to identify how it is possible for standards to drop to such a catastrophic level and how to improve regulation to protect the safety of future care home residents.”
Laura Barlow, a medical law expert at the firm, said: “Whilst we welcome the publishing of the SCR into Orchid View which promises to identify failings and draw up recommendations so that the same mistakes cannot be repeated, we believe the horrific scale of neglect warrants a completely independent inquiry.
“The scale of the deficiencies in care is unprecedented in the provision of care to the elderly in the UK.
“Numerous safeguarding alerts in relation to failures to adequately care for vulnerable people at Orchid View were not acted upon.
“The failure of the CQC and the local authority to intervene whilst such shocking treatment was evident is suggestive of a much wider problem across the care home industry.
“A public inquiry must be convened to ensure that the elderly and vulnerable are protected against unsafe and unacceptable practice across the care home industry and to ensure that the safeguarding authorities are fit for purpose.”
Ms Barlow added: “The management void within Southern Cross was shocking and how that wasn’t picked up by those charged with safeguarding the residents of Orchid View is something that cannot be allowed to happen again.
“The fact that we continue to read reports about other care homes that grossly let down residents or fall short on acceptable care standards, including at Francis Court which was formerly Orchid View, shows lessons are not being learnt and homes are not striving to provide the best care possible.
“An independent public inquiry that considered the SCR and investigations into other scandal-hit homes would set out a system of guidance and blueprint for reform which all private care providers can adopt and ensure their residents are looked after appropriately and safely.
“It is also vital that care homes return to being run as just that, rather than as businesses which put profits before people.
“The lasting legacy of the investigations into Orchid View must be an overhaul of the care industry to ensure neglect on such a terrible scale can never happen again.”
Today’s press conference panel will include report author Nick Georgiou, Judith Wright, of West Sussex’s adult safeguarding board, and Amanda Rogers, director of adults services for West Sussex County Council.
There will also be Wendy Vodrey, of Sussex Police, Vicky Daley, of Crawley and Horsham Clinical Commissioning Group, and Julia Dutchman-Bailey, of NHS England.