Last updated: 27.01.20

Serious Case Review: Orchid View (2013)

Local authority: West Sussex

What happened?

Orchid View was a nursing home owned by Southern Cross Healthcare in West Sussex. There were 19 unexplained deaths at the home between November 2009 and October 2011. In 2011, an anonymous alert to the police was made concerning deaths at the home. Following investigations, it was found five people had died where neglect was a contributory factor and several deaths were attributed to poor care. Worryingly the Care Quality Commission (CQC) had rated the home as ‘good’ in 2010.

There was an insufficient number of staff at the home to provide safe care. Resident records were falsified and the manager had ordered records to be shredded to hide overdoses, errors in medication administration and neglectful care.

What went wrong

Contributory factors to the abuse and neglect identified by the Serious Case Review (SCR) were:

  • Poor oversight by the service provider: This included insufficient checks and visits on the service to ensure it was safe.
  • Absence of a registered manager: There was no registered manager throughout most of the time the service was open. This meant concerns and level of monitoring was insufficient, allowing the continuation of poor practice.
  • Failure to check qualifications: There was a failure to check the qualifications and professional registration of nurses working at the home.
  • Insufficient training: Staff did not always know what action to take when a resident had died, in both expected and unexpected deaths. This indicated insufficient training had been completed by staff.
  • Poor information sharing: This led to poor safeguarding investigations by the local authority when concerns of abuse were reported.
  • Lack of information sharing with ambulance services: Information sharing with ambulance services, in respect of the high number of safeguarding alerts, could have prompted them to gain a better understanding of circumstances. This would have encouraged an improved vigilance for indications and symptoms of suspected abuse, triggering prompt action to reduce the occurrence of abuse.
  • Inability to act when concerned: Visiting professionals, such as a pharmacist, had concerns about the home. They did not act though, as they assumed the CQC were dealing with matters.

Actions for improvement

Following the findings of the SCR, the following improvements and actions were taken to reduce the reoccurrence of events at Orchid View:

  • Introduction of a duty of candour, placing a duty on professionals and services to be open and honest when something goes wrong with their treatment, and harm was caused or there was potential for harm and neglect to occur. This is now a legal requirement by the CQC which regulates and inspects health and social care services.
  • Introduction of ‘fit and proper’ persons to be in managerial and senior managerial positions.
  • Development of a workforce strategy that ensures frontline workers receive robust, comprehensive training to perform their roles safely and competently.
  • Requirement by the CQC for a registered manager to be put in place.
  • Requirement for care providers to check the qualifications and professional registration of staff.
  • Improved and prompt response to safeguarding alerts by the CQC and local authority.

Read the full report here.