A Serious Case Review (SCR), commissioned following an inquest into the deaths of 19 people at Orchid View care home, has published its findings.
Among the elderly residents who died at the home in Copthorne were Jean Halfpenny, John Holmes, Enid Trodden, Margaret Tucker and Wilfred Gardner.
Their deaths were all ruled by a coroner to have been attributed to by neglect.
The SCR was commissioned by West Sussex Adult Safeguarding Board following an inquest in October 2013 where the coroner described a culture of ‘institutionalised abuse’ at the home, which was run by Southern Cross Healthcare.
A spokesman for West Sussex County Council said the independent review, chaired by Nick Georgiou, was set up to reduce the likelihood of a repeat of incidents of substandard care, management and neglect.
Among the 30 recommendations made in the 100-page review, which was published today (Monday June 9), was a call for stringent checks to be carried out by employers to ensure staff had the qualifications they claimed.
While acknowledging the recommendation was “essentially stating the obvious”, the report read: “This recommendation relates to concerns in regard to the thoroughness with which Southern Cross Healthcare checked the qualifications of nursing staff they recruited.”
The lack of information made available to the families of residents was also highlighted and a recommendation was made to ensure relatives were given the opportunity to discuss the care being given and to raise any concerns with inspectors from the Care Quality Commission (CQC).
The report said “too much tolerance” had been given to Orchid View, which had no registered manager for most of the time it was open, and a recommendation was made for such information to be fully available on the CQC website.
It added West Sussex Adult Safeguarding Board should make it very clear where the public could access information about significant safeguarding issues and concerns raised at homes.
Known as a Duty of Candour, the information would help people make informed choices about the homes they choose for their loved ones.
Responding to today’s report, 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.”