In October 2013, an inquest was launched into the deaths of nineteen residents at the Orchid View care home in West Sussex, run by Southern Cross Healthcare. The inquest found that neglect had contributed to five of the deaths and that the other deaths had been caused by 'sub-optimal' care. The Coroner, Ms Schofield, commented on the appalling conditions at the care home stating that it was awash with 'institutionalised abuse'. In 2010 the CQC had rated Orchid View as 'good', Ms Schofield was concerned that such conditions and poor treatment of residents could go unnoticed by the authorities.

In response to this, in June 2014, the West Sussex Adults Safeguarding Board commissioned a Serious Case review into the failings at Orchid View.  The review has now been published and here we consider some of its key findings.

Key Findings

The first part of the review looked to answer four questions which were asked by the relatives of residents at Orchid View.

  1. How can the public be confident that care providers are properly managed, with good governance and financial security and that the level of care that they advertise and are paid for is being provided? 

The review highlights the issues around governance of independently run care homes and their current exemption from the NHS Provider Licence requirements of NHS organisations. An evaluation of this exemption has been scheduled for 2016/17 and it is proposed that the requirement should apply to large businesses with a turnover of over £10 million. The review also refers to consultation documents produced by the Department of Health, which discuss the Duty of Candour and Fit and Proper Person scrutiny for senior management of independent care homes, as well as CQC consultations on extended powers.

The review points to an inadequate workforce recruitment and development strategy. It supports the Cavendish Report’s proposals on improved training and status for health and social care assistants and makes clear that care providers should be able to evidence robust plans to recruit and sustain a properly trained workforce, which offers established professional development opportunities.  The review also emphasises the importance of thorough pre-admission assessment for prospective residents.

  1. How can people be confident that they or their relative will be safe and well cared for?

The review makes a number of recommendations relating to practice and procedure issues.In particular, it proposes that care homes with nursing ensure that care plans refer to a specific nurse responsible for the individual resident, which is communicated to the resident’s relative or advocate.

The review also discusses how multi-agency safeguarding and information from inquests can be used to ensure that information is shared and that where there are patterns of poor performance, these can be picked up as soon as possible. It also recommends that health and social care commissioners review their contracts to ensure they have robust contractual clauses to protect the public purse against claims from organisations that fail to deliver the quality of care, stipulated in the contract.

  1. What support and information is available to residents and their relatives - how do they know about it and are they able to use it if there are concerns about the service?

The review acknowledged that there is guidance available to relatives about considerations which should be made about the suitability of a care home, but that full information is not shared with the public where there are concerns about specific homes.The review recommends that the local adult safeguarding board develop a threshold for informing the public about significant safeguarding concerns and a means of making the public aware they can access this information. It also recommends care providers should be contractually obliged to hold open meetings with residents and relatives, to discuss issues of general concern and to advise of any significant safeguarding concerns.

  1. How can organisations and professionals be held accountable for the safety, quality and practice in their services?

There was considerable frustration that no one at Southern Cross Healthcare was held accountable for its failings.The review recommends that the CQC obtain information on all referrals to the Nursing and Midwifery Council and the Disclosure and Barring Service, and that the CPS carry out awareness training to include scenarios in which safeguarding issues may arise and the criminal offences of ill-treatment or wilful neglect may have occurred. It also recommends that the CPS seek expert advice when considering potential prosecutions relating to neglect and safeguarding.


The review also gives detailed background and a chronology of events and safeguarding work at Orchid View.  The report makes a series of 34 recommendations to address the issues raised, some of which are dealt with above.

A number of the issues raised in the review are already being addressed.  For example, the Care Act 2014 provides a clearer framework for the governance and inspection of care providers.  It also provides greater clarity on the role of local authorities, for example by making it clear that local authorities’ responsibilities where a provider fails extends to all people receiving care, including those who are privately funded.

A key area of focus for the review is on using a multi-agency approach to ensure that where there are issues, patterns are picked up and safeguarding alerts are properly and consistently dealt with.  Again, the new provisions in the Care Act 2014 should support this.

In terms of recommendations specific to care providers, some of these relate to issues recently subject to consultation, such as the Fit and Proper Persons test and the Duty of Candour.  Many of the recommendations are already routinely adopted by care providers as a matter of good practice.  Suitable training, for example, is a cornerstone of most care providers’ operations.  Recommendations such as an allocated nurse for each nursing resident in a care home are also mirrored in the practice adopted by many care providers of allocating a key care worker to each service user.

It is clear, however, that the review forms part of a wider picture of regulatory change and ever increasing scrutiny on businesses operating in the care sector. A full copy of the Serious Case review is available here.