Care Quality Commission Still Failing Vulnerable People

They are to be given new powers in England in April but as long as they are not doing unannounced visits and allowing staff to present false facades as they did in the case of Argyll and Bute Women’s Aid, they will continue to let people down. A lot of planning went in to ABWA inspection visits and on the surface everything probably looked fine but it wasn’t and even when things did go wrong, the CQC was very limited in what it could actually do despite acknowledging that they had failed me very badly in more ways than they could address. And the CQC NEVER approached the women ABWA was supposed to be caring for to hear their opinion, which borders on the ridiculous. The same applies in every case where support workers are being allowed to pretend that they’re doing the right thing one afternoon a year. It happened when I worked in care too but that’s a story for another day!

Thousands of allegations of abuse and neglect of elderly people were made in England last year, the BBC has learned.

Some 14,888 claims about the welfare of care home residents aged 65 and over in 2013-14 were reported to 74 councils, 5 live Investigates has found.

Relatives say the system designed to handle such complaints is flawed and they often go unheeded.

The body representing senior social services managers says there needs to be more investment in care staff.

Anyone is entitled to raise suspicions about a person’s care, and local authorities are obliged to look at the claims.

If necessary, they launch what is known as a formal safeguarding investigation to decide what action should be taken.

But some families who have raised safeguarding concerns say the system is not working.
Orchid View, which has since reopened under new management, was run by Southern Cross

In West Sussex, 19 people died after suffering “sub-optimal care” at the Orchid View care home in Copthorne.

The problems at Orchid View came to light following a police investigation that started in 2011 – but in a two-year period before that, families and health workers had been raising concerns about the care in the home.

A serious case review into the Orchid View scandal revealed there had been 20 separate safeguarding referrals. The home has since closed.

A number of those concerns were substantiated but it was not until the police inquiry started that the decision was taken to shut the home.

Families want to know why action was not taken sooner given that so many safeguarding investigations had taken place.
Enid Trodden died less than a year after going into the home

Lesley Lincoln said she complained constantly about the care given to her late mother, Enid Trodden.

She says she wrote letters raising concerns to health professionals, the Care Quality Commission and the council’s safeguarding team but she says no-one saw it as a safeguarding issue.

“I felt I was tearing my hair out and nobody was listening,” she said.

“It was only treated as a safeguarding alert after I raised the roof when she went into hospital,” she says.

“It was only after my mother’s death and the inquest, I realised there had been so many (safeguarding) referrals at Orchid View.”

In a statement, West Sussex County Council said: “We take all safeguarding concerns extremely seriously. We are working hard to reduce the likelihood of a repeat ever happening again and this includes work to implement all the recommendations of the serious case review.”
Families ‘not informed’

The Local Government Ombudsman has also investigated cases where families have felt the safeguarding system has not worked.

In one case, the ombudsman found a council was at fault after its safeguarding team asked the home at the centre of an allegation of poor care to conduct its own safeguarding investigation.

In other cases the ombudsman found delays in launching safeguarding inquiries, poor investigations and that families had not been given information.

Seventy-four councils out of 152 responded to the request by 5 live Investigates to state the number of safeguarding referrals they had received for people aged 65 and over in care homes – the first investigation of its kind.
‘Investment in care’

Between them they reported that they had received 14,888 referrals. Of those, 4,523 – about one third – were substantiated. If all the councils approached had provided data, the overall figure would obviously be higher.

David Pearson, president of the Association of Directors of Adult Social Services, said: “Needs are rising as resources are falling. Adult social services have sustained a 26% reduction in funding since 2010.

“Prevention is better than cure and we need to ensure there is sufficient training and investment in care staff.

“It is crucial that we have sufficient social workers working with other professionals to carry out investigations.”

The Department of Health called the abuse and neglect of vulnerable people “deplorable”.

A spokesman said the new Care Act which comes into law in April will give the Care Quality Commission greater powers to prosecute providers and company directors for unacceptable care and introduce new, tougher standards for inspecting care homes.

NHS staff afraid to speak out, whistleblower report finds

A review into the treatment of NHS whistleblowers has heard “shocking” stories about staff who raised concerns being ignored, bullied or intimidated.


“Sir Robert said he had learned from previous inquiries of the distress caused to patients and their families when their concerns were not listened to. He said the same was true of NHS workers.

Staff who are not supported “can suffer hugely,” he said.

“I’ve heard some frankly shocking stories about [staff] whose health has suffered, and in rare cases who’ve felt suicidal as a result of their perception of them being ignored or worse,” he said.”

So, when they aren’t bullying patients, they’re bullying each other!

The Care Quality Commission does it again. Fails miserably, that is.

GPs have told the BBC their reputations have been “tarnished by incompetence” from the health watchdog.

The Care Quality Commission has been forced to apologise to hundreds of GPs for giving incorrect patient safety risk ratings.

A BBC investigation found serious errors in the calculations used by the CQC.

The British Medical Association is calling for the whole ratings system to be withdrawn.

Around 60 practices have been taken out of the highest risk categories and four low-risk surgeries need early inspection.

John Flather, a GP in Hadleigh, Suffolk, said his practice had been incorrectly banded as high risk.

He said he was “totally disgusted by the process” and that a formal complaint had been made.

He told the BBC: “Our reputation, which has been built over many years, has been tarnished by incompetence that they purport to eradicate.

“If they had only given us a chance to view their ratings we could have pointed out their errors and avoided this mess.”

Dr Chris Cullen, from Ipswich, said: “My practice was rated for highest risk despite being one of the very high achieving practices in the country.

“The CQC claim we gave flu jabs to 24% of our patients, in fact it was over 96%.

“Our true rating should be for lowest risk, but the CQC aren’t interested and have not returned our calls.”

Bad data

Practices were judged on 38 indicators of performance, ranging from how easily patients managed to get appointments to how good doctors were at picking up conditions such as dementia.

Practices were graded in six bands, with Band 1 being the highest concern, and Band 6 the least risky.

The majority were of low concern, but 11% were rated in the highest risk band.

The BBC discovered that for one indicator, whether patients were able to get an appointment with a GP or nurse the last time they tried, the calculations were so flawed that the CQC has been forced to remove the indicator altogether.

A further four indicators had to be refined based on revisions to data provided to the CQC by NHS England.

Hundreds of practices will now be assigned a different band.

In its initial register, published two weeks ago, the health watchdog ranked 7,276 practices out of the total 7,661 in England, and placed 864 practices in the “highest concern” category.


Original rankings

GP survey

As a result of the recalculations, around 60 practices will be lifted out of the two “highest concern” categories, and four that were previously deemed low-risk have been found to be in need of early inspection.

The CQC says 519 practices will move bands, but most were between the lowest risk bands.

The CQC register was set up to help target inspections, and the watchdog said it did not necessarily indicate poor GP surgery performance.

Sir Mike Richards, chief inspector of hospitals for the CQC, told the BBC: “We will make them a big apology. This only became apparent when we ran the data on the thousands of practices rather than just the hundreds that we tested them on.”

He defended the publication of the risk bands in the interest of transparency.

He said: “We are using the data to help us know where we might go first. Our judgement comes from a combination of data and inspection. The main thing that is going to matter is that we are going to be inspecting every practice.”

Dr Khan, Dunoon Community Hospital A&E Dept. 16 December 2012

Before I continue I want to say that I have the utmost respect for most of the nursing staff I’ve met at Dunoon Community Hospital. They have gone a considerable way towards restoring my faith in the profession and have been absolutely wonderful to me and my family whenever we’ve needed their care. They put into practise on a daily basis all the good things about the nursing profession and my community is fortunate to have them. The person who let them, and me, down badly was a General Practitioner working in their A&E department. His total lack of care, concern and respect for the Mental Health Act and common decency resulted in me being physically abused by two police officers and sent to a hospital 40 miles and a 2 hour ambulance journey away when it was completely unnecessary and medically unjustified. These are the bruises I received from being manhandled and HANDCUFFED by police when I went to A&E for care:

Bruises left arm Bruises both arms Bruises right arm Handcuff bruises hands.

I got these bruises, and the assault that caused them, because of the failure of a doctor called Dr Khan to do the job he was paid for. I also had severe pain in my right elbow on the slightest touch for weeks after the assault, which was totally unnecessary and entirely triggered by Dr Khan. This and the rest of the bad things that happened to me that night were a direct result of his failure to properly care for me.

This was the last time I sought healthcare from my local hospital.

Since writing this, I have had a meeting with two managers at the hospital who informed me that what Dr Khan did was wrong, that he apologised (not to me, he didn’t), that changes have been implemented and that this would never happen again.

However, in the absence of evidence of this I am still unwilling to trust the hospital with my care.

(to be contd.)


FOUR separate parts of NHS fail, NHS Complaints Process fails and Ombudsman fails.

NHS blunders led to Devon toddler’s death

A string of blunders by NHS workers led to the death of a three-year-old Devon boy, a review has found.

Sam Morrish died in December 2010 from a treatable condition because four health service organisations made mistakes, the Parliamentary Health Service Ombudsman (PHSO) said. He died of severe sepsis after a “catalogue of errors”. Sam’s parents also said they had “serious concerns about the competence and accountability” of the ombudsman. Ombudsman Dame Julie Mellor said that had Sam received the appropriate care, he would still be alive today. Cricketfield GP Surgery, NHS Direct, Devon Doctors Ltd and South Devon NHS Trust were all criticised. Failures included inadequate assessment of the toddler, not recognising that he was vomiting blood and a three-hour delay before he received antibiotics at hospital. His family said as well as losing their son, they feel they have been “failed” by the NHS complaints system. In a statement released through the Patients Association, they also criticised the ombudsman.

“The astonishing length of time it has taken for PHSO to finalise this report has inescapably prolonged our distress.

“Although we are grateful that the PHSO has upheld our complaints… we are left with serious concerns about the competence, capability and accountability of the PHSO itself.” Sam’s mother Susannah Morrish said: “The report looks the way it does because of our constant intervention. “The fact there had to be two draft reports, both of which looked radically different to this final report, says something. “Our involvement included providing information, pointing out omissions, correcting factual errors. “Our thoughts were if we didn’t do this, who would?” Sam’s father Scott Morrish said: “The thing that we’re still trying to push for is, we’re not clear who the ombudsman is accountable to, we’re not clear who really understands what happens behind the scenes there, and we’re not entirely sure that Parliament is actually able to look at anything more than what comes out in the report.” Dame Julie said: “I accept that the family are right that the investigation method used in this case was not adequate to the complexity of the case. “I really recognise that this contributed to the family’s distress and we have apologised for that and thanked the family for their feedback on the particular method we used in this case, because we are developing new investigation methods.”


Dame Julie said that Sam’s devastated family suffered “further injustice” because health officials failed to properly investigate the youngster’s death.

“But this case has to be looked at in the context of taking on over 4,000 cases to investigate every year, and receiving very few complaints about the quality of our decision making. “When we do, we treat it like gold dust to help us improve our service. “We’ve published this case so that the wider NHS learns from Sam’s death,” she added. NHS England was ordered to pay £20,000 to the family. Mr Morrish said: “The irony is we never wanted to lodge a formal complaint. “We only did because we were advised to by the Patients Association in response to the NHS completely getting it wrong, not once, but twice. “We didn’t want it to be about blame, we wanted it to result in good learning.”


Key recommendations

  • Cricketfield Surgery should train reception staff in directing patients through telephone triage system
  • NHS England should review out-of-hours guidelines and ensure other NHS organisations regularly test their own procedures
  • South Devon and Torbay Clinical Care Groups (CCGs), Northern, Eastern and Western Devon CCG and South Devon NHS Trust should provide bereavement services to families such as the Morrishes
  • Staff should be trained in bereavement services
  • South Devon and Torbay CCG and Northern, Eastern and Western Devon CCG should develop procedures for investigating serious incidents
  • Within three months, there should be people at the organisations trained to investigate serious incidents
  • The Morrishes should be paid £20,000
line break

Dr Graham Lockerbie, speaking on behalf of the local NHS, said: “Sam died when he should have survived.” “We all accept the blame for that. Quite simply, we should have done better. “When we investigated, we were still unable to provide adequate answers to Mr and Mrs Morrish about what had gone wrong, or to reassure them that things would change for the future. It is clear that this only compounded their grief. “Again, on behalf of the local NHS, I apologise.”  

I’m going to wager a guess that there are two reasons the Health Ombudsman receives very few complaints about its decisions: One, because they often fail to bother investigating instances of poor care anyway and two, because once you’ve gone through the effort involved in taking a legitimate complaint TO the Ombudsman, you are absolutely done with complaining and fail to see the point of getting back to them yet again. And you start a blog instead!

DLA/PIP – you CAN ask for a claim form in writing!

I made a claim for Disability Living Allowance about three years ago and was not only turned down, but told at a tribunal that they didn’t believe I even have agoraphobia!

How ironic then that support workers employed to support me in the last few years seem to be of the opinion that I’m too crazy for their ‘ickle sensibilities! Yet, the DLA people think I have nothing wrong with me. Nice little cleft stick there.

I will include the DLA debacle in this site if I can ever revisit it long enough to so so. It was so harmful to me to be told that I was making up an illness that has ruined my entire life that my partner keeps begging me not to apply for PIP in case they do the same thing again. She’s that worried about the effect it had on me last time.

But, yes, I don’t see why the people on the tribunal and the GP who handed me to them on a plate shouldn’t be named and shamed here too. F**k them.

I’ve put off claiming for PIP because until today I was under the impression that you have to phone for them to send you a claim form. Nowhere on the official DWP site does it tell you that you can also write for a form, as far as I can see.

I am also terrified that the same thing will happen again but at least this time, when I go to them I will know beforehand that they might actually challenge the existence of my illness. Before I attended the tribunal I was told I had only to prove that I required extra help – not that I had a particular illness.

But you know, with the current focus by government on the weakest members of society – the poor (“benefits scroungers”) disabled (“perfectly able”) in order to justify not paying them – I should have known better. Now I shall be armed with as much written evidence as I can obtain from all the psychologists and shrinks who’ve seen me since I was 14.

Oh, that reminds me – when I was applying for ESA when the benefit rules changed last year, one of the questions was along these lines: “has anyone ever said you are hard to deal with” or something…and I said well, my last support worker dumped me like a hot shitty, brick because she suddenly found me SO hard to work with! They wanted to know the reason too, but to this day, I still haven’t got a clue. Let them ask her.

If you’re unable to use the phone to claim PIP

If you can’t use the phone, someone else can call the claim line on your behalf. However, you’ll need to be with the person making the call so that you can give the DWP permission to speak to that person.

If you’re unable to use the phone and you can’t get anyone to make the call with you, you can write to ask the DWP for a paper claim form PIP1 or ask for a paper claim by textphone on 0800 917 7777. The address to write to is:

Department for Work and Pensions

Personal Independence Payment New Claims

Post Handling Site B
WV99 1AH


OR! You can always get yourself a support worker to phone for you!      8bbd60b820f4a5ecc77e2b592834b28b




The Care Quality Commission is an absolute disaster

This is a disgrace. These people should be taken out and shot, in my humble opinion. The CQC needs to stop giving these people warnings that they’re coming to do inspections and start coming unannounced.


More than 30 recommendations have been made after a scandal-hit care home in West Sussex saw 19 unexplained deaths.

A serious case review found action to rectify problems was avoided at Orchid View. It also said “ineffectual action plans” were not acted on.

Five of the deaths at the now-closed home, which was run by Southern Cross in Copthorne, involved neglect.

The Care Quality Commission (CQC) has admitted a series of failings in how it handled incidents there.

An inquest last year found that all 19 people whose deaths were unexplained had received “suboptimal” care.

‘Catastrophic’ care standards

Residents were left soiled and unattended, and one night shift saw staff make 28 drug errors.

The five whose deaths involved neglect were Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77.

Earlier, lawyers representing the families of those who died called for a complete overhaul of the care industry, and also a public inquiry to find out how standards dropped to “such a catastrophic level”.

But after the serious case review findings were published on Monday, independent chairman and report author Nick Georgiou said: “It is not possible to say that this report or any other will prevent all future safeguarding alerts.

“It will not do that, but acting on the recommendations will lessen the risk to other residents in other settings.”

 West Sussex councillor Peter Catchpole said the report would help prevent similar cases in the future

Following publication of the serious case review findings, the CQC also published its own report.

Andrea Sutcliffe, chief inspector of adult social care, said the primary responsibility for failings at Orchid View rested with care home staff and Southern Cross, but the CQC had looked at its own role and knew it did not fulfil its purpose of making sure the home provided safe, compassionate and high quality services.

“The way we worked when these serious incidents happened meant we did not respond to early warning signs, we were too easily reassured by the responses of Southern Cross and the people who worked there – and we did not take appropriate enforcement action quickly or strongly enough,” she said.

Ms Sutcliffe said work had been carried out to make the CQC more responsive to risks, to improve inspections, and appoint and train more inspectors. She said further improvements would be made.

‘Harrowing case’

The serious case review was commissioned by the West Sussex Adult Safeguarding Board.

Its 34 recommendations included that care operators must prove to the Care Quality Commission (CQC) they can recruit and keep trained and skilled staff.

The report also called for relatives always to be given a named point of contact in care homes and for concerns to be escalated outside the home if not dealt with promptly and properly.

Other recommendations included that care homes should hold open meetings with relatives and the local council.

And the report said there should be a threshold for informing the public about significant safeguarding issues to help people make informed choices about the homes they choose for their loved ones.

West Sussex councillor Peter Catchpole said: “What happened at Orchid View was harrowing.

“Nothing will help ease the pain of the families who were affected by these terrible events and who lost loved ones.”

But he added: “We do believe that acting on the recommendations contained in this report will go a long way towards preventing this happening again.”

The care home has since reopened under a new name and new management.