SCR Makes Over 30 Recommendations Following Orchid Care Home Scandal

The Serious Case Review into the abuse and neglect that contributed to the deaths of five elderly people at the Sussex care home, has made 30 recommendations to prevent a repeat of what the Department of Health called ‘truly appalling’ care.

At an inquest last year into the deaths of 19 former Orchid View residents, a coroner described a culture of ‘institutionalised abuse’.

West Sussex coroner Penelope Schofield heavily criticised the quality of care at the Southern Cross-run home in Copthorne and identified failings such as an absence 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.”

Nick Georgiou, former director for adult services of Hampshire County Council, was commissioned by West Sussex Adult Safeguarding Board to chair a Serious Case Review into the abuse and neglect at the care home.

He said: “Undertaking this Serious Case Review into what happened and how to guard against future failings was complex. It was not designed to place blame on any organisation or individual. However, it does not shy away from criticising organisations that could and should have done better.

“The report’s recommendations are intended to promote service quality and improved information to the public and stronger accountability drawing on the practice, management and scrutiny of Orchid View to improve such services into the future.”

Among the recommendations are:

  • That all service providers are required to ensure that their induction of new employees and the continuing training of staff includes clear guidance on the necessary procedures and actions where a death occurs, be it an expected or unexpected death.
  • West Sussex County Council and partner agencies should review the current processes and systems available for collating information relevant to safeguarding, in order to identify emerging patterns or concerns. This should include analysis of the impact and effectiveness of action plans over time where a number of investigations have been required in relation to the same provider service.
  • That NHS England ensures that GPs are provided with clear guidance about their responsibilities in regard to care homes in their practice area as provided for within the General Medical Services contract.
  • That the CQC pursues the development of an information App that provides up to date information about care services that proactively enables public awareness of services they might be using or be interested in using.
  • Local authority and NHS commissioners share impartial information about concerns in services with existing and prospective residents and their families. This will support people to make informed decisions about the suitability of the service to meet their needs.
  • Care providers should be contractually required to hold open meetings with residents and their relatives on a regular basis to discuss issues of general concern, and to make relatives aware of any significant safeguarding concerns in their home. The local authority should be notified of such meetings and able to attend, with minutes from them shared with commissioners.

The full report can be found here.


Responding to the 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 thehome 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.”

“We wholeheartedly support the recommendations made in this serious case review and want to see them acted upon so that individuals, private businesses and companies can be held to account when it comes to failings in care.

“The care provided at Orchid View was extremely poor and our own health and social care teams were faced with a difficult set of circumstances when they began the safeguarding investigation.

“We do believe that acting on the recommendations contained in this report will go a long way towards preventthis happening again by encouraging all families and stakeholders to share information to enable emerging themes and patterns to be identified and acted upon.


“As the report notes we are developing a new information system at West Sussex County Council that will facilitate this. This system will be accessible to authorised staff from key partner agencies.

“The report also captures the difficulties any local authority will have in revealing safeguarding concerns about care homes but we do support the idea of a Duty of Candour.

“These recommendations do not excuse the poor care provided at Orchid View, nor will they bring back loved ones, but they should provide confidence to people with relatives within the care system.”











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