Category Archives: CQC

When troubleshooting goes bad…

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Blimey. More documents pinging mysteriously into the Justice shed. Including a letter written by the then Sloven board chair to Monitor (now NSH Improvement) raising serious governance concerns in 2011. [Yes. Really]. At first graze, a dense, detailed, informed, harrowing and enraging addition to an apparently unlimited evidence pile highlighting Sloven governance failing.

I’m typing this post listening to Laura Veirs. A vague balm. Rich and I have spent the last three days since the faux announcement of Katrina Percy’s (yet to be properly confirmed) ‘resignation’ in a harsh and agitated space. It’s not about her, as a person. It was never about her as a person. Blimey. She didn’t make it to the Connor Manifesto. But it’s becoming more and more about her. 

Percy failed to lead effectively. We all know that. The board failed, and continues to fail, as an executive board. The Council of Governors remain split between an enlightened minority and the waste of space rest. There remains a consistent and shocking lack of competence, authority, knowledge and sense among both the board and council. Backfilled with a frenzied focus on reputation and apparently unlimited funds to buy in whatever spurious consultancy or legal support they think will magic away the disorder that surrounds them.

Deeply depressingly, the documents leaked to us today were shared with Tim Smart to provide context to his review of the board. Now we don’t know (I don’t think anyone really knows) what Smart based his (30 June) judgement of the board on. We do know he scathingly dismissed the Mazars review during the meeting with My Life My Choice and we now know he must have dismissed the serious concerns raised by the board chair back in 2011.

We also know he agreed to the very recent secondment of Sandra Grant and Flash Gordon to new pastures (as well as gifting Percy a substantially reduced role on a CEO salary). Why you would give a board under serious scrutiny a clean bill of governance health and then start seconding execs five minutes later is a mystery. Oh. Unless you finally, and belatedly, realise the board is as grubby as they come.

Indeedy, it’s probably about time some of the spotlight shifts to Smart and Jim Mackey (the CEO of NHS Improvement My Arse). What this pair of muppets are doing is beyond me. Did they really not anticipate the inevitable backlash against such offensive and scandalous news? Did Smart not realise erasing all whiff of failure in Percy’s leaving statement, blaming press interest, would simply enrage and inflame? What an almighty pigs ear of executive and regulatory ‘action’.

Ironically, one of the biggest failings here is candour and transparency. From where we’re sitting, it appears Smart made the wrong judgement on June 30 because he is incapable of listening. Days later Michael Buchanan broke the news about dodgy contracts. Patient deaths are clearly nothing compared to doshing your mates £millions for going viral nonsense. Once Roy Lilley was on Radio 4 condemning the spiralling of a £300k contract to £5m, the writing was on the wall. Failing governance a go go.

Instead of a clean sweep, an acknowledgement of failings – of letting down hundreds of patients and their families, of a board gone bad – Smart, Mackey (and Hunt?) ballsed it up. Big time. Generating more media attention and public outrage than the publication of the report revealing that Sloven investigated less than 1% of the unexpected deaths of learning disabled people over four years. A report that led to the appointment of Smart as the troubleshooting interim chair.

What a stinking mess. Do the right thing someone. Please.

A written version of Winterbourne View

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Here we are. Late summer 2016. Another day and another failing CQC inspection of support for autistic people. This time the much feted National Autistic Society (NAS). A harrowing read. The NAS have simply shut the provision, Mendip House, down (‘home’ to 6 people who were unable to say if they were being harmed), belatedly issued a half arsed press release after a bit of twitter agitation and carried on trousering the readies from their other provision. Same craphole activities as, er, Mencrap. Another glossy charity losing its way big time…

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A summary of the obscene inspection findings (in non CQC speak):

  • The formal communication system (pics) used by two people had been stopped.
  • Concerns about abuse were raised and no action taken.
  • Staff regularly stole money from the people they were supporting.
  • Lack of staff training.
  • Mismanagement of medication and no record of medication reviews.
  • Hot water temperatures were too high so risk of scalding.
  • Using saucepans on the door to raise the alarm if someone slipped out failed.
  • No attention was paid to changes in people’s behaviour to understand how they felt.
  • Accidents and incident reporting was crap and records went missing.
  • Some staff had no CRB clearance or employment references.
  • Staff played on the playstation, ignored people and came and went without record.
  • Dodgy or no induction processes/records or ongoing supervision.
  • Poor or no health plans, health checks or recording of any GP appointment.
  • Care plans were out of date.
  • Rubbish epilepsy plans/assessment [howl].
  • People ate crap nosh (little fruit and veg) and were dehydrated.
  • The Mental Capacity Act wasn’t followed and people’s rights were trashed.
  • The decor was worse than rubbish and worn out.
  • The house was dirty and appliances needed replacing.
  • No one was supported to be independent or have relationships with family/friends.
  • Complaints by family members were ignored.
  • There were few opportunities to go out spontaneously because of staffing issues.
  • A gang of male staff arranged to work on the same shifts and ignored people.
  • A “laddish” and “gang culture” developed through lack of effective senior leadership.
  • The NAS identified “culture issues” in 2014.
  • That “Senior Management Team were concerned with Mendip” was minuted in 2015.
  • Issues identified by the NAS in January 2015 hadn’t been acted on 18 months later.

Given we don’t know what went on in Mendip House with this laddish gang culture ruling the roost for over two years, this is as bad, if not worse, than the abuse captured on film in about 5 minutes by the Panorama team back in 2011.

In Mendip House, run by the National Autistic Society, the senior team were aware of serious problems for two years. They did fuck all.

Of mice and (NHS) monstrousness

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A story ‘broke’ yesterday about extortionate NHS interim director costs. Sickening figures of waste, greed and mismanagement. At senior levels. Again.

In another of those ‘you couldn’t make it up’ NHS moments, the highest paid interim Improvement Director named in the report, Steve Leivers, was helicoptered into the trust Tim Smart, now Sloven interim Board Chair, previously ran. Yes. Really. Not Smart in non action. Again.

I read this latest news having been unable to move beyond Chris Hatton’s recent analysis of Sloven’s annual report. Cut and paste Katrina. And extraordinary senior exec salary figures. With Lesley Stevens, Medical Director at the top of the ‘leader’ board. A cool £365-70k per annum including jaw dropping pension contributions. How can she possibly ‘earn’ this sort of dosh? Let’s have a look at her performance during LB’s inquest last October.

Lesley Stevens and LB’s inquest

Reasonably confident while reading out her evidence and then being (sleep) walked through clearly rehearsed questions by the Sloven barrister, she floundered big time when questioned by the six remaining barristers. Her answers so deeply insubstantial (a generous interpretation) it was as if the courtroom had switched to watching CBeebies.

£365-70k per annum…

Some examples:

LS1

LB died in July 2013. The (post Mazars review) CQC inspection in January 2016 found the Sloven epilepsy policy had yet to be signed off. Paul Bowen, QC, carefully questioned each Sloven staff member about their knowledge of epilepsy during LB’s inquest. No one answered in other than the vaguest ‘ain’t got a clue’ terms. There was no up-skilling staff over two years after LB’s death.

[Howl].

LS3Here Paul Bowen seeks clarification of Stevens outlandish statement that all learning disabled patients with epilepsy were reviewed before the CQC inspection in September 2013. At that point, Sloven were still spinning the line that LB died of natural causes. They did nothing to check the provision in STATT (it failed on all 10 domains inspected 6-8 weeks after he died) let alone review patients with epilepsy in their wider provision/outposts.

A blatant and contemptible lie. Perjury to us herbs outside of senior NHS circles.

LS2Paul Bowen tries to drawn Stevens on the failure of the RiO system. A failure that persists to this day. She resorts to her default response. A murmur/mutter noise reminiscent of the dog ate my homework type responses from school. Not the sharp, authoritative, informed, engaged response you’d expect from a senior exec at an inquest over two years in preparation, with nearly £300k squandered on ‘defence’ costs.

When questioned by Adam Samuels, another barrister, about the reduction in Band 6 and 7 staffing reductions in STATT (and the next door John Sharich House), Stevens says:

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‘We make savings where we have to make them…’ On frontline staff. While you continue to draw an obscene salary

Monstrous. And remorseless. Just one, among so many.

When did the NHS we grew up with, took for granted and loved, become so riddled with greed and rot… with complacency and arrogance, with inaction and protection. At senior levels?

Cut and paste leadership and the pro-Percy HQ

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Sloven financial irregularities (that is, bunging apparently endless amounts of public dosh to mates for little or no return) hit the news on Friday, via Michael Buchanan. Today Chris Hatton published his analysis of the Sloven (or Sudden Wealth) 2015/16 Annual Report. I can’t recommend reading this post enough. Just one titbit (and there are so many) is that KP simply cut and pasted the last paragraph of her closing statement from the previous Annual Report. Unbelievable action in any annual report, but breathtaking given the content and context. The end of the paragraph states:

Notwithstanding this, my review confirms that the Trust is taking appropriate actions to deliver the agreed undertakings and ensure compliance with the Trust’s provider licence and to address any weaknesses in the system of internal control.

Those failings and enforcement notices clearly just roll over yearly. Sickening demonstration of the contempt the Sloven board have for patients, staff, regulators and the wider NHS, and the public. And further indication the Sloves (or Suddens) are not capable of improvement.

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What is actually going on here?

Let’s have a little look see at what’s happened since the Mazars review was published:

  • In December 2015 Jeremy Hunt announced the CQC would go in and inspect Sloven again with a focus on death reporting.
  • In April, the CQC announced serious (continuing) failings.
  • Ball over to NHS Improvement who send in Clive Bell as Improvement Director and, subsequently, Tim Smart as Interim Board Chair.
  • Tim Smart did a tinpot investigation (no family involvement), Katrina Percy was subjected to six hours of psychometric tests and he gave the board a clean bill of health. A week ago he commended the performance of the board to the Council of Governors (audio from 17.10 here…)

 

So blinking awkward. In the light of the Buch-Hatt findings this is a serious egg on the face situation for Smart (who signed off the Annual Report) and Jim Mackey (CEO of NHS Improvement). It also offers some chunky old clues about where pro-Percy HQ is based. [And believe me, many people are asking this question…] Jezza took action, the CQC took action, things get snarled up in an NHS Improvement pretend party. Interestingly, a Sloven staff fairy heard that Sloven exec, Paul Streat (who worked at, er, NHS Improvement before joining the trust) was arrogant and dismissive about #JusticeforLB in a Senior Viral training day.

Mmm…

We heard yesterday a rumour that KP won’t be returning from her holiday after pressure from the Department of Health. Jezza now has Alistair Burt’s (love him) portfolio for mental health/learning disability issues. He has the ball firmly back in his court. Here’s hoping he takes action (or further action if Percy has been pushed) and removes other culpable board members. The rot in that room is extensive.

He should then perhaps ask questions of Mackey and his merry band. It really ain’t the job of campaigners and journalists to reveal what is in full sight of NHS Improvement, NHS England and the Department of Health.

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Updating LB

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Hello matey,

Three years now. Well we’re into the fourth year really. I thought I’d update you on where we’re at in terms of justice and accountability. Not far really. [Sorry]. Various investigations limp on. The General Medical Council (GMC) has spent over two years collecting evidence about the clinician who was kind of in charge of you. You know. That woman who spoke to you for about 15 minutes across your whole time in STATT from what I can tell from the records. And gave you Bonjela after you had that seizure. She’s got about a week left to respond to the allegations the GMC have put to her. We’ve no idea what these allegations are because it’s all secret squirrel stuff. She’s working in the Emerald Isle now. Still responsible for patients.

She pitched up at your inquest in October with a barrister who was like the worst of worst baddies in a Simon Pegg film. He, like Sloven peeps, questioned whether we wanted you home. We did. I’m so sorry if that got lost over those hideous weeks in the unit. We stupidly, stupidly thought you were in a safe space while support was being sorted. Turns out all the failings in the unit were written in a report the summer before you went there. But nothing was done. [Howl…]

Your inquest went as it should have done. Superb legal representation (as you’d have expected) and a jury of nine members of the public who listened and understood how deeply you were failed by Sloven.

Other investigations are going on. Still. We met three people from the Health and Safety Executive (HSE) on Thursday with Norman Lamb. The meeting was in Portcullis House which you’d have loved. Heavy weaponery, police presence and security… The meeting was disappointing. Not the objective, razor sharp, robust, investigative scrutiny I imagined. Mind you, the writing was on the wall given the speed in which they slapped a charge against a production company for Harrison Ford’s leg injury in June 2014. 

There seems to be a fog engulfing and dispersing any critical challenge by public bodies of public bodies. And when you stupidly ain’t considered to be fully human, that fog just thickens. 

We managed to get a review commissioned by NHS England into deaths in Sloven ‘care’. This found a scandalous lack of interest or engagement in investigating unexpected deaths. We thought this report would lead to sharp and immediate action. But nah. Seems like this is ok.There’s a bit of tweaking going on round the edges but no commitment to really looking at these deaths or to act with any conviction. You’ve been mentioned a few times in the House of Commons though which would make you smile. 

Meanwhile, Sloven failings continue to pile up. They are seriously shite. NHS Improvement sent in a troubled shooter, Tim Smart, to look at leadership failings. He spent a few weeks there, avoided speaking with families, got some psychometric testing organised and decided there were no leadership probs.

I can hear you saying ‘Mum? Why mum?’ into infinity and beyond.

I dunno. I was waiting for the Scooby Doo gang to pitch up and unmask him as Mr Crawls or one of the other villains in the end. Such a nonsensical, cartoonish judgement. Apparently Alistair Burt, the social care minister, is still looking into it but for some reason, that rag bag bunch of muppets remain in post. 

These systems we loosely brought you up thinking were good, right and just, simply and sadly ain’t fit for purpose. While the public have stepped up and created an explosion of brilliance around you, your life and the lives of so many other people, you were and continue to be well and truly fucked over by those you always firmly believed in. 

There was a story in the Guardian mag about you a few months ago. A very funny journalist, Simon, came round and later a photographer. You’d have liked them both. Joel souped up some of our old photos. Like this one. No orange binoculars but the old shower cap and goggles. Rocking life as you always did. Your way.

Connor

Connor

xxx

Cameron’s wave and Smart evidence

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We’re having the bath replaced with a shower downstairs. In the garage that was converted into a bedroom/en suite jobby over 10 years ago with LB in mind. The bath that had the bath bell. [Howl]. I’ve not had a bath in nearly three years now so it made sense. It’s a small space needing a tiny sink. Not easy to find. Eurgh.

I ended up back online at the Bathstore earlier and a box popped up asking if I wanted help from someone. Yep. Thank you. Cameron appeared in the top right hand corner of the screen. Wearing a set of headphones and a type box under his pic. We started messaging about tiny sinks. So blinking exciting.

I shouted to Rich:

Hey I’m actually having a chat with a guy from the Bathstore…!

It’s not real.

Yep, he’s here with headphones on.

Yeah, but he’s not a real person.

He bloody is. Come and see…

[When Rich came in, the real Cameron was briefly replaced with a photo of possibly Cameron, while he searched for tiny sinks…]

It’s not real.

There he is look, he’s been looking for stuff.

He’s not live.

He is. Look! He looks down when he types….

He’s not really there FFS!!!

 

bathstoreCameron waved. We laughed. He didn’t have any small sinks.

We’ve been a bit anxious since the meeting on Tuesday with Tim Smart, interim Sloven chair.  Rich’s blanket dismissal of Cameron reminded me of Smart’s dismissal of the Mazars review as ‘wrong’. Someone (NHS Improvement, NHS England? Jezza Hunt?…) seriously needs to make sure Smart is given the opportunity to ‘see the Mazars wave’. And for him to be prepared to accept, or at least engage with, the evidence shown.

Sigh.

Postscript: Perhaps unconnected, Rich returned to twitter this afternoon and sent his second tweet in five years. Quality rather than quantity he says.

Of course you can cry…

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Tim Smart, interim Sloven board chair, met with My Life My Choice (MLMC) champs yesterday. The meeting is described in detail by Kate here [recommend reading this because I muse in a piecemeal way below]. Peculiarly, it was difficult to know what to make of it all.

kate

Smart began by giving a heartfelt apology to our family and said there was no doubt we had been failed completely by Sloven. After nearly three years [howl] of non, fake or mealy mouthed apologies prised out of the Sloven directorate this was the real deal. Deeply moving and very much appreciated. He made it very clear how important it was to him to make sure there were improvements at Sloven. He’d been deeply upset when he saw the tv coverage of the extraordinary board meeting in January and couldn’t imagine if it had been his son who had died.

Sloven have, till now, repeatedly failed to say sorry. They have said sorry for our loss, for the upset we feel. They have let us know they will take the opportunity to apologise to us at a particular meeting (can you imagine?) They have bypassed us altogether and bunged the ‘apology’ on their website. Smart nailed it with openness, honesty and compassion.

Shaun and Jackie then asked a series of questions.

Slade House was a bit of a slippery topic. An assurance that the future of the site would be discussed in public with an acknowledgement that he probably/possibly wouldn’t be chair then. Allowing similar wriggle room to previous chair Petter;  if we sell it the money stays in Oxon but if someone else flogs it type stuff.

The final question (“It’s a nasty one I’m afraid Tim”) was about why the CEO is still in post. Smart’s response was around gathering an evidence base to make a judgement around the potential removal of any board members. Fair enough. He then said none of the reports about Sloven laid the blame at Katrina Percy’s door. Bit odd. The Mazars review explicitly identifies board level failings. And failings schmailings are ultimately the responsibility of the chief exec. Mmm…

Shaun asked if Smart could continue to attend these meetings even if he was no longer board chair as he didn’t ‘BS’ them. Smart was visibly moved by this question. He said it was one of the nicest things things that had ever been said to him and he was at the risk of becoming emotional.

“You can be emotional Tim” said Shaun, cheerfully. “Of course you can cry. I’m always crying… ”

Another one of those moments when I’m just in awe of the brilliance of the My Life My Choice team. Keeping it real. Human. With an extraordinary ability to ask tough questions, offer challenge and remain encouraging and supportive.

Then, into this emotional space, and I can’t  remember how it came up, Smart said very brusquely he hadn’t read the Mazars review and wouldn’t “because it was wrong”.

Blimey. One of those cartoon screechy brakes moments. A quick photo and Smart and I left for a brief chat. Outside, he said he had read the Mazars review but was dismissive of talk of thousands of deaths in the media [and clearly still dismissive of the review itself]. He told me a story which I didn’t get then went off to get a cab.

So. Where are we at? What does any of this mean? I’ve no idea really.

Vague, half formed, thoughts:

  • Tim Smart is genuinely sorry and shocked about what happened to LB and the treatment we have experienced.
  • He recognises (some) obvious and sustained failings in Sloven provision.
  • He prides himself on his integrity, honesty and straightforwardness while remaining closed to actually listening or engaging with some of the evidence.

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I went back to work feeling upset and pretty low.

Sense and reason, at last

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After nearly three years of atrocious responses from Sloven to what happened to LB, this document arrived anonymously in the Justice shed earlier. An emergency motion presented at the governors meeting on April 26th. Apparently, from what we can glean from Michael Buchanan’s tweets and other sources, some of the governors were taken aback by the never before seen candour and transparency they were confronted with, without warning.

Petter, then chair, decided that the motion would be held back to an extraordinary meeting to be held within 7-10 days of the CQC report being published. I suppose to allow certain people the space to recover their shock and horror that, for once, their cosy slumbering and collusion with the board was being challenged.

I can’t describe what it feels like to read these words. Such a careful, reflexive, comprehensive and sensible engagement with the catalogue of failings since Mike Holder’s report in 2012.

I’m not sure I’d add anything other than, good on you, Mark Aspinall and the other governors who expressed support for it. What a refreshing contrast to the simply offensive letter we were sent on Thursday. And here’s looking forward to the extraordinary meeting in the next week or so.

-REBbBU_

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Sloven and the ligature risks

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A few weeks ago, we found out someone sent an anonymous letter to the Sloven CEO in 2011 flagging up health and safety concerns. Katrina Percy was, of course, totally oblivious. An independent Health and Safety consultant, Mike Holder, was appointed to troubleshoot. Two months later, he handed in his notice. Sloven were not prepared to listen or act.

Holder has shared the relevant documents and his leaving report with the Care Quality Commission (CQC), the Health and Safety Executive and Hampshire MPs, Suella Fernandes and Kit Malthouse. I caught up with some of this paperwork this evening. A couple of things leap out (outside of Holder’s meticulous detailing of the myriad ways Sloven were breaking Health and Safety legislation). These relate to ligature risks.

Holder shared this diagram showing the increase in ligature incidents over four years with the Interim Director of Nursing and AHP (dunno what AHP stands for) in Feb 2012.

lig incidents

Her reply is enough to make hair follicles seal up:

Nurse reply

Holder’s reply. Challenging the nonsensical with sense and clarity:  

Holder reply

Rich and I chatted about this earlier. He was reminded of this quote from Clifford Geertz, a classic anthropologist: 

I have never been impressed by the argument that as complete objectivity is impossible… one might as well let one’s sentiments run loose. As Robert Solow has remarked, that is like saying as a perfectly aseptic environment is impossible, one might as well conduct surgery in a sewer. 

Sloven clearly and consistently embrace the sewer approach with an abandon and a carelessness that is sickening. [There was another report today about the death of another patient/Sloven failings. Lesley Stevens, who seems to have a full time job attending inquests, was again bleating about ‘changes’.]

Changes my arse.

Dipping back to Feb 2012, the second, related point, is around action plans and (non) actions. Someone working with Holder emailed him with serious concerns around ligature risks. The assessor was concerned that either the risk scoring was inaccurate or signalled a general lack of understanding about how to complete ligature risk assessments. Both were deeply worrying. He concludes:

Finally there are action plans in each of the assessments which list all the points where actions are required; there appears to be no record of any actions being completed. This raises the question as to whether the actions have been completed at all, and the assessments not updated to reflect that, or whether the actions are still outstanding.

The same old, same old shite. Across four years now. Documented and shared with the senior management team. Who ignore it.

Given that Holder’s appointment came about because of an anonymous letter raising safety issues, you’d think his resignation and the various health and safety breaches he identified in a couple of months, would be taken seriously.  But no. It was business as usual. Six months later, in August 2012, a quality review, detailing shocking failings at the unit where LB died, was similarly ignored. [Howl]

Fast forward to April 2016, whipping past numerous failed CQC inspections, numerous deaths, inquests and Prevention of Future Deaths reports. Past the publication of the Mazars review… to which Sloven, four years after the above discussion about ligature risk, applied the same baseline stats (non) defence. The latest CQC inspection report will be published later this week. The Sloven senior team are, by all accounts, mounting their schmooze counter-attack. There isn’t a reflexive bone in their collective body that allows them to think, hang on a minute… We’ve really ballsed up here. Repeatedly. Patients have died. Repeatedly. And we clearly can’t do what is needed to improve the services we provide…

Nah. Nothing like it.

This CQC inspection was part of Jezza Hunt’s response to the Mazars review. It was the necessary first step before the CQC and NHS Improvement decide on any regulatory action. [I know]. Given the inspection identified failures generating warning notices a week or so ago. Given everything that has gone before. Given everything. There cannot be any more propping up of this toxic senior management shower. Surely.

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