Category Archives: CQC

Just imagine

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Just imagine. Nearly three years after LB died. After two ‘independent’ reviews by Verita were published. After the police closed their investigation into LB’s death because they couldn’t find any evidence that linked the Sloven senior team to the crap provision at STATT. After a two week inquest…

Just imagine you get sent a previously unseen document, anonymously, via My Life My Choice. A document which shows that Sloven knew that the provision on the Slade House site was crap in August 2012. Nearly three months before they took over the Ridgeway provision.

A Quality and Safety Review, conducted as part of the Governance Work Stream. That details lack of clarity in care plans, risk assessments not updated or appropriate, issues with RiO, lack of assessment from the wider team, dirt, lack of maintenance, crap about Mental Capacity stuff, and so on. And so on.

August 2012.

So everyone knew it was shite. Nothing was done about it. And our son died. He died. 

And Sloven buried the document.

Thank you to the person who sent it.

I think we’re back to corporate manslaughter territory.

Fuckingtosswankerybastards.

 

What are we waiting for?

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Superb piece about LB in Guardian Weekend on Saturday. Written by Simon Hattenstone with pics by Joel Redding. They got on and did a cracking job. No fuss or prevarication. Sensitive, comprehensive and thoughtful. Not an easy gig. More light in contrast to the stench we continue to experience from the variously implicated organisations.

So what are we waiting for? In no particular order, as always:

General Medical Council investigation into consultant [679 days]
Care Quality Commission Fit and Proper Person’s Requirement (FPPR) into the Sloven CEO’s fitness to practice [92 days]
Nursing and Midwifery Council investigation into nursing staff [58 days]
A reply to my letter to the Sloven governors [94 days]
Health and Safety Executive investigation [392 days]
Any meaningful action from NHS Improvement (previously Monitor) [109 days]
An apology from Oxfordshire County Council for their sordid and secret review [356 days]

There can be no excuse whatsoever for this level of delay.

This complete fucktivity.

But hey ho. Here’s a pic of the kids that didn’t make the mag to keep the light shining.

Connor with his brothers and sisters

Monitor and the (non) improvement director

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‘Er, Jim, you know we said we’d appoint an improvement director for that Trust, down south. You know. The one that was caught out covering up learning disability deaths?’

‘Yes. I remember. How could I forget? That godawful meeting with that service user’s mother. Dreadful, dreadful woman.’

‘Well, it’s been quite a while now and we did sort of suggest it was going to be an urgent action…’

‘Surely we can rope in some herb to do this. Christ. Sloven must have a range of external consultants who can step up for a few weeks. I mean it’s not real work. We just said we’d appoint someone. It doesn’t mean anything…’

‘Well it’s a bit awkward because social media makes this stuff transparent and, to be fair, it has been a few months now. And, er, the trust didn’t investigate hundreds of deaths.’

‘Don’t get sucked in, Jim Junior. A word of advice. If you want a career in this biz, question nothing. Keep your head down. Once you start to engage with patients and their families, you might as well give up. Just ignore them. They disappear. Or become so desperate, it’s easy to bat them away.

And another thing. Monitor won’t exist for much longer. NHS Improvement is the way forward. We are going to shine a beacon on poor practice.

Was there anything else you wanted?’

‘Sorry boss, but we’ve heard that BBC Breakfast are running a feature tomorrow morning. A pretty forthright piece asking what we’ve all done since the Mazars review was published.’
‘FFS.’
Tap tap tap.
‘Get old whatsi, you know… that other improvement director we’ve got. Alan whatsi. And get comms to put out a release. And hold it till end of play so it gets lost in Easter. Bloody pain in the arse stuff.’

[Text in bold added after Monitor announced the appointment of Alan Yates after 6pm the day before Easter weekend.]

The moon on a dick

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Dear Moon,

Out of people to write to so thought I’d try the moon. Or a moon. Any moon really. Full or otherwise.

Jezza Hunt, the Secretary of State today made a speech about patient safety.  He starts with ‘intelligent transparency’. Word rubbish. ‘Intelligence’ doesn’t mean anything other than fake measures of fake, plumped up fakery. LB scored below zero on ‘intelligence tests’ but beat the pants of most of us for getting stuff. For just being. But ‘intelligence’ carries weight. It’s a sought after marker of summat. 

‘Intelligent transparency’ leads to action he tells us. And then goes on to explain how it doesn’t. [I know, just try to hang in there if you can…]  Each NHS trust in England has been asked to self report their annual number of avoidable deaths. Yes. Self report. Mark your own homework. I think we can anticipate a chunky zero from at least one trust not 100 miles from here. And, even more absurd… the way in which each trust does this marking varies so there is no ‘national standard’. Across the, er, National Health Service.

Some may use an abacus. Some may use a mix of patient and local roadkill intelligence. Some may use quantitative or qualitative methods. Some may just count how many toenails they can ping into the bin in the corner of their office from their swivel chair. It simply doesn’t matter. It’s action. That comes from intelligent transparency.

What matters is that trusts are, at last, estimating avoidable deaths and being open about it. 

There are a few Mikes involved in this new process. Richards and Durkin. A coming together of the Care Quality Commission and NHS England. Richdurk. An integral part of  making the NHS the world’s largest learning organisation. [You gotta read some of this stuff for yourself, Moon. Sorry. There are sections that are so full of bullshit I can’t precis them…]

Picking up the speech from ‘A true learning culture must come from the heart … ‘ [not the tagline for a new Sunday night BBC drama but the actual words of the Secretary of State]. He talks about the suffering band of rellies who have cried out to him in frustration about the lack of accountability. Blimey. What a patronising and demeaning load of guff.

And he includes us in this shite with mention of Sloven. That painfully, awkward, 30 minute ‘meeting’ in the same (not safe) space as him allows him to nail us to his suffering family mast. We were forced to listen to him indignantly spout his human factor speak while he completely ignored our concerns that learning disabled people are being effectively erased. 

[Families should be given a public health warning after experiencing the catastrophic death of a family member in an NHS setting. Alerting them to this parasitic leeching by public representatives who should actually be doing stuff. Instead of feathering their nests. And furthering their cult like causes.]

Turns out our attempts to get some sort of accountability for LB’s death is misguided. Bad mistakes can be made by good people and a ‘proper study of environment and systems in which mistakes happen’ is needed.  And when patients are given an honest account of what happened alongside an apology, the impact is less litigation, lawyers and more rapid closure ‘even when there have been the most terrible tragedies’. 

My arse.

The JezzRichDurkBromTit* version of human factors feeding into the new HSIB (Health Safety Investigation Branch) is simply absurd:

Affected patients or their families will need to be involved as part of the safe space protection. And while the findings of investigations will be made public, the details will not be disclosable without a court order or an overriding public interest, with courts being required to take note of the impact on safety of any disclosures they order. This legal change will help start a new era of openness in the NHS’s response to tragic mistakes: families will get the full truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong. What patients and families who suffer want more than anything is a guarantee that no-one else will have to re-live their agony. This new legal protection will help us promise them ‘never again’.

Er, sorry Jez, you made a bit of a leap there. Families want accountability. In the same way they want accountability when someone dies outside of the ‘safe space’ of the NHS. And how can you talk about a new era of openness in the same paragraph as court orders? Just barmy. Oh, and HSIB will only look at 30 deaths a year. And Jezza has decreed these will be in maternity services.

Intelligent transparency anyone?

Just boys and their toys.

L1018365*Hunt, Richards, Durkin, Bromily, Titcombe

Questions from the public

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A short post. I read this extract from the latest Sloven board minute papers last night and had one of those moments when I couldn’t see the screen for tears. James should not have died. Mike Holder wrote to Katrina Percy in 2012 detailing the safety concerns he had. These concerns were ignored. The CEO and board didn’t care.

Mrs Younghusband should not have to go to a NHS Trust board meeting to say the unspeakable.

There is a clear and incontrovertible link here between corporate decision making and James’ death. And the slimy Sloven bastards tried to stop Mrs Y from taking civil action by limiting the time she has to act.

The lack of action by those who should be acting (Monitor, Department of Health, NHS England, CQC, yawn-di ya-di da) makes me wonder when most of the principles guiding the NHS were ditched? Southern Health NHS Foundation Trust is no part of a National Health Service I recognise or believe(d) in.

Board meeting

A shave and a haircut… the CQC way

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Lengthy twitter discussions earlier today following on from news of the 80 bed unit planned up in the North East, blogged about by Mark Neary yesterday. The proposed unit is to be run by the same manager of the Lenore Care Home in Whitley Bay which had a pretty positive CQC inspection report in June 2015.

cqc ratings

The two sides of the twitter discussion today can be summarised (roughly) as:

This home is well run, ‘residents’ reported good quality of life and the proposed unit could be equally as well run for people to lead independent lives without becoming isolated in the community.

The CQC report findings don’t capture anything approaching a typical home and it ain’t remotely likely that the proposed new unit will be ‘home like’. It represents a return to institutionalisation.

I wrote a post soon after LB died about accepting the unacceptable. Something people, parents, carers, health and social care professionals do. For different reasons. The unacceptable becomes unremarkable and the norm. And we use different criteria to judge the treatment certain people receive.

So let’s have a closer gander at this inspection report. Thinking about what is typical for many/most people. Rather than typical for a few.

The 23 bed ‘care home’ has 21 people, a manager and three staff on during the day, two staff on sleeping over duty at night. I assume there’s a range of different aged people living there. Learning disabled people tend to be lumped together in an ageless way. Which is pretty grim.

The inspection involved observation, interviews and reviewing documents. There are a lot of positive comments; friendly, supportive, well trained, supervised and informed staff. People were clearly supported to attend health appointments and the manager was praised by people. There was a dog that one person looked after to learn about keeping a pet. All good.

A big part of the dispute on twitter revolved around the clear lack of available support to enable people to go out and about. Such a small number of staff meant that, if people weren’t able to take themselves off, they’d be stuck indoors. We don’t know how many people were able to go out without support from the report. An important omission.

Alarm bells rang for several reasons:

  1. A finger print keypad security system. 
  2. Computers available in the communal lounge and staff supporting people to stay safe when using the internet. 
  3. ‘The food is good; always two choices on the menu and you choose before 11am.’
  4. The provider continued to be the corporate appointee for a small number of people living at the home with regard to their financial oversight (plans to change this apparently). 
  5. A resident saying “I feel safe. I hardly ever go out because it’s safe here.” 
  6. No one at the home was currently accessing support from an advocate or advocacy service.
  7. At night people could call for assistance through the use of buzzers in their rooms or by knocking on the staff room door.  
  8. There were no specific care plans or instructions in place to indicate when ’as required’ (PRN) medicine should be given.  
  9. ‘We looked at the social activities records for people that were updated on a daily basis. This document was task based and most recent comments noted only that people had been given a haircut or a shave

You can read into this report that a small bunch of good staff, lead by a thoughtful and competent manager provide a (pretty much safe) and well run outfit. Or you can think about people’s lives. About potential, aspiration, social interaction, fun, work, engagement, holidays and so on. Most of which seem to be absent.

Has everyone got fingerprint access to come and go? Why has no one got their own laptop or tablet, and is there no wifi? Why, if the aim of the home is to prepare people for independent living, is no one involved in shopping, cooking or choosing food to prepare/cook?

Why have none of the 21 people got advocacy support? Surely some would need it?How can the provider be in charge of people’s finances without external scrutiny? How can people never leave their ‘home’ and this not be queried? Does anyone go out in the evening (the emphasis on the buzzer situation suggests people stay in/in their bedrooms)?

How much PRN (which is typically sedative type stuff) is given to people and how often? And why are no social activities recorded other than personal hygiene activities?

Oh, and the biggy. Why are 21 adults living in a ‘care home’ in the 21st century?

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Nothing in this report suggests anything approaching what I would describe as home life. Quite the opposite. Which raises the question; how often do CQC inspectors use the unacceptable as the bar for good, or good enough, when it comes to learning disability provision? [And the answer should not involve mention of ‘experts by experience’].