The CQC, Ford escorts and failings


Oh dear. Andrea Sutcliffe, Chief Inspector of Adult Social Care at the Care Quality Commission, has written a blog that makes my eyes repeatedly blink. And my brain slowly and repeatedly turn and churn. Chucking me back to days of car sickness and towel caught vomit on the back seat of a Ford escort. Here’s a walk through…

Writing about the Panorama programme shown this week documenting abuse at a residential home run by the Morleigh Group. [I’ve not watched the programme. I need to develop guts of steel to do so.] Sutcliffe is both defensive and distancing in her ramblings. 

She kicks off in the first paragraph with the statement “We warned [in a report] that adult social care is approaching a tipping point…” Mmm. A better start, given the content of the Panorama programme, might have been something along the lines of “I’m horrified that such abuse continues to happen in care provision in the UK, despite our continued efforts… We clearly need to do better.”

And continues: “The Panorama footage was not shared with the CQC in advance so I watched like everyone else.”

Blimey. Not sure what the point of this statement is but it doesn’t half ring some serious ‘queen of the land’ bells. A moment or two of self reflection (or a good mate to pull you up on these developing tendencies) might be in order… 

Sutcliffe found that “two moments in particular made me despair”.

Phew. It wasn’t that bad. Only two moments. Allowing reference to the mum test.

“That could have been your mum or mine…”

This was followed by a remarkably weak defence of CQC actions around the Morleigh Group:

“these are services we have been worried about for some time; we had kept them under close scrutiny, inspected regularly and set out what they needed to do to improve through our reports and enforcement action”.

‘Worrying about’ services you know to be failing really ain’t a robust defence. And, clearly, close scrutiny and regular inspections aren’t working. These are people’s lives. A fact that an entire gamut of senior NHS bods apparently still do not get. I ‘worry’ about getting to a meeting on time. About meeting funding deadlines. Not about people (residents) being brutalised.

There’s a muddled and confusing tale of inspections before and after receiving info from Panorama and the (necessary) identifying of “a serious decline in quality”. The CQC never at fault. Failing services brought to public attention by the actions of public and/or journalists have typically ‘just declined’ between news breaking and the previous inspection. Removing any need for scrutiny of the inspection process and what might be missing in terms of identifying failing practice the first time round. Before people are brutalised. Or worse. 

The CQC role section is a cracker. Beginning with unqualified condemnation of the Morleigh Group. Of course. The responsibility lies with them. 

cqc-roleThen the bizarre statement ‘But it is not unnatural when dreadful things happen in the sector’. ‘Unnatural’?  Eh? How far have senior CQC staff become detached from reality?

The following paragraph is also deeply concerning.


Setting clear expectations? They were kept under close scrutiny? Sigh. The Morleigh Group failed. The CQC failed. There is no wriggle room. Bleating about working hard while failings continue is deeply offensive (and makes utter mockery of the mum test).

Sutcliffe continues to dig a deeper hole. Including an extract from a ‘fairy tale’ letter from a punter which rings even louder alarm bells about CQC processes.

cqc3‘I think I should give you a resident’s viewpoint…’ ‘Recovering from the shock’? ‘Right the wrongs here… ‘ Eh? Really? I’m trying and failing to imagine the concerned ‘resident’, sitting in her bedroom, pen poised, reflecting on how much better life is now staff no longer do ‘wrongs’ to her and other ‘residents’. Nah. I can’t.

The overall message of this ill judged post: it wasn’t the Chief Inspector of Adult Social Care or her CQC kingdom what done it. The failings lie firmly with the provider. [And we all know, sadly, they ain’t an outlier.]

Writing what’s happened…

I’m writing a book. I know. A book. Lofty aspirations. I can barely read one these days. I’m determined to write a book. I’ve never written a book. I write all the time. I vomit out blog posts. I now struggle to write academic papers.

The process of writing this book is generating rage beyond rage. So much so fucking wrong. I’m beginning to reflect more clearly, three and a half years later, on the broader acceptance of the circulating shite. My initial rage at reading the brutal content of briefings, email exchanges and reports is shifting to those who read rather than those who write this content. And say nothing.

Those who received the Background Briefing of Mother’s Blog in their inbox on July 5 2013. A day after LB drowned. Can you imagine? And sucked it up. Those who received the ‘internal’ review‘ by Oxfordshire County Council two weeks before we’d seen sight or smell of the stench of this secret and tawdry investigation. A report chucked into my inbox without warning one Monday morning by an Oxfordshire County Council Social Care Director, strangely off sick for the rest of that day.

Could you try to step outside the smug, judgemental, self serving space you typically enjoy. And challenge this shit? Keep your eye on the human.

It may make you feel better about yourselves. And what you do.

Or maybe not.


Conflict negotiation and Trump stickers

I’m in a space of Trump denial. In a 4.5 star hotel booked for €120 for four nights in Santa Cruz for a work gig. An outside lift reminiscent of The Towering Inferno. Loo roll with a dark blue sticker (figure with upraised arms) on the end sheet. This figure appears variously on a cocktail stirring stick (I think) and other stuff in the room.

fullsizerender-3A Trump like figure. Directing me to the start of a loo roll/tug ritual I’ve mastered since I was a tot. There are no cocktails.

On the plane I had an aisle seat. The woman by the window was a conflict negotiator. With no one between us we bonded over her well worn walking boots and my dusty trail shoes. She trumped the #CaminoLB with 15 or so years of walking different trails/adventures.

We totally owned that middle seat as she quietly reassured me about the robustness, independence and power of the Health and Safety Executive. Apparently, being formally interviewed by the HSE is a deeply, serious step. I was reminded of the clear and sensible info given by the police back in the day.

“This isn’t your conflict any longer…” she said.

Just imagine.

Flight of the Camino

Not long to go now before we set off on the CaminoLB. The route is here (it’s a bit anarchic organic and loosely formed). What we know so far: George Julian, John Williams, Dave Griffiths and I (me?) are setting off on Tuesday evening on the 24 hour ferry from Portsmouth to Santander. With the #JusticeforLB quilt and bus. Postcards of Awesome, the #JusticeforLB flag and anything else we can tuck in our pockets and socks.



We hand the booty (other than the bus and the flag if I can find it) over to Alicia Wood in Santander in advance of the #JusticeforLB exhibition planned for 2 Dec. We start walking with the bus first thing Oct 27 with a cheeky 37 miles to cover in the first two days. Luckily John and Dave are doing those two days. Two comedians who are planning to train by doing a few laps of the deck on the ferry. John has Body Glide anti-chafe cream and Compeed. Dave will be wearing his crown.

Various people will join us along the route. With a build up across the final three days when five people from My Life My Choice (including Dawn Wiltshire, Paul Scarrott and Shaun Picken), Rosie Tozer, who is walking in memory of her son, Danny, and Ruth Glynn Owen join us. Paul points out that it may be the first time learning disabled people have done anything like it. I think it probably is. Demonstrating the limitations of the big charity guns – Mencap, Scope, National Autistic Society – who typically manage, orchestrate and erase the talk, enjoyment and involvement of people in a relentless drive for self promotion and self serving nothingness.

We’ll be meeting with Spanish school kids who are making gingerbread figures and local dignitaries during those last three days. Finishing the walk on Nov 3 in Aviles. Dropping the bus off where the exhibition will be held in December.

This afternoon my sis, Agent T (pitching up at Poo next Saturday to walk the remaining walk) and I caught up with packing plans. The weather forecast is spectacular. Coats/waterproofs ditched. Ipads/laptops still up for grabs (well, for me anyway). Various devices for having an unobtrusive piss en route to be tested. I’m running with some £4.99 jobby from Go Outdoors…

With the help of behind the scenes organisation magically sorted by Alicia, Mariana Ortiz and Henry Iles [thank you] we may well have the experience of a lifetime. Laughter, tears and, hopefully, more laughter.

Here’s hoping a few laps of the Brittany Ferry deck on Wednesday will reap rewards.

LB would bloody love it.

[And there’s always time for anyone (er, cough cough, Mencap, Scope, NAS… or whoever) to join us. Why not smash the boundaries and just do summat?]

An exemplar in absurdity (and conkers)

A sort of follow on from the (updated) The Talented Mr Martin and viral impact post. Underpinned by continuing incredulity at the removal of the Talentworks website. A ‘leadership’ consultancy with the tagline:

Meet the Talentworks team… hired for our large brains, love of psychology and impeccable dress sense.

Yes. Really. Well, and at least £5m of public money.

In the continued absence of any apparent scrutiny from NHS Improvement and others who should, we’re left digging deeper into shit we should never have to go near.

Talentworks. A virtual collective of people with large brains… etc have not only been getting obscene amounts of dosh from Sloven. They’ve also been working closely with Thames Valley and Wessex Leadership Academy (TVWLA). An academy led until last year by Katrina Percy.

I’m rubbish with figures but the Talentworks ‘blah blah’ work with the Thames Valley bunch (Financial Summaries available here) seems to involve a shedload of dosh for the two years Percy led the academy (around £500k and £370k)  dropping to around £20k after she stepped down. [As an aside, how could Percy dismiss Mike Holder’s safety concerns while championing Chris Martin and his jibber jabber? [howl]]

A brief browse of the Talent Management pages on the Thames Valley Leadership Academy pages:


A teeth achingly meaningless statement. Just noise. How the Wessex leadership gang allowed this to be published on their website makes me want to weep. I’m left wondering (again) is this about stupidity, incompetence, fear, corruption, bullying, greed, narcissism or simple slumbering?  The focus on this hocus pocus crap, while staff were left without leadership, untrained and unsupported to provide the most basic care to keep LB and so many other patients alive [alive], is haunting.

More bollocks…


Greater pipeline intelligence? A driver of culture change? It’s like the Stepford Wives meet NHS England.


I’ve not read this blinky blonky table yet. The headings alone suggest nonsense. I just want to know who authorised payments for this ‘work’? Where were the internal (and external) audit processes? Did no one ask what is this about and is it effective?

Did Talentworks really have a blank cheque to do whatever?

What are the links between Chris Martin, Katrina/Iain Percy and others?

What does it mean that Talentworks have withdrawn their website?

What the actual fuck?

Here’s a photo of conkers we collected in the park earlier. I bloody love this photo. These are conkers. As simple and uncomplicated as.



No (NHS) improvement (whatsoever)

More tales of dismal practice and bullying at senior Sloven levels are arriving in the shed. [Thank you for speaking up]. Apparently Mark Morgan, the Director for Mental Health and Learning Disability has a bit of a tawdry background. A serial interim manager, he was reported to be earning £28,000 a month back in 2014 at the Medway Foundation Trust. His director blurb on the Sloven page states:


Bit of a funny statement about ‘pending a recruitment process’ but it turns out that Morgan (allegedly) wasn’t appointed when he was first interviewed for the post. Not very confidence inspiring and means he was an interim for longer than necessary [yes, my fingers can barely type these words, the level of absurdity is so extreme.] Prof Hatton was keeping a careful watch on the data and tweeted:


Mark Morgan was paid just under £300,000 for 8 months work.

[Fill in your expletives here:_________________________________  I’m out]

This afternoon, a 38 page investigation report into the care of a patient at the Ridgeway Trust. This is the assessment and treatment unit that takes Oxon patients now the STATT unit is shut. The harrowing complaint, made by the patient’s mum (terribly difficult woman I’ve heard, and no doubt has “hostile” written all over her son’s files) has 29 items relating to the unit in 2014-15.

The covering letter is from Julie (scores on the) Dawes who must be wondering what she’s wandered into but I’m assuming Mark Interim Morgan must have signed it off. It’s under his remit. A tiny bit of context here for any new blog readers:

In 2013 the CQC failed an inspection of the STATT unit where LB died. It found a hideous set of failings including a lack of therapeutic environment [howl], poor record keeping, no involvement from people using the ‘service’ and so on. 

Today’s report upheld complaints in 13 different categories of complaint:

access to services, communication, discharge, nursing care, failure to follow procedures, record keeping, attitude, clinical care,funding, medication and prescribing, aids and appliances, code of openness and equipment

Some low lights:

  • A lack of active engagement with the patient’s mum.
  • Failure to record incidents on RiO or Ulysses or inform families
  • No therapeutic engagement with patients
  • Little access to the community because of low staff levels
  • A distant and unhelpful psychiatrist at the team meetings
  • Misreporting of the patient’s activities at the team meeting
  • Inconsistent communication
  • Failure to effectively minute meetings or act on action points
  • Trust and NICE guidelines were not followed around medication use
  • No specific care plans or risk assessments around observation levels* and their purpose.
  • No discharge report received ‘because of an administrative error’.

LB didn’t get to the discharge bit. Otherwise this is pretty much a repeat of the failings identified three years ago. Sloven clearly are clueless and have no learning disability and mental health expertise at senior level. They don’t get it and they don’t give a shit they don’t get it. While Dawes is cognisant of the failings the report identifies how can any patient/member of the public have any confidence that the recommendations (listed below) will actually happen? We have been told over and over and over again that lessons have been learned and improvements made.

I’ve nothing else to say about Jeremy Hunt, NHS Improvement, NHS England, Oxfordshire County Council and the Oxon CCG. It’s all been said repeatedly.

The system is clearly broken.


* This reminds me of LB’s psychiatrist (currently missing in Ireland) who when asked by Paul Bowen to explain the difference between an observation and a ‘check’ at LB’s inquest, said “Ah, now I’d have to really drill down to do this”. These are people’s lives.

Take. what. you. need.

I was at the Disability Studies Conference at Lancaster a week or so ago where I met a small group of Icelandic academics/self advocates. I was delighted to hook up with them because I love the work of Kristin Bjornsdottir and team. And their campaigning. The George Fox building, where the conference was held, was dotted with these posters…


Kristin talked about using #JusticeforLB in teaching and subsequently posted this:



Tim Smart resigned unexpectedly (but not surprisingly) today. Both Sloven and NHS Improvement demonstrated what Chris Hatton described as ‘a mulish aversion to honesty’ in their press statements about his resignation.

There is no candour. No honesty. We’re left with a ‘trust’ with an interim CEO, no Board Chair, no Chief Operating Officer, no Communications Director and 8 governor vacancies. Well, and financial irregularities over contracts worth millions. And a dodgy new (or old) made up post for Katrina Percy costing around £250k. And left with a deputy board chair who shared the findings of the Mazars review pre-publication with his teenage son who rubbished the findings on social media.


What a complete and utter (chilling) shambles. Meanwhile, Jeremy Hunt repeatedly deflects MPs questions with non answers.

It’s more than apparent that the likes of Jim Mackey and gang, the remaining Sloven senior exec and ex-CEO, really need to take what they need. And act accordingly.

Or do one.


The talented Mr Martin and viral impact

I wrote about Talent Works when the scandal of a £300k leadership training contract turned into £5m spoondoonies for Chris Martin and crew first broke. Since then, a few staff members have got in touch to describe their experiences of the training. Not good.

I went on Going Viral while at SHFT. It was compulsory regardless of how busy you were. Insistent on overnight stay in the hotel even though I lived 20 mins away. It was awful. Crap management twaddle. Every session we had to “check in” no thought for people like me who were not comfortable sharing in public. I gained nothing from the whole hideous experience.

Yes I’m embarrassed to admit I’m a Southern Health employee. I don’t have anything to whistle blow, and I’m sure no satisfaction to offer you and similar families but suffice to say there are a lot of us within my immediate colleagues of middle management and below who find no surprises in the latest round of revelations of farcical nonsense. Some of us have been on Going Viral and Gone Viral (there really is no opt out for certain pay bands) and while of course finding some of it interesting and sort of useful (especially meeting clinical staff and even patient advocates and hearing about their challenges) have come away feeling it’s too much corporate nonsense with ice breaking tasks and dreaded role play scenarios.

Apparently it costs £6k per person to attend, is compulsory and you have to stay the night at an expensive hotel. (Sloven spent £135k on accommodation in 2013/4 for staff to attend.)  Here’s the Talent Works partner, Sarah Law, talking about the Going Viral programme two years ago [cringe warning]:

I know Katrina is really keen for everyone to get the chance to get involved in this...” Yeah. Of course. At £6k a pop. Sadly, she wasn’t as keen for staff to be trained in epilepsy care or to remove ligature risks.

What the training involves isn’t clear. But hey ho. A little look at the Talent Works website reveals more work with Sloven who were one of the pilots for this gig:


Bizarrely, Talent Works evaluated the pilot themselves (yes, really). Eleven staff took part in the pilot but only 7 provided feedback on it. That, in itself, should get alarm bells ringing somewhere but apparently didn’t. And the farce continues with this nonsense:


So, there was no way of effectively evaluating whether the pilot was effective or not. Asking people to remember how they felt before doing something is simply ludicrous. One person was apparently worse after the intervention, the others the same and yet this is a ‘successful pilot’. This reminds me of the equally nonsensical appreciative inquiry gig Sloven funded recently. The senior management/exec are clearly not very bright if they keep swallowing this shite. And, as always, NHS Improvement are hands firmly clamped over the ears and eyes shut.

Meanwhile, at Sloven’s annual public meeting last week, the finance bod, Paula Anderson, was asked about the Talent Works contract (from 1:01:46):

She clearly states; It’s fair to say when we’ve looked at it we’re not happy with the procurement process and there are issues with that. Stating the bleeding obvious but there’s definitely no governance issues here, are there Mr Smart?

So a little summary of what is deeply wrong:

  • The contract was originally awarded to the CEO’s mate for £300k.
  • Sloven eventually paid Talent Works over £5m.
  • There is no outcome measure to know if there is any benefit of doing the Going Viral training (and given the leadership failings, I think we can probably say there ain’t much benefit at all).
  • Apparently this doesn’t matter and Talent Works are being funded (by who? NHS England?) to extend their biz across other trusts…

It’s truly, truly obscene. And in one last little joining of the dots, one of Talent Works partners is, erm, the charity set up in memory of Percy’s brother, Iain’s, sailing partner. Another grubby, sordid little tale.

Update [23 September 2016]

In addition to the illuminating comments below (including evidence from John Green that the Going Viral course is rubbish), we got sent a copy of a timetable…


And this analysis:
3 overnight stays, = 6 days lost + 2 days for launch and review + 2 0.5 days for learning sets = 9 days of work lost. On one course, there were three consultants. Assuming they were newly qualified, it would cost around £5.6 of service loss for the 9 days on the course. If at the top of the scale, £7.5k (not to mention the loss of outpatient appointments or the cost of backfill).


Talentworks removed their website today. Shortly after their tagline was shared on twitter:

‘Meet the Talentworks team… hired for our large brains, love of psychology and impeccable dress sense’.

Removing your website can only be an admission of guilt…

The Sloven senior exec allowed £5m of public money to go into the pockets of Percy’s mates. For training not fit for purpose. In the meantime, they failed to ensure that staff were trained in the basics and that the environment was safe.

This is sounding increasingly criminal to me.

Down but not out…

Levels of incredulity at the continuing unfoldings down Sloven way – apparently supported and endorsed by NHS Improvement – have reached crisis point. Even our brilliant, informal, campaign media archivist, is flailing…


Behind this battering is a peculiar situation which seems to be baffling pretty much everyone apart from the Sloven exec (plus Katrina Percy), NHS Improvement and Jeremy Hunt. Even Simon Stevens, CEO of NHS England, has publicly said Sloven have let down patients and families…


There is sensible and widespread condemnation of the recent sidestepping of the CEO into a new (or old depending on who and when you ask), part time role at the same salary and perks as a CEO (on top of the other, well documented failings). Including this statement from Philippa Russell on behalf of the National Valuing Families Forum.

The story of Smart’s stint as Interim Board Chair which only started in May is that he apparently commissioned two (yes two) so far mysterious reviews which found that the Sloven board are fit to practice. This was announced on June 30 without any engagement with families (other than an ‘accidental’ meeting with My Life My Choice who have since decided to no longer engage with Smart). The annual board meeting held last week demonstrated woeful engagement with families and patients (forced, as always, to sit through interminable presentations/talk with public question time compressed to barely any time at the end). This seems to last as long as Smart’s patience (if you can bear to listen to the audio recording). Appalling senior action still from a trust who have been in the public spotlight relentlessly for failing to engage with patients and families.

Strangely, Smart has agreed to the secondment of two directors (including the Chief Operating Officer).  Chris Gordon to NHS Improvement and Sandra Grant to another trust or commissioning group. And unilaterally (it appears with NHS Improvement dove from above agreement) agreed Percy’s new or old position.

Just a few questions. [No answers expected…]

  • Why would you insist a board is fine and then allow the secondment of (key) execs when the terrain is rocky?
  • Is there now no Chief Operating Officer or Communications Director alongside an interim Board Chair and CEO?
  • Is anyone at the highest levels of the NHS, in this foul and grotesque tale of abuse, deceit and pantomime, going to find it in themselves to stand up and act with integrity?

I suppose, if nothing else, a necessary light is being shone with a bloody big torch not on only Sloven murkiness but also the gaps, limitations, failings, impotence, pointlessness, corruptness and fatcattery that exist within and among senior NHS spaces. I dunno how you sleep at night.


Walking back from the original gingerbread protest at Jubilee House earlier this summer.

A cheeky bit of media advice to Smart and gang


We’re weary in the Justice shed. Weary of the continuing horrors, absurdities, scandals, lies, deceit, cover ups, failures in accountability, delay, obstruction, lack of decency, sense and fairness. Broken Trust, shown this week, was pretty horrific and devastating for families involved to watch. In the spirit of productiveness, and to distract from raging, I thought it might be useful to offer Tim Smart and other senior NHS bods a few pointers in engaging with the media. His interview (and Katrina Percy’s) with David Fenton was an exemplar in how not to. Just a few twitter responses:


3 2


Now I certainly ain’t no expert in media appearances. We have no comms team/resources behind us. In fact the only time I was on local radio before this devastating unfolding, was for work. I forgot the third (stereotypical) characteristic of autism through a rabbit in headlights/fear situ. Deeply awkward and embarrassing at the time. Now just budgie feed.

Here’s the transcript of the interview with Smart with thoughts and suggestions added in red. Please feel free to add further reflections/advice in the comment section below. There is clearly plenty to learn.


1Obviously this interview will have been edited and mucked about with. But the ills and errors were spoken and so available to produce this version. Thoughtfulness, care, honesty, reflection and openness are the very basic ingredients. With knowledge, underpinned by experience, and broader understandings of and engagement with the wider context essential at such a senior level. At a senior level, and on these massive salaries, I’d also expect a clear understanding of media engagement (and the potential pitfalls) and some ease (taught or otherwise) of sitting in front of a camera or microphone.

The third ‘autism characteristic’ I forgot, back in the day, that afternoon at BBC Radio Oxford, was ‘theory of mind’. I was mortified at the time. I resolved to avoid announcing a number of things, in advance of listing them, and to prepare a list of key points in advance. I hope Smart, Percy, and those around and above them, are revisiting the seriously gut wrenchingly awful presentation of Sloven senior culture presented in Broken Trust. And that serious questions are being asked around what has, and continues to happen, at higher levels.