The update from Sloven on their staff disciplinary actions has weighed heavily since we received it.

I sit in the Justice Shed surrounded by LB ‘stuff’. He’s woven through the fabric of our home, hearts and lives in ways that are both visible (in bus and related memorabilia (is that the right word?) and through the memories/thoughts and laughter we (and this space) constantly evoke. I’ve said recently how much he’d expect and enjoy many aspects of the #JusticeforLB campaign. The buses and lorry named after him. The police and HSE involvement. The human rights legal team. The inquest process and Divine Comedy tweet. Norman Lamb talking about ‘Connor’s law’ at the Lib Dem Spring conference.

His death has captured so much of his imagined future. A future we never really imagined.

He would be enraged by Sloven actions though. They would upset his view of the world. Of the people and organisations you can trust and rely on. Police are good/burglars bad categorisations.

When we told him, that terrible day two years ago tomorrow, that he was going to hospital, he was fairly chilled about the idea. He’d enjoyed visiting his grandad weeks before at the JR. He loved the attention paramedics gave him when he’d had seizures. The NHS was in his good column. When we turned left at the crossroads instead of right, and ended up outside a crappy bungalow where we were almost not allowed in, he became less keen. But it was an NHS hospital (we thought). And even though a few hours later he was subject to violent and extended restraint and then drugging, we thought they must know what they were doing. [I know].

Since the whole foul tale of the Sloven acquisition of the Ridgeway has unfolded (see Chris Hatton’s latest forensic analysis here), Sloven have consistently proved themselves to be at best crap. They really ain’t worthy of the public service label. That’s probably what we’d have said to LB in the end. ‘They ain’t really NHS mate. Just a business pretending to care’.

Some factoids (LB loved Steve Wright):

• I’ve not named any member of STATT staff on this blog.
• We’ve not, in our lengthy and tortuous campaign for justice, made it about individuals (other than the board chair/CEO who really are/should be where the buck stops).
• Until we know the outcomes of the staff disciplinary processes, we will not know whether we should refer staff members ourselves (in addition to the person we referred after being told s/he had left the country).
• Candour, transparency and honesty are big themes in the post-Francis, post-Keogh, post-Kirkup new NHS world.
• A journalist, not Sloven, told us last week that, 21 months after LB died, the disciplinary actions were complete.

And Sloven haemorrhoids: NHS England today told us that Sloven will not provide information on the specific disciplinary actions taken in relation to staff. All we can be told is this:

Dear …,

As discussed, I wanted to share with you some information regarding the conclusion of the STATT unit disciplinary process, and would be grateful if you could share this information with Sara Ryan:

Disciplinary processes for staff at the STATT unit have now concluded with appropriate disciplinary action being taken and relevant professional bodies being informed. The processes took a longer than we would have wished for several reasons, including:

1. A series of internal and external investigations took place, each one prompting a halt to the disciplinary processes to ensure that all relevant information could be considered. Indeed external investigations are still underway; a decision was taken to proceed as further delays were unacceptable.

2. Cases were frequently delayed as we awaited the return to work of staff members who were on sickness leave and upon whose statements each disciplinary case relied.

3. There were scheduling issues around ensuring staff had adequate representation from their staff side bodies.

4. At various points through the process staff or their staff side representations raised grievances or challenges that staff were not having fair hearings due to the media and social media attention being given to the STATT unit (which also was often given as the reason for staff absence) These challenges needed to be resolved prior to proceeding with disciplinary hearings.

Despite these genuine reasons, the Trust is committed to re-examining this process to consider what might have been done differently, as there is no doubt the resultant delays have added to the distress felt by all parties. The Trust is working with Staff Side bodies, our Director of Nursing and other parts of the NHS to consider such delays could be avoided when several staff are subject to disciplinary action at the same time within one working area.

Best wishes …

Blimey. Where to start? Just for now some initial thoughts:

1. 1 and 3 are non excuses/examples of incompetence/poor organisation and leadership. These investigations began 9 months after LB’s death and any of these issues could and should have been anticipated.
2. As 1. above, I’m not sure staff disciplinary actions are typically delayed because of media attention. This too should have been anticipated (and was, given the blog briefing circulated a day after LB’s death).
3. Seems as plausible that staff absence would relate to an endless staff disciplinary process as much as discussions about the STATT unit (which closed in 2013) on social media.
4. How do we know any action has actually happened*?
5. Should it be up to Sloven to decide what is ‘appropriate’ action in the circumstances?
6. If no further info about these disciplinary processes is forthcoming, do we now have to refer pretty much everyone (including the CEO and Board Chair)?
7. Might this bizarre level of secrecy be related to an end game attempt to ‘frame’ one or more staff members for what happened?
8. Do Sloven know what an ‘outcome’ is?
9.  Was this NHS Change Day [cough cough] pledge, made by a senior Sloven staff member less than a week ago, a complete load of billy bullshite?
10. Is this really how the NHS want to (or be seen to) respond to a family whose 18 year old son was allowed to drown, unsupervised in the bath, in specialist learning disability provision?

So many thoughts/questions. #JusticeforLB is a vanguard (joke) movement using social media to try to redress the toxic power differentials that can exist within the NHS when it comes to responding to catastrophic occurrences. We have been, and are, enormously reasonable with our ‘demands’. Despite extraordinary and consistent provocation, delay, obstruction and deceit, we have remained pretty measured. We have worked our socks off, we have met with various relevant organisations and contributed a Justice shedload to the mouldering, stale and faction ridden space of post-Winterbourne View learning disability provision/organisation, for nothing. ‘Fresh air’ has been mentioned numerous times in relation to our campaign, which has also been recognised and remarked upon by various influential people (which we thoroughly appreciate). And yet Sloven continue to demonstrate behaviours/actions that characterise the worst of vintage NHS.

Remarkable. Sadly.

*Just to be clear here, we are in no way arguing for any naming or shaming of individual staff members. Simply that the process is followed transparently.

Another remarkable letter today from the Sloven Board Chair (who I’m now beginning to think might be deluded). We’re still thrashing through various issues around Sloven’s behaviour since LB died. Real scum bucket behaviour. Perhaps not surprising really given the Kirkup report this week that details shockingly awful actions in another NHS “Trust”. We’re clearly a way away from candour, honesty and transparency. Despite all the blather.

So. One part of the letter was about social media surveillance. Mr Waugh states

Like many organisations, the Trust monitors media and social media mention of its name, hence the content of the briefing to which you refer. This does not constitute surveillance of an individual.

Mmm. A quick Oxford dictionary search…..

Surveillance: ‘close observation, especially of a suspected spy or criminal’.
Monitoring: ‘maintain regular surveillance over’

Ok. Not sure the monitor/surveillance distinction is holding up here. I blogged about this issue a while back but a screen grab is helpful for a quick glance. Yep. Clearly monitoring. The blog written by the mother. An individual. A specific and targeted close observation (particularly given we rarely mention the Trust by name (unless it is now actually called Sloven)).

This briefing was written and circulated one day after LB died. [He died?] How the Board Chair of a public body can continue to be so deceitful and underhand to the family of a child they let drown in the bath is unfathomable. You were monitoring/surveilling my social media activity and it was more important to your organisation to think about reputation protection, less than a day after our son died, than seriously look at the service being provided in the STATT unit.

How can this level of dishonesty and immoral action possibly be allowed to continue?

The CQC Sloven inspection findings published today are something that demand careful reading. Remaining mindful of the amount of behind the scenes preparation and coaching that goes on for these inspections.

Brief headline: overall finding requires improvement.

We heard of many new initiatives and the trust was continually looking for ways to improve. However it was clear that time was needed to fully realise the scale and complexity of the changes and embed these across the trust.

Mmm. The bar clearly set so blinking low from the off. Businesses can have teething problems expanding, take-overs and the like. Mistakes can happen. For trusts those mistakes have high stakes. Like LB’s life. [He died?]

Growing so big, so fast and spreading yourself so thin across a wide geographical area inevitably ain’t going to work well. As the report today illustrates.

And a startling number of issues identified in previous CQC inspections in Oxfordshire that still occur. The stench ridden “Always about to…” model very much alive and kicking still in Sloven Towers. ‘Point a CQC inspector at us to show us the right route and we’re on it‘ jibberjabber spewing like vomit from a carsick toddler.

Only they ain’t.

Todays batch of failings:

Not enough staff, delays in the supply of equipment, mismanagement of medicines, buildings unfit for purpose, ligature risks, inappropriate seclusion and restraint practices, lack of crisis services and an unanswered crisis line, lack of available local beds, lack of examination of patients by doctors on admission, long assessment waits, uncertainty and low morale among staff, inaccessible records.

There’s some positive stuff I’m not going to record here. The positive stuff is people doing their jobs properly. Good. But not remarkable. The above list, combined with previous CQC inspection findings should lead to action. Not nonsense ‘learning fluff’ spouted by Sloven execs but real action. This bunch of muppets clearly should not be running an empire of crappy healthcare provision across four or five counties.

I worked at home today. Unexpectedly. And the phone didn’t stop ringing. Various people asking for thoughts about the report. There have been some cracking responses (in addition to the now legendary local news coverage). Andy McNicoll at Community Care and Chris Hatton’s contributions are stand out moments.

But hey, what about the Slovens? How have they responded to a grandly piss poor review of their services? Particularly  given their obsession with awards and all things shiny?

In a typical Sloven way.

Heard on the grapevine the big old CQC inspection of Sloven will be published tomorrow. Probably good timing to have a little whizzle through some CQC inspections of Oxfordshire based Sloven provision conducted since LB’s death. Particularly given we’re a year on from publication of the Verita investigation into LB’s death.

STATT/JOHN SHARICH HOUSE [November 2013]: No therapeutic interaction, illegal deprivation of liberty, privacy, modesty and dignity of patients not respected, impoverished environment, family and friends not involved, inappropriate risk assessment, lack of training, no understanding of neglect or institutional abuse, mismanagement of medication, out of date oxygen, no battery in the defibrillator, out of date oxygen, unsafe buildings, ligature risks, faeces on chair, inadequate quality monitoring, inaccurate record keeping, poor engagement between management and staff.
Sloven response [Katrina Percy] The team are reviewing internal processes and providing “the leadership and knowledge required to ensure best practice is shared.” 

PIGGY LANE [March 2014]: Lack of staff (a “problem with the Sloven recruitment practice”), lack of appropriate assessment, care, treatment and support, poor engagement between management and staff, delay in getting necessary equipment, lack of records about safeguarding incidents, inaccurate medical records, out of date medication, poor management. “It is so unsafe here at times, you have no idea“.
Sloven response [Phil Aubrey-Harris]:  We have reviewed the levels of quality and immediately put in place an action plan to address all of the issues raised. After subsequent re-failure in June 2014 Sloven unattributed response: a “robust action plan” has been put in place to ensure it was compliant in all areas.

EVENLODE [April 2014]: near miss incident in seclusion, ligature risks, poor engagement between management and staff, a culture of “listen but do nothing constructive”.
Sloven response [Lesley Munro] welcomed the report and took the findings “very seriously”. Necessary building works to ensure the unit is fully compliant were “due to be completed imminently”. 

HOUSE 2, SLADE HOUSE [Jan 2015]: No registered manager, not enough staff, lack of leadership and poor engagement between management and staff.
Sloven response [spokesperson]: The CQC report acknowledges that appropriate actions have been taken in response to their concerns, in most cases, on the day of the visit, that was over 4 months ago. 

Wow. A seedy, foul little whizzle. I almost apologise for dragging you back through it. Still. Big statements from Sloven big guns about stuff about to happen or be put in place.

Must admit, I’m baffled beyond bafflement the more I learn about the workings of the NHS. Particularly this whole patient safety stuff that is big at the mo. Details circulating on twitter this morning about the latest HSJ money spinning awards [for a full analysis of previous HSJ delights, click here] now combined with the annual Patient Safety Congress.

What confuses me is the content of this congress (concordat/concrap). ‘Making the business case for safety‘ and ‘Preparing for a CQC inspection‘. Eh? Patient safety? Isn’t that about keeping patients, er, safe? Not number crunching and coaching to pass inspections. Serious brain melt stuff.

At the same time, at a more personal level, the Sloven board chair last week reiterated Sloven’s acceptance of the Verita findings and recommendations into LB’s death. One of the reasons the Sloven bigwigs wanted to meet with us apparently was to confirm their “absolute acceptance of every aspect of the Verita report”.

Oh. That’s a bit odd. Why the hell are they wasting public money having a legal team, including barristers, who have tried to narrow down the scope of the inquest then? Why have legal representation at all? 

I just don’t get it.

It’s like the music is playing loud and clear, but Sloven, and the NHS, insist on dancing to a different tune.