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risk assessment, lack of training, no understanding of neglect or institutional abuse, mismanagement of medication, out of date oxygen, no battery in the defibrillator, out of date oxygen, unsafe buildings, ligature risks, faeces on chair, inadequate quality monitoring, inaccurate record keeping, poor engagement between management and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staff, delay in getting necessary equipment, lack of records about safeguarding incidents, inaccurate medical records, out of date medication, poor management.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.

Received a response from Simon Waugh (SW), Board Chair, Sloven Health this afternoon. That it came by email is about the best thing I can say about it. Selectively copied in to the cc list (bypassing Katie Razzall, Newsnight and JusticeforLB headquarters).

Brief context: We had questions, Katrina Percy refused to answer them, SW answered them Sept 17 2014. In a really crap way. In such a crap way I arranged to talk with him on the phone (23.9) convinced he wasn’t really up to speed with what was happening under his watch.

The big conversation back in September? A mistake really other than the occasional droplet of insight. We’ve continually shot ourselves in the foot and made ourselves look as incompetent and uncaring as possible. Er, yep. The truth is simple. His care was not what it should have been. Yep. SW also said he’d learned to reflect about being on the receiving end of letters from him in his capacity as Board Chair and think about what it must be like to receive such a letter (does it help or does it widen the gap?). Good stuff. (Though this was in connection with sending my sis a letter meant for another patient, rather than real reflective stuff about the content and meaning of what you write).

Unfortunately, these drops were obliterated by a drill hammer communication style, clearly aided by a set of key points) that looped across the two hour conversation (LB was fab, fit and able, staff forgot he was a patient, Sloven appear crap (but ain’t really) and there are valid excuses (or cliches) for everything). Once the repetition became apparent, it was a really uncomfortable conversation.

A couple of examples of the excuses:

Sloven didn’t dive into the unit to see that the hell was going on when a “fab, fit and able” young man died unexpectedly in the bath [he died?] because the police told them not to. Mmm. Not sure about that SW. How come the CQC could just pitch up and inspect weeks later?

“Well you’re damned if you and damned if you don’t”, was the slightly tetchy non answer. Followed up by a seedy little attempt to lay the beyond appalling CQC failings as having occurred in the six weeks or so after LB died. That pesky cleaner walked out 10 days before the inspection… [at several points during this conversation I wondered if I would experience long term effects from the sickening rage it generated.]

The second example involves the other patients in STATT. SW wrote that “unfortunately” STATT patients were unable to attend LB’s funeral because of “the family’s understandable restrictions on staff attending”. Not true, I said. I explained how we wanted staff not directly related to LB’s care to bring them. Bluster bluster.. SW meant the other patients’ families thought their relatives weren’t in the right mental state to attend. Oh. Why didn’t you write that then? I asked. Puff, huff and puffenstuffen, Dr Ryan. He couldn’t possibly include every line he wanted to include in the letter. It would be impossible.

Another damned if you do and damned if you don’t situ. Clearly.

So, back to today. The emailed reply. First of all he attached the letter sent on Sept 17th for the partial cc list to read. The fudged and fake responses letter. That is pretty crap. He reiterated the fact we’ve refused to meet across two paragraphs. Yep. With regard to staff disciplinary actions apparently the final one is part-heard and will be completed shortly. Mmm. (17 Sept letter “The final hearings for the remaining investigations are scheduled to be completed in the coming weeks”. 23 Sept phone call, staff disciplines will be completed “in the next 2/3 weeks”.)  There have been no delays with the second Verita investigation and the incredibly insensitively timed email, sent on 23rd December, wasn’t sent by the Trust’s solicitor. Even though it, er, was.

Wow. Mr Waugh. That stuff about reflecting on letters sent, foot shooting and incompetence (or worse)… ? You got a bit of a waugh to go, I’m afraid.

In addition to the delay I banged on about in the previous post, I found out from NHS England this week that Sloven staff disciplinary processes are continuing. In Sloven time. On the midnight train to never never land. I’ve had this conversation several times now. It sort of sits at a junction between Tedious as fuck and Off the scale of outrageous. With a backdrop of Howl mountain.

‘What can we do?’ I asked the bearer of no news. Gnawing on the handset.
‘Nothing really’, was the answer.
‘There must be someone we can contact to say ‘This delay is unacceptable for everyone, can you do something about it?”
‘Not anymore, the only person really is the Board Chair’.

A heartsink statement given my 2 hour conversation with ‘Mr In Denial’/’Mr Kept in the Dark’ (sadly not ‘Mr Know it all’) a few months ago.  Anyway. I sucked it up, fired off a letter with the keyboard smoking, and copied it to pretty much the whole world in his hands. Including Jezza, Norm, Si, Davie B and KP too.

I was chatting to Little Sis Sam earlier and she said how outrageous it was that we’re having to do this. Yep. And how awful it must be for families who haven’t been able to meet with the various people we have. Yep. Bit of a double edged sword really, she said.

More triple edged really. If that’s possible.

1. We shouldn’t have to do it.
2. It stinks that some families have more traction than others in trying to get accountability.
3. What has actually happened?

Those wagons are firmly circled.

As the old growler sang;

Mud can make you prisoner
And the plains can bake you dry
Snow can burn your eyes
But only people make you cry…

Found out earlier the disciplinary process for the staff member we referred is delayed. Again. An extension has been granted for additional time to read through records. We referred this person in May 2013.

“I’m not being funny”, I said, on the phone, “But all this delay stuff is always on the part of the system; the Department of Health, the NHS, the CCG, the local authority. And it impacts on families who are utterly devastated. Crushed by the process. And who have nothing to answer to. We’re 20 months on from LB’s death and no accountability. Just waiting. On wait.”

How can this possibly be?

No real answer. Though very apologetic engagement.

On the bus home I read this tweet. And again my brain screamed there’s simply no excuse to delay any part of the process of accountability. It’s the absolute minimum that should be done when you’ve got something so catastrophically wrong. I can’t describe the additional pain generated as weeks, months and years go past and fuck all happens.

This established practice of embedded, accepted and unremarked upon (by those with any sniff of  power) delay needs stamping out. It’s simply inhumane.

When LB was in the unit there was a patient (one of five) who didn’t look brilliant. I only saw him/her dressed once. Most of the time we visited s/he was in a dressing gown and didn’t seem to go out much. S/he had a bit of a wry sense of humour and chatted away, like really chatted away. A bit like LB really.

I read months later that a patient died of cancer days after LB died. Eh? What? How could someone so close to the end of their life through terminal illness be in a secure unit days before their death [howl]. And why was this discussed in a document reflecting on the additional distress her/his death caused staff. No apparent consideration for other patients. Again.

In the 107 days LB was in the unit, we saw how the inmates (let’s not dress it up) connected with each other and had a sometimes uneasy, occasionally hilarious but a recognisably collective sense of being there. How the three living (remaining?) patients have dealt with the trauma they experienced during that hot, hot July, without specialist support (no post-Winterbourne View/JIP related, apparently gold plated, support here) is unimaginable. Were they able to attend this second funeral if nothing else?

I heard this week, through another dicky bird (the scourge of the candour duty obliterators) that some staff had been concerned about the wellbeing of this patient over some time. [Good]. These concerns were not really listened to. Allegedly, through the whistle blowing process, Sloven have only recently started an internal (that is, chocolate teapot jobby like) investigation into this person’s death. Over a year and a half later.

Wow. If nothing else, the shite that continues to become visible is, er, consistently, shite.

One of our campaign aims was a review into the deaths of all patients in Sloven learning disability and mental health provision since 2011. This was commissioned by David Nicholson last spring.The Death Review got off to a shaky start given nonsense about having Sloven and local CCGs on the expert advisory panel. It looks like this has been resolved but here’s hoping the review gets to the heart of the rotten core. It isn’t about number of deaths but about the response to these deaths. Not only are people denied humanity in life but also in death.

Chilling and unforgivable.

I was astonished to get a call from BBC Radio Oxford (love em) yesterday about the new failed CQC inspection at Slade House. Eh? I said. A what? Slade House?

Yep. Turns out Slade House 2, which has six patients, failed on management/leadership and staffing. There was no registered manager and no nursing staff available (or even on site) overnight despite two patients with complex health care needs (which, er, don’t stop when darkness falls). Nah. A joke. Surely. I thought. A unit, a stones throw from where LB died, in which patients lives are endangered by inadequate staffing levels? And failing leadership/management? (Though clearly superhuman efforts on the part of some frontline staff). That can’t possibly be. Each patient is funded at a cost of around £3500/£4000 a week. Not providing nursing staff overnight is simply obscene.

[Not just on the part of Sloven but also the part of the commissioners (Oxon CCG and the Oxon County Council) who are apparently content to pay enormous sums of money for crap all. Not only consigning people to lives devoid of an imagined future but also leaving them in spaces of  risk and danger. Can you imagine? Can you begin to imagine what this must be like to experience? No one comes out of this with sniff of integrity or decency.]

I was genuinely bewildered. How many CQC fails are the Slovens trying to chalk up in the ‘north of their patch’? How low can you go? How crap can you actually be while your Chief Exec tweets bland and empty nonsense about ‘leadership’?

Well, that leads us back to the big old million dollar (sorry) question really. Why did the Sloves want to take over the Ridgeway Partnership back in the day? Mmm. Worth a little bit of back to the future stuff. Back to early 2012… and a delvelet back to the heady days of the Ridgeway Roadshow….

[I feel chilled thinking that I could have easily driven past this meeting, a short distance from home.. without sniff of what was to happen and our dealings with this bunch].

Take it away Katrina Percy, Sloven CEO. Roadshow Rodeo Extraordinaire. Why do you want to take over the Ridgeway?

The first big thing for us is to create a big voice for learning disabled people..

Eh? A big voice? Wow. Just wow. How the hell did you try to do this? By allowing the Oxon patch of your provision to sink into such malaise drenched disarray that LB died [he died?] and the CQC failed inspection after inspection after inspection?

Sadly there are even more billy bullshit arguments from 2012: Moving quickly on – from a set of such meaningless statements I want to stab myself in the eye with a sharp stick coated in scotch bonnet chillis – we’re left, quite simply, with not much more than the £8 million reserve and good old Chunky Poundland. Mmm. Awkward. So blinking awkward and wrong.

If Sloven lose the contract in Oxfordshire (which lets face it, ain’t looking unlikely given their track record of such consistently abject shite) they can hypothetically/ allegedly withdraw to Sloven Towers, leaving their ‘patch in the north’ without a backwards glance, clutching a full to bursting bag of Oxon designated bullion.

To borrow from the legendary Ron Burgundy. As ever. Stay classy Sloven. And next time you want to ‘create a big voice for learning disabled people’, park it eh?

Delay. The last 20 months or so have been characterised by delay. In July 2014 I wrote this about Sloven delay. Last summer. A year after LB’s death.

Delay is typically a negative experience. Often frustrating and stressful to endure. In many ways it involves being forced into a space that anthropologists call liminal. Neither something nor another. No longer here but no longer there. It involves occupying a sort of hinterland of nothingness, caught between what was and what may become. Even when there’s excitement attached to delay (birth maybe) there’s still an urge and urgency to get there. Or get out of the uncertain space.

From the moment LB died we were flung into a truly foul liminal space seemingly guarded and controlled by Sloven Health and the Bevan Brittans (their legal hench team). And, through a lack of action, NHS England, the CQC, Monitor, Department of Health and pretty much anyone else who may lay claim to any sniff of power to do anything to stop em. Even an independent report, clearly stating that LB’s death was preventable and the outcome of utterly shite practice, published in February 2014, has led to no outcome. Nearly 12 months on. [Howl].

Our beautiful son drowned in an NHS bath, the facts are known and nothing has happened. How can this possibly be? Can you begin to imagine how this feels?

Delay is clearly a key Sloven tactic and I can see why. It’s a form of torture to experience. And the Slevan B’s use it relentlessly, remorselessly and effectively. I won’t rehash the myriad examples here  – these pages are weighted with em – though I gather that the second Verita investigation into the wider issues surrounding LB’s death is in the process of, er, being delayed by Sloven practice. And I don’t suppose the police are holding their breath to receive documentation they’ve requested as part of their on going investigation into LB’s death in the near future.

So yep. We’re consigned to a hellhole space of continually waiting for some two bit, crappy NHS Foundation Trust who couldn’t be arsed to check if their provision in the pesky ‘north of their patch’ was good enough quality after they allowed a young laddy to drown in the bath in one of their units, and then were indignant to be publicly chastised by failing a series of CQC inspections laying bare their crapness. Behind the scenes documents (from FOI requests) are almost hilarious around this*. The Slovens (including Simon Waugh, a Board Chair who should really be removed from post after embarrassing demonstrations of ignorance of foul Sloven practice) attended one particular meeting with Oxfordshire County Council and the Oxon CCG last year which was almost comedic in their protestations/irritation around criticism of their provision. Indignant? When the CQC revealed a Fawlty Towers type level of operation.

But of course it ain’t funny. At all.

Anyway, readers may not be surprised to hear that despite an unrivalled record in delaying all and any action, Sloven and the Bevan B’s managed to call our solicitor on December 23rd. Eh? No way?? Yep. When a lot of the country were already on their crimmy break, this bunch of complete non deliverers picked up the phone at the last possible moment before Christmas.To deliver non urgent information we didn’t need or require but which fitted their strategic and calculated approach to this process*.

A cynical, nasty, deliberate and calculated action. Designed for maximum impact and pain. (More than happy to be put straight on this, if anyone has any alternative explanation for such a bizarrely timed action). Christmas is the time of pain for any family who have experienced a bereavement and they certainly managed to put the boot in brilliantly. But Sloven certainly play the timely card when they choose (like producing a briefing on my blog less than 24 hours after LB’s death). Simply cruel. And inhumane.

Now if anyone can let us know how this bunch of fuckers can really be part of the National Health Service, please crack on.

Cheers.

*We only delay (haha) publishing some stuff/detail because we have to be careful/wait for advice but we will make sure that the entire story is published in time.