A justice ‘pilgrimage’…

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It’s confirmed. A celebration – Of Rights and Colour – organised by Learning Disability England will be held on December 2 in Aviles, Northern Spain.

Truly, truly spectacular…

It wasn’t long before talk in the Justice shed turned to walking the #JusticeforLB bus and flag to Aviles from Santander in readiness for the event. A bus made from cardboard boxes by the Boumelha family for 107days of action. And a flag that has graced two Glastonbury festivals and travelled as far as New Zealand via Sydney (meeting People First, Dunedin and the NZ Disability Rights Commissioner among others) thanks to Katherine Runswick-Cole, Rebecca Lawthom, Dan Goodley and families.

Along the Northern way of the Camino de Santiago. We’re planning to set off on October 25 and cover the 150 miles in around 12 days. George Julian, Agent T (my sis) and me so far [anyone is very welcome to join us on part or all of the route]. I think it’s fair to say we ain’t brilliantly fit. And our vague convos so far around how to get the bus from A to B are along the lines of the odd “Maybe we should strap it to a backpack” to “Pull it along on a trolley?” type exchanges on twitter…

But whatever. It will be a remarkable and deeply powerful experience. A time to reflect. To laugh, cry and rage. And maybe make some sense of what has happened over the past three years or so.

Of rights and colour. And love.

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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:

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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?

In search of rights and colour…

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Came across some serious craftivism this evening. Mind and the Drunken Knitwits (among others) set too on the Radcliffe Camera. A welcome distraction from the continuing non action by those who should.

Left me thinking about plans for a bit of a #JusticeforLB shindig later this year (not quite confirmed) called In Search of Rights and Colour. Involving people, human rights, commitment, explosions of colour, love, brilliance, enthusiasm, stitching, passion, double decker buses and a pilgrim path.

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Drops of brilliance.

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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pillow talk and going viral

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So the latest Sloven shitfest hit the fan yesterday. Michael Buchanan continuing to shine a light on the murkiest of murky practices in the dank and musty corridors of Sloven towers. Reading the latest unfolding in a sneaky preview, we thought (again) game over. Stupidly. [LB died, CQC failings, Verita, repeatedly negative coronial determinations, CQC failings, Mazars and further CQC failings…] As the day unfolded, it was back to now familiar and stale feelings of incredulity, disbelief and despair.

Background

Basically (thanks to George Julian for spotting this gem) Katrina Percy apparently set up a programme of leadership development in 2009 which she later ‘follows on’ from as CEO of Sloven. [Note how she switches to ‘I’ when it comes to claiming a bit of glory. Elbowing staff and the ubiquitous ‘we’ out of the way when it comes to relentless and shallow self promotion…]

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The story exposed how this ‘investment’ (a cracking misnomer) spiralled 2000% over the original tender amount (from around £300k to £5.365m). For a naff old programme called, er, Going Viral. Oh, and the tender went to an associate of KP; Chris Martin and Talent Works. Cosy. (Apparently, by the end of the current contract CM/Talent Works will receive £9m… £9million). A second associate, Paul Gray, who used to work with KP in pre-Sloven times has earned £602,000 since 2011 without bidding for a contract. Over half a million pounds… Without bidding for a contract.

What is Going Viral?

Good question. We don’t know because Sloven has removed the link to the programme on their website. Shifty move given the weight of the public gaze on what £5m buys. But, in true viral fashion, it has mutated into other cash cows; Senior Viral, Viral Essentials and Gone Viral. [I know].

Handily there are a few vimeos (not) explaining what Senior Viral is. For example:

 

This includes gems like One of the biggest priorities has to be the number of complex priorities that staff are having to work with” (unknown woman) and, as baffling, So Sloven is big enough almost to be a system its own but I guess we probably need to think about the wider system… (Chris Gordon). It’s taken me about 20 minutes to transcribe two sentences as I kept being overcome with hysterical laughter. £5.365m…

Are.these.really.executive.board.members?

What a painfully awkward situation. £millions spent on a ‘leadership programme’ run by mates so publicly exposed, four (seven) years after inception. In an organisation that continues to fail…

Rest and recuperation

Not surprisingly twitter nearly collapsed under the weight of people tweeting the link to the BBC story throughout the day. Spending cuts, a buckling NHS, ‘post-truth’ politics, etc, etc, make the continuing utter wrongness of Sloven practices sharper and clearer to us herbs.

Later in the afternoon chat (rage) rightly returned to how such sums of money could possibly be necessary for individual trusts to spend (remember there is in existence an NHS Leadership Academy), and what the £5.365 (£9m) could have funded…

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Asda pillows. £6 a pop.

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If nothing else, that money could have bought 894,167 pillows. Nearly a million pillows.

Apparently NHS Improvement are saying that Sloven have done nothing wrong. Procurement processes have been followed. (Mackey and his bunch of yes bods on fire as ever). I think [hope has long gone] this is the touch paper to finally bring this foul, toxic and beyond brutal charade to a close.

Those who have refused to listen for whatever reasons. Those who have refused to act for whatever reasons. Those who so readily discounted the life of our beautiful, beautiful boy, along with so many others [howl] for whatever reasons. Those who watch and read what is happening and do fuck all for whatever reason…

There must come a tipping point.  A point at which those who have taken the chunky salary, who pretend they are ‘doing their job’, who kid themselves the bigger picture is more important than the odd (numerous) casualties along the way, are forced to admit something is seriously off. A point at which even the family, friends and colleagues of those who can, start to shake them, or more vigorously shake them, to the point at which the tinted specs finally fall off.

The spotlight has been on Sloven for the last few years now. It is obvious to pretty much everyone there are serious failings and a toxic culture at board level. These are reflected in these financial irregularities and the use of the CEO’s mates (over half a £million without bidding for a contract?). (As Roy Lilley said on the Today programme, despite what Sloven say, these aren’t ‘specialist’ tasks that only a small number of organisations can deliver.) The Sloven board are failing patients and bringing themselves and the various NHS organisations around them into disrepute.

It’s time for action.

Woman on all fours

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In honour of the £5.365m of our money spent on this shite. Here is the woman on all fours. Who called it for what it was.

 

Update: September 25 2016

A day or so after posting this in July, our solicitor got in touch to say a Sloven solicitor had been in touch:

She said that there is a video which has been posted on your blog which contains a female member of staff […]. Apparently that member of staff withdrew consent in relation to that video some time ago and so the Trust has not been using it and she has reported that the republishing of the video is causing her a lot of upset and therefore wondered if it could be taken down.

At the time we took it down immediately.

Today, we found out that the current total paid to Talentworks (who are behind the Going Viral programme talked about in the short film) is now £5,861,424.03. Another £500k since Michael Buchanan’s original expose?

I’m reposting the film. I’m sorry to the staff member if this causes upset (and please contact me directly if it does – posting a comment below for the first time is private) but the full extent of the rubbishness of the training needs to be seen.

Going viral. At nearly £6m of NHS money.  Talentworks? Gone to ground…

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Seeing and doing different things…

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Caught up with a mate’s son earlier who used to take LB out on a Saturday when he was at college and LB was about 11/12. He was a quiet guy, thoughtful and kind. They used to go down to town on the bus and typically wander about a bit then sit in a cafe on the High Street, eating cake and watching the buses go past. One day he went with LB to London for the day. Lashing rain, the Science Museum and a much loved trip on the Oxford Tube. They had an easiness in each other’s company.

Now, aged 32, and living in Oz for the last five years, he chatted about some of those outings. Bit of a blub moment. Especially when he said he’d seen things he wouldn’t have seen and done things he wouldn’t have done. Yep. That.

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When trusts go bad

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Walked into Oxford earlier with Rich. One of those days when there were no end of brilliant photos to take. Including a cheeky bee.

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Got home to find out one of the rebel governors, Peter Bell is under formal investigation by Sloven. Yep. Sloven are formally investigating the actions of a (rare) governor.

Sloven who:

  • initially said LB died of natural causes and all due process was followed.
  • tried to stop the publication of the first Verita investigation which found LB’s death was preventable.
  • spent nearly £300,000 on legal expenses at LB’s inquest to try to avoid accountability.
  • spent nearly £50,000 to try to sink the Mazars review into their death reporting.
  • have been found to be failing by numerous coroners over the past five years
  • etc, etc, etc…

Blimey. A formal investigation…
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‘Seriously derogatory remarks’…. Not sure where, in the guvs’ code of practice, it states ‘thou shalt not say owt negative against the hallowed trust’. What a load of bullying bullshite. Those of you following this deeply harrowing tale of a trust gone bad will know that an extraordinary meeting to discuss a vote of no confidence in the Sloven leadership was stopped on May 17 by interim chair, Tim Smart. He got the Capstick heavies involved. The discussion remains to be had. Now this.

Truly, truly extraordinary.

Extraordinary timescales too. An ‘investigation’ into the actions of a governor with such priority it can be sorted in a month. We’re into the fourth year of investigations into LB’s death. GMC, NMC, HSE.. Every one of them drawn out because of Sloven slovenliness. Delay and obfuscation.

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LB died. He died. Without any accountability. But the investigation into the actions of a governor is racing on. Interviews, evidence collecting and all. By an organisation who failed to investigate 100s of unexpected deaths in their care. I almost think I’ll wake up in a mo. Surely this can’t be happening in full view of NHS Improvement, NHS England, the CQC and Jeremy Hunt?

Surely…

In a final piece of [no words left] the Sloven annual report has been signed off.

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My incredulity monitor has finally broken.

Another sordid little tale of failure

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Sloven have shut the psychiatric intensive care unit at Antelope House for 8 months. Reported in the media last week. The board papers published yesterday provide more detail (around p72).

The closing of these beds mean patients who really should not be, will be shipped to a unit in London. To a unit that ‘needs improvement’ according to the latest CQC inspection. Yep. Closing shite provision and shipping seriously unwell patients to sub-standard provision. Extraordinary.

The board papers describe how a ‘tipping point’ was reached:

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To the extent the Deanery raised concerns about the quality of Antelope House as a training place for Junior Doctors…. Deep breath. Hold on to something solid.

Sloven run a unit that isn’t a fit space to train doctors.

How can any NHS Foundation Trust run a unit that is not considered a fit space to train doctors?

What about the safety and wellbeing of the patients?

I suspect Deanery concerns led to the sudden closure of the ward at Antelope House. The CEO/Board could clearly ignore the 4/5 year of failings publicly documented over the past 3/4 years. Lives lost. Non lessons learned. Inquest after inquest after inquest, failed CQC inspection after failed inspection and the Mazars review.

Deanery rumblings and concerns around junior doctor training (with implications for Vanguard membership) generates ‘action’.

As my brain, again, slowly, slowly melts, I (easily) stumble upon a news report about Antelope House from September 2011. Yep. Really.

A report on failings identified during the inquest of a patient in 2008 and a recent (2011) failing CQC inspection report. Risk assessments not updated,                                                                                                                                                inadequate records, lack of training, etc etc. The same old same old failings. Identified over and over and over again. The then Medical Director, Huw Stone, long gone (sensible guy), did the old learning lessons spiel:

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Mr Stone, back in the day, 14 months before Sloven took over the STATT unit LB died in, said all care plans and risk assessments were now reviewed. Extra checks were conducted on standards of care. And further made up blarney. How any NHS exec can stand in front of the press/coroner and say these empty words when the lives of patients are at stake is beyond me.

No other words really.

I just wonder.

  1. How those who should be doing something about this continue to look the other way/slumber despite documented failings.
  2. How those around those who should be doing something about this, allow their colleagues, family or friends, to continue look the other way/slumber despite documented failings.
  3. How those directly implicated look the other way/slumber.
  4. When any of the the above will realise that we will continue to document this shite for as long as it takes.