Joining the dots
Andrea Sutcliffe, Chief Inspector of Adult Social Care at the Care Quality Commission.
On Friday evening I joined nearly a thousand people in the Grand Opera House, York, for A Night To Remember — and it truly was. A celebration of music and song to raise money for the Alzheimer’s Society and raise awareness of dementia. Organised by Big Ian (Ian Donaghy of Training for Carers and Dear Dementia fame) who made sure we all had a fabulous time. Here’s my tweet review:
I loved the fantastic entertainment but my highlights were chatting with people from the care sector who turned out in force; meeting Brenda and Jim who visit the Harmony Cafe every month, a voluntary service that will benefit from the funds raised; the montage of photos featuring positive images of people living with dementia with family and friends; and this wonderful film featuring Ian’s mother-in-law Liz:
Morecambe Bay inquiry
Saturday brought me back down to earth with a bump. Engineering work on the east coast line doubled the train journey home to four hours, so I took the opportunity to read the report of the Morecambe Bay inquiry from cover to cover. It is a distressing read. At the very least, please take a look at the summary, which clearly sets out the failures at every level of the NHS that led to the avoidable deaths of mothers and babies.
Before I make any further comment, I would like to pay tribute to James Titcombe, the father of baby Joshua who died in 2008. James, together with other families, has campaigned tirelessly and with great dignity to uncover the facts of what happened and make sure lessons are learned. I count myself extremely lucky to have James as a colleague and friend at CQC.
But what does a report looking at the avoidable deaths of mothers and babies have to do with social care? More than you might imagine. A tale of dysfunctional teams, poor joint working, inadequate leadership, false assurance and a lack of candour is sadly familiar in social care when we look at things that have gone wrong.
Orchid View
On Wednesday last week I met with representatives of the Orchid View families — the care home where residents suffered and died from neglect and sub-optimal care. Like James in Morecambe Bay, Ian, Lesley, Judith and other relatives want to make sure lessons are truly learned and that families do not have to relive their terrible experience.
Our discussion covered many topics. At CQC we have acknowledged our own errors in failing to respond adequately to the emerging problems during 2010 and 2011. What happened at Orchid View had a profound effect on me personally and influenced the shape and design of our new regulatory and inspection approach. We were able to discuss progress but I know we still have much more to do.
What is still concerning Ian, Lesley and Judith though was the importance of people working together at a local level to identify and tackle poor care. Their relatives at Orchid View suffered first from a catastrophic failure of care at the hands of the provider who did not recognise it or deal with it and then suffered again when local (and national) agencies did not spot and respond to the situation until too late. Better joint working, sharing of information and a questioning, not an accepting, frame of mind are actions we all need to take in health and social care. This was the lesson from Orchid View and has again been reinforced by the Morecambe Bay inquiry.
Joining the dots
So the key messages from Morecambe Bay are relevant to social care — we all need to join the dots to make sure teams work well together; that they are led and supported by managers who establish an open and transparent culture where concerns raised by families and staff are listened and responded to appropriately and when mistakes happen we find out why, report honestly and act to prevent in future; and all organisations involved in health and care make sure they communicate, communicate, communicate.
At the SCIE roundtable last week on the leadership needed to implement the Care Act, expert by experience Larry Gardiner put it very simply:
“I want you to use your leadership to make good things happen and stop the bad things from happening.”
The enthusiasm and energy that Ian generated on Friday night from so many people makes me think it is possible. It’s what all the Liz’s in this world deserve.
Originally published at www.cqc.org.uk.
