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CQC response to Orchid View Serious Case Review

9 June 2014
  • Media

9 June 2014

Following a Serious Case Review in relation to Orchid View carried out by West Sussex Adults Safeguarding Board, the Care Quality Commission (CQC) has today (Monday 9 June) published its own report.

CQC’s report is to provide a full picture of the regulator’s involvement at Orchid View between September 2009 and October 2011, including lessons that have been learned and action that has been taken.

The reports follow an inquest into the deaths of 19 people living at Orchid View care home last year. The coroner found that neglect had contributed to the deaths of five residents with other residents suffering ‘sub-optimal’ care.

Andrea Sutcliffe, the Care Quality Commission’s Chief Inspector of Adult Social Care, said: “I was appalled by the descriptions of what had happened at Orchid View.

“Today’s Serious Case Review once again shows what a truly tragic situation this was and my thoughts remain with the people who suffered such awful care and with their families.

“The Serious Case Review shows the primary responsibility for these failings rests with the people providing services at Orchid View, together with their owners Southern Cross.

“When things go wrong in health or social care services, families affected want to make sure that others do not have the same experience. To do this, we need to be honest about our mistakes, be clear about changes that are needed and then make sure they happen.

“At CQC we made a commitment to take a long, hard look at our role, make sure lessons were learned – and most importantly – turn those lessons into action.

“We know from our own review that we did not fulfil our purpose of making sure Orchid View provided services to people that were safe, compassionate and high quality.

“The way we worked when these serious incidents happened meant we did not respond to early warning signs, we were too easily reassured by the responses of Southern Cross and the people who worked there – and we did not take appropriate enforcement action quickly or strongly enough.

“Since then, a great deal of work has been done to drive forward significant and sustained improvements on many issues we identified as areas of concern and we are changing for the better.

“CQC is now more responsive to safeguarding and other notifications of risk; our inspection techniques have improved; we have additional money which we are using to appoint more inspectors and better training has been provided in relevant areas.

“However, there is more we can and should do and our new approach to the regulation and inspection of adult social care is designed to do just that. We will keep working hard to make further improvements in partnership with people running care services, local authorities and other agencies to ensure the recommendations of the Serious Case Review are implemented.

“I am determined that all of us at CQC will play our part in making Adult Social Care the best it can be.”


For media enquiries about the Care Quality Commission, please call the CQC press office on 020 7448 9401 during office hours or out-of-hours on 07917 232 143. For general enquiries, please call 03000 61 61 61.

Last updated:
30 May 2017

Notes to editors

Specific actions highlighted in CQC’s report:

  • Ratings in the new approach will not be awarded if there is insufficient evidence to do so – for example, very low occupancy as in the case of Orchid View.
  • Arrangements for quality assurance and monitoring of inspections will be strengthened and specialist teams of inspectors are being established with smaller portfolios of services to improve regulatory risk management.
  • Information systems will continue to be developed so that data collection and analysis is improved and worrying trends more clearly identified.
  • Information provided by people using services, their families and carers as well as staff who raise concerns are increasingly being used to help focus inspection activity.
  • Inspections will ask five key questions – is the service safe, caring, effective, responsive and well-led?  Guidance will be provided to inspectors to support more consistent and robust gathering of evidence.
  • Clear information on the outcome of inspections will be given to providers and publicly shared to encourage improvement.
  • Enforcement action will be taken and the full use of our powers deployed when this is required to secure improvement, constraints or closure of services.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, caring, well-led and responsive care, and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet national standards of quality and safety and we publish what we find to help people choose care.