Our response to Orchid View Serious Case Review

Published: 10 June 2014 Page last updated: 3 November 2022

Following a Serious Case Review in relation to Orchid View that was made public by West Sussex Adults Safeguarding Board this week, we have published our own report.

This is to provide a full picture of our involvement at Orchid View between September 2009 and October 2011, including lessons that have been learned and action that has been taken.

Both the Serious Case Review and our report 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, our Chief Inspector of Adult Social Care, said: “I was appalled by the descriptions of what had happened at Orchid View.

“The 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.”

You can view a copy of our report and West Sussex Adults Safeguarding Board Serious Case Review here.

Read the reports

Download the report on our involvement at Orchid View.

Orchid View: Chief Inspector's foreword

Orchid View: Investigation report

The Serious Case Review is available to download from the West Sussex Council website.