SSC227: Working Together to Safeguard Vulnerable Children, Young
People and Adults
University of Sunderland in London
Health and Social Care Programmes
Canvas Deadline: Thursday 22nd Sept 2022 by 2pm
Summative Assessment
Choose 2 case studies and answer questions under them. The assignment will be 3,000
words. Each question is worth a total of 25 points.
Answer your chosen four questions as fully as possible. Remember to present a critical
evaluation of the case, based on your own assessment, not just present what is written in
the case reviews. Do not copy information from the SCR documents as this will be
considered plagiarism and treated according the university’s misconduct procedures.
Consider issues such as hindsight bias, learning lessons (not blaming individuals), and
organisational and policy issues that may affect work conducted etc.
Case 2: CHILD M
SCR-Child-M-Overview-Report-FINAL-November-2016.pdf
“The SCR concerns the services provided for a child who is subsequently referred to as Child
M. Child M was aged 17 in March 2013 when she died as a result of a drug overdose taken
1
while in the company of at least one adult. This was the last in a series of overdoses that
Child M took which had resulted in hospital admission and serious health concerns from
May 2011 onwards. Child M grew up in Surrey and lived there for the majority of her life. In
September 2011, when she was 16 years old, Child M moved to East Sussex. In December
2011 she was made the subject of
an Interim Care Order and a Secure Accommodation Order. East Sussex County Council was
granted a Care Order in April 2012 and Child M remained a looked after child in the care of
the local authority at the time of her death. Between August 2012 and January 2013 Child M
had been living in supported lodgings accommodation in Surrey. From late January 2013
until her death she had lived in Bed and Breakfast accommodation in Hampshire, a few
miles from her original family home. Child M had a history of substance misuse which
according to some agency records went back at least six years.”
Q3. Identify and evaluate the effectives of procedures in the Local Authority Contact
Centre, in relation to Child M. (25 points)
Q4. Critically consider how effective the School was in coordinating early help for Child M
e.g. implementing the CAF. (25 points)
Case Study 3: ORCHID VIEW orchid-view-serious-case-review.pdf
“Orchid View was a nursing home owned and managed by Southern Cross Healthcare. It was
registered with the Care Quality Commission (CQC) as a care home with nursing to
accommodate up to 87 people in the categories of old age and dementia.
Orchid View opened in November 2009 and was closed by Southern Cross Healthcare in
October 2011. While it was open there were a number of safeguarding alerts and
investigations, including the deployment within the home from August 2011 of a team of
health and social care staff to mitigate the poor quality of care, leadership and management
within the home and provided by Southern Cross Healthcare at regional and national
levels.”
Q5 Critically evaluate the effectiveness of the ‘Care Plans’ at Orchid View – consider both
the problems with, and recommendations for, effective care plans. (25 points)
Q.6 Critically evaluate the effectiveness of the leadership and management at Orchid View
and how that was directed by its owner, Southern Cross. (25 points)
2
Generic Assessment Criteria – Undergraduate Bachelor’s degree
These should be interpreted according to the level at which you are working
Categories
Grade
Pas
s
86 –
100%
76-85%
Relevance
Knowledge
Analysis
Argument and
Critical Evaluation Presentation
Reference to Literature
Structure
The work examined is exemplary and provides clear evidence of a complete grasp of the knowledge, understanding and skills appropriate to the Level of
the
Qualification. There is also unequivocal evidence showing that all the learning outcomes and responsibilities appropriate to that Level are fully
satisfied. At this level it is expected that the work will be exemplary in all the categories cited above. It will demonstrate a particularly compelling
evaluation, originality, and elegance of argument, interpretation or discourse.
The work examined is excellent and demonstrates comprehensive knowledge, understanding and skills appropriate to the Level of the qualification.
There is also excellent evidence showing that all the learning outcomes and responsibilities appropriate to that level are fully satisfied. At this level it is
expected that the work will be excellent in the majority of the categories cited above or by demonstrating particularly compelling evaluation and
elegance of argument, interpretation or discourse and there may be some evidence of originality
The work examined is of a high standard and there is evidence of comprehensive knowledge, understanding and skills appropriate to the Level of the
70 –
qualification. There is also clearly articulated evidence demonstrating that all the learning outcomes and responsibilities appropriate to that level are
75%
satisfied At this level it is expected that the standard of the work will be high in the majority of the categories cited above or by demonstrating
particularly compelling evaluation and elegance of argument, interpretation or discourse.
Directly relevant
A substantial
Good
60 –
to the
knowledge of
69%
requirements of
the assessment
May contain some
Well written, with Critical appraisal of up-
clear and orderly logically structured,
Distinctive or
standard spelling todate
relevant material,
using an appropriate
independent
and grammar, in a appropriate literature.
showing a clear
mode of argument
thinking; may begin readable style
Recognition
grasp of themes,
and/or theoretical
to formulate an
with acceptable
different perspectives.
questions and
mode(s)
independent
format
Very good
issues therein
analysis, Generally coherent and
and/or
of
use
position in relation
source material. Uses
to theory and/or
practice.
a range of sources
of
Some attempt to
Adequate
Some analytical Some attempt to
Sound work which
Competently
Uses a variety of
50 –
address the
knowledge of a
treatment, but
construct a coherent
expresses a
written, with only
literature which includes
59%
requirements of
fair range of
may be prone
argument, but may
coherent position
minor lapses from some recent texts
the assessment:
relevant material,
to description,
suffer loss of focus and
only in broad terms
standard
and/or appropriate
may drift away
with intermittent
or to narrative,
consistency, with issues
and in uncritical
grammar, with
literature, though not
from this in less
evidence of an
which lacks
at stake stated only
conformity to one or acceptable format
focused passages
40 –
49%
Some correlation
with the
requirements of
the assessment
but there are
instances of
irrelevance
vaguely, or theoretical
4
substantive amount
appreciation of its clear analytical
significance
purpose
mode(s) couched in
simplistic terms
more
standard
views of the
topic
Basic
understanding of
the subject but
addressing a
limited range of
material
A basic argument is
evident, but mainly
supported by assertion
and there may be a
lack of clarity and
coherence
Some evidence of a
view starting to be
formed but mainly
derivative.
Largely
descriptive or
narrative, with
little evidence
of analysis
necessarily including a
beyond library texts.
Competent use of
source material.
A simple basic
style but with
significant
deficiencies in
expression or
format that may
pose obstacles for
the reader
Some up-to-date and/or
appropriate literature
used. Goes beyond the
material tutor has
provided.
Limited use of sources
to support a point.
Fail
35 –
39%
Relevance to the
requirements of
the assessment
may be very
intermittent, and
may be reduced
to its vaguest and
least challenging
terms
A limited
understanding of
a narrow range of
material
Heavy
dependence on
description,
and/or on
paraphrase, is
common
Little evidence of
coherent argument:
lacks development and
may be
repetitive or thin
Almost
wholly
derivative:
the
writer’s
contribution rarely
goes
beyond
simplifying
paraphrase
Numerous
deficiencies in
expression and
presentation; the
writer may
achieve
clarity (if at
all) only by
using a
simplistic
or
Barely adequate use of
literature.
Over reliance on
Material provided by the
tutor.
repetitious style
The evidence provided shows that the majority of the learning outcomes and responsibilities appropriate to that Level are satisfied – for
compensation consideration.
30 –
34%
The work examined provides insufficient evidence of the knowledge, understanding and skills appropriate to the Level of the qualification. The
evidence provided shows that some of the learning outcomes and responsibilities appropriate to that Level are satisfied. The work will be weak in some
of the indicators.
5
15-29%
The work examined is unacceptable and provides little evidence of the knowledge, understanding and skills appropriate to the Level of the
qualification. The evidence shows that few of the learning outcomes and responsibilities appropriate to that Level are satisfied. The work will be weak
in several of the indicators.
0-14%
The work examined is unacceptable and provides almost no evidence of the knowledge, understanding and skills appropriate to the Level of the
qualification. The evidence fails to show that any of the learning outcomes and responsibilities appropriate to that Level are satisfied. The work will
be weak in the majority or all of the indicators.
6
Orchid View
Serious Case Review
June 2014
1
Orchid View Serious Case Review • June 2014
Contents
PAGE
• Acknowledgements
3
• Executive Summary
4
• Findings and recomendations
6
1. Introduction
17
• Orchid View
17
• Southern Cross Healthcare
18
• What is Safeguarding?
20
2. Background
23
• Orchid View
23
• Commissioning this Serious Case Review
24
• Questions posed by the relatives of people resident at Orchid View
24
3. Chronology of events and safeguarding work at Orchid View
26
• Phase 1 – From the planning of the home and its opening until
the police alert at the beginning of August 2011
26
• Phase 2 – The level 4 Adult Safeguarding Investigation until
the closure by Southern Cross Healthcare in October 2011
31
• Phase 3 – Completion of Safeguarding Investigations
after the closure of Orchid View
34
4. Review and recommendations: safeguarding concerns and actions
37
• Phase 1 – In the period from the home’s opening to the alert to the police in
August 2011 – phase 1
37
• Phase 2 – In the period from August 2011 to the conclusion of investigations
48
5. Review and recommendations: Orchid View’s development and opening
52
6. Review and recommendations: regulation of the financial and
governance robustness of care providers
53
7. Review and recommendations: Care Quality Commission’s work
with Orchid View
57
2 | Orchid View Serious Case Review • June 2014
8. Review and recommendations: safeguarding awareness and
agencies working together
64
• West Sussex County Council Adult Social Care
64
• NHS Services
67
– Primary care
67
– Hospital care
70
– South East Coast Ambulance Service
70
– Community nursing
71
– Continuing Healthcare Team
71
• Sussex Police
72
• The CQC’s direct engagement with the safeguarding investigations
73
• Boots Pharmacy
75
• The Service provider – Southern Cross Healthcare
76
• Local Authority and NHS Commissioning
77
9. Review and recommendations: people in privately funded care and
information for potential residents and their relatives
81
• Information for people considering entering a home
81
• For the resident in the home
84
• Paying for care
85
10. Review and recommendations: workforce issues
86
• Managerial
86
• Professional competence and training
86
• Unqualified care staff
87
• Concerns raised by employees – alert to the police
88
11. Review and recommendations: accountability
90
• Professional regulation
90
• Criminal prosecution and legislative framework
90
Appendix 1 Terms of Reference for this Serious Case Review
94
Appendix 2 Panel membership and contributors
96
Appendix 3 Methodology
97
Appendix 4 Safeguarding
98
Orchid View Serious Case Review • June 2014
Acknowledgements
I want to record my thanks to the relatives of residents of Orchid View. I am
grateful for the time they gave me. It was very helpful to meet them and to
hear directly about what their relatives experienced in the home. This was
not always easy for relatives who told me about the poor treatment and
standards of care their relatives had endured. A former resident at Orchid
View also agreed to give her views about her experience at the home and I
am grateful for this personal perspective.
In compiling the Findings and Recommendations from this Serious Case
Review, I have attempted to frame and respond to the questions raised by
relatives in the considerations of the review.
The West Sussex Senior Coroner shared information with me from the outset
of this review, and I am very appreciative of the availability of this material
and for her time as this work progressed.
I have asked a lot of the Serious Case Review panel who contributed
openly and fully to this review. This positive approach from the range of
agencies involved in West Sussex will now need to be sustained as the West
Sussex Adults Safeguarding Board takes forward actions to implement the
recommendations in this review.
Nick Georgiou
Independent Chair of the Serious Case Review Panel
June 2014
3
4 | Orchid View Serious Case Review • June 2014
Executive summary
1
Orchid View was a nursing home owned
and managed by Southern Cross
Healthcare. It was registered with the Care
Quality Commission (CQC) as a care home
with nursing to accommodate up to 87 people
in the categories of old age and dementia.
2
Orchid View opened in November 2009
and was closed by Southern Cross
Healthcare in October 2011. While it was
open there were a number of safeguarding
alerts and investigations, including the
deployment within the home from August
2011 of a team of health and social care
staff to mitigate the poor quality of care,
leadership and management within the
home and provided by Southern Cross
Healthcare at regional and national levels.
3
Following an anonymous alert to
the police in August 2011, there
was sustained police involvement in the
safeguarding investigations and in the pursuit
of possible criminal offences. Five members
of staff were arrested and questioned but
in the event the Crown Prosecution Service
(CPS) determined that there was insufficient
evidence to pursue criminal charges. An
inquest was concluded in October 2013
when the Senior Coroner found that five
people had “died from natural causes
attributed to by neglect” and that several
other people “died as a result of natural
causes” with “insufficient evidence before
me to show that this suboptimal care was
directly causative” of their deaths. It is
also the case that this suboptimal care
caused distress, poor care and discomfort
to residents and the families of people
who were not the subject of the Inquest.
4
Since the closure of Orchid View and
the inquest, the Department of Health
and the CQC have published a number of
consultation documents, some of which are a
direct follow on from the Francis Report into
care at The Mid Staffordshire NHS Foundation
Trust published in February 2013. These
documents are referred to throughout this
Serious Case Review and a significant feature
they have in common is to extend actions
identified in the Francis Report into the wider
sphere of service providers beyond the NHS.
5
These developments are very welcome
and reflect the reality that increasingly
we, as a society, are entrusting the care
of vulnerable people to independent
sector organisations. So, just as in the
NHS, it is necessary to strengthen quality,
governance and financial monitoring, it
is necessary to do so with independent
organisations, be they “not for profit” trusts
and charities or commercial businesses
such as Southern Cross Healthcare.
6
This Serious Case Review (SCR) was
commissioned by the West Sussex
Adults Safeguarding Board (WSASB) and
commenced work in October 2013. It has
focused on safeguarding in line with its terms
of reference. The range of considerations that
inform these findings and recommendations
are set out throughout the report, however,
they are presented here in relation to
the questions raised by relatives. By
their nature, some of these findings and
recommendations go beyond any particular
question area, and where this is the case the
recommendation has been located in relation
to the question that it is most relevant to.
5
Orchid View Serious Case Review • June 2014
7
9
Question 1
How can the public be confident that:
• the organisations they entrust their
care to, or that of their loved ones,
are properly managed, with good
governance and financial security?
• they provide the good quality of
care that they advertise and receive
payment for from private individuals
and from the public purse?
10
The questions raised by relatives have
been synthesised into the following four
questions and the recommendations are
set out in relation to each of the questions.
Question 2
How can people be confident that they or
their relative will be safe and well cared for?
Question 3
What support is available to residents
and their relatives, how do they know
about it and how to use it if there
are concerns about the service?
Question 4
How can organisations and individual
professionals be held accountable for the
safety, quality and practice in their services?
8
Orchid View was a regulated service,
and as such was subject to a regulatory
framework, specific requirements in line
with that framework and inspection by
the CQC. We know from the CQC’s own
assessment and the work of this SCR that
this was inadequate at Orchid View.
The CQC has recognised this and is
publishing its own internal review in June
2014: Investigation Report. Southern Cross,
Orchid View September 2009 – October
2011: An analysis of the CQC’s responses
to events at Orchid View identifying
the key lessons for the commission and
outlining its actions taken or planned.
At some point all services are likely
to have safeguarding concerns that
need to be investigated. A safeguarding alert
does not of itself mean that a service is poor.
It is though a serious event and there is an
onus on the service provider to treat it as
such and to remedy the concern. A sign of a
good service is how they rectify things that
go wrong. What happened at Orchid View
was more an avoidance of positive action to
rectify problems, and a series of ineffectual
action plans that were not acted on.
6 | Orchid View Serious Case Review • June 2014
Findings and recommendations
There are numerous considerations within the body of this report. The recommendations
set out below are intended to promote strengthened scrutiny of organisations and the
services they provide. These recommendations all relate to specific concerns at Orchid
View or to how businesses, increasingly important in providing health and social care,
are managed and regulated. A number of them might seem very obvious. However,
the experience of looking in detail in what happened in this care setting does mean
that they are necessary. The numbering of the recommendations is as they appear in
the body of the report together with a reference to their location within the report.
Question 1
How can the public be confident that:
• the organisations they entrust their care to, or that of their
loved ones, are properly managed, with good governance
and financial security?
• they provide the good quality of care that they advertise
and receive payment for from private individuals and from
the public purse?
Recommendations relating to
the governance and scrutiny of
care service providers
During the timescale of this SCR the
Department of Health has issued consultation
documents in regard to independent sector
organisations having a Duty of Candour, and
to Fit and Proper Person scrutiny for senior
appointments. These developments are
very positive and are discussed in the body
of the report. Similarly, the CQC has issued
its consultation documents on its extended
powers. In addition, the anticipated Care
Act in 2015 should provide an improved
framework promoting better governance
and scrutiny of independent sector service
providers. As these new arrangements are
being promoted, no specific recommendations
are made in this SCR.
The recommendation below relates to the
increasingly important role that independent
sector nursing homes have in providing health
care. They are however currently explicitly
exempted from the NHS Provider Licence
requirements of NHS organisations. The
government has committed to a review of
how well this exemption is working in 2016/17
and the recommendation seeks specific
consideration of this issue in the general
review. It is not appropriate to apply this
requirement on small homes but does propose
that it applies to large businesses with a
turnover in excess of £10m annually which is
equivalent to the requirement on NHS Trusts.
Recommendation 7 (SEE 6.22)
That in its review of how the exemptions
regime is working the Department of Health
specifically considers the possible extension of
the provider licence to care homes owned and
managed by large national businesses with a
turnover, from all sources, in excess of £10m.
*****
This recommendation is drawn from the
experience of the CQC when the quality
7
Orchid View Serious Case Review • June 2014
of their inspections was adversely affected
because of the heavy load placed on them
to re-register some 25,000 homes in line
with new legislation. It is essential that when
such an additional burden is placed on an
organisation it is resourced and managed to
carry out its ordinary responsibilities while
dealing with its new or extended remit at the
same time.
Recommendation 8 (SEE 7.19)
That where large scale reorganisation and the
introduction of additional responsibilities to
meet legislative change is being implemented,
it is imperative that an impact assessment
is undertaken to ensure the organisation
maintains the ability to carry out their routine
responsibilities while at the same time
implementing the reorganisation.
*****
Recommendations relating to the
service provider’s responsibility
to ensure a competent and well
managed workforce
When Orchid View was in development
and on its opening there was inadequate
development of a workforce strategy or
consideration given to recruitment, support
and development of staff competent to
deliver the care required.
This recommendation recognises that it can
be difficult to recruit staff, particularly in areas
where there are other employment options, as
is the case in this part of West Sussex. Health
and social care businesses are dependent on
a good and skilled workforce and need to
evidence that they have robust arrangements
in place to secure such a workforce. There is
no indication that Southern Cross Healthcare
implemented an effective workforce
recruitment and development strategy.
The Cavendish Report,1 promoting improved
training and status for health and social
1
care assistants, is strongly supported by this
SCR and provides a way forward, nationally,
with its implementation. Additionally it is
important that care businesses can evidence
and deliver effective workforce recruitment,
training and support.
Recommendation 6 (SEE 6.17)
That care businesses in development and
currently trading, can evidence robust plans
to recruit and sustain a trained workforce to
meet the needs of those people dependent on
the care they as individuals, or the statutory
sector, purchase to meet their needs. Delivery
of this requirement should be monitored by
the CQC.
*****
There was too much tolerance given to Orchid
View as they operated without a registered
manager for most of the time they were
open. It is understood that this requirement
is being enforced more rigorously now in
West Sussex by the CQC and is identified
in the CQC consultation documents as a
requirement they will enforce more strongly.
This SCR supports such action and also that
information about the absence of a registered
manager is publicised on the CQC website,
Recommendation 10 (SEE 7.31)
That where there is no registered manager in
place this information is made public by the
CQC on its website.
*****
Management and leadership of the service
was inconsistent and weak. These recommendations relate to the responsibilities carried by
a service provider and their registered manager for the staff group. An essential element of
this is a responsibility for the performance and
competence of staff, qualified and unqualified within their team. As such they should be
explicitly required to demonstrate managerial
as well as clinical competence to carry out this
The Cavendish Report, An independent Review into Healthcare Assistants and Support Workers in
the NHS and social care settings, July 2013, published as a follow up to the Francis Report
8 | Orchid View Serious Case Review • June 2014
responsibility, showing qualities of leadership
and compassion.
These recommendations relate to the
importance of established professional
development opportunities and that the
regulator satisfies itself that these are actually
being delivered and are not just a paper
exercise.
Recommendation 5 (SEE 4.1.39)
Recognising the increased potential for
nursing staff to work in more isolated settings,
providers of nursing home care should provide
and facilitate the continuing professional
development of their staff. Information
about the training undertaken should be
provided to the CQC and local commissioners.
Recommendation 29 (SEE 10.10)
That service providers are required to
demonstrate to the CQC that they have
established training, supervision and appraisal
processes for their staff, both qualified and
unqualified, and that the regulator spot
checks training records – with the necessary
agreements as required.
This recommendation is made as it was
remarked on that for a number of staff there
were some language difficulties as English was
not their first language. It is not evident that
Southern Cross Healthcare sought to provide
support and training to help these staff to
improve their communication skills. Difficulties
in communication would have impeded the
relationships with residents, with relatives and
potentially with other members of staff. It
may also have impeded their understanding
of procedures and access to information with
the result that it could have been detrimental
to the overall quality of the service. This should
have been factored into both induction and
continuing training for care staff individually
and as a group in the home.
Recommendation 30 (SEE 10.14)
Where there are specific needs to be
addressed among care staff such as in cultural
understanding, communication and language
difficulties, there are evidenced processes
to mitigate any possible diminution in the
quality of care offered as these needs are
addressed.
*****
This recommendation relates to concerns
in regard to the thoroughness with which
Southern Cross Healthcare checked the
qualifications of nursing staff they recruited.
This related to a particular nurse and while it
cannot be ascertained if they had a particular
failing in this regard, it does prompt a specific
recommendation that is essentially stating
the obvious, but this experience suggests it is
nonetheless necessary.
Recommendation 28 (SEE 10.8)
That stringent checks are carried out by the
employer to be confident that staff do have
the qualifications they claim and that where
appropriate their professional registration
is current. In the case of professionally
registered staff this will include obtaining the
person’s registration PIN.
*****
At Orchid View it would seem that some
residents were admitted from hospital to the
home who were inadequately assessed by
Orchid View staff prior to their acceptance
and admission. Accepting people who are at
the margin of the home’s competence and
capacity will have a detrimental impact on
existing residents as well as the person being
assessed. Nursing homes must be competently
staffed and managed to be able to provide
care to people with significant needs in line
with their CQC conditions of registration.
They are becoming increasingly important
as care providers for people with significant
healthcare and nursing care needs, so it is
critically important that they have levels of
competence to enable them to deliver care in
line with their registration criteria.
Given the increasing pressure across the
whole health and social care system this
will become increasingly important. This
9
Orchid View Serious Case Review • June 2014
SCR therefore recommends that the CQC
explicitly includes in its inspections the quality,
inclusivity and timeliness of pre-admission
assessment by the responsible registered home.
Recommendation 2 (SEE 4.1.25)
That the process, timeliness and quality of
pre-admission assessment from hospital
settings is explicitly tested within the CQC
inspection process with an emphasis on the
staffing levels and skills within the home to
deliver safe and good quality care within the
home’s conditions of registration.
*****
This recommendation relates to the
importance of staff knowing and acting on
existing policies and procedures so that they
are in use on a daily basis and not just left
on the shelf. This particular illustration is in
regard to taking timely action when there is
a death in the setting, but can be interpreted
more widely.
Recommendation 3 SEE 4.1.35)
That all service providers are required to
ensure that their induction of new employees
and the continuing training of staff includes
clear guidance on the necessary procedures
and actions where a death occurs, be it an
expected or unexpected death.
*****
Recommendation relating to the
CQC’s engagement with relatives
of people using care services
At present there is little scope for relatives
of people in care homes to be involved in
CQC inspections. This recommendation is
to extend the inspection process to involve
relatives, or residents’ advocates as necessary,
to include the offer of face to face meetings
with relatives
Recommendation 9 (SEE 7.24)
That as the CQC develops its inspection
framework and process, specific attention
is given to invite and include discussion
with the relatives of residents, and offers
the opportunity of private discussion with a
member of the inspection team.
10 | Orchid View Serious Case Review • June 2014
Question 2
How can people be confident that they or their
relative will be safe and well cared for?
These recommendations relate to a number of
practice and process issues that will improve
safeguarding work in the future
Recommendations to improve
safeguarding processes
The quality of care plans at Orchid View was
very poor. They did not contribute to the care
needed for that person, or identify anything
personal to the individual. Additionally they
were often out of date and did not contain
core information necessary to provide good
quality and safe care for the person.
Recommendation 1 (SEE 4.1.17)
That all care homes with nursing ensure
that Care Plans contain the name of the
responsible nurse for the resident and that the
resident and their relatives or advocate know
the name and contact arrangements for this
member of staff.
*****
This recommendation relates to the difficulty
reported by emergency services on getting
a response often experienced at night when
they have been called out to a residential
home.
Recommendation 4 (SEE 4.1.35)
That care homes are required to provide
contact details, e.g. a named person, contact
phone number that will be answered, method
of entry, etc. to the emergency services when
they contact them, especially important at
night, to enable access to the home without
delay.
*****
Individual safeguarding cases were
investigated and although themes were
identified at Orchid View, information from
all agencies was not consistently gathered
in all cases. It is important that emerging
themes are identified and shared with
relevant agencies so that they all have as full
a picture as possible as they deal individually
and jointly with individual cases. The new
information system being introduced should
provide the potential for improved awareness
and coordination of information in regard to
services commissioned locally.
There is no overarching information system
across all the agencies established in any
part of England so this is not an issue unique
to West Sussex. There is however a positive
approach to improving access and sharing of
information across agenci