Today’s publication of the Care Quality Commission report on Southern Health reminds us that the days when care homes were run without anyone investigating their work are long gone. Now such organisations are held accountable and the CQC shines a bright light into all the dark corners of their work. These days it’s impossible for such organisations to cover up any wrong doing or evade examination of their methods, staffing, policies and finances.
Or is it?
Supported living care homes are not registered with the CQC. Supported living care does not fall under the Health and Social Care Act of 2008. The CQC has no powers to inspect a supported living care home unless they are invited to do so. No independent inspection of these homes is ever carried out. The closest they get to an inspection is when a quality monitoring review is carried out by the Local Authority, who has commissioned the care anyway.
Southern Health run supported living care homes in Hampshire and Oxfordshire. They run the supported living house where Nico died.
In July 2014 I contacted the CQC to find out how much they knew about Nico’s death. They told me that they had never heard of the home where my son died. They were unaware that a service was being run there, let alone that someone had died there. Supported living homes don’t have to be registered as care homes and the lack of registration means that they don’t even appear on the CQCs radar.
The CQC told me that everything run by Southern Health Foundation Trust is the responsibility of their mental health team and then passed my emails onto the correct member of staff. He is a very senior member of staff (actually named in today’s report), who responded very quickly. He emailed me and explained that the CQC received notification of Nico’s death from one of the managers at the home on the day he died but it didn’t name the home or say it was a supported living care home. None of this information was given in the notification. But of course, they didn’t have to give the name because they knew the home wasn’t registered with the CQC. Although the notification said that a post mortem was going to be carried out, it in no way suggested that Nico’s death was unexpected or required investigation.
The email went onto tell me that as part of the report on Southern Health carried out by the CQC, they would be asking them for “information regarding their investigation into the death of your son”. Whether they asked Southern Health about Nico as part of their review or not, we don’t know. His name does not appear anywhere in the CQC report. There is no mention that the CQC asked for information or followed up on Nico’s death. The name of the supported living care home where he died is not even amongst the very extensive list of care facilities run by Southern Health at the start of the CQC report.
In fact none of the supported living care homes run by Southern Health NHS Trust are included on this list. Nor has any of the supported living care homes run by Southern Health NHS Trust ever been inspected (to our knowledge) by the CQC for the simple reason that they do not fall under their jurisdiction.
Our golden boy fell through the cracks. The CQC didn’t know he existed. They didn’t know the place he lived in existed.
With no-one watching what you do; no-one keeping an eye on the way that things are run, it’s all too easy for mistakes to be covered up and vitally important things like dangerously low staffing levels to go unnoticed. Lesley Stevens (see blog post https://justicefornico.org/2015/01/25/dear-southern-health/) was interviewed this morning on the Phil Gayle show (BBC Radio Oxford) and said she isn’t concerned about low staffing levels at Southern Health run care homes.
At Nico’s inquest the coroner said “Nico would have been saved if he was checked within the guidelines of his care”. Mr Aubrey Harris of Southern Health said “There was a guideline in place that Nico would be checked every 20 minutes but it was inevitable that with one staff member to four other severely disabled people that on occasion these checks wouldn’t be able to be maintained and I’m inclined to agree with the coroner with the benefit of hindsight”.
He went on to say “Lessons have been learned, but we believe that one staff member to 4 young people was adequate”.
I think that Nico would disagree with that. Following Nico’s inquest, Southern Health have made no changes to their staffing levels and tonight, in that supported living care home that the CQC didn’t even know existed, four young people will be cared for through the night by one care worker. I hope and pray with all my heart that tonight nothing goes wrong.