Blistering billy bullshite

The CQC Sloven inspection findings published today are something that demand careful reading. Remaining mindful of the amount of behind the scenes preparation and coaching that goes on for these inspections.

Brief headline: overall finding requires improvement.

We heard of many new initiatives and the trust was continually looking for ways to improve. However it was clear that time was needed to fully realise the scale and complexity of the changes and embed these across the trust.

Mmm. The bar clearly set so blinking low from the off. Businesses can have teething problems expanding, take-overs and the like. Mistakes can happen. For trusts those mistakes have high stakes. Like LB’s life. [He died?]

Growing so big, so fast and spreading yourself so thin across a wide geographical area inevitably ain’t going to work well. As the report today illustrates.

And a startling number of issues identified in previous CQC inspections in Oxfordshire that still occur. The stench ridden “Always about to…” model very much alive and kicking still in Sloven Towers. ‘Point a CQC inspector at us to show us the right route and we’re on it‘ jibberjabber spewing like vomit from a carsick toddler.

Only they ain’t.

Todays batch of failings:

Not enough staff, delays in the supply of equipment, mismanagement of medicines, buildings unfit for purpose, ligature risks, inappropriate seclusion and restraint practices, lack of crisis services and an unanswered crisis line, lack of available local beds, lack of examination of patients by doctors on admission, long assessment waits, uncertainty and low morale among staff, inaccessible records.

There’s some positive stuff I’m not going to record here. The positive stuff is people doing their jobs properly. Good. But not remarkable. The above list, combined with previous CQC inspection findings should lead to action. Not nonsense ‘learning fluff’ spouted by Sloven execs but real action. This bunch of muppets clearly should not be running an empire of crappy healthcare provision across four or five counties.

I worked at home today. Unexpectedly. And the phone didn’t stop ringing. Various people asking for thoughts about the report. There have been some cracking responses (in addition to the now legendary local news coverage). Andy McNicoll at Community Care and Chris Hatton’s contributions are stand out moments.

But hey, what about the Slovens? How have they responded to a grandly piss poor review of their services? Particularly  given their obsession with awards and all things shiny?

In a typical Sloven way.
sloven

 

Always about to… a very Sloven condition

Heard on the grapevine the big old CQC inspection of Sloven will be published tomorrow. Probably good timing to have a little whizzle through some CQC inspections of Oxfordshire based Sloven provision conducted since LB’s death. Particularly given we’re a year on from publication of the Verita investigation into LB’s death.

STATT/JOHN SHARICH HOUSE [November 2013]: No therapeutic interaction, illegal deprivation of liberty, privacy, modesty and dignity of patients not respected, impoverished environment, family and friends not involved, inappropriate risk assessment, lack of training, no understanding of neglect or institutional abuse, mismanagement of medication, out of date oxygen, no battery in the defibrillator, out of date oxygen, unsafe buildings, ligature risks, faeces on chair, inadequate quality monitoring, inaccurate record keeping, poor engagement between management and staff.
Sloven response [Katrina Percy] The team are reviewing internal processes and providing “the leadership and knowledge required to ensure best practice is shared.” 

PIGGY LANE [March 2014]: Lack of staff (a “problem with the Sloven recruitment practice”), lack of appropriate assessment, care, treatment and support, poor engagement between management and staff, delay in getting necessary equipment, lack of records about safeguarding incidents, inaccurate medical records, out of date medication, poor management. “It is so unsafe here at times, you have no idea“.
Sloven response [Phil Aubrey-Harris]:  We have reviewed the levels of quality and immediately put in place an action plan to address all of the issues raised. After subsequent re-failure in June 2014 Sloven unattributed response: a “robust action plan” has been put in place to ensure it was compliant in all areas.

EVENLODE [April 2014]: near miss incident in seclusion, ligature risks, poor engagement between management and staff, a culture of “listen but do nothing constructive”.
Sloven response [Lesley Munro] welcomed the report and took the findings “very seriously”. Necessary building works to ensure the unit is fully compliant were “due to be completed imminently”. 

HOUSE 2, SLADE HOUSE [Jan 2015]: No registered manager, not enough staff, lack of leadership and poor engagement between management and staff.
Sloven response [spokesperson]: The CQC report acknowledges that appropriate actions have been taken in response to their concerns, in most cases, on the day of the visit, that was over 4 months ago. 

Wow. A seedy, foul little whizzle. I almost apologise for dragging you back through it. Still. Big statements from Sloven big guns about stuff about to happen or be put in place.

Confusedcongress.com

Must admit, I’m baffled beyond bafflement the more I learn about the workings of the NHS. Particularly this whole patient safety stuff that is big at the mo. Details circulating on twitter this morning about the latest HSJ money spinning awards [for a full analysis of previous HSJ delights, click here] now combined with the annual Patient Safety Congress.

What confuses me is the content of this congress (concordat/concrap). ‘Making the business case for safety‘ and ‘Preparing for a CQC inspection‘. Eh? Patient safety? Isn’t that about keeping patients, er, safe? Not number crunching and coaching to pass inspections. Serious brain melt stuff.

At the same time, at a more personal level, the Sloven board chair last week reiterated Sloven’s acceptance of the Verita findings and recommendations into LB’s death. One of the reasons the Sloven bigwigs wanted to meet with us apparently was to confirm their “absolute acceptance of every aspect of the Verita report”.

Oh. That’s a bit odd. Why the hell are they wasting public money having a legal team, including barristers, who have tried to narrow down the scope of the inquest then? Why have legal representation at all? 

I just don’t get it.

It’s like the music is playing loud and clear, but Sloven, and the NHS, insist on dancing to a different tune.
old pics

Cup of tea, bit of a sprint and the Jam Factory

Oxford City Council have funded My Life My Choice to make a film about LB. Oxford Digital Media (ODM), a hip and happening video production company, are working with them. (Here’s an example of a recent collaboration between the two organisations, both based in the Jam Factory). Coolsers gone wild.

This afternoon, Sam and Guy from ODM came round to meet a few people who knew LB well and get a bit of an idea about who he was. There was no end of stories and laughter. Including a bit of back story about a set of tea making pics that have been pinned on our fridge for a few years.

Justicequilt-64

LB rocked the tea making with some novel adaptations. And a cheeky bit of sprinting that still makes me chuckle.

Waugh? What is it good for? Absolutely nothing

Received a response from Simon Waugh (SW), Board Chair, Sloven Health this afternoon. That it came by email is about the best thing I can say about it. Selectively copied in to the cc list (bypassing Katie Razzall, Newsnight and JusticeforLB headquarters).

Brief context: We had questions, Katrina Percy refused to answer them, SW answered them Sept 17 2014. In a really crap way. In such a crap way I arranged to talk with him on the phone (23.9) convinced he wasn’t really up to speed with what was happening under his watch.

The big conversation back in September? A mistake really other than the occasional droplet of insight. We’ve continually shot ourselves in the foot and made ourselves look as incompetent and uncaring as possible. Er, yep. The truth is simple. His care was not what it should have been. Yep. SW also said he’d learned to reflect about being on the receiving end of letters from him in his capacity as Board Chair and think about what it must be like to receive such a letter (does it help or does it widen the gap?). Good stuff. (Though this was in connection with sending my sis a letter meant for another patient, rather than real reflective stuff about the content and meaning of what you write).

Unfortunately, these drops were obliterated by a drill hammer communication style, clearly aided by a set of key points) that looped across the two hour conversation (LB was fab, fit and able, staff forgot he was a patient, Sloven appear crap (but ain’t really) and there are valid excuses (or cliches) for everything). Once the repetition became apparent, it was a really uncomfortable conversation.

A couple of examples of the excuses:

Sloven didn’t dive into the unit to see that the hell was going on when a “fab, fit and able” young man died unexpectedly in the bath [he died?] because the police told them not to. Mmm. Not sure about that SW. How come the CQC could just pitch up and inspect weeks later?

“Well you’re damned if you and damned if you don’t”, was the slightly tetchy non answer. Followed up by a seedy little attempt to lay the beyond appalling CQC failings as having occurred in the six weeks or so after LB died. That pesky cleaner walked out 10 days before the inspection… [at several points during this conversation I wondered if I would experience long term effects from the sickening rage it generated.]

The second example involves the other patients in STATT. SW wrote that “unfortunately” STATT patients were unable to attend LB’s funeral because of “the family’s understandable restrictions on staff attending”. Not true, I said. I explained how we wanted staff not directly related to LB’s care to bring them. Bluster bluster.. SW meant the other patients’ families thought their relatives weren’t in the right mental state to attend. Oh. Why didn’t you write that then? I asked. Puff, huff and puffenstuffen, Dr Ryan. He couldn’t possibly include every line he wanted to include in the letter. It would be impossible.

Another damned if you do and damned if you don’t situ. Clearly.

So, back to today. The emailed reply. First of all he attached the letter sent on Sept 17th for the partial cc list to read. The fudged and fake responses letter. That is pretty crap. He reiterated the fact we’ve refused to meet across two paragraphs. Yep. With regard to staff disciplinary actions apparently the final one is part-heard and will be completed shortly. Mmm. (17 Sept letter “The final hearings for the remaining investigations are scheduled to be completed in the coming weeks”. 23 Sept phone call, staff disciplines will be completed “in the next 2/3 weeks”.)  There have been no delays with the second Verita investigation and the incredibly insensitively timed email, sent on 23rd December, wasn’t sent by the Trust’s solicitor. Even though it, er, was.

Wow. Mr Waugh. That stuff about reflecting on letters sent, foot shooting and incompetence (or worse)… ? You got a bit of a waugh to go, I’m afraid.

The footy guy nights

old pics (2)

Most evenings, sitting in the front room, I end up looking at the floor. And think about LB. And spaces. Wow. He did a number on spaces. Occupying different spaces within our space. Like sleeping on the Billy bookcase as a tot. Or hanging out in the swing bin. Now that sort of space isn’t occupied it’s odd/hard to remember it ever was. Who lies on their side on the living room floor? Across years…

Back in the day, the footy guy nights were a pretty unremarked upon part of family life. Like so much other stuff. Absorbed into our ‘normal’.

old picsI look at the floor and wonder how he fitted. With Chunky Stan, and the Playmobile audience. It’s a tiny space really.

There was no guessing when the box of ‘footy guys’, goal and makeshift ball would appear. In a seamless and low key celebratory joining in of a mainstream footy event. In his own way. How the hell did he fit in that tiny space?

He sort of studiously ignored the match on TV. Applying sometimes silent, focused concentration on his match. Remarkable really as footy fell outside his typical interests. At the same time, he was fully engaged in the moment. Some of the real time match entered his commentary but his match had its own dynamic. And own moments. LB was no slave to premier antics. old pics (3)

I loved these footy guy nights. I loved his absorption in the match, played out with a ball made of scrunched up paper and Sellotape (made after the original tiny ball went missing). I also loved (without realising it at the time), how everyone fitted around him. Picking across the guys to sit down. Respecting his engagement.

LB kept his footy guys in a Spongebob box. The goal and ball were stored in an old CCTV camera box. Which doubled as the second goal. Everything carefully packed and stored in his room until the next time.

I photographed this one evening. I don’t know why. Or why that night. January 29 2011. He was 16. Capturing a school boy. Absorbed in doing something he loved.

As he should be.

old pics (1)

 

Paint your wagon and other songs

In addition to the delay I banged on about in the previous post, I found out from NHS England this week that Sloven staff disciplinary processes are continuing. In Sloven time. On the midnight train to never never land. I’ve had this conversation several times now. It sort of sits at a junction between Tedious as fuck and Off the scale of outrageous. With a backdrop of Howl mountain.

‘What can we do?’ I asked the bearer of no news. Gnawing on the handset.
‘Nothing really’, was the answer.
‘There must be someone we can contact to say ‘This delay is unacceptable for everyone, can you do something about it?”
‘Not anymore, the only person really is the Board Chair’.

A heartsink statement given my 2 hour conversation with ‘Mr In Denial’/’Mr Kept in the Dark’ (sadly not ‘Mr Know it all’) a few months ago.  Anyway. I sucked it up, fired off a letter with the keyboard smoking, and copied it to pretty much the whole world in his hands. Including Jezza, Norm, Si, Davie B and KP too.

I was chatting to Little Sis Sam earlier and she said how outrageous it was that we’re having to do this. Yep. And how awful it must be for families who haven’t been able to meet with the various people we have. Yep. Bit of a double edged sword really, she said.

More triple edged really. If that’s possible.

1. We shouldn’t have to do it.
2. It stinks that some families have more traction than others in trying to get accountability.
3. What has actually happened?

Those wagons are firmly circled.

As the old growler sang;

Mud can make you prisoner
And the plains can bake you dry
Snow can burn your eyes
But only people make you cry…

image (3) 

Delay and inhumanity

Found out earlier the disciplinary process for the staff member we referred is delayed. Again. An extension has been granted for additional time to read through records. We referred this person in May 2013.

“I’m not being funny”, I said, on the phone, “But all this delay stuff is always on the part of the system; the Department of Health, the NHS, the CCG, the local authority. And it impacts on families who are utterly devastated. Crushed by the process. And who have nothing to answer to. We’re 20 months on from LB’s death and no accountability. Just waiting. On wait.”

How can this possibly be?

No real answer. Though very apologetic engagement.

delay

On the bus home I read this tweet. And again my brain screamed there’s simply no excuse to delay any part of the process of accountability. It’s the absolute minimum that should be done when you’ve got something so catastrophically wrong. I can’t describe the additional pain generated as weeks, months and years go past and fuck all happens.

This established practice of embedded, accepted and unremarked upon (by those with any sniff of  power) delay needs stamping out. It’s simply inhumane.

Justicequilt-53

OCC, ‘the BLOG’ and power

Bit of a ragbag ramble this evening. Including some tips for social care bods. I had a bit of a sort out today and a few choice docs from Oxfordshire County Council (OCC) popped up. Now OCC are doing a seriously cracking job at keeping their heads down so far, despite clearly being concerned that their involvement in what happened might come under the spotlight at some point. A lot of their exchanges are fuelled by this blog (or “the BLOG” as they call it).

The Director for Social and Community Services didn’t write to us after LB died. Or after the CQC found appalling failings at STATT in a report published in November 2013. Or after the Verita report found LB’s death preventable in February 2014. Nope. He wrote on April 2nd (saying sorry ‘about the death of’ LB) in response to comments I’d written about OCC. [Tip 1. Write to families straight away if someone dies an unexpected death in provision you commission. Not just when you feel publicly threatened]. OCC also declined to attend the pre-inquest review meeting recently (‘nothing to do with us guv’) even though the coroner’s court is in their building [Tip 2. Send someone to inquest meetings when the person’s death was preventable].

There’s a long list of things we think OCC did wrong. Not least giving STATT a green light in their quality review at the end of 2012. A month or so before a Winterbourne View JIP team of three (including an Oxon commissioner) visited and thought the place was a shithole. The commissioner put in a decorating chit (and now says no crap other than shabby detected) while the other two assumed the commissioner would do something about the place. Other than a lick of paint.

OCC self preservation workings are very apparent in docs disclosed to us. For example, in response to a request from the Clinical Commissioning Group (CCG) to offer us a meeting (as I seemed to be softening on my blog. Yes, really), a senior OCC official’s response was What if she brings her solicitor along with her? I think we need to do a bit more thinking before offering a meeting out of the blue. S/he then decides if the meeting goes ahead an OCC person should attend too in order to know what the CCG geezer is saying. Wow. [Tip 4. Second guessing responses and back watching suggests a right old toxic culture which needs urgent attention/disinfectant].

This blog seems to have evened out (only slightly mind) the power differential between families and health/social care organisations. It features in so many exchanges in disclosed documents often with links to posts. Slovens solicitors wrote a pretty steaming letter to us a couple of weeks ago (copying the coroner in) because I’d made an error on a recent post (now corrected).

I was a bit mortified at the time as I’ve tried to be accurate throughout. But given the amount of ‘errors’ cough cough the Sloves have made throughout this foul process (and the slimy, smearing Briefing document they circulated to fuck knows who else in addition to NHS England, Monitor), one error is pretty remarkable really. In the circumstances.

What a murky, murky little biz.

Stay classy, y’all.

Justicequilt-50