Orchid View care home scandal review 'not enough'
A man whose mother died at a scandal-hit care home has said a serious case review has not gone far enough and the private care home sector has failed.
Russell Tucker, 54, whose mother Margaret Tucker died at Orchid View, has called for government action to prevent other similar cases.
The West Sussex home saw 19 unexplained deaths - five cases involved neglect.
The review has made 34 recommendations. The Care Quality Commission (CQC) has also admitted a series of failings.
Orchid View, which was run by Southern Cross in Copthorne, closed in 2011.
The care home has since reopened under a new name and new management.
After the serious case review findings were published on Monday, Mr Tucker, from Oswestry, Shropshire, said: "It doesn't go far enough.
"We know the remit was tight. Useful information has come out on a local basis, but equally issues have come out that impact nationally that is outside the remit.
"Given that is the case, we think it does warrant a full public inquiry."
He added: "The government needs to step up to the mark and behave responsibly. The private sector is not the place for the care of the most vulnerable in society, and it has failed."
'Catastrophic' care standards
An inquest last year found all 19 people whose deaths were unexplained had received "suboptimal" care.
Residents were left soiled and unattended, and one night shift saw staff make 28 drug errors.
The five whose deaths involved neglect were Wilfred Gardner, 85, Margaret Tucker, 77, Enid Trodden, 86, John Holmes, 85, and Jean Halfpenny, 77.
Earlier, lawyers representing the families of those who died called for a complete overhaul of the care industry, and a public and independent inquiry to find out how standards dropped to "such a catastrophic level".
Solicitor Laura Barlow also said questions remained over who was ultimately accountable and added: "What is clear is that the independent sector needs to be subject to the same level of scrutiny that the NHS expects."
The serious case review, commissioned by the West Sussex Adults Safeguarding Board, made 34 recommendations.
'Ineffectual action plans'
They included that care operators must prove they can recruit and keep trained and skilled staff; relatives should always have a named point of contact; concerns should be escalated outside homes if not dealt with properly; open meetings should be held with relatives; and there should be a threshold for informing the public about significant safeguarding issues.
Independent chairman and author of the report, Nick Georgiou, wrote: "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."
He said he believed a public inquiry looking at the national care industry could have merit, and called for a new law of wilful neglect to provide accountability.
Following publication of the serious case review findings, the CQC issued its own report.
Andrea Sutcliffe, chief inspector of adult social care, said Southern Cross and Orchid View staff were primarily responsible for failings, but the CQC had looked at its own role and knew it did not fulfil its purpose.
"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," she said.
Ms Sutcliffe said action had been taken to make the CQC more responsive to risks, and to improve inspections and further improvements would be made.
Some of the recommendations were local to West Sussex, and others were applicable more widely.
West Sussex councillor Peter Catchpole said: "What happened at Orchid View was harrowing.
"Nothing will help ease the pain of the families who were affected by these terrible events and who lost loved ones."
But he added: "We do believe that acting on the recommendations contained in this report will go a long way towards preventing this happening again."