Southern Cross Health Care operated at St Michael‟s View with a culture that had no effective measures in place to prevent abuse and neglect. There was a lack of clear governance, direction and oversight from managers, nursing and care staff. There was lack of effective workable policies and procedures. In addition there appeared to be a lack of awareness of whistle blowing procedures or any effective safeguarding training to support staff to raise appropriate concerns in line with their safeguarding responsibilities. Therefore the voice of the resident was not apparent.
- There were lessons also to be learned across wider services responsible for regulation, commissioning, monitoring and/or delivering services to vulnerable adults which should have identified these problems earlier.
- Hospital based processes could have been strengthened to recognise when safeguarding alerts should have been made when vulnerable adults were subject to repeated admissions to hospital from a care home.
- There was a need to strengthen commissioning, quality assurance and monitoring processes so that they are sufficient to identify and address opportunities for intervention when abusive or neglectful practice is suspected.
- The importance of relatives having clear information about safeguarding protocols and where to get help external to the care provider when they had complaints about the care of their relatives.
- Recognition of the collective impact of consistently poor standards of care practice with regard to the dignity and respect of residents.