.4 Evaluate how serious case reviews or inquiries have influenced quality assurance, regulation and inspection relating to the safeguarding of vulnerable adults
The purpose of serious case reviews or inquiries is not blame or to reinvestigate incidents of abuse but to establish whether there are lessons to be learned from the circumstances of the incident about the way in which local professional and agencies work together to safeguard vulnerable adults , and to learn from the past experience . In May 2011 the BBC Panorama programme aired a documentary showing shocking undercover footage of abuse and humiliation carried out by a team of carers at the Winterbourne View Hospital. As a result of this programme, a serious case review was under taken leading to 11 employees being charged and the closure of Winterbourne View as well as criticisms of the CQC for its failure to act when complaints had been made. Lessons learned from this serious breach of human rights led to a review of management structures by the providers of the care at Winterbourne as well as new strategy for quality.
Orchid View was a nursing home registered as a care home with nursing for up to 87 people in the categories of old age and dementia. This care home was closed following revelations of a number of safeguarding alerts and investigations and possible criminal offences. In October 2013 an inquest found that five people had died from natural causes attributed to neglect and several other people died as a result of natural causes this was the subject of the Inquest (Orchid View Serious Care Review, June 2014). This two cases highlight the need for quality assurance, regulation and inspection procedure to be in place and monitored to ensure that safeguarding is foremost in our care giving. The Safeguarding Vulnerable Group Act is a major element of a wide ranging programme of work established across the government to address the systematic failure identified by the inquiry. Efforts to address such abuse has been ongoing for number of years. The House of Commons Report of 2003-2004 on elderly abuse highlighted the plight of the elderly and other vulnerable groups with respect to addressing issues of abuse. This resulted in changes that brought by the No Secrets document. The Francis Report (2010) also highlighted the experiences of the patients at the Mid Staffordshire NHS Trust and recommendations for change were made.
Without doubt the serious cases reported in various research have moved government and health care organisations to address the issues relating to vulnerable person in care.
4.4 Recommend proposals for improvements in systems and procedures in own service setting
In my personal view I feel that the aspects policy and procedures in regards to Safeguarding and Complaints are sufficient and robust therefore I feel that I do not need to make any recommendation. There are points that I have come across where staff working on the Adolescent service are faced with historical abuse and this are discussed during safeguarding meetings which comprises of the safeguarding lead for the hospital and senior management including the safeguarding links i.e. mental health support workers. There are clear guidelines what staff need to do should a disclosure of abuse reported to them. All new employed staff have safeguarding training before they work on the wards and they are also taught about reporting systems out of hours and all this systems are working well supervised by social worker. The systems are robust as there are also Safeguarding supervisions to discuss and review lessons learned. This help to establish where there are lessons to be learned about the incident and the way the professional and other agencies work together to safeguard vulnerable people


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