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Our response to Margaret Flynn’s independent review on ‘Operation Jasmine'

We welcome Dr Margaret Flynn’s report and we are keen to learn from its findings.

The report describes very poor, unacceptable care to vulnerable elderly people and identifies people who suffered very serious neglect. It explains the impact this has had upon their relatives and the on going distress they have endured. We told the relatives we met as part of the review how sorry we were, but we were able to assure them that inspectors at the time were very diligent in trying to address concerns and tackle failing services. Clearly though, none of this should have happened.

Care and Social Services Inspectorate Wales (CSSIW) provided extensive evidence to the review. Officials spoke to some of the families involved and were able to give them information about specific action taken as a result of the concerns they raised.

The report sets out the actions taken by the regulator at the time, as well as some of the legal challenges it faced when seeking to close care homes. Our modernisation programme began in 2010 and took effect in 2012 and was a response to a number of issues which arose from Operation Jasmine. In particular we have made the accountability of providers clear, toughened our enforcement processes, placed the experiences of people receiving care at the heart of our inspections and streamlined our approach to responding to incoming concerns.

CSSIW would like to thank Dr Flynn for her work. We will carefully consider the report’s findings and recommendations, while continuing to strengthen our approach to regulation and inspection of care homes to reduce the risk of this ever happening again.

Chief Inspector Imelda Richardson said:

Dr Flynn’s report is an important step for the families and relatives of those who suffered harm, and who have shown immeasurable strength and courage in situations no family should ever have to face. The report describes the damaging effect that completely unacceptable care had on people’s lives.

These events should never have happened. We told families when we met them how sorry we were.  CSSIW recognised that we needed to strengthen our work, focus on people, drive improvement in the care sector and ensure timely enforcement. Everything we have done since has been built on the principle of putting people first.

We do not tolerate failing care. Providers have an opportunity to put things right, but when they don’t, we take prompt action.

I would like to assure members of the public that the safety and wellbeing of the people who use care services is at the heart of everything we do, and that the quality of care is our utmost priority. I’d also like to assure people that we find many examples of good care in Wales, and it is a small proportion of providers who cause very serious problems.

We are far better sighted on services of concern than ever before, but we do rely on members of the public, care staff and relatives to tell us if they see poor care or if they have concerns or worries. 

Now that the report has been published, we will carefully examine and reflect on the recommendations. We will work with our National Advisory Board to go through the report and ensure that our work continues to serve people who need and use care services.  CSSIW continues to put people who use services at the heart of our work.


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