Tales of The Un-Inspected
Care Home 37
By Eileen Chubb
( This report is the Copyright of Eileen Chubb)
Dear Mr Brown,
I have looked at the inspection history of…………………………..Care Home 37, these are my findings.
Inspection report dated 19th to 22nd of February 2008.
The report states, that this inspection is being carried out as the result of serious concerns being brought to the attention of the authorities by relatives and healthcare professionals, as the concerns are very serious a pharmacist inspector has been involved in the inspection.
My Comments, I note that relatives and healthcare professionals raising concerns results in an investigation which includes a drug audit.
The report states, The homes recruitment practices must be more robust, when staff do not declare any criminal convictions in their job application and it later transpires they have a conviction the manager must assess the persons integrity before they start work, also references should be checked to ensure their authenticity.
My Comments, Recruitment practices need to be more robust, I do not think they are robust at all, when you consider this home has firstly employed people who have turned out to have had criminal convictions, secondly not questioned the staff when they were made aware of this and thirdly has not checked references. The inspector thinks the remedy for this is that the manager should have assessed the staffs integrity when this came to light, I think that people who give false references and lie about criminal convictions are highly unlikely to have integrity and the last person who should be judging integrity is a manager who employed such staff in the first place.
The report states that the company audits on the conduct of the home must be provided to the inspectors.
My Comments, I am not surprised these reports have gone missing, because when it turns out there are major failings in a care home the company reports will show everything was fine. A care company should never be expected to give an accurate assessment of themselves. Monthly reports are a cursory tick list and only a fool would place any trust in their credibility.
The Report states that care plans were poor, for one resident the entire information included her name and weight on admission, moving and handling was poorly completed or not completed at all, which GP residents were registered with was missing in some cases.
My Comments, The report lists a catalogue of negligence that went unnoticed by the authorities and the company which owns the home until concerns were raised. I know this is often the case and when relatives or staff raise concerns directly with the authorities this should ring alarm bells that something is very wrong.
The report states that medication practices within the home put residents at risk, A GP reported the home for not administrating medication he had prescribed to two residents who had to be admitted to hospital as a result.
Controlled drugs were not securely stored and could not be audited as staff did not keep the correct records, The records used by the company did not demonstrate medication had been given as prescribed, some records were electronic and could not be shown to us at all, some of the MAR sheets were handwritten and what was given was not clear, a resident said staff had tried to give him medication he was not prescribed, some residents had medications in their room, staff had made no record of most of the medication in the home, records of medication disposed of had been kept.
My Comments, This is the new improved medication procedure that keeps people safe? at least that is what the Department for Health would have the public believe. The reality is that vulnerable elderly people can be denied the medication they need to stay alive. I have seen first hand elderly people given lethal doses of Anti-psychotic drugs obtained from illegal stockpiles, drugs of residents who had died. I have seen the system that an abuser is able to exploit, I have also seen the suffering that is inflicted as a result. This has gone on for years and thousands of elderly people have suffered and died. How many more need to die before you act?
The Report states that there was insufficient records to show how or if the manager had investigated the one complaint recorded as received.
My Comments, Why is this manager even expected to have paperwork to show how he investigated a complaint? Two Anonymous complaints and one concern were made by those with relatives in the home relating to staff and medication were made to the CSCI as were reports from staff in the home who raised concerns about medication. It is extremely likely these concerns were raised with the homes management first. However when a Doctor raises concerns it warrants an inspection.
The reports states the whistle-blowing and protection of vulnerable adults policies of the organisation keep residents safe, action is required by the company and home manager to remind staff about their responsibilities to report abuse.
My Comments, The staff who reported their concerns outside the home did so because either they felt unable to blow the whistle within the home, or they did blow the whistle but no one listened. It is a slap in the face for those decent brave staff who risked raising concerns with an inspection authority that thinks this care company is blameless and its staff who should be reminded of their responsibilities. That is what The Public Interest Disclosure Act protects, the abusive company with all the right bits of paper.
The Home is graded zero Star Poor.Inspection report dated July 2008.
Five Months Later.
The report states that whilst relatives made critical comments about the care, positive comments were made also.
My Comments, Only the positive comments have been listed.
The report states some medications were checked and gaps found, this means staff are not always signing for medication they have given, when doses varied there was not enough guidance on what should be given.
Relatives raised concerns on the surveys about medication but there was not enough information to uphold this issue.
My Comments, Relatives raised concerns but they are not upheld as the inspection survey form they were given to record concerns did not allow them to give sufficient information in order to have those concerns addressed by the inspectors who gave them the forms.
The Report states the home manager is now registered as they successfully passed the, Fit persons, Process.
My Comments, The fit persons process is not fit in that case.
The report states two staff files are checked and the recruitment process is robust.
My Comments, If you read the opening paragraph as a member of the public you could be forgiven for assuming that the recruitment process was robust and read no further. However the final paragraph states that the files did not document why employment references were not pursued instead of accepting character references.
The report states, two members of staff were asked about handovers taking place, one staff member said they always did, one staff member said the never did.
My Comments, The positive evidence was preferred by the inspector. Who graded the section it fell under as good.
The Home is graded 1 STAR Adequate.Inspection dated 11th of June 2009.
( 11 Months Later )
The report states, Medication practices have now improved.
My Comments, No drugs are checked the finding is based on the home having robust procedures for medication, the same robust procedures in place when the drugs put residents at risk.
The report states that people are now cared for as there care plans record all their needs.
My Comments four care plans checked, all praised except the final one which recorded a residents needs had significantly altered and the care plan did not record this.
The report states that people can be confident that any concerns they have will be listened to and acted upon.
My Comments, The above statement would be true but for the fact that the Care Quality Commission had been contacted by members of the public who raised concerns about the home, four of these concerns were referred back to the home to investigate, two of the complaints were safeguarding issues and what they were or what happened is not mentioned. The inspectors felt the issues would be best investigated by the home in spite of the complainants coming to them.
Six different people raising concerns outside of a home says something is very wrong.
The vulnerable in this home will have to wait three years or more for another inspection because of the grade that was awarded at the recent inspection.
THE HOME IS GRADED 3 STARS EXCELLENT.
My Comments, Perhaps you should put health warnings on these inspection reports, I suggest that something along the lines of
These inspection reports have the potential to damage your health if you rely on the information contained in them.
I look forward to hearing from you on this report and those previously sent. Eileen Chuubb