Tales Of The Un-Inspected
Home Number 67
By Eileen Chubb
( This Report Is The Copyright Of Eileen Chubb)
I looked at……………………..Home Number 67, these are my findings,
Please note that this home is owned by the same company as homes 33, 36, 41, 48, 49, 50, 54, 59, 60, 62, 63, 64, 65, 66.
82 year old Betty Delaney suffered excruciating bedsores whilst in the care of home 67. The sores were only discovered when Mrs Delaney was admitted to hospital. It was subsequently found that this home had not only failed to provide the equipment needed to prevent the sores in the first place but failed to even notice the wounds. Two of the wounds were grade four exposing bone and would have taken a considerable time to get to that stage. Mrs Delaney’s family said they found her crying in agony every time they saw her in the last months she spent in the home. The Local Council said they would be informing the care home regulator, CQC of the issues raised by the families solicitor.
Another family saw the above story and said,
,, I cannot believe this is still happening after six years, my uncle died in the same circumstances as this poor lady, he was admitted to hospital from this same home with terrible pressure sores, we even took pictures. He died two weeks later. I felt sick to my stomach when I read this story in the paper tonight. We reported our concerns to CQC and an investigation was done by them and we have still have the report that outlines many recommendations they made. Obviously this was not followed up as six years later this poor lady and her family have had to go through what we had to go through. I am absolutely disgusted and how many other residents at this home have suffered many who have probably not got relatives to look out for their welfare. How many times are they going to outline areas for improvement and then do nothing about them. They also expressed their deepest sympathy to my family but it has not made any difference to the care they give.REGULATORS INSPECTION REPORT DATED 24TH OF OCTOBER 2005.
THE REPORT. The company needs to make available records of visits to the home. Care plans were looked at and in some cases did not fully detail residents needs. Some care plans did detail needs but staff were not following the care plan. The company have provided full training to staff on care planning. The company have also provided better supervision to the senior staff to ensure needs are both recorded and met.
My Comments, When a company carry’s out the required visits to a home and fails to leave a record it is an indication that something is very wrong. The training and supervision that has allegedly been given to staff is clearly not working, I see this as an indication that either the staff are so unsuitable that no amount of training will have any effect, or that the training is flawed or the company are not doing what they claim. The fact is that needs are not being met and whilst the regulators terminology makes this sound like a minor thing, when people have needs that require them to be in a care home it is because they need care to stay alive.
THE REPORT, The home has a complaints procedure in place that is well known to residents and relatives, it was evident that the number of complaints we the regulator were receiving that some residents and relatives were not satisfied with the care and facilities provided by the home. The home has systems in place for quality assurance. The standards that relate to complaints 16 and 18 were judged at the last inspection and fully met.
My Comments, The complaints procedure is well known to relatives and residents because the home has received a large number of complaints. The inspectors had received a large amount of complaints about the home at the time of the last inspection but graded the requirements fully met at both the previous inspection and this one. They state that no more complaints have been made to them and I can see why, their attitude to complaints about care is to label those relatives and residents as ,, Not Satisfied with the care provided ,, This speaks volumes about their attitude as I see a situation where a large number of people both relatives and residents have raised concerns about a lack of care, firstly with the home as the complaints procedure is well known through usage but worth nothing. When one person raises a concern outside a home it is my experience that all else has failed and they are desperate get the issues addressed because those issues are serious concerns. When I hear that a large amount of relatives and residents have gone to the regulator every alarm bell is ringing as something is seriously wrong. The regulator is told by the company that only one complaint has been recorded because the company has gone to great efforts with a robust Quality Assurance System, and this is accepted without question. We shall see what price is paid for accepting Quality Assurance Systems as evidence in a care system driven by profit whose customers are the frail and vulnerable, where families are ignored or told they expect too much if they raise a concern.
25 standards are judged, 20 are Fully Met, 4 are Almost Met and 1 is a Major Shortfall. Pre star system the grades amount to good.
REGULATORS INSPECTION REPORT DATED 5TH OF MAY 2006.
( Six Months Later )
THE REPORT. Three care plans were looked at, the care plan for a resident on the dementia unit had not been updated to reflect her current needs. The plans had been written in consultation with relatives but two were not signed by relatives. A key worker for one resident had left and another assigned but when we spoke to the key worker they were not aware they had been assigned as such and were not familiar with the residents needs. A visiting district nurse was spoken to who said generally residents were well cared for but that communication needed to improve. It was noted that for various reasons five residents had run out of medication over the weekend. Returned drugs had been returned from one unit but not the other. A comment card from a GP said improvement was needed in medication.
My Comments, For every negative comment something positive is listed however as the negative findings relate to things like leaving residents without medication prescribed for possible life threatening conditions, when followed by comments such as residents dignity and privacy is upheld by staff knocking on doors before they enter, it is an apology for saying anything negative at all. I fail to see how knocking on the door of a resident before entering and perhaps finding them dead from not having their medication upholds anything. The desperation of the inspector to state something positive after every negative finding is a pathetic excuse for regulation. This is reflected in how the home is graded.
THE REPORT. Activities are good, there was an activities programme on each unit. There was clear evidence residents are protected from abuse, 25 staff had been fully trained in POVA and whistle-blowing. One complaint had been recorded and dealt with. Staff rotas were checked and there were some shortfalls of staffing hours, the manager said she thought the staffing numbers were agreed with us the regulator. Additional staff are required to meet the needs of residents. The activity organiser had been escorting residents to hospital. Staff files were looked at and were difficult to check. There were robust recruitment policies and procedures. The two new staff files did not have any evidence of induction training. Staff training has greatly improved and the new manager has made staff training a priority.
My Comments, Of course all the above statements are written in different parts of the report as to put them all together would not look good. If this is the managers idea of giving training priority then I wonder what other areas she is commended for. I can see by the evidence noted by inspectors that residents are in real danger and yet whilst noting these facts inspectors arrive at an entirely different conclusion.
THE REPORT. The company has a robust Quality Assurance Tool in place which is utilised. Relatives questionnaires were sent by the company and 12 had been returned, these were not available as they had been sent to head office to be collated. The manager has an open door policy and the home is run by an experienced fully qualified manager who has a clear understanding of what needs to improve for residents. The staff said the manager was excellent.
My Comments, Only one complaint, only 12 questionnaires allegedly returned but sent to head office so not actually seen so not actually evidence at all. Quality Assurance is relied on again.
22 Standards are judged, 15 are Fully Met, 7 are Almost Met.
The home is graded good.
REGULATORS INSPECTION REPORT DATED 8TH OF DECEMBER 2006.
( Six Months Later)
My Comments, Please note that whilst the inspection report is dated six months later it contains the information that just 8 WEEKS after the home was judged good the following occurred.
THE REPORT. Two complaints have been made to the Local Authority, one is still on going, the police could not proceed with an allegation as the staff member denied the allegation and it was their word against the residents word, the crime committed remains on police files as undetected. We received a complaint and many of the concerns were found to be true when investigated.
My Comments, All the warning signs were there for years but the inspectors chose to rely on the homes, Quality Assurance Systems, and residents paid the price. But even now the warning signs are ignored, whilst the serious issues are noted they in no way impact on the inspectors opinion of the home. I have listed below extracts from both reports.
Report May 06. Health and Personal Care.
This area is adequate. Care plans checked contained detailed risk assessments for skin pressure areas, falls ect and residents healthcare needs were well recorded. One care plan was not updated with current needs. Five residents medication had run out. Standard 7 is judged a minor shortfall, standard 8 is fully met, standard 9 is a minor shortfall and standard 10 is fully met.
Report Dec 06. Health and personal Care.
This area is adequate. We looked at four care plans and found personal care and healthcare needs well recorded. This is particularly important given the concerns raised in recent months. The district nurse felt things were improving but communication was still a problem. The manager was now meeting with district nurses every three months so problems could be acted on immediately. Minutes of August and November meetings showed pressure areas were healing and staff attitude had improved. A pharmacist inspection took place in September 06 and found poor record keeping. A GP had raised concerns that staff did not understand residents needs and there was not always a senior staff member on duty. Handwritten MAR sheets were not signed by two staff. Medical advice was not always followed. Residents had been ill and the GP called and medication prescribed but when a GP was called to the same residents one or two days later it was found their medication had not been administered or even obtained. MAR sheets still had gaps. There were errors found in the recording of controlled drugs. All staff have been given medication training but clearly there continues to be shortfalls. Residents spoken to on the first floor said they were treated well. Staff knocked on doors and respected dignity. Standard 7 is a minor shortfall, standard 8 is fully met, standard 9 is a minor shortfall and standard 10 is fully met.
Report May 06. Daily life and Social Activities.
This area is good, Activity programmes were displayed on both units. The residents religious needs were being met. Food was good and the chef provided a good choice. Questionnaires were very positive about the manager. Standards 12,13,14 and 15 are all fully met.
Report Dec 06. Daily life and Social Activities.
This area is good. The activity organiser was also working as the maintenance man in addition, issues had been raised about the lack of activities. No evidence was seen of improvements. The activities programme displayed was not always implemented. Residents said there was still not much to do. Some care staff had taken residents shopping on their days off . Standard 12 is a minor shortfall, standards 13, 14, and 15 are fully met.
Report May 06. Complaints and Protection.
This area is good. There is clear evidence residents are protected from abuse. Twenty five care staff has been trained in the companies POVA and whistle blowing procedures. This had been carried out by the homes highly experienced manager. An effective complaints procedure was in place. The manager was responding to complaints very well.
Standards 16 and 18 are fully met.
Report Dec 06. Complaints and protection.
This area is adequate. One resident said he would report any concerns to one particular member of staff because she was really nice. In July 06 we the regulator investigated an anonymous complaint and it was found to be true, it related to healthcare, personal care, hazards, lack of activities, health and safety and staffing. As a result the manager has made changes to her audits. As given the other investigations and issues in the last months the manager should attend local authority training on POVA. The manager informed us of the investigation. Standards 16 is fully met and standard 18 almost met.
My Comments, The inspectors even now rely on Quality Assurance systems and state again that there is a robust corporate quality monitoring and assurance system in use. But on the last page of the report it is stated the all the hoists in the home had not been serviced and that the extensive training allegedly given to staff had all been done on the same day. The manager had not reported the abuse allegations to the regulator but had reported the investigation being conducted by police. Also the open door policy the manager was commended for previously is not evident to me in a home where serious allegations of abuse are made anonymously outside the home.
23 standards are graded and 13 are fully met, 9 are almost met and 1 is a major shortfall, even now the home is considered good. It gets much worse.
REGULATORS INSPECTION REPORT DATED 23RD OF AUGUST 2007.
( 8 Months Later )
THE REPORT, Health and Personal Care, This area is good, the manager has rewritten and reviewed all the care plans since the last inspection. Residents are encouraged to be responsible for their own personal care where possible. All staff are fully trained in the companies robust medication procedures. Medication records provide evidence staff follow procedures. Staff told inspectors how committed and caring they are.My Comments, I find it of concern that the manager has re-written and reviewed all care plans as the manager would not have experience of residents care, the staff who attend to residents needs every day should be writing the care plan. When ever I have seen unkempt neglected residents I have been told they are being encouraged to be independent. The staff being trained in robust medication procedures is worth noting for now, as for staff commenting on how caring they are it is not evidence at all.
THE REPORT, DAILY LIFE AND ACTIVITIES, This area is good, great importance is attached to ensuring residents are given the opportunity for stimulation, there is an activities organiser who encourages residents participation in each days events. Residents were being assisted to eat in an unhurried manner.
My Comments, I note the above is accepted without question, however in another section of the report it is noted that both relatives and residents have told inspectors there is not enough staff to care for residents, so staff being observed to be feeding residents in an unhurried manner is not consistent with the evidence given to inspectors. There has been an activities organiser at all previous inspections and the homes commitment to this area is not demonstrated by sending this staff member to escort residents to hospital appointments instead of carrying out activities.
THE REPORT, COMPLAINTS AND PROTECTION. Residents are confident complaints will be listened to and acted on. The manager may wish to record smaller issues for monitoring purposes. We the regulator were informed by the Local Authority of a complaint about the home which was being investigated. We the commission have received three complaints about the home. All staff have been fully trained in adult protection and whistle-blowing procedures and staff interviewed demonstrated their knowledge in these areas. The safety and protection of residents is a priority in the home.
My Comments, What is stated amounts to everyone has received complaints about the home except the home itself who has not recorded any complaints at all.
THE REPORT MANAGEMENT, This area is good. The manager is fully qualified and experienced and runs the home in the residents interests. The manager has demonstrated a clear sense of direction and there are good management systems being utilised. The manager is completing monthly audits as were senior management from the company. The corporate quality monitoring and quality assurance system is robust and was being fully utilised to ensure residents were well cared for.
My Comments, We shall see what this amounts to.
The home has no outstanding requirements and 23 standards are judged, 21 are Fully Met and 2 are Almost Met. The home is still judged Good.
REGULATORS INSPECTION REPORT DATED 19TH OF OCTOBER 2007.
( 8 WEEKS LATER )
THE REPORT. The reason for this inspection is that since the last inspection we have received an anonymous complaint. The local authority have inspected the home and found serious issues of poor care which has been reported to us.
My Comments, The local authority told the regulator that the home they considered good just 50 DAYS ago is a shambles, the regulator had received anonymous complaints about the home before but failed to act and accepted the homes Quality Assurance as actual Assurance Of Quality. The alarm bells have been ring for years but now the suffering and damage done is on such a scale that even the regulator, CQC have to acknowledge what was always there for them to see. However their past record indicates it will not be long before they start ignoring the warning signs again. Listed below what was reported by concerned relatives and Social Services and only now inspected by the regulator and found to be true.
1. THE REPORT. The Manager has left this home to work in another home owned by the same company.
My Comments, This highly qualified manager who 50 DAYS ago was praised for her open door approach to concerns and complaints is reported by relatives for never taking any action when concerns are reported to her. As for her being able to carry on working in the care system that is why abuse continues as even when abusers are identified, which rarely happens as they are usually highly thought of by the regulator, they are still allowed to continue working and inflicting damage.
2. THE REPORT. The AQAA was not sufficiently detailed and contained inaccurate recordings about many areas, for example it stated no one in the home had pressure sores when this was not the case.
My Comments, This AQAA was accepted as true previously, This is what Quality Assurance Systems amount to and now we see the price that is paid for relying on such. The inspectors look at the care plan of just one resident with pressure sores and find she is identified at risk and what action should be taken to prevent sores developing. No further care was evident and no reference made to this until June when it was noted she had developed grade two pressure sores, the next recording is made by a district nurse who notes the sores had deteriorated to grade three and very recently a further three pressure sores were found. The care plans were said by inspectors 50 DAYS previously to be detailed and all to a good standard, however that conclusion was based on what they were told by the AQAA, the reality is quite different had anyone bothered to check this.
3. THE REPORT. Residents who suffered drastic weight loss had no action taken to address this. Relatives said there were not sufficient staff to care for residents, A visiting relative said her mother was left alone to feed herself when she could not manage to do this.
My Comments, 50 days ago inspectors were told by relatives and residents that there were not enough staff, but they concluded that residents were fed in an unrushed manner in the dining room, I would have looked at those behind closed doors as that is where you see the true picture. If there are that many people saying that there are not enough staff then it follows that there is not enough care, without care people die.
4. THE REPORT. We looked at the care plans of two residents who had suffered drastic weight loss, one had not been weighed at all and the other had lost over 14 kilos but no action was taken to address this.
My Comments, These residents were presumably not amongst those being fed in an unhurried manner by staff 50 days ago.
5. THE REPORT, Risk assessments were carried out on admission but when we checked this against the care plans the information did not correspond. All residents will need to be reassessed.
My Comments, Everything that was judged good for years is now found to be wrong. When a home goes from good to dire in 50 Days you have to ask was it ever good? What concerns me is the evidence available to inspectors contradicts how they graded the home. Years of people asking for help ignored, years of poor care because of poor inspections until too many people have suffered to excuse it or contain it any longer.
6. THE REPORT. Medication was not accurate, some medications were not available, PRN medications were not correctly recorded.
My Comments, This would have been discovered soon had the medication been inspected as well as the records.
7. THE REPORT, Many residents were mentally frail and unable to say if they were treated with respect and felt safe.
My Comments, 50 days ago they were able to say at least the previous report lists all the positive things residents were alleged to have said. The home is registered to care for 18 residents with dementia and 22 residents not in that category, now we find the home in breech of its registration conditions as it seems 22 residents have developed dementia in the last 50 days. As no staff are now discovered to have training in dementia care I expect the inspectors will see this as promoting equality and diversity in that all residents will be neglected and abused to the same degree.
8. THE REPORT, One resident told us she wanted to go out but was frightened to ask staff as she would get into trouble. She was very distressed and said there is never enough staff to take her out. Staff said they had no time to do activities. The activities organiser was of sick and activities were not being done. The documentation made reference to activities done in the past but these were very vague. It was evident that little time was given to activities.
My Comments, I checked the last report had the correct name on it as the contents of these two inspection reports are so different they could be different homes, yet this is the same home that 50 days ago demonstrated a commitment to activities for residents stimulation and enjoyment, this is what the AQAA told inspectors anyway, what the residents asked told inspectors was, There is still nothing to do,, but that was ignored in favour of the AQAA. Now the truth is exposed and this time it does not result in a commendation for commitment to activities.
9.THE REPORT, Those residents able to get themselves up looked groomed and cared for. Other residents were got up at various times.
My Comments, The helpless were left neglected in conditions that allow bedsores to develop. 50 days ago people were considered encouraged to be responsible for their personal care, what that amounts to is neglect in the name of promoting independence and choice has nothing to do with it.
10.THE REPORT, The kitchen had been taken out of use and the home did not report this as an incident that could affect residents. Lunch was supplied by caterers and other meals made in the staff room.
My Comments, The inspectors worry this may affect residents choice of food, I had to read much further in the report to find that the kitchen was taken out of use because it was found to be filthy by the local authority, the inspectors never noticed this until now. This is a home where residents are left lying in bed behind closed doors for anything up to 18 hours, where people are not fed and unable to feed themselves and where drastic weight loss goes unchecked and they worry about choice of meals, I worry the food can not get from plate to mouth first as that is the basics of sustaining life. Showing residents pictures of food that will be left in front of them and taken away uneaten seems to me to be a tactic of torture. Then there are those lucky enough to be able to feed themselves only food poisoning can be lethal for elderly people who have the misfortune to be eating food prepared in a kitchen so dirty it is shut down by the council and was somehow overlooked by the regulators who inspected the home previously. It would make a good advert for, Spec-savers, if it were not so tragic.
11. THE REPORT. Relatives said they gave up raising concerns as nothing ever was done. Staff were not trained in protection and whistle-blowing procedures. There appeared to be two complaints files in use, the operational director said she would make them up into one. A senior staff member was unable to say what abuse was, he said he had never had any training.
My Comments, 50 days ago all staff were trained in abuse and whistle-blowing and residents and relatives were said to be confidant that concerns would be acted on. I have seen the two complaints files scam used before, there is the file that looks bad as nothing done and the file that is shown to inspectors.
12. THE REPORT, We checked two toilets both had faeces on the seats and one had no toilet paper, the home was found dirty in many areas by the local authority.
My Comments, This was all judged good 50 days ago.
13. THE REPORT, staff files were found in disarray and not all contained the required information. The number of staff stated to have the NVQ in AQAA was not correct. Also three new staff had all their skills for care documentation completed but without having undertaken the training.
My Comments, The AQAA was a pack of lies and never to be relied on as evidence. Skills for care training was designed for the care industry by the care industry as was the AQAA.
14. THE REPORT, The company and the management team have put a action plan into place to address all shortfalls. The corporate quality monitoring system was being fully utilised by the previous manager who conducted full audits as did the regional company manager in accordance with Quality Assurance Systems, given the number of concerns identified by Social services, and ourselves the validity of these systems needs to be checked by the company monitoring these issues.
My Comments, The validity of these systems needs to be monitored by this system. The validity of Quality Assurance as a source of evidence costs lives. There are many other failures in the report, too many to list but it is best summed up by the question, What does the home do well? The inspectors state they are unable to identify anything at all this home does well.
21 Standards are judged, 2 are fully met and 9 are almost met and 10 are major shortfalls. The home is judged Poor.
Two further inspections take place, the first rates the home 1 star adequate five months later, in March 2008. I will only list evidence not contained in AQAA.
Evidence, Unable to locate any reliable evidence.
The last inspection report for this home is dated two years ago in August 2008 and rates the home 2 star.
The AQAA and the home tell the inspectors what they want to hear.
The home said it was not treating any residents with pressure sores when asked. One year later Betty Delaney dies crying in pain from untreated grade four pressure sores, Betty Delaney needlessly suffered excruciating pain, her bone exposed through negligence. What was the protection offered to this women by, Robust corporate quality Assurance?On August 25th 2010 I met with Baroness Jo Williams and asked her why this home was not inspected after 2008, she said that would be looked into. Should an inspection report suddenly appear on the CQC web site stripping the stars from this home, it will be as a result of the actions taken by Compassion In Care. I also asked why the CQC were condemning the vulnerable by relying on the evidence of the AQAA, she replied that they intended to rely on quality assurance systems even more in future. I was given a copy of new care regulations, a very large glossy document full of impressive sounding jargon. I have read this document fully and it amounts to lists of what is referred to as prompts. Prompts to help care homes tell the CQC what they want to hear when they write up their AQAAs, but there are six words contained in this document that sum it up,
, Evidence will not be routinely required,
In short the CQC have produced a document telling care providers what to say in order to meet requirements and all care homes have to do is write it in their AQAA. I have lost count of the times that I have been told care homes will be better regulated in future, only that time never comes and with each new improved inspection system come more deaths and more suffering. This charity will keep exposing those failures,