Tales Of The Un-Inspected

Home Number 75

By Eileen Chubb Ó 2010

I looked at the inspection history of ……….. This home is among those listed as closed as a result of CQC enforcement. However it is still open and under the same ownership. Before I visited the home I looked at the past inspections reports which had to be obtained from other sources as CQC have wiped this homes past history so all the following information is kept from the public. The question is would you want to place someone you loved in this home if you knew its past history?

This home is one of those I visited and the work of this charity in exposing the lack of protection is featured On BBC Radios 4, File on Four on 23^rd of November 2010.

The first inspection report I looked at for this home is dated 26^th of September 2007, I have listed below the most relevant information, followed by my response in bold text.

1. This report notes the home has a past history of poor care and non compliance with requirements. Unmet requirements impact on the welfare and safety of residents and enforcement action may be considered.

To be fair the inspector lists her findings in full and sends the information to the enforcement team who do nothing, which is incredible given the state of this home.

2. The home cares for 34 residents with dementia nursing care is not provided. The home is part of a care village operated by the same company.

Current fees for the home range from 700 to 1100 pounds a week.

The fees for this home are very high for residential Dementia care and given the extortionate rates, any lack of care in this home could certainly not be blamed on too little money available.

3. The home is staffed at minimum levels, there are two staff working 8am to 8pm on the upper floor and three staff working 8am to 8pm on the lower floor, staffing levels do not allow residents adequate support. Five staff to 34 residents with dementia is not enough staff to offer the basics to keep people alive never mind any quality of life. The fact that staff are working 12 hour shifts is ringing every alarm bell also. Working with people who have dementia is extremely stressful, if you put staff who are working 12 hour shifts, constantly short of enough staff to care for residents, staff will become run down and demoralised and you have a situating where abuse and neglect can easily occur. The staff are being pushed way past the limits of endurance.

4. The homes environment is poor We found the following shortfalls, by the entrance to the home in the car park there was a large amount of rubbish dumped, which included old furniture and electrical equipment.

There was clinical waste being stored in bathrooms.

Large areas of the home needed significant re-decoration.

Kitchen doors were ill fitting, work services stained, many carpets were worn and stained. One relative expressed concerns about security as they felt anyone could walk in. Many bedrooms were bare and had worn furniture, some had debris on the floor and dust on the skirting boards. A number of toilets were heavily stained. Chest of drawers had broken handles, a missing handle for a window and exposed screws posing a hazard. This home is charging more for a weeks stay than a four star hotel yet it has more in common with a scrap yard. I always place more importance on care rather than decoration but when neither are evident than things are as bad as it gets.

5. One relative is paying extra for her relative to be fed by an internal domiciliary staff agency located in the care village, these costs are not made clear in the homes brochure. People are paying up to 1100 hundred pounds a week and have to pay extra for their relative to be fed, what of those residents who can not pay extra for this basic element of care? This company is a disgrace.

6. There are not enough staff to care for residents, the manager and activities organiser help to feed residents. The manager often helps to carry out care tasks. Many residents were left unattended in the main lounge for long periods. Staff said they tried to get residents up before 11.30, they said they can not get round to everyone. It was nearly lunchtime and one resident was found in their nightclothes coming out into the corridor. Staff were struggling to feed residents, serve the lunch, clear the tables and do medication, staff were trying to feed more than one person at a time. Some residents wandered of before they could be fed. Throughout the inspection residents were seen in need of assistance, one was trying to repeatedly open the doors another began to shout. Staff recruitment was not robust. The manager had no office or computer and often had to work at weekends. This is as bad as it gets and if this is happening when an inspector is in the home then it’s the bound to be even worse the rest of the time, if people are being left in their rooms without care they are being neglected and denied all basic care.

7. Care plans contained comments such as, x would not go to bed when told, xx is co-operating today, It was also noted in one care plan that a resident was at high risk of pressure sores, a later entry said skin red apply cream, another entry said skin broken apply more cream, no other action or medical assistance was sought. Being left in bed with no care, food or fluids is the norm in this home and I am surprised people have not died for the want of care. There needs to be urgent action taken but apart from pages of requirements being listed yet again nothing is done. 21 Standards are judged, 6 are Fully Met and 15 are almost met and None are considered to be a Major Shortfall.

The home is not inspected again for a year.

The next report is dated 8^th of September 2008, I have listed below all relevant information from this report followed by my comments in bold text.

1. Staffing levels do not allow for residents needs to be met, two staff work from 8am to 8pm on the upper floor and three staff work 8am to 8pm on the lower floor. The manager is often counted among the five care staff on duty. The rotas showed many staff working 12 hour shifts seven days a week. Staff said a number of residents needed the assistance of two staff for their needs. One relative was paying extra for a domiciliary care agency within the care village to feed her relative at lunchtime. Staff interaction with residents was minimum, one staff member was seen trying to comfort a distressed resident but was called away leaving the person sobbing. Two residents were arguing and there was only a domestic staff member in the vicinity who tried to resolve the situation. Mealtimes showed there were clearly inadequate staff and residents who needed the assistance of two staff members meant the remaining residents were left unattended.

This information is taken from different parts of the report and is just some of the many issues of concern, but it gives me a very clear picture of a care home that should have been closed at least a year ago as the residents are not safe and whilst the inspector takes paperwork and evidence from the home to the enforcement team, no action is taken. What is more incredible is the home is found to be poor at handling complaints, yet when two families raise concerns about the lack of staff with the regulator, the regulator asks the home to investigate itself.

2. Some rooms were very bare. There was a strong smell of urine. Furniture was broken, we checked the linen on beds and found it stained, one person was in bed at 11.30 and dishevelled and marked sheets and debris in the bed. People did not have access to call bells as they were tied up. There was discarded furniture by the entrance. Carpets were stained and a large amount of armchairs had food debris on them. Toilets had brown stains, drip marks and brown particles on the seats. The sluice room was foul smelling and heavily stained with brown smears, a mop head stored there had brown stains and brown particles. Other areas had mops and buckets stored which were stained and covered in brown particles. A hairbrush stored in the sluice had a quantity of gray hair in it

There is much more found wrong. The home is graded Zero star poor.

1. Staffing levels are, The same as before.

2. We asked the service to provide us with an improvement plan, Five requirements are now considered repeated. We issued a statutory requirement notice requiring newly admitted residents to be assessed, this is now being done. So the enforcement taken in effect required the home to assess peoples needs before admitting them to the home, regardless of the fact those needs would not be met as the home provides no care. As for an improvement plan it is way too late for that. People have been living in squalor with no care for years, frail, vulnerable, residents who are considered to be totally dependent on the care of others for all their needs, if they survived these conditions that long.

3. Since the inspection took place there have been two safeguarding alerts investigated by the local authority, one was not upheld due to insufficient evidence and the second is being investigated. Anyone not upholding a safeguarding alert on this home is negligent. You only have to look at the available evidence. The cry’s for help have managed to make it outside the home only no one is listening.

4. There is poor handling of medication. One male resident regularly came out of his bedroom into the corridor in night clothes, staff said this person liked to stay in bed all day. Out of sight out of mind, this is neglect if a person wanted to stay in bed all day they would not keep coming out of their room. The residents in this home are unable to speak for themselves due to severe dementia and leaving someone behind closed doors uncared for is not a residents choice in this home its their fate.

5. Two peoples relatives were paying for domiciliary agency staff to feed them at lunchtime. One resident was noted to become agitated when given food he not like. Some staff were involved in providing activities on the day of inspection. A staff member led a resident who had been standing over to us and said, Look One Hundred Per Cent Dementia, But Dancing Good Yes?, This showed no respect for dignity. This showed staff thought inspectors would think activities were improved, which they did think so it worked.

6. Page 28. A safeguarding referral was made in March 2009 in which a resident said a staff member had injured them, the manager spoke to the police and the community psychiatric nurse and it was agreed the investigation would go no further. The worst abuse happens to those with dementia because they are often unable to tell and even if they cried for help no one would believe them. Given the conditions in this home I would be very surprised if some less good staff were not abusing residents, given that good staff are being forced to neglect residents daily. There are numerous other concerns I have about statements in the report, there is clearly a pattern of putting residents in bedrooms if they are more vocal in expressing their needs and this is common in homes as bad as this. I call this approach the, If you can not hide the persons neglect then hide the person.

The home remains Zero Star and the threat of enforcement action is made yet again, as it has been for years.

The home is not inspected for 6 months and then it is graded one Star Adequate.

This is listed by CQC as a home closed as poor, yet it has remained open and under the same ownership and even the responsible person is the same.

The inspection report dated 29^th of September 2009. The evidence that contradicts this home is improved is taken from this report and listed below with my comments in bold text.

1. Two new residents admitted to the home had not been fully assessed. Evidence of no improvement.

2.Relatives are paying for staff to feed their relatives. No improvement.

3. The home said staffing levels were increased. A staff member said they were able to do more with residents due to the number of vacancies. There were now three staff on each floor. Later in the report. A member of staff said to us she had been sent from another home for the day. From another section of the report. Staff files have been checked and one member of staff has been recruited in a non care role and checks made. So the home has employed no new care staff and sent over from another home a member of staff which just so happens to be on the day inspectors are in the home. No evidence of improvement.

4. The home has made one safeguarding referral. It also emerged that a member of staff was sleeping on duty. There have been two staff members suspended and subject to disciplinary procedures after a police investigation. A further incident has come to our attention and a staff member withdrawn from the home as a protective measure. Too much abuse to be ignored totally has spilled out into the open, one incident was reported by the home and the rest came from elsewhere, how many residents have suffered and how is kept secret but I recall the previous report where a resident tried to get help to no avail. As to improvement I see none.

5. Meals times had improved and extra domiciliary staff were available, these agency staff were well known to residents. These extra staff were being paid to feed residents by relatives concerned their loved one would not be fed otherwise. This is not evidence of improvement it is desperation to find some where none exists.

In fact there is no evidence this home has improved at all unless you count the assertions made by LB the responsible person who has been on site for years whilst so much neglect has been allowed to continue unchecked.

Are the public told about this homes appalling history? No they only have access to this one sanitised inspection report.

I was in the home around half an hour, there were several visitors in the lounge area. I asked the manager how many staff were on duty each shift, she said two on the top floor and three on the lower floor. I saw only five staff. The home had a large number of vacancies also five residents had recently died. The staff I saw with residents were all very caring and doing their best. If more residents are admitted and staff numbers do not increase the residents will be at high risk.

Tales Of The Un-Inspected

Home 74

By Eileen Chubb

Ó 2010

This care home is on the list of homes said to have been closed by the regulator CQC.

This homes past inspection history and record of providing poor care has been wiped from the official record so is no longer available from the CQC website but I managed to obtain these reports via another means.

I looked at these reports and found the following areas to be the most concern, and I decided what I would look for when I visited the home.

1. The homes most recent inspection report is dated March 2010 and states the home has changed ownership.

What I found

This is totally untrue the home is owned by two sisters and has been for over twenty years they have just registered the name of a new company as owning the home but they are the directors. The CQC inspection report goes to great lengths to state this is a new company even though the two sisters are noted to be present in the home.

2. A condition of this homes registration is that they should not admit any new residents, this is very unusual so I put it to the test.

What I found

I visited the home looking for a place for my fictional relative and was offered a place.

3. The now secret inspection reports noted these owners were admitting residents to the home without assessing their needs.

What I found

Whilst visiting the home another potential customer was also looking for a place for their relative and was also offered a place. This home is firstly in breech of its condition of registration and secondly up to its old bad habits.

4. There were numerous concerns in the past about how this home cared for peoples nutritional needs, the basics of life. Residents were noted to be seriously underweight and their food intake not monitored.

What I found

Immediately on entering the home I saw a resident was seated in the dinning room slumped side ways in a chair with a biscuit and un-drunk cup of what appeared to be tea in front of her. This lady was seriously underweight to the degree her bones were clearly visible as she had so little flesh covering her entire body. Though I spent over an hour in the home at no time was this lady encouraged or prompted to eat what had been placed in front of her. She was wearing a bib to protect her clothes which indicated she had been sat at this table since breakfast. She had no pressure cushion and would be at risk of developing a pressure sore due to her weight. She was woken and taken into the lounge after an hour and left to sleep in a chair. At lunchtime all the residents were taken by staff to the dinning room except this resident who staff said could eat later. So a seriously malnourished resident was left without food or drink for another meal.

5. This home has a past history of providing poor food.

What I found

I was shown three weeks of menus, I noted liver and onions with seasonable vegetables was due to be served this day. I told the manager my fictional relative was a very poor eater and was told they had cared for people with poor appetites in the past and it would not be a problem. I said my relative preferred traditional food and was not keen on any foreign or processed food and was told they did not provide anything like that. However I noted from the menu that the food listed was very cheap, with a heavy reliance on jam Sandwiches, beans, fish fingers, Pizzas, sausage rolls and pork pies. I noted that bacon and egg was not offered at breakfast but was listed as a main meal. The owner said lunch was served at twelve thirty and that many people were seated in the dinning room but the tables were not set and there was no sign of lunch. I looked through the glass into the kitchen and saw empty pots and pans but a dirty looking deep fat fryer was cooking something on the stove, which would not have been the promised liver and bacon casserole. I felt the staff were reluctant to let me see the food being served.

6. The home cared for both elderly people and adults over 50 with mental health issues. These two groups have very different needs and it is my experience that mixing these groups can involve a risk. For example a younger person faced by a frail elderly person with dementia may find the older persons behaviour distressing and lash out causing serious injury. I noted concerns had been raised by a staff member who felt these two groups should be separated. I would look at this on my visit.

What I found

Whilst these two groups were seated in separate lounges there was nothing to stop residents moving from one to the other, the bedrooms upstairs also made no distinction between older and younger people. I commented that one resident looked young to be in the home and the owner said the home also cared for younger adults, at no time was I informed that the younger adults could have conditions such as schizophrenia or other mental health illness.

7. The recent inspection report noted the home had a manager.

What I found

It was clear this manager was a member of the care staff, the sisters were the managers in this home and always had been. It was also a concern that most of the staff team were the family members of the owners.

8. Residents at risk of falls did not have risk assessments.

What I found

Even if all the paperwork was in order, residents who were clearly unsteady and who were attempting to move across a narrow hallway in clear sight of the owners, who briefly glanced at them but made no attempt to monitor their progress or assist them in any way. The hallway being narrow and over crowed with other residents, a visitor with a pram, two black rubbish bags, the owners myself and two other visitors, one of whom had a large dog and her elderly relative.

9. General. What I found Four residents were in the lounge known as the ladies room, one lady seemed quite independent and was talking to a carer who was looking after a visitors small baby. Two residents slept throughout what was quite a noisy period and the fourth lady watched was awake but unresponsive to her surroundings and appeared to be sedated.

Many residents looked unkempt and had dirty looking hair in particular one resident whose hair was so matted and dirty it hung in large clumps.

I saw no evidence that residents could access any drinks and saw known offered. I was shown three empty rooms and around five occupied rooms and noted the occupants permission was not asked. One of these rooms belonged to a male resident and there was a smell of tobacco. There was dirty underwear left on the windowsill, bedside cabinet and several other places.

Before leaving I noted that lunch was still not served, the owners were very keen to talk about the problems they have had with the local authorities social services, which included the information that social services wanted to closed the home and even turned up with ambulances to move people out and that they banded together with a home down the road which they were also trying to close and fought to stay open. This was followed by the information they were treated fairly by CQC who helped them stay open in spite of Social Services.

This home is claimed by CQC to have been closed by enforcement but in fact it was protected and allowed to stay open, its past history wiped and the public denied crucial information they would need to make an informed choice. Would anyone put their relative in a home where there were concerns about poor care going back years, where it was so bad Social services raided the home and tried to remove people? The answer is no. Please see this weeks BBC Radio 4, file on four, which has covered this charities work in exposing abuse where it matters, on the front line.

Eileen Chubb

Tales Of The Un-Inspected

Home Number 73

By Eileen Chubb

( This Report Is The Copyright Of Eileen Chubb 2010)

On the 21^st of July 2009,an elderly resident was admitted to hospital from home 73 and was found to have severe necrotic bedsores, was dehydrated and unresponsive, she died soon after admission. Her condition was considered to be consistent with severe neglect and the alarm was raised by hospital staff. Subsequently four other elderly residents from this care home died, in a four week period five deaths, from similar neglect and Social Services considered others were at risk so the home was closed. I read the serious case review into the case and felt some of the conclusions required further investigation, these are my findings.

The serious case review states, The home was registered to care for people with Dementia and long standing mental conditions but by July 2009 it was clear they were caring for people with those needs plus considerable physical and nutritional needs that they simply could not manage.I looked at the last six inspection reports for this home in order to see if there were indications before July 2009.

I looked for a pattern of a home not able to care for residents with complex physical and nutritional needs and I found all the warning signs were there. The first indication of problems is contained in the regulators inspection report five years earlier in September 2004,

The report, risk assessments were a concern throughout the three care plans looked at. One resident had a pressure sore on admittance to the home, the manager said the resident was being treated by the tissue viability nurse but there was no evidence of this in the care plan. Another resident was at risk of developing pressure sores but there was no documentation on what action had been taken but the resident did have pressure relieving equipment.

Enough to ring alarm bells at this point. The next inspection report is dated April 2005, listed below is the relevant evidence.

The care plans were still not detailed enough and did not show what action was taken about risks and needs identified.

Given that only two care plans were looked at, it is clear to me from above information that this home had residents with complex physical and nutritional needs and was failing to care for them.

The next inspection report is dated September 2005, five months later.

Many of the residents have advanced dementia and express difficulty in communicating and expressing their needs.

Firstly very little evidence is contained in the report but from the little there is I can see all the danger signs. The report is flawed also as most residents are noted to be incapable of expressing their needs yet more than half of them managed to fill in questionnaires. Pressure care is not mentioned in the healthcare section but the requirement is no longer listed. It is quite clear that the home had residents with high physical needs and that those residents were at risk of not having their needs met, furthermore the regulator is fully aware of this situation, four years before the events that led to five deaths.

The home is not inspected for 1 year and three months until December 2006, when a key unannounced inspection takes place. I note this is a Key inspection and would have expected it to consist of around 30 pages of evidence, there is barely 20 pages in total.

The healthcare section consists of only 25 lines, no mention of pressure care as other areas such as mental stimulation are mentioned which do not belong in this section at all,

No consent or risk assessment for the use of bedrails was in place for one resident.

The home is not inspected again for One Year and Eight Months, the inspection report dated 13^th of November 2008 is the last inspection of this home.

The reports main source of evidence is the homes AQAA, it is a Key inspection yet contains barely five pages of evidence.

The report grades the home 1 Star Adequate, I note there is nothing borderline in the scoring,( This is later pleaded as a defence) all six areas are graded Adequate. Listed below is the information that I find of concern.

We saw two residents with more complex physical needs sitting in armchairs that looked uncomfortable.

The two residents judged to be sitting in uncomfortable chairs could well have been uncomfortable sitting in any chair if they had pressure sores.

When an inspector can not form an opinion on the standards of care in a home because the home has not told him what to think in its AQAA, then this is not inspection at all, its negligence.

Again it is stated many residents have complex needs, yet no requirement is made to increase staffing levels this is merely a recommendation. Yet a quarter of the homes beds are empty so if the home admits further residents and is full again this will tip the staffing levels into further crisis.

The manager is recommended to oversee the home more but it is not enough of a problem to make a requirement on, it is merely recommended.

The home is not inspected again.

The Serious Case Review.

When I see the words, NO INDIVIDUAL OR ORGANISATION CAN BE HELD ACCOUNTABLE FOR EVENTS, I know that nothing will change as lessons can never be learnt unless you have accountability.

The above words are used in this review, however I would strongly dispute this for the following reasons,

1. The review states that CQC considered the home to be borderline 1 Star, this is not upheld by the evidence.

2. The review states that a safeguarding board held a meeting prior to the events becoming known in July when the alarm was raised, it seems that someone else reported concerns prior to the deaths but no action was taken, what is more suspect is there seems to have been no minutes or any kind or documentation on this meeting available and furthermore none of the board members have any recollection as to what it was they convened to investigate.

3. The review states that CQC, the regulator were aware standards were slipping in the home, that is totally untrue the CQC had not inspected the home so therefore had no concerns for the residents safety.

4. The review states that other agencies need to inform CQC of standards in homes, which begs the question, what are CQC for?

5 Finally a paragraph of the review deals with issues of, Dignity, as this is considered a crucial part of safeguarding and as residents belongings were removed from the home in bin bags there dignity was not respected. I hate the word Dignity, because it deflects from the true horrors. When the use of Bin Bags to remove belongings from a home is mentioned in more detail than the people taken out in Body Bags after dying in agony, it is not dignity that should be considered but Accountability.

My Sincere condolences to all those families that suffered the loss of someone they loved in such appalling circumstances.

Eileen Chubb

Click on the below links to see our what we have been doing recently to expose abuse.

1. Eileen Chubb BBC File on Four

http://www.bbc.co.uk/programmes/b00w1zy4

2. BBC News. Read how this charity was the first to question CQC and and exposed thier failures

http://www.bbc.co.uk/news/health-11789475

Tales Of The Un-Inspected

Home Number 72

By Eileen Chubb

( This Report Is The Copyright Of Eileen Chubb 2010)

This Home is owned by the same company as homes 33,36,41,48,49,50,54,59,60,62,63,64,65,66,67,68,70,71.

I looked at the inspection report dated 17^th of April 2007 and noted that the home had been taken over by the above company a few months previously. There were no outstanding requirements from previous inspections. I have listed the most information relevant information from this inspection report below, followed by my comments in bold text. Due to subsequent events in this home I have looked at specific areas of care in particular.

Staff have received refresher training in safeguarding and manual handling which has improved the care provided.

This is an indication that there have been identified problems in these two areas.

All risk assessments were completed comprehensively. It was clear however that a number of people continue to lose weight despite referral to healthcare professionals and the use of food supplements. The quality of the food has improved but its not clear if the food provided to people with mental frailty is effectively meeting their needs.

To get to the point, firstly risk assessments being filled in correctly is no guarantee of care being delivered in this home.

Secondly the inspector is looking at the quality of food being delivered whilst I would question if food was delivered at all given comments taken from throughout the later sections of the report.

A relative visits every day to feed their parent and monitor their food intake.

The inspectors do not choose to see this as an indication that relatives can not trust the home to feed people, it is seen as something to commend the home for in encouraging food intake.

We observed people were served food on trays in their bedrooms, however these were out of reach.

This says a lot about the delivery of food and explains why people continue to lose weight in spite of being recognised to be at risk. Prior knowledge of the risk means the situation is not one of neglect but one of abuse.

Staff spoken to had a clear understanding of what constituted abuse and whistle-blowing procedures.

Entering false information in care plans is not thought to be a problem.

The company carry out regular audits and maintenance and servicing of all equipment is carried out to ensure the home is a safe and a risk free environment.

22 standards are judged of which 12 are fully met and 10 are almost met.

The next inspection report for this home is dated May 2008, one year and one month later.

Three care plans were checked and contained all relevant risk assessments such as falls, nutrition, manual handling.

3 care plans checked from a total of 137, is not enough, also the paperwork and the reality are two very different things in this home.

One member of staff was observed to be attending to a resident when called away to attend to something she gave no explanation to the resident, we spoke to the manager about this and the staff member was suspended.

This tells me there are not enough staff in the home but the inspector hones in on what he considers disrespectable behaviour, rather than looking at why the staff member was being asked to do two things at once.

The manager said that the nutritional value and presentation of food had improved. Some staff appropriately assisted residents to eat, in some cases there was little or no interaction between staff and residents, on one occasion we saw a member of staff feeding a resident called away to do something else and who gave no explanation to the resident.

This is yet another indication there are not enough staff to feed all the residents who need help, the inspector sees this as a lack of respect or dignity but I see it as something much worse, if there are not enough staff to feed residents when inspectors are watching, then it is bound to be much worse the rest of the time.

We saw evidence that regular audits were carried out to check gas and electrical and fire equipment. We noticed an unpleasant odour and the manager said it was due to the dressings of one resident.

It rings alarm bells when a residents dressings smell bad enough to be noteworthy as someone who has smelt the rotting flesh of infected bedsores I would have investigated any such smell. As for auditing the homes audits this amounts to an over reliance on Quality Assurance.

The home is graded 1 Star Adequate.

Nine Months later an 83 year old resident is taken to hospital from this home suffering from alleged hypothermia and she died a few hours later.

The regulator then inspects the home in February 2009, to check the actual heating as opposed to the Quality Assurance.

This inspection is the result of a recent death at the home and subsequent visits by Social Services under safe guarding vulnerable adults procedures had raised serious concerns about the temperatures of the home and the safety of those living there. We checked the home was monitoring the temperatures and records showed they were. The temperatures on the second floor was lower then the other two floors by around five degrees, we spoke to residents who said they felt chilly. A procedure has been put in place.

It is Social services again that tells the regulator what is going on the care homes they inspect, too late for those who have suffered.

There are no outstanding requirements listed and no new requirements made, the home remains 1 Star Adequate.

Just 12 weeks later it is inspected again and is graded 2 Star Good, the report dated May 2009, the evidence for this?

The AQAA quality assurance, the following information is also noted,

The home must ensure that important documents that monitor pressure care and fluid intake are complete.

Not my idea of good.

We looked at the records of five residents and found recordings were not made in stances, such as fluid intake of residents at risk of dehydration not made, up to date body maps recording injuries or wounds, turning charts of residents at risk of pressure sores not completed.

Not my idea of good.

The home has four dignity champions.

The residents will have a dignified death whilst dying from thirst and avoidable bed sores.

Residents were observed having lunch and were assisted by staff.

The residents behind closed doors, the most vulnerable, were not checked.

I can not list much more as any thing that begins with, The AQAA or the home said, is not evidence. The home is not inspected again. 11 months later a second resident dies after being admitted to hospital and found to have a broken leg, she died a few days later. The home deny she suffered any injury but a post Mortem and Coroners inquest found she had suffered trauma to her leg which resulted in bleeding and blood clot, aggravated her existing heart condition and she died from acute heart failure. The injuries occurred a few days before the home sent her to hospital. A broken leg, no painkillers and no one noticed for days in care home? In a Two Star good care home according to the regulator. As yet no one has died of bed sores or hunger that we know of, but all the warning signs are there.

Tales Of The Un-Inspected

Home Number 71

By Eileen Chubb

( This report is the Copyright Of Eileen Chubb 2010)　

I looked at the inspection history of this home and made a visit, these are my findings.

Please note this home is owned by the same company as homes, 33,36,41,48,49,50,54,59,60,62,63,64,65,66,67,68,70,

The first inspection report I looked at is dated July 2006, the information I found most concerning is listed below.

1. Accurate records of controlled drugs need to be kept.

These drugs are monitored more strictly because of legal requirements, if controlled drugs are not in order then I think there may be more widespread problems with medication generally.

2. Complaints are not recorded on the correct forms.

This tells me that complaints or concerns are not dealt with, in another part of the report it mentions the home has received one complaint but the regulator goes on to say that they received an anonymous letter expressing concerns. This tells me that someone was desperate enough to approach the regulator directly whilst being too afraid to give their name. This rings alarm bells but the regulator judges the home handles complaints well.

3. When someone is identified at risk of pressure sores developing then a preventative plan needs to be put in place. When someone is at risk of pressure sores and nothing is done to prevent them, should they occur it is the result of abuse. The regulator considers that healthcare is good which is of concern as this company has a dire history of failing to prevent pressure sores which has resulted in terrible suffering and fatalities.

4. Activities were advertised on the notice board and on the day of the inspection there were activities taking place, someone was feeding pigeons from the window of their room and another person was sitting in their room. 

The inspector states the home has a lovely sensory garden, the inspection is taking place in July yet no one is observed in this garden, the nearest contact with it is a resident feeding birds from a window.

I place little faith in activities put on for the day of an inspection and given the inspector thinks someone sitting in their bedroom to be an activity I would question there judgement overall. There is also great emphasis placed on the fact the home has decorated a room and called it the Hollywood room. This home is presenting an image but there is little evidence to back it up.

5. The home was clean and there were no odour problems.

I note this conclusion given what I found when I visited.

The home is considered good. The next inspection takes place one year later in July 2007.

1. Procedures on medication handling have been tightened up, records checked were completed fully. 

It is not stated how many records were checked, there is an over reliance on what the home says it does and on bits of paper. Actually counting the drugs is what I would consider evidence.

2. The home is recording complaints on the correct form but needs to give more information, there have been three complaints, one was responded to, once was withdrawn and one was investigated by the home and social services. There have been no adult protection issues since the last inspection. There needs to be improvement in complaint recording. This area is good.

This area is graded as fully meeting the requirements, yet it is stated that improvements are needed.

3. There are currently no residents in the home with pressure sores and healthcare specialists continue to visit the home. We looked at three care plans.

Three care plans is not enough to presume all are in order. My main concern is that there appears to have been residents with pressure sores and that healthcare professionals continue to monitor the situation.

4. It was a very hot day and two male residents were sat in the garden. Other residents were in their rooms. One resident became very upset during one activity and staff comforted them, other residents were dozing. Residents are said to enjoy using the Hollywood room.

It is good the garden was being used this time. There is no activities organiser as staff are expected to carry out this role. What activities are taking place during the inspection is not sufficient evidence to presume this is the norm. There is once again great emphasis placed on the, Hollywood Room.

5. There was a mild odour on the middle floor compared to the ground floor.

The home is considered Good. The next inspection takes place one year and six months later and only because an anonymous complaint is made to the regulator about the quality of care provided in the home. The inspection is focused on investigating the complaint and whilst the issues are not stated, what is looked at is an indication of the what concerns were.

1. Challenging behaviour, the manager said she is trained to train staff in this.

2. Lack of activities, the home employs an activities organiser for twenty hours a week and advertised events included a Halloween and Christmas buffet, one resident said she enjoyed an outing to a local attraction. We were shown ceramics made by residents to give as presents for their relatives for Christmas. Six residents were seen doing glass painting.

3.Residents looked well groomed. 

4. The chef said he made a mistake with the meat order so the food was not as advertised on the menu that day.

5. All but seven staff have been trained in adult protection.

6. Residents on the upper floor said they could have a drink if they wanted one, we suggested to the manager about placing jugs of juice within easy reach.

7. The company has a robust complaints procedure to deal with complaints.

8 Healthcare professionals are consulted when needed.

9. The Hollywood lounge is enjoyed.

10 There are sufficient domestic staff to keep the home clean.

11. All accident forms were completed corrected.

12 There were no missing persons reports made.

We found no evidence to support the concerns raised, we did make an immediate requirement as medication was found on a table. 

There was no effort made to find evidence in support of the extensive concerns raised. This is yet another indication that things are not right in this home but yet again it is ignored by the Regulator. The home is graded Two Star Good.

The next inspection takes place 6 months later in July 2009.

Some requirements from previous inspections may have been deleted or carried forward as a good practice recommendation. But only if considered it will not put people at risk.

My Comments, I call this the above, The Killer Clause, for good reason, These words above all others sum up the Regulator CQC attitude to bad homes, which is translated as, In future we will have to take enforcement action if a statutory requirement is outstanding but rather than do that we would rather delete or downgrade them to a recommendation. I see the killer clause used only in the most dire care homes, how else could CQC allow them to exist? The company that owns this home has been given the protection of the CQCs Killer Clause more than most. 

1. Medication procedures need to be followed, we checked records and found gaps, several residents had pain relief signed as administered but stocks showed they were not given, one residents controlled drug, morphine, stock levels did not tally with what was given and what came into the home. Healthcare is good.Pressure sores or the treatment and prevention of is not mentioned at all.)

2. Complaints handling is good, the home has received no complaints. One issue was raised through safeguarding but resolved

3. (Pressure sores or the treatment and prevention of is not mentioned at all )

4. Activities are good, the home has recently received a grant of eleven thousand pounds from the local council to improve facilities for residents. There is a Hollywood room that residents enjoy. 12 residents were seen taking part in a art session. There is a ceramic made by residents on display.

5. All areas of the home were clean and odour free. 

The home remains Two Star Good. The most recent inspection was 9 months later in June 2010. 16 WEEKS before I visited.

By Now its quite obvious that something is wrong, well to me anyway as there are only 21 residents left in the home, 18 empty rooms. Either a large number of residents have died or relatives have removed people as raising concerns in this home is pointless, and going to the regulator CQC is pointless also.

1 The home has robust polices and procedures and carries out regular quality assurance audits on all aspect of care, care plans, medication and management housekeeping ect.

So much for Quality Assurance and bits of paper.

2 Complaints, There have been no complaints or safeguarding alerts made. 

Well relatives have obviously voted with there feet and perspective customers have looked around the home and gone elsewhere.

3. Pressure care, not checked.

4 Activities are good.

The home remains Two Star Good.

What I found on my visit.

On entering the home there was a strong smell of urine which became worse on the upper floors where the smell was so bad it was hard to endure. This smell was not the result of an accident or two with incontinence. The odour of urine pervaded the whole home to a degree of severity it would have taken a considerable period of time to get so bad.

I was shown around by the manager, I said my relative had Dementia and wandered and was firstly offered a room on the ground floor, which is not designed for residents with dementia. I said I was worried they would get out the front door as it was not secure so I was taken to the upper floors. The smell of urine was so strong in the lift it being a confined space it was intolerable.

In the lift was the manager, myself and a young carer going to the first floor, whilst the manager gave me all the spin about how wonderful the home was, I noticed this young carer had an expression of disgust on her face. It could have been the urine odour that caused this but given she would be accustomed to that, I got the impression the managers sales pitch was the source of her disgust.

We all left the lift and I was shown around, the only member of staff on the upper floors was the young carer who came up with us in the lift.

Seven residents were sat in a lounge, most were slumped sideways in armchairs asleep, except for one lady who as soon as she saw me appealed for help so I went over and spoke to her, she was very distressed and had been looking for someone to tell her that her animals were alright. This lady could hold a good conversation and was very clear about what she was worried about. She repeatedly said that I was the first kind face she had seen in a long time and she begged me to take her out of the home as they were so nasty to her. The manager looked very uncomfortable and said she has dementia you can not listen to her. The lady was clinging to me by this time and saying please get me out of here. I believed this lady as I have cared for people with dementia and know that the memories of fear and pain are not so easily lost. The manager went to the single member of staff and the young carer tried to comfort the women but did not have the experience or skills to so. I said I would go and find out about her animals and managed to calm her, I left the room and asked the manager who looked blank.

The manager continued to show me around and another resident met us in the corridor, she approached the manager and obviously wanted reassurance about something, the manager gave none, she just walked off and continued to show me around, she glanced back and commented whilst rolling her eyes upwards, oh no she will follow us everywhere now in a derogatory tone. This women had no compassion or ability to work with elderly residents with dementia, I found her attitude shocking. The residents in this home were not given the smallest gesture or word or comfort and the pain and distress this caused was hard to witness, I have walked out of homes and cryed, this was one of them.

The manager continued to say how wonderful the home was and went back to get the key for the Hollywood room, which it took the young carer some time to locate as she was doing her best to care for residents on her own. After a while the key was located and the manager showed me the Hollywood room I had heard so much about in inspection reports for years.. On opening the door the manager said, oh its stuffy in here and went and opened the window. This room was the only area in the whole home that did not have any smell of urine, in fact it was clearly not used, the T.V remote control was covered in dust, as were the random video cassetts I pulled out to look at under the pretence of being impressed how suitable they would be for my relative. The room contained a bar which I was told made the residents feel they were down the pub, this of course had fixtures that were false but gave the impression of a pub. The whole room was a sham opened up for the benefit of inspectors and perspective customers. The latter not so easily impressed in a home with so many empty beds.

The call alarm was sounding for room 23 for about fifteen minutes. In all the only staff seen were the one young carer, who was the only member of staff on the upper floors. I saw one cleaner and one member of kitchen staff. On the lower floor I saw one carer pushing a medication trolley.

The home was decorated for Halloween, which is not something that would have been celebrated by the generation of residents in the home by using large amounts of decorations which are the result of modern marketing. This showed little thought especially as large dolls were pinned up near the lift which may have been intended to look ghoulish but which had a strong resemblance to the grim reaper.

Tales Of The Un-Inspected

Home Number 70

By Eileen Chubb

2010 Ó

This home is owned by the same company as homes 33,36,41,48,49,50,54,59,60,62,63,64,65,66,67,68.

I looked at the inspection report dated 31^st of March 2008 and these are my findings,

This is the first inspection of this home since it was taken over by this company, it is clear that the staff in this home are well thought of by the residents and relatives.

From the time the new company takes over there suddenly are concerns about the staffing levels. Surveys returned from relatives state there are not enough staff to care for the residents, whilst these are included in the report they are not investigated further. The inspector grades the staffing as excellent exceeding all requirements.

This home has been considered an excellent care home for sometime but a new company has taken over and things are changing for the worse. The inspector seems determined to ignore the warning signs. However without sufficient staff the care given to residents will deteriorate very quickly.

The home remains 3 Star Excellent.

I looked at the next inspection report dated, 9^th of December 2008.

I have listed below the most relevant information given in this report followed by my findings in bold text.

1. The staffing levels on the dementia unit have been increased. The staffing levels were not sufficient to care for residents.

2. There is no permanent manager and the staff have continued to be very professional and maintained the previous standard of excellent care. The staff in this home are really good and should be valued as such.

3. The company needs to continue to support and supervise staff. There is low staff moral.

4. On the day of the inspection there were two nurses and six care staff on duty. This is a nursing home for 60 residents, it states elsewhere in the report that staffing has been increased to 3 care staff on dementia unit. 8 staff in total for 60 residents, the staff must be at breaking point.

The staff in this home have continued to give excellent care against all the odds, the odds being the company they work for.

5. During the inspection the inspectors were approached by a number of staff who were concerned about the management situation and their ability to provide the care they feel they should provide given the staffing levels when there was sickness, they agreed they were managing to provide good care as they were committed. When a single member of staff in a home approaches an inspector with concerns every alarm bell should be ringing, but when a number of staff do so then a home is in real trouble and staff are desperate enough to raise concerns with the regulator it is means a home is in real trouble. Good staff should be valued and retained at all costs but this company is pushing staff beyond breaking point.

The home retains its 3 Star Excellent rating. As a result of this the home will not be inspected again until December 2011. However all the warning signs are there that this home is in real trouble and it will not take much to tip it over the edge.

When this company takes over a care home it cuts staffing levels to the bone, I see this as having a domino effect on care, without enough staff residents are neglected, good staff leave and are gradually replaced by staff who are not so willing to go beyond the call of duty. The dedication of good care staff is holding this home together and if that changes the last one to know will be the regulator.

Eileen Chubb

I have been all over the country in the the past month, looking at care homes undercover and giving talks to raise awareness on the issues. In fact I am often so busy taking direct action that I have too little time to report the huge progress we have made. The magazine Private Eye have published numerous accounts of the needless suffering that has been uncovered. Last weeks Private eye and the issue published today show the results of our joint investigation into the CQC assertions that they closed dozens of homes, when in fact this was not the case at all. I am sincerely grateful to private Eye for helping us expose a story that has laid bare the CQC and its failure to protect the most vulnerable. I would also like to thank all the members of the public whose donations allow us to achieve so much. We were offered a substantial donation recently from care providor, of course this was declined, we have managed on a few hundred pounds but the little we have is clean money as we can not serve the interests of the vulnerable in care homes if we are in the pay of a care home providor. So please continue to support us.

Eileen Chubb