Home Number 40
Tales Of The Un-Inspected
Home Number 40.
By Eileen Chubb
( This Report Is The Copyright Of Eileen Chubb )
To The Prime Minister.
I have looked at the inspection history of……………………….Home number 40, these are my findings.
This home has a history of abusive practice going back years, as no mention of this abuse appears in the inspection reports I have enclosed details.
A relative contacted me with concerns about both the appalling abuse of her loved one and the authorities failure to act on those concerns. As a result I wrote a full report and sent it to Baroness Young, ( A copy of that letter is also attached and published at the end of this report) no action what so ever was taken to address the issues.
These issues related to serious abuse, your ministers have told me that all such abuse will be investigated and acted on, this is not true. The system for safeguarding alerts consists of the following,
1. Someone raises concerns about abuse, it is required to be treated as a safeguarding issue.
2. The home reports it as such.
3. A safeguarding board is convened and decides if,
(a) If it is abuse.
(b) Who should investigate.
( c) What the verdict is.
As a result of my investigation on this home I discovered information that was withheld from the victims family. Namely who sits on this Safeguarding Board which made the decision not to even investigate? The Home Manager of the care home where the abuse occurred.
The family never stood a chance from the outset, I can understand why these boards meet in secrecy, this goes to the very heart of why abuse and abusers thrive in a care system where the only protection is for the care home company, the bigger that company the more protection they are afforded by the system.
In effect what this means for the victim of abuse, is that the care home is Judge, Jury and executioner.
Inspection Report Dated July 2nd 2008.
The Report states, The home acts on complaints, there have been 12 complaints and there have been four safeguarding alerts, the home investigated three and healthcare professionals the fourth.
My Comments, The verdicts are not mentioned. The details of the complaints are not mentioned, The home managers position on the safeguarding board is not mentioned. If it were no one would bother raising concerns again. I could be a staff member wanting to blow the whistle about abuse in this home, I may well be aware the manager sits on this board, what are the chances I would dare go outside the home to report abuse? Nil.
The report states that residents told them that night staff are not always nice, another said staff had a bad attitude at night.
My Comments, This is not pursued as it is not considered a concern, when residents say anything bad about staff it is usually said after weighing the risk of possible retaliation. The residents took that risk here and nothing was done. My Concern is there is a very real risk that if these staff members are showing a bad attitude to residents able to say something, what kind of treatment are the residents with dementia receiving as staff would not have to worry about those residents saying what was happening to them. Care home inspectors failing to pick up such warning signs is a fundamental failure.
The Report states, staff told the inspectors they had excellent training, the number of staff with NVQ is 15%.
My Comments, Not that NVQ matters but if staff say they have excellent training why so few with NVQ? The report states a resident was calling out for help and a staff member nearby did not attend them, that is basic care and the alleged excellent training is either not being put into practice or is not so excellent after all.
The report states, there are a lot of staff from overseas especially at night, these staff talk to each other in their own language around residents, the inspectors were told it was hard to understand them.
My Comments, There are a large number of residents with dementia in this home it would be impossible to care for people when you cannot communicate with them.
The report states, relatives said there were not enough staff, three quarters of the staff who returned surveys said there were not enough staff, one member of staff spoken to said there were never enough staff on every shift. A relative spoken to on the day said she often found carers sitting chatting to her mother in her room. We think there is enough staff but residents sometimes have to wait a short while.
My Comments, All the signs are saying there is a serious staff shortage, but the inspectors ignore these signs, they go to great lengths to suggest that the one relative who found carers talking to her mother in her room means there are enough staff. This is a joke, bad care staff will often hide in residents bedrooms pretending to chat, this may not be the case here but it is a well known skiving tactic, well known to everyone but care home inspectors. Either way it is not enough to base a conclusion on that there are enough staff. They say residents may have to wait a short while before staff come, but that is at odds with the resident they heard calling for help as no staff came not even the staff close by.
The report lists the negative and positive comments received about the home.
My Comments, Only the positive comments merit highlighting in italics, the negative blend in with the general text and are not quoted word for word.
The report states, residents help with fund raising to go on three outings a year.
My Comments, This is Multi-national, Multi Billion pound company and residents have to raise funds for three trips out a year?
The report states there is not enough information on how residents pressure sores are cared for or how much food they have eaten. We expect the home to take action rather than make a requirement.
We looked at a sample of Medication records and found, doses on variable medication not clear, some medication did not add up to what was supposed to be on the sheet. We found two medications which were being given to residents which had no record of the medication, so nothing to guide staff on how much to give, we expect the home to act and make no requirement this time.
My comments, Staff giving medication that there is no record of do not need guidance, they need investigation, expecting the home to act without making a requirement is a joke.
The report states, the manager told the inspector how the home was addressing concerns raised by the fire officer.
My Comments, They do not mention what these concerns were, however this is an area of concern for this company given their track record.
The Home is graded 2 STAR, Good.Inspection Report dated September 10th 2009.
The reports states they had received none of the surveys they believed they had sent out. This is why we carried out this inspection.
My Comments, Firstly the reason for the inspection is said to be they did not get surveys returned, yet throughout the report reference is made to the contents of surveys returned. I believe they carried out the inspection because this charity acted on behalf of the family who had previously been ignored without any investigation taking place, I can easily conclude that The adult Safeguarding panel on which sit’s the home manager, found the home not guilty to the extent no investigation was required. Given the nature of the issues raised it saddens me to discover others have been subjected to suffering that so easily could have been avoided if action had been taken.
The report states that they tracked the care of a resident, he had bedsores and the turning charts provided no evidence of turning, the tissue viability nurse visited the home and gave instructions for care of this resident, these were not carried out, the resident was visited in their room and found with sore heels on bed and complaining of pain.
My Comments, This vulnerable resident develops bed sores because of neglect, for that is what it is what ever way its embellished, treatment is prescribed by the Tissue nurse and that treatment is not carried out by the staff. This person is then in such agony that a doctor prescribes a morphine based pain killer, the resident tells the inspectors he is in pain and asked for pain relief one and a half hours ago but no one brought it and the call bell was wrapped around the socket to ensure it was out of reach. If this is what happens when the inspectors are there, then what happens the rest of the time? Imagine laying for hours at a time, day after day in terrible pain and even though you are prescribed pain relief no one comes to give it and you have no way of calling for help. This is in a CARE HOME, a place where your pain is noted but ignored. This is what a social worker or inspector would describe as a unsatisfactory care experience, this is what any other human being would describe as suffering for want of care.
The report states people who had lost weight had insufficient records, we made a recommendation that food intake should be monitored at our last inspection.
My Comments, They did not make a recommendation that is not true,, they stated an expectation that these things would be addressed, as they did with many other issues of concern, expectations which were not met why should they be when there are held in contempt by a home that is beyond the law as when failures are noted, the law is not enforced.
The report states that medication is generally in good order, one residents record checked showed they were being given drugs to control behaviour without any justification for its use and no guidance for how much and when staff should give it, medication for some residents had run out but the home audits medication and quickly acts on deficiencies.
My Comments, A resident can be given what is a dangerous Anti-Psychotic drug, which puts their life at risk and there’s no reason what so ever to justify it, this is not the picture this company puts out to the media, about its care of dementia residents and the use of these drugs.
The concerns raised by the family who contacted me relate to the serious mis-use of such drugs. Yet this appalling list of failures is stated and the fact that the homes audits had not picked them up no way impacts on their credibility.
The report states safeguarding procedures were in order, including staff involved in safeguarding alerts were subject to refresher training.
My Comments, If training could not reach some staff the first time, no amount of repeating it will reach them.
The report states that there had been widespread problems with clothes going missing, but laundry staff assured us they knew how to deal with infection control issues.
My Comments, if they can not get the basics right such as returning clothes, than I would question everything else.
The report states one nurse did not have her NMC registration on file but the home went and got it during the inspection.
My Comments, This is the same home that not only employed an unqualified nurse just a few years ago, but promoted this nurse to head of clinical nursing care for the entire home. How could that happen? It could happen because when such shortfalls are found on inspections excuses and the word of the home is accepted instead of proof.
The report states that the fire safety records were checked and found to have been filled in correctly, but the home should investigate why they had filled in dates in the future also.
My Comments, This is known as Fraud, concerns about fire safety were raised the year before, so the home falsifies records to mislead the authorities next time. One person has died in one of this companies homes when a ceiling fell on her, in another one of its homes a staff member is accused of setting fire to an elderly residents bed, what do the records state in those homes and can they be believed? When there is a concern falsify records is hardly the response one would expect, but for this company it is of serious concern. What else is falsified?
There are many other failures listed in this report, all consistent the concerns raised and ignored about this home in the past.
The Home is now graded 1 STAR POOR yet of the 24 grades assessed, 18 are judged No shortfall good, 5 are considered only minor shortfalls and only 1 is graded a major shortfall.
I think it will not be long before the Star rating is upped as the evidence suggests it was only inspected because this charity raised issues that had previously been ignored by the inspection authorities.
Mr Brown I have two questions to ask, firstly is this your idea of an ethical company? And if its not will you be returning the five thousand pounds they gave for your leadership campaign? That money has blood on it, it was earned through the suffering of elderly people and amounts to thirty pieces of silver.
The Home is in the area of…………………………………………..
27th of July 2009
Dear Baroness Young,
I have recently been approached by Mrs J. B in relation to the appalling abuse suffered by her husband, John B, whilst resident at the above named premises owned by …………..
Mrs B has made every effort to have these issues investigated to no avail. It should be noted that in my opinion Mrs B has presented her concerns in a clear and precise manner and provided full factual documentary evidence in support of her concerns. Furthermore it was immediately clear to myself that these issues related to serious abuse and warranted immediate action, action that should have been taken by the authorities.
Whilst CQC have all of the detailed evidence provided by Mrs B, I have summarised some of the main issues for your information.
1. A residents care plan is the starting point in judging the standards when inspecting a care home. There is indisputable evidence that there has been a fundamental and systematic failure to provide a care plan that reflected Mr B care needs which has resulted in those needs not being met and needless suffering has been caused as a result.
2. Photographic and documentary evidence shows the drastic deteriation that Mr B suffered from the time he entered this institution, which can not be attributed to the Alzheimer’s as drastic improvement occurred once he was removed.
3. Mr B a helpless and vulnerable man due to suffering from Alzheimer’s, and was totally dependent on the staff in this institution for his most basic needs, yet his care plan instructed staff he could feed himself even when both his arms were in slings, were it not for his family’s intervention in feeding him he would not have been able to eat or drink, as eating and drinking is needed in order to sustain life, I am seriously concerned for those residents who have no family to provide the basic care. Mr B paid sixteen thousands pounds to have care provided and it was not provided.
Mr B was found daily soaked in urine that had seeped through the incontinence pad, his clothing and the chair he was sitting in and accumulated in a puddle on the floor. A situation that was the result of persistent neglect. When a Sheath Catheter is later fitted it had to be removed as Mr B was in severe pain due to the fact that only a small percentage of staff were trained in this area and often none of these staff were on duty.
Mr B suffered not only from a lack of basic care that was grossly negligent but also suffered grievous bodily harm as a result of the culture of negligent and abusive practices that have been allowed to continue unchecked by both this homes management and by those authority’s responsible for ensuring residents safety.
Persistent unexplained bruises’ and injuries continually recorded, injuries that indicated physical abuse was occurring and no investigation takes place. Yet it is recently reported in the national press that a member of staff at this home, J N, was found guilty of abusing residents at the time these injury’s were occurring.
Entry’s recording Mr B vomiting violently due to being fed a bar of soap by allegedly another resident.
Persistent severe injury’s caused by staff manually lifting Mr B as no hoist available, in spite of this same company having prior convictions for deaths in their care homes caused by staff lifting residents incorrectly.
Care plans and accident reports were fraudulently completed when Mr B was taken to hospital on 6/10/04, he had only been in the home ten days when he was found unconscious in the day room and an ambulance was called. No member of staff accompanied Mr B to hospital, his wife arrived at to the hospital to find her husband frightened, and confused staff thought he was drunk and did not know he had Alzheimer’s, he was wearing only incontinence pad and pants, his son had put him to bed wearing pyjamas the previous evening. Mr B suffered a broken hand, badly lacerated arms, hands and eyebrows needing stitching and was admitted to a ward.
Once Mr B was settled his wife returned to the care home to collect some things for his hospital stay, she could not find his glasses but found them some time later in a pool of blood in the grounds of the home. She informed the hospital who called the police. It subsequently emerged that Mr B had been found in the grounds of the home unconscious and staff said they routinely allowed residents to wander round outside late at night despite it being October.
Mr B was displaying signs of Drug induced Parkinson’s, and shaking and choking, the family had to repeatedly request a GP.
Haloperidol requested by nurse in the home over the Telephone and it was prescribed, the family had no knowledge of this. The home subsequently stated the drug was never administered but records show it was ordered month after month and not returned. Mr B new GP on leaving the home, wrote to the home and asked why this drug continued to be ordered by them.
The home reply but do not give an explanation so the GP asks again and the home decline to comment. So a dangerous sedative drug is ordered by the home who say they did not administer it to Mr B, so where did it go? The home say it was not checked into the home, the Medication Administration Records show it was accepted and not returned. This is serious medication abuse and has gone on in spite of the home being inspected and in spite of the authorities being informed. Mr B is not the first resident to be drugged on the say so of a nurse or care worker, it is as easy as saying this resident is violent, yet not one single piece of documented evidence supports the homes request to sedate this resident.
Mrs B placed her husband in this home as she needed to have surgery and trusted that this home would care for him, instead he suffered bruises, broken bones, head injuries and was unrecognisable in a short time, slumped in a wheelchair, with no pressure care, soaking wet for hours at a time and a care plan that did not even record his most basic needs.
My investigations have revealed that yet another nurse was found to be abusing residents in this home, B. S, who was struck off by the NMC for medication abuse and tying residents to chairs.
I looked at the last inspection report for this home on your web site, it grades this home two star which implies the care is good, it relies upon what the residents say about the home, out of 156 people only 29 residents returned surveys, those on the dementia unit would not appear to be included.
The report states the following,
There have been four safeguarding referrals in the last year, the home investigated 3 and an independent person investigated one, I can understand a home investigating complaints but not issues that relate to the safety of residents.
The report states the following issue came to light,
That night staff are not always nice to residents and are annoyed at being called,
That staff appear to be sleeping on duty,
That overseas staff are not easy to understand.
There is not enough detail in care plans on how residents are getting enough to eat.
It was noted the Mar sheet for one resident did not tally with the amount of medication stored. Two other Mar sheets did not tally with the medication in the care plans.
Several staff said they had NVQ qualifications, the records said otherwise. Those staff asked said they were not enough staff on every shift.
On each section of this report shortfalls are found but in every single case no requirements are made for the home to improve, in every single case the words, We expect the staff to improve in this area, appear and no requirement is made.
To sum up this report I would say it amounted to great expectations but no enforcement, is that what the National minimum standards amount to? The fact is that when this home has failed the law has not been enforced. Is this home beyond the law?
I suggest that that immediate action is taken to investigate these matters and that Mrs B concerns are treated seriously as to date your inspectors have done nothing more than ask………. to investigate its self, needless to say they found themselves not guilty.
I look forward to hearing from you,