Home Number 80
Tales Of The Un-Inspected
Home Number 80
By Eileen Chubb
( This Report is The Copyright Of Eileen Chubb 2010)
The local Authority recently moved all their residents out of this home after serious concerns were raised about the standard of care, I looked at the inspection history of the home to see if these problems could have been identified and acted on earlier, these are my conclusions,
The first inspection report I looked at for this home was dated April 2007, this reports refers to the homes previous failures meet requirements. It is quite clear to me that in spite all the homes promised improvement plans, things will not improve as the staffing levels are dangerously low.
It is obvious there are a core of good staff in this home but what they are being asked to do is impossible. Staff tell inspectors there are problems with newer staff not being able to speak English.
The Local Authority are investigating a safeguarding issue on restraint of a resident.
There are indications of problems with medication and care plans in particular how care is recorded and if it is actually delivered and this is described as very poor and needs urgent attention. But the homes owner just makes all the right noises about taking this on board and accepting that this needs to be improved and that is accepted.
The next inspection takes place 1 Year Later in April 2008.
What I find incredible is a home with a history of poor care has been allowed to register four more places when it could not care for the 50 residents it already had.
I can see that the home has dangerously low staffing levels and inspectors refer to this as the bare minimum but without staff there can not be care. The staff are being pushed to the limit and the harm being done to residents is clear, these shortfalls are not connected to staffing levels.
The care of six residents was looked at and half were identified at high risk of pressure sores but nothing was done about, no equipment was provided, nor was medical advice sought in fact it was just noted they were at risk.
One resident found to have lost a significant amount of weight and it was not recorded in the care plan.
Medication was checked for three people and discrepancies found.
Staff were considered by inspectors to be not upholding residents dignity by feeding several residents at once, this is an example of the emphasis on dignity obscuring the true problems. What I see is evidence of staff struggling to provide the basics to sustain life because there are not enough of them, if inspectors looked at the reality they would see evidence of people at risk of mal-nutrition or de-hydration and you can die without food and drink, you can not die from a lack of dignity.
The Home is graded 1 Star Adequate.
The next inspection takes place 9 months later in January 2009. It is noted this inspection is only taking place because the regulator has been told that there are serious concerns about care in this home.
It later transpires that a social worker visiting a resident in the home found they had been sedated to the degree that they were bed bound and unable to move. Because of them raising the alarm inspectors visit and note this resident has been taken of the sedation and is up and walking around quite well. They note he is no longer at risk of pressure sores as a result.
However it is not linked to the medication shortfalls found by a pharmacist nor is it seen in terms of risk to other residents.
The medication is found to be overstocked, no records of what came in, went out, medication signed as given when it was not. Medication being kept in un- marked bottles with no information as to what is was or to who it was being given to. Another residents medication had been stopped by the GP was still being obtained and administered. Controlled drugs were not accounted for.
People were losing significant weight, people did not have the correct pressure care equipment.
The inspectors finally realise staff do not have time to read care plans and state this must be done but do nothing about the staffing levels other then tell the company to review them again as they have done for years without effect.
Staff seemed reluctant about putting concerns in writing and said this would have to be done by management, most of the staff spoken to had no idea what a whistle-blowing policy was when asked.
The report mentions that residents have been abused by other residents and the Local Authorities investigation had been hindered by the homes actions.
The home is described as not clean and cold in parts.
Now it is graded Zero Star Poor.
The home is inspected again five months later and upgraded to 1 Star Adequate.
Inspectors seem not to agree with this but say they had to score the home on healthcare using current guidance, but this did not reflect their judgement that the home had significant shortfalls that needed to be addressed urgently.
This included the care of a resident whose pressure care or lack of it was raised at the last inspection and still found to be not acted on. A resident was seen to be hoisted in a sling too big for them and staff said they had asked for more slings. Pressure relieving equipment is not being used correctly. Medication was still found to have discrepancies and the home said it had taken a number of actions including an extra nurse on duty each morning but this was not the case on the day of the inspection so is likely to be not the case at all. This tells me that every resident in this home is at risk.
The home is not inspected for another ten months until may 2010 this is very brief and refers to the home meeting a number of requirements but provides no supporting evidence, the are also concerns noted about pressure care placing people at risk. Care plans are all newly introduced and those checked had crucial information missing. Medication requirements were still found outstanding. The home has submitted an extensive improvement plan again as they did four years earlier but there are no plans to improve the staffing levels as that is not a requirement.
The home remains 1 Star Adequate.
In November 2010 The Local Authority said they would be removing their residents from the home as there had been attempts to improve care for some time but it became clear to them this was not going to improve.
However a few days before residents were moved an 84 year old resident died and police opened an investigation into the circumstances surrounding their death. All 35 residents were removed by the Local Authority after they carried out an inspection in November.
Police are said to be working with the Local Authority and The CQC. However this resident died and countless others have suffered for years for the want of a care home regulator, the police should not be working with the CQC, they should be charging them along with the care home company. This is the inevitable outcome of accepting excuses when action should have been taken long ago.
Eileen Chubb.