Home Number 99
Tales Of The Un-Inspected
By Eileen Chubb
( This Report Is The Copyright Of Eileen Chubb )
This Home is owned by the same company as homes, 29, 35, 40, 42, 45, 46, 51, 55, 61, 98.
The Regulator, CQC, has posted a press statement about this home on their website, which gives the misleading impression that the CQC are on the case, however the reality is very different. I looked at what the regulator knew about this home and what action was taken at the time.
Regulators Inspection report August 2006, ( 5 Years Ago )
It is noted that this home has a history of problems and that it is providing poor care. There is noted to be an increasing amount of serious concerns being reported to the regulator.
Some staff are described by relatives as having serious attitude problems.
Residents are considered to be at serious risk of harm from being moved in an unsafe manner.
Social Services and the Health Authority are said to have raised numerous serious concerns about the poor care in the home.
There are some good staff in the home who are said to mistrust their colleagues.
One new 17 year old care worker was found to be working unsupervised, generally all staff were left to their own devices.
Untreated preventable pressures sores.
All the evidence tells me the home is not fit to care for vulnerable people, the regulator however asks the company to provide yet another improvement plan.
December 2006 another inspection takes place.
The inspector concludes some improvement has taken place as the regulator has not received any more serious complaints.
Two staff were observed talking to residents in a disrespectful way.
A resident was admitted to hospital and concerns were raised about their condition. The home reported one incident where a resident said they had been harmed, no further information is given about this.
No mention of moving and handling other than a single sentence stating staff were observed moving several people safely, it is not mentioned if care plans were checked to see if they were being moved in the correct way.
The next inspection takes place 8 months later in August 2007.
It is noted that a number of issues have been raised with the regulator and Social Services about how some residents have been treated and spoken to.
There have been a number of safeguarding issues raised by healthcare professionals and Social Services. But what rings every alarm bell for me is that a member of bank staff blew the whistle to a unit manager about practices within the home, correct procedures were followed but the workers concerns were not upheld. However when a member of bank staff raises concerns they know they risk losing work and would not raise concerns lightly.
The maintenance records were not checked as the home assured inspectors all was in order.
The next inspection takes place 10 months later in June 2008.
The home was not due to be inspected for another year but had to have the inspection brought forward as a reaction to the fourteen people raising serious concerns to the regulator.
The inspector says there has been a marked deterioration in standards of care, however they are all the same old problems that had never improved. What is incredible is that in the space of ten months whilst all this was going on the home managed to register 21 extra beds with the regulators approval when it could not and never had cared for the residents it already had.
Staff are noted to be cutting corners in moving and handling placing people at serious risk of harm.
Complaints and concerns are ignored and there’s a fear of reprisals if concerns are raised.
Relatives have had to summon medical assistance from outside the home. The nurses are said to do nothing but paperwork leaving care staff to do what they like.
One resident was observed walking around with an overfull urine drainage bag.
Many people are spending most of their time isolated in their rooms.
Concerns reported to the regulator concern neglect of care needs, scant regard for safety when moving people, the attitude and competence of some staff. The companies senior management totally deny all of these concerns. A whole raft of requirements are made yet again, but a company that denies anything is wrong is not going to comply.
The home is rated Zero Star Poor and yet another Improvement Plan is requested.
The next inspection takes place 8 months later in February 2009.
The home is upped to One Star Adequate, which is incredible given the following facts are noted,
Section One, Assessing new residents has improved from adequate to good according to the inspector, however given no new residents have been admitted this is a flawed conclusion.
Section Two, Healthcare was poor but is now upped to adequate in spite of care plans not recording the actual care given, drugs found that staff say were not ordered and no clear audit trail of what drugs were given to some residents.
Section Three, Activities was graded adequate last time but are now rated Poor, mainly because there were no activities.
Section Four Complaints, last time graded as poor now upped to adequate in spite of the following being noted,
Some people have not been protected from harm,
The regulator has not received any complaints,
The home has not informed relatives of how to contact the regulator if concerns are not dealt with by the home,
A resident tells the regulator they had not been treated well and yet they had not made a complaint about this,
Some serious concerns have been raised by hospital staff about residents admitted from the home.
Section Five, Environment, was good last time but is now graded as adequate.
Section Six, Staffing, no change from adequate, care staff tell inspectors nurses just sit in the office, one carer told inspectors she had never worked with a nurse.
Section Seven, Management, remains adequate, There is now no registered manager,
Inspectors now check staff training and practice on moving and handling as an incident occurred where a new member of staff was moving a resident and they were injured. ( This company has an appalling record of deaths after frail people have been injured during moving and handling) I hope this particular incident will be warning enough to improve things in this home.
I see no evidence of improvement.
The next inspection takes place 11 months later in January 2010, the home is now upped to Two Star Good,
The report notes there are a significant number of vacancies, the public are not as easily impressed as the regulator when looking at a home.
Care plans are still a mess and not improved from previous inspections.
Pressure prevention was not recorded for someone at high risk who went on to develop pressure sores and no record of treatment was found.
There have been incidents of poor staff conduct and attitude being dealt with and that training has been provided.
Uneaten food was taken away.
The regulator has been contacted directly about concerns.
There have been seven safeguarding investigations to ensure people are safeguarded, three reported by the home so more than half not reported as required.
The manager is highly qualified and fit to run the home.
A few months after this inspection the residents in this home are found to have suffered serious harm.
The regulator reacts after being informed about the quality of care in this home, the regulator should be telling others what care to expect from a home but it is always the other way around.
The report is dated March 2011 which gives the misleading impression that is when it was last inspected, however the inspection took place in the 2nd week of December 2010 and no other report has since been published.
Residents were observed who were upset, ignored and frustrated.
A resident says they don’t like a male carer and they can not say as they are frightened, its not investigated by the inspector just noted.
A number of residents have sustained injuries due to unsafe or inappropriate moving and handling. Injured residents suffered long delays before receiving medical attention for the injuries sustained.
Staff tell inspectors they cut corners when moving people as there are not enough staff, other staff have not received training though the training matrix was up to date.
There have been 18 safeguarding incidents in four months where staff have not taken action to prevent abuse or harm from happening.
A resident who was found by police in the road and the subsequent investigation could not find out how they had left the building.
Equipment was not kept in good working order.
People were seen calling out for help and being ignored by staff.
Some staff could not assist residents with dementia.
Two members of staff see things that are not right but feel they can not report this.
Untreated pressure sores.
Unsafe equipment resulted in injuries to a resident dropped, the home said the particular hoist had been fixed. But it was checked and found to be untrue. The homes manager has been sacked for gross misconduct and senior quality assurance managers from the companies head office are monitoring the home. Yet even after harm has been done are they willing to act to prevent further harm? No, instead their stance is one of denial. I would also ask why the manager could be sacked for gross misconduct in August and it take four months before the regulator inspects the home?.
The company insists in its AQAA that it is compliant with all regulations ( It would Do)
Following a recent allegation of abuse by staff to a resident, the home took appropriate action to protect people and support the staff member. I find this incredible as the only way you can support someone who abuses vulnerable people is to support them out the door and out of the care system.
Staff were observed standing talking in groups after walking past residents calling for assistance.
Many other things of concern are found wrong, but I will finish by listing comments on page 40 of the inspection report, which notes that activities organisers say they have difficulties with conversations with residents as care staff had not informed them of peoples deaths. Not much hope attention if no one knows if your dead or alive.
The company has been asked to provide yet another action plan.
For more than six years people have suffered in this home, will anything change? I very doubt it but I will be watching.