Home Number 34
REPORT ON HOME NUMBER 34.
By Eileen Chubb. ( COPYRIGHT APPLIES )
Dear Mr Brown,
I have looked at the inspection history for this home for the past four years and these are my findings,
Care Home……………………………………………………………. Referred to as home 34.
CSCI Inspection Report dated July 2007 notes the following,
1.There was a history of problems regarding medication practices in this home and that these were serious enough to warrant a pharmacists inspection.
My Comments, What the pharmacist found is not disclosed but a number of requirements were made to be met, however the medication standards are still considered to have been met as they are graded as such. The inspector relies on the assurances of the home manager that systems have been put in place to check for medication errors before they occur, the inspector considers these systems to be robust.
Further on in the report the inspector mentions that a relative raised concerns about medication errors, it is clear to me that if there was a robust system it has failed. The managers word is not questioned even though the inspector is aware of information that contradicts the manager.
The home is praised for its care of the residents across all but one area, but as the residents are mainly out of sight in self contained flats I can see a situation where people could be badly neglected and it not be noticed. It is stated that 10 of the 41 residents have dementia and I can see no system for monitoring people who need care nor the staff numbers to allow for the possibility.
2. The report states that staff did not report an adult protection incident to the homes management for over four weeks. Complaints and protection is graded good.
My Comments, The fact that this could happen, go unreported for so long and still not affect how a home is graded is why abuse thrives.
3. Staffing is graded as adequate due to a staff reference discrepancy.
My Comments, the inspector notices that a staff file has no reference from their previous employer, a short while after the homes administrator tells the inspector the reference has been found and that is accepted, yet this reference is not produced its just the word of the administrator and it is accepted.
In summery the home is considered to have fully met 23 of the 29 standards judged and only had six minor shortfalls. In spite of the concerns over medication and the requirements made the home is not inspected again for over two years.
NEW CQC INSPECTION REPORT DATED 24th of June 2009
4. This report notes that the inspection is being carried out due to the fact that controlled drugs have gone missing and that during the investigation into that the following was discovered,
That medication was not checked into the home, there was no way of auditing it correctly, it could not be checked what medication in what dose was being given to which resident, one of the two care plans checked had no record of medication being given, M.A.R sheets were missing, large amounts of medication being stored in unlocked areas, some medication had been ordered twice.
My Comments, Only two care plans checked and one with such a serious failing, yet no other care plans audited as a result. It would appear that the robust systems of two years earlier were not so robust after all, the whole thing is a shambles but what should not be forgotten is for over two years at best vulnerable people have been left in pain and distress without their prescribed medication and at worst could have been given medication not legally prescribed and there was not a single safeguard in place to protect them. This is post Dr Shipman and nothing has changed at all as lessons have not been learnt, the whole thing is treated like some minor event and as the home manager and staff have assured the inspector that a robust system is being put in place the home is graded as TWO STARS GOOD. The fact that the home had not met the requirements going back three years previously did not impact on their credibility at all. The inspector even commends them for their knowledge of the residents medical needs. I consider the fact that they knew what needs that were neglecting intentional negligence and certainly not something to be congratulated. Then it gets even worse.
C.Q.C INSPECTION REPORT DATED 27th of August 2009. (Eight weeks later)4. What the report mentions, That serious concerns have arisen,
Residents left in their flats behind closed doors unkempt, uncared for, not fed, not weighed, lack of knowledge about medical needs, repeated falls, injuries not treated, medication not being correctly administered, relatives complaining, 2 of 3 requirements made last time not met.
My Comments, Everything that could be wrong is now suddenly wrong, the same staff and management that had so much knowledge of residents medical conditions just eight weeks ago now seem to be suffering from amnesia. It is noted that residents who needed help with basic care did not receive it, one resident had not been washed for so long or her room cleaned or even checked, the smell of neglect could be smelt in the corridors. People were found to have not been eating, getting food into their mouth with no one to help them resulted in drastic weight loss in many cases.
The medication is now seen as a danger, the possibility of over dose is listed. The report states the manager assured us but did not comply is stated as if there was the remotest grounds to have that expectation.
What’s even more incredible is the fact that this has resulted in everything being judged to be wrong, the layout of the building and the décor which previously was not a problem is now not suitable for residents needs. The fact is the inspectors never knew what those needs were in the first place, the home is registered for ten dementia residents but many residents had much higher dependency levels and most needed more assistance than was being provided, that was clear from the outset but the warning signs were not acted on.
The home is graded ZERO STARS POOR and issued with a statutory notice and 19 requirements to met by Sept 2009. It gets worse.
C.Q.C INSPECTION REPORT 19th October 2009. (Eight Weeks Later)5. The Records did not demonstrate that action had been taken to address the issues, residents not given food supplements prescribed by Gps, food and fluid intakes not recorded, medical assistance not summed for repeated reports of chest pain.
My Comments, These are some of the concerns noted however of the 19 requirements made at the last inspection 7 are listed as not assessed on this occasion, the remainder have no evidence of being met but are unaccounted for, 4 new ones are made including the below,
The Home must ensure the proper provision for the health and welfare of the people living in the home and appropriate treatment is sought when concerns are identified to ensure people receive treatment without delay.
My Comments, obviously there is no hurry with the term without delay as the date the home has to comply by is 10th of November 2010, over a year for people who have waited for protection for so long.
The home is graded as TWO STARS GOOD.
C.Q.C INSPECTION REPORT DATED 9th of NOVEMBER 2009 (22 days later)6. The home has sorted out the medication, all of the outstanding statutory requirements not inspected.
My Comments, Now the home is assessed as meeting medication requirements it is graded as ZERO STARS POOR, what it will be next week is any ones guess but there is one certainty and that is the reality of the care and the star rating awarded for care will be at total odds.
Is this a regulator carrying out inspections that keep people safe or is it an audition for a remake of Mr BEAN?
Do you think this is going to protect the defenceless and if you do not, what are you going to do about it?