Home Number 35
Tales Of The Un-Inspected.
Care Home 35, A Report By Eileen Chubb.
( Copyright of Eileen Chubb )
Dear Mr Brown,
I have recently looked at the inspection history for home number 35, whose identity is disclosed to you in order for you to act.
………………………………………………………………………These are my findings,
The CSCI Inspection report dated 28th Feb and 4th of March 2008 states the following,
1. Prior to the inspection relatives surveys were sent out but only one was returned, residents spoken to during the inspection were positive.
My Comments, The fact that only one survey was returned is an indication to me that this is not a home where people feel they can say too much, the fact that residents spoken to were positive is not enough as often people feel they will suffer retaliation if they say anything negative.
2. The report states that medication procedures are not being followed by staff, that medication records are not accurate, considerable amounts of medication signed for as given were found to be still in the home, records of medication destroyed or returned had not been completed. The management told the inspector last time that the home had liaised with The Nursing and Midwifery Council on training for the nurses in the home but nothing had improved. This has been an on-going requirement for three inspections.
My Comments, The medication practices in this home have been an on-going requirement since 2005, three years of recommendations ignored. The report states that enforcement action will be taken, but that is not something a care provider fears as it is rarely taken and usually only when the media become involved. The fact is this home is dream for anyone wanting to steal drugs in order to sell them, as no one can account for what is missing as no one knows what should be there in the first place. There is an ingrained culture of drug abuse in this home, weather it be to hide criminal theft of drugs, or in order to keep residents quite or because they simply do not care if residents get pain relief or life saving drugs like insulin. Whatever the reason the culture is ingrained in the home and in the company that owns the home, as the company has carried out all the required audits and done nothing. They know what is going on and by their inaction are complicit. This situation can have lethal consequences for the elderly residents and every day it continues is a day too long, it has continued for three years at this point.
3. The report states that two residents were asked about staff, one said they were the best, the other resident said some staff were better than others, the reports states two other residents said the staff were great and lists the two comments.
My Comments, I notice the two positive comments are given prominence by highlighting them in italics and placing quotation marks on each so they stand out from the text. The negative comment however is left to merge with the text and this speaks volumes to me as to the attitude that is taken when concerns are raised, what is of concern is the attitude of the inspection authority who are supposed to be ensuring the people in that home are safe. The matter of the staff that are reported be, not so good, is not pursued by inspector. It is surely an indication that staff could be abusive, that it could be noted and not considered worthy of investigation says it all.
4. Feedback about the food did vary, the highlights all the positive comments.
My Comments, Again all positive comments are highlighted, but what about negative comments? These are not included at all other than it being mentioned some residents were dissatisfied.
5. The report states that a resident had developed pressure sores and a complaint was made directly to the authorities about lack of care.
My Comments, Relatives rarely make complaints outside the home without repeated efforts within the home to get issues addressed in my experience. This says complaints are either not being recorded correctly, or they are treated with contempt. An examination of this relatives records proved the complaint to be true, the sores had developed and no specialist medical assistance was not sought and the care plan said the resident should be turned four hourly, however this was not done. As a result of this complaint the care plans of two residents were checked on this inspection and found to be in order as far as medical assistance was now being sought, but not acted upon. It is of grave concern that people can get pressure sores which are totally avoidable but even after these sores have developed nothing is done to prevent them getting worse. Bed sores can be fatal.
6. Care plans also revealed food and fluid charts not maintained, residents at risk not weighed, falls not maintained.
My Comments, This company has all the right paperwork but that means nothing, if there is no care given then blank pages sometimes result.
7. The report states there have been four adult protection investigations undertaken in the home, three allegations about poor standards of care and the fourth arose during the inspection, a resident screaming for help whilst being attended to by a carer was heard by a nurse, the resident was found to have facial bruising, the incident was reported to relevant authorities and the carer suspended pending investigations. The other matters were partially upheld and one was not upheld.
My Comments, Firstly the allegations about poor care, there is evidently a prior history of poor care and yet allegations of such are only partially upheld and even the partial bit upheld is about communication between the home and relatives driven to complain.
The poor care bit is conveniently not mentioned, the third complaint about poor care is not upheld. The home investigated itself and found itself not guilty. A home should not investigate itself because that is what happens.
The assault that took place during the inspection is never mentioned again, where the member of staff is today is not known, another dangerous abuser caught and allowed to melt back into the care system to abuse again and again. The fact this assault could take place whilst an inspection was taking place shows that the abuser felt very secure, how long they had worked at the home is not mentioned but they will very likely be known to the homes management if they had been there for some time. Also the fact that staff were considered well trained and supervised warranted a good grade. Training alone will never stop abuse only accountability will and I have never come across a case of that.
7. The report states, The manager is well qualified and experienced to run the home and has been in the home a number of years, management is graded good.
My Comments, the medication practices that put residents at risk have gone on for years and the manager in charge during this time is supposed to be good, I wonder what would warrant a grade of bad.
The home is graded 1 Star, Adequate.CSCI Inspection report 23rd of July 2008.
1. The reports mentions that three other inspections have taken place, two by a pharmacist and one regarding a complaint.
My Comments, These other reports have been kept from public view but it mentions that the first pharmacist found the medication practices that had resulted in statutory notices had now been complied with. Sounds good until you get to the second pharmist who says there are now more concerns about the medication and as a result a warning letter has been sent to the care home company. However the original concerns and the new concerns look suspicially similar. It seems if a company or home has not complied with requirements for years is suddenly found to have complied than no action is required, however four weeks later a pharmacist finds new concerns than the whole process can begin again which buys time for an inspection that has no inclination to prosecute care providers, especially the ones that are big companies. There is four weeks between the two pharmacists reports. If only as much thought and effort was put into protecting the residents.
2. The report states the home uses an effective organisational wide system for monitoring the wellbeing of residents.
My Comments, If it has failed in this home than it can fail in all their homes, it is a tick list.
3. The report states, the home has good paperwork listing all the needs of residents.
My Comments, It looks very good until you examine its contents. If you do not dwell on the fact there are no safeguards to ensure residents get their medication and not someone else’s, that if you are diabetic you are likely to be in real trouble if you expect nursing care. This company has previous on this issue in another home so its company wide monitoring system would not appear to be working.
4. Dressings have not been changed causing risk of infection, fluid charts not maintained, there has been another complaint about pressure sores.
My Comments, if you do not get fluid you die, after your mouth has split and your screaming in pain whilst your organs fail, but you die. This seems obvious to most people of course but this is a care home inspection and matters of life and death result in requirements and statutory notices that go on for years and no one really wants to think about the consequences for those reliant on this inspection process.
5. The report states, There were no discrepancies found in the medication this inspection. However we did not count any medication.
My Comments, When you know a care home has a history of appalling medication practices and you go into do an inspection, you do not count the medication. It amounts to a see no evil policy after all if a home is repeatedly ignoring the law, the last thing an inspector wants is to call it to account.
6. The report states residents dignity was not protected and recites numerous incidents such as staff not asking the resident before subjecting them to the indignity of stripping them and exposing their private parts to public scrutiny.
My Comments, When peoples right to life is not respected then why does the inspector seem surprised when their dignity is treated in the same way? Going back to the companies national monitoring system, this company was the first to be prosecuted when one of its staff took photographs of a defenceless elderly women who had Alzheimer’s, naked to the waist and held up by both arms and distributed the images on the web. The report also says that the manager who is considered good, has disclosed personal information to the inspectors about a residents family and all because one of the family had made a complaint about care. Another member of the staff was heard discussing a resident that had complained as manipulative and they would never be happy with the home. Hardly surprising.
7. The company has a clearly defined complaints policy.
My Comments, The Manager decides what is a complaint and what should be written down, investigates those that are and finds themselves guilty of things like communication when the complaint was about poor care.
The home is graded as1 Star, Adequate.
New C.Q.C Inspection report dated 7th and 8th of May 2009
1.The Report states, The company and manager check the medication at regular intervals and all is well now with robust systems, one medication we checked was not right.
My Comments, The manager says so is hardly any basis to presume all is robust, yet in spite of the previous history and the few sample checks showing things are still not correct. This home is now graded as meeting medication standards. Drugs disposed of are placed in a bin and a record is made of what is taken away. The only check is the outside of the bin has a code, what is written on the returns sheet is not checked against the contents of the bin.
2. The report states a significant number of residents of the home are quite poorly but they had paperwork such as life maps and a range of other tools.
My Comments, Its hardly surprising so many of the residents are ill, the report states all the impressive care plan paperwork in place to make sure their needs are met but has failed to check on one crucial thing, if you are bed bound and ill it is not the bits of paper in the care plan that will bring you a drink it’s a real person in the form of staff. Despite the high number of dependent residents being noted, no increase of staffing has taken place, furthermore the possibility is not even considered at all.
3. The report notes a relative is satisfied with the care of her relative or the investigation of her complaint, safeguarding issues are still being logged as complaints. The home records well compliments about care.
My Comments, I bet the home records complements better than complaints, for years this home has received complaints, for years relatives have gone to the authorities and still there are indications that there are unsuitable staff in the home and nothing is done.
The New CQC would solve all the problems I have been repeatedly told by the government, it is clear to me that the new CQC have failed miserably again, this home has flouted every rule and has got away with it, the new CQC upgraded this home,
It is now 2 star Good, It amounts to a cover-up and a betrayal of the vulnerable who have to rely on these inspections for protection.
I ask you if this is your idea of protection, who is being protected and what are you going to do about it ?