Breaking The Chain of Elderly Abuse Complacency - Ignorance - Denial - Silence | Reg. Charity No:1102282
SAFEGUARDING SHAMBLES THREE.
This report is our response to the serious case review, SCR into Hillgreen Care Home London. A copy of the SCR is attached.
The reason this SCR took place at all is due to the Times Newspaper running a front page story about CQC covering up a rape at a care home after documents were given to the Times showing who knew what and when.
SCR is a process used after safeguarding authorities have been involved in appalling failures and want to exonerate themselves of any blame by enacting an inquiry into their actions that subsequently never finds any anyone responsible and holds no one to account. This particular SCR is a spectacular example of this type of self-preservation.
The case relates to P. A serious sex offender who committed a number of serious sexual assaults on both members of the public as well as on the vulnerable people he was housed with at Hillgreen care home.
Much is said in the report about how they now recognise that someone like P will repeatedly commit assaults; of course this is obvious and would be recognised as a risk by any random member of the public asked to assess such a risk.
There is also much concluded about how information was gathered and made available. Appalling failures occurred in logging the history of P .Incredible in an era where a few clicks of the mouse would give you all the information you need for example on a model of washing machine, all gathered in one place including reviews.
Most incredible of all is the SCR conclusions in relation to the CQC on pages 22 to 23. Firstly they state that CQC would have had to take risk and care plans at face value.
However I discovered when I looked at the CQC inspection report for July 2009 when the home was rated Zero Star, it was noted that “A care plan did not include information that was noted in the preadmission document in relation to Significant behaviour” This clearly identifies a very serious issue that should have been investigated further. It is merely noted by CQC.
The home is rated Zero Star at the next inspection on October 21st 2009 yet less than 8 weeks later in December 2009 it jumps to 2 Star.
The inspection history remains compliant until 2013 when the last of two inspections pick up general issues with care plans not recording enough detail about activities, and epilepsy care. No Major concerns.
The section on staff training said any failures were considered to be only minor.
Yet this is not reflected accurately in the SCR reference to this inspection on page 22.
Most significantly the SCR glosses over the CQC inspections between 2015 and 2016. The rape occurred in 2015 and CQC subsequently inspected the home in relation to issues that the home was not clean; no mention of any safeguarding incident is mentioned at all.
The only conclusion I can draw from all the available evidence is that CQC did withhold vital information from the public and that fact is so clear that the SCR report amounts to a whitewash.
There is one final detail that the SCR has omitted completely and which I think is relevant. The deputy manager of this home was a convicted sex offender illegally in the country and CQC regular inspections of staff recruitment records did not pick this up either.
CQC must be sighing with relief that this SCR has let them off scot free considering the evidence that dams them.
What happened at Hillgreen is a story of incompetence, indifference and misconduct and finally when an opportunity for accountability occurs it concludes with the usual “Lessons have been learned” guff trotted out sadly far too many times when of course nothing has been learnt but how to spin the facts.
There was information leaked about this home, as always there are individuals who do their best to protect people alas there is not enough of them.
Edna’s law investigation requirements will use this case as one of the examples of how not to investigate such failures. It will also be one of the many cases we have that demonstrates why we need Edna’s law and not the Safeguarding shambles that allows so much abuse to occur.
My heart goes out to the victims and their families, they deserved better than this excuse for an inquiry.
Eileen Chubb ©