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Update on Home 44

Update on Home 44

By Eileen Chubb

Copyright November 2012

The report I wrote on Home 44 is copied below and it quite clearly highlights serious concerns about care in this home as far back as 2008 especially in the area of pressure sores. The Owners fobbed of the regulator with repeated promises of changes being implemented.

One thing that really stood out was the good staff in this home had appealed to the regulator ,,Please help us,, this cry for help was not acted on.

This week a Coroners inquest into the death of Elsie O’Donnell a resident from home 44 who died from multiple infected bedsores, ruled death by natural causes and the homes owners said changes have been put in place. It is appalling that death from neglect can be considered natural causes even more so when you consider the evidence that was not disclosed to the court, year after year of suffering and neglect and all the authorities knew but did not act. This women died in agony with bed sores to the bone because no one acted year after year.

Since I wrote my report on this home several further inspections have taken place which I comment on below.

CQC Inspection April 2010 ( 13 Months after my report on home 44)

The report states this home is 2 star good, it states the local authority visit this home once a month and say the care is good. 

CQC Inspection February 2011 ( 10 Months later )

Now the home is found to be failing in all the areas it has failed in for years, one male resident with severe pressure sores found not turned, people not given enough food and drink. People are said to be at risk. It managed to get into this state in spite of the local authority monitoring visits. Owners said to be implementing yet another action plan.

CQC Inspection March 2011 ( 4 Weeks Later)

Now said to be fully compliant again in just four weeks, in the area of pressure care said meeting all standards in spite of looking at pressure care for one resident and finding pressure relieving equipment stated as required was not being used.

CQC Inspection June 2012 (1 year and 5 months later)

Please Note in the time between the last inspection when all was said to be fine when the evidence on pressure care contradicted CQCs judgement, and this inspection Elsie O, Donnell died, she died because every single safeguard that should have protected her failed to do so and to add to the injustice her death is excused as natural causes.

It is no surprise to find the home is graded non compliant but its ok the owners are putting in place an Action Plan. 

I visited this home in February this year, was left sitting in the hallway for nearly half an hour and heard the alarms going constantly. Saw one young staff member rushing about and was then told there were not enough staff on duty and to come back another time.

Tales Of The Un-Inspected

Home Number 44

By  Eileen Chubb

( This Report Is The Copyright Of Eileen Chubb )

I Looked at the inspection history of…………………………Home Number 44, these are my findings,


This care home has raised two issues in particular, firstly the use of independent inspectors. I recently spoke to someone who was taking part in the ( Expert By Experience) initiative which allows people to accompany inspectors on visits to homes. They felt their views about homes differed from inspectors and that whilst their opinion was included in a report it did not impact on how a home was graded. This person had read my book and felt it had given an insight into care homes but they felt such insight was not welcomed by inspectors. 

Secondly I raised serious concerns about the Governments policy of allowing care homes to assess themselves, this self assessment is called the AQAA,  (Annual Quality Assurance Assessment ) This amounts to a tick list designed by care companies, for care companies to make themselves look good. My concern has always been that such a tick list would be relied upon as evidence when inspecting a home. If this document was fraudulently completed by a care home would the law prosecute? No it would not. This particular care home shows all my concerns to have been well founded. 

Inspection Report Dated 30th of June 2008.

The Report States, The Home has a complaints procedure that complies with the requirements, but people say  they do not feel safe or listened to by staff.

My Comments, I note that people feel they are not safe and not listened to by staff, seeing both these facts together says something is very wrong. When residents say they do not feel safe they need help and need it fast, but the inspectors take the view that they should raise why they do not feel safe, with the people that have caused them fear.

The report states that people have the information they need so they can make an informed choice before moving into the home and the managers says she only accepts residents she has the staff to care for, this area is good.

My Comments, I can not see that the home can provide such assurances when it fails to care for people already in its care, were those people told in advance they could expect a sorry excuse for care? What the home says it provides and what it actually delivers should have resulted in a grade of unfit for human habitation, but it meets the requirements of this section in full!

The Report states, Health and Personal care is poor, We received several concerns prior to this inspection from relatives, staff, residents and visiting professionals, 

My Comments, Everyone who could speak out, did speak out. 

The Report states, we looked at care plans and found one resident had a care plan which said they were at risk of pressure sores, but no action recorded as to what was being done to prevent them. Another care plan had good skin integrity documentation.

My Comments, Half the care plans looked at, showed people were at risk of developing pressure sores. There is no mention of how many people in the home had sores. Nor is any further action taken to ensure if the resident who was identified to be at risk had medical intervention immediately.

The report states, some care plans did not show measures in place protect people from falls.

My Comments, This was checked concerns were raised that a resident had fallen and no one came to answer the call bell and the resident had to telephone a relative for assistance. As a result of this complaint it came to light that call bells were always left ringing, that there was a very high number of falls in the home. I am concerned that the homes staff are also expected to provide assistance for the residents in the 23 bungalows in the grounds. there should have been a separate staff team allocated for this. 

The report states, the home has been given a NHS contract to provide care for people coming out of hospital who needed assessments before moving on. There was no evidence of care planning or what rehabilitation had been provided, a nurse told us that, We do not know what we are supposed to do with these people, one lady went home, I told Social Services she could not manage, people do not know they are coming here, their relatives ring up looking for them after the hospital tell them they have been sent here.

My Comments, This is a shambles, these people are sent to this home for rehabilitation, a home that can not even care for the residents it has is given a public contract and when it comes to light that the home is in breech of that contract to the point people are in danger, nothing is done. God knows what happened to the poor women sent home who could not manage, no one seems bothered about it except the nurse. As for sending people from hospital to this home without their consent or informing their relatives, it says much about what kind of hospital it must be.

I am also concerned that people who raise concerns with the inspectors are being clearly identified in the report, whistle-blowers are often subject to retaliation in such an environment as this.

The Report states, A large number of people in the home told us they are not happy with their care. We observed call bells ringing for long periods. Residents said the following to us,

They could wait for hours to be put to bed, 

Staff tut if I ask for help,

Sometimes I would like to stay in bed but they whisk you out,

There’s a sharp divide between staff, some are excellent but they are the minority

Staff talking together very loudly in corridors,

I had to wait three days for a jug of water,

Staff will not take you to the toilet outside toileting times,

Not enough staff, not enough know what they are doing

Young staff are very rough,

My Comments, This is clearly a dire situation, these are the residents who can speak, but the home cares for those with dementia also, they will be even more at risk. These people are in a nursing home because they need care, calling for help day in and day out is a nightmare existence for people to have to endure when they are at the mercy of this home for the most basic care. The report states that the first time these concerns were raised was after the last inspection, which had failed to note these issues.

The report states staff are moving residents in a dangerous manner and staff speak to residents without a care for their dignity. Two people were sitting in wheelchairs by the front entrance who said I wish I could go out.

My Comments, I can imagine too well what it must be like for those people who just want a someone to take them for a walk, something most of us take for granted is opening the door and going out. It saddens me beyond words that a generation who ask for so little could be treated like this. 

The report states we observed the lunchtime meal being served, staff are trained to assist people to eat who need help.

My Comments, This is not actually evidenced, if people are waiting three days for a jug of water, then food which is served to everyone at the same time is hardly likely going to be managed with so few staff. Staff might be trained to feed people but that is not enough to base a presumption on that residents are being fed.

The report states, people are not protected by the complaints policy, there have been a large number of falls, including a resident who had been asking to go to the toilet who threw herself out of her wheelchair. Another resident was sitting in a wheelchair in her bedroom and had a lap belt on which could be viewed as restraint and should have been sanctioned in her care plan by a Multi disciplinary team meeting and agreement.

My Comments, Every time I hear the words, Multi-disciplinary team meeting, my heart sinks, what it means is a bunch of people who have long been known to go along with things that are plainly wrong, sit around and agree to cover the home by signing away the human rights of some poor soul who needs care.  A couple of years ago a defenceless elderly women in another so called, Care home, slid down in a wheelchair and strangled on the strap, but that’s alright because the Multi -Disciplinary team would have ticked the boxes. What was the women doing in her bedroom in a wheelchair strapped in with no one watching over her was what I would ask, bugger the Multi-Disciplinary team, there sanction of neglect does not make it alright.

As for the resident desperate for the toilet who threw themselves out of the wheelchair they were likely trying to crawl there and that sums up the care they were expecting.

The Home is a pleasant place to live, bathrooms and toilets meet requirements and all fixtures are in place.

My Comments, It could be done out like the Hilton hotel but if there is no one to take you to the toilet it matters not what standard the décor of the toilet is. 

The Report states, staff have the skills to care for people and are trained however there are not always the numbers of staff and at times people have to wait.

My Comments, Its quite clear to me that firstly if staff are trained, the training is useless, secondly to state there are times people have to wait for help is ludicrous given what people have told the inspectors. It would have been truthful to have said, there are times people have to wait for assistance and those times are whenever people need assistance.

The report states, the home has all the right policies and procedures, but staff told us they are tired and cut corners to get things done, the AQAA did not reflect this. It did not give a true picture.

My Comments, what did they expect from the AQAA? 

The home is graded as follows,

27 Standards were judged,

14 Standards were fully met

11 Standards were almost met

2 standards were not met.

The Home is rated Nil STAR POOR, This home is way beyond being considered just poor, but too much over grading on things like Décor and Choice of Home bumped it up to poor, What it needed was emergency measures to be taken, immediate action by the authorities.

What happens? Nothing.

The next inspection is not until spring of the following year. It gets worse. 

Inspection Report dated 19th of March 2009

( 9 Months Later )

The report lists the complaints it has received about the home throughout the report.

My Comments, It would have given the public a more truthful picture of this home if those concerns were listed in full detail at the front of the report, however the first priority of the regulator is to tell you what the home does well, plus all the positive comments received are listed here. I do note that the relatives of the more independent residents have more positive things to say. It is also of interest that the positive comments are not only about the care of the relative but some go to considerable efforts to say all residents are well cared for which I find odd, for example all residents are checked in their rooms, how could someone visiting possibly know that. It is not a reflection of the truth at all.

The information that reflects the reality for the majority is spread throughout the report.

This inspection included an ( Expert By Experience ) and I have listed their findings separately, but would like to commend this person for their diligence, the same can not be said of the inspectors. 

The Report states, we looked at care plans, one resident was being visited by the community matron and needed palliative care and when we looked at this residents care plan there had been no review to say needs had changed.

My Comments, If someone deteriorates so drastically their dying and it is not recorded then that sums up care plans.

The Report states, we noticed a group of frail residents sitting together in a small lounge, one of these ladies was very distressed and shouting on both days we were there, there was little evidence of staff interaction, we spoke to the manager who said a doctors visit had been arranged. However we noticed most of these residents were sitting in recliner Kirton type chairs, when we looked at their care plans there were no reasons or decisions documented, it is a requirement that the Multi- Disciplinary team and the persons relative be involved in this as these chairs can be seen as a form of restraint.

My Comments, These chairs are seen as a form of restraint due to the fact that is what they are used for, now that we have the latest piece of protection called, Deprivation of Liberty safeguarding, it is immediately followed by the legal loophole called, The Multi- Disciplinary Team.

What it means for the residents stuck in chairs they can not escape from is,

I. They lose their mobility ( Which they have or they would not need restraining) as they are unable to move.

2. Its my experience such residents are often segregated into some back lounge out of sight and out of mind. They get food and drink after every one else, if they are lucky.

3. If they were continent before sentenced to restraint, that will be lost as pads will be used to save time and the fabric of the chairs.

4. They are deliberately put at risk from pressure sores because they are deprived of movement.

5. So there they sit day after day, and should they scream in despair, What will the homes manager consider could help this person, human contact? Stimulation? food or drink? No the doctor is only summed  for people who are shouting for one reason, they are to be drugged for their own good of course.

So against all the odds the regulator happens one day to visit a home and hear the screaming and finds a group of people restrained in a lounge, what is the first consideration? Why has the torture not been approved by the Multi Disciplinary team?

The report states, complaints were not recorded and this was attended to during the inspection.

My Comments, The norm is an inspector looks at the complaint book and if there were no complaints in it then they would presume there were no complaints. The expert by experience picks up complaints have been made and not responded to and what does the inspector do? Just allow the home to go through the motions of filling in the blank paperwork but the culture in this home is not addressed at all.

The Report states, MAR sheets should be printed and not written to avoid errors.

My Comments, When you hand write a MAR sheet, you are prescribing what should be given. 

The report states, We have received two complaints about the home which were dealt with by the home. Social services received one safeguarding alert.

My Comments, If you read no further you would think that was it, but the inspectors conclude complaints have dropped, yet a relative tells the Expert By Experience she had reported concerns to the home manager but nothing was done, concerns which included finding their relative in a distressed state after being restrained in a chair in her room for two days, with a table in front of her to stop her moving. The inspectors spoke to the manager who said she was unaware of this. This is what safeguarding amounts to, the manager did not even treat this as a complaint never mind a safeguarding issue, but what is worse is the inspectors did not consider it such either. The expert by experience is uncovering more about this home than any inspector has to date but even then the information is noted but not acted on.

The report states, there are not enough staff in the home and we are still receiving anonymous calls about staffing levels.

My Comments, It was stated earlier that only two complaints had been received about the home and that complaints to the regulator had fallen, but now we hear there have been anonymous telephone calls, people are beginning to despair if they will not give their name.

The report states, we have received two anonymous letters about the home, the contents were reflected by the staff we spoke to, the letters said there was concerns about the management of the home and one letter ended with the words, please help us.

My Comments, There are 38 pages of findings in this inspection report but the fact that staff are raising serious concerns about the management of the home in anonymous letters is to be found on page 36. When I read that staff were appealing to a regulator and using the words, PLEASE HELP US, I knew what I was seeing was the last decent staff in a care home making one last appeal to the people they thought could help. This is as bad as it can get, if staff are saying please help us then you can be sure that residents are in big trouble.

There are many other concerns listed in the report such as staff with no recruitment checks, anonymous calls about lifting equipment which are confirmed to be true.

28 requirements are graded, 13 no shortfalls, 15, minor shortfalls and NO MAJOR SHORTFALLS, the home is given ZERO STARS POOR.