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Update on Home 59

Update On Home 59

By Eileen Chubb

Copyright August 2012

Yesterday’s Daily Mail ran the story of Care Worker Mirela Aionoaei, who poisoned vulnerable residents with illegally obtained drugs including sedatives and Anti-psychotics in order that she could sleep through her night shift. The question where did she obtain these drugs? has not been asked.

What is most shocking is that this Middlesex care home was reported by Compassion in Care in 2009, please read Tales Of The Un-Inspected Home 59, which is printed below.

However our warnings were ignored. Why does abuse happen? Because when the Authorities are aware of what is happening they do not act and the consequence is more vulnerable people suffer. The now secret inspection reports which show what was known about this home as far back as 2008 are a damming indictment of the regulator CQC.

The Whistle-blowers who went to the police are to be commended. I note that like many others they did not feel able to ring the Southern Cross “Whistle-blowers Helpline”

Eileen Chubb 

Tales Of The Un-Inspected

Home Number 59

By Eileen Chubb

( This Report Is The Copyright Of  Eileen Chubb )

I looked at the inspection history of………………….Home number 59, these are my findings,

This home is owned by the same company as homes 33, 36, 41, 48, 49, 50 and 54.


THE REPORT, We have serious concerns about care on the 1st floor, care plans were poorly completed. We looked at 4 care plans on this unit and found little information on a resident with complex care needs. Five residents with wounds did not have information about dressings and treatment. We received information that pressure relieving equipment was not available. Pain assessments were not completed. All care plans viewed contained comprehensive assessments which had not been filled in.

My Comments, This means residents are developing pressure sores for the want of basic care. The company may provide all the right bits of paper but even the pretence of care is not evident as the sheets are left blank. This area is so bad even the regulator had to make a safeguarding referral as those residents with pressure sores were not receiving treatment or even pain relief despite significant wounds, wounds which were the result of deliberate neglect in the first place.

THE REPORT, Medication is of serious concern, there were more drugs in stock than could be accounted for with the exception of pain relief where residents had not had pain relief for up to a week in cases. Relatives had complained and supplies had been obtained, but had not always been administered as prescribed. Some residents had been given the wrong doses. The medication room was unlocked and the keys to the controlled drugs cupboard were left in the lock. Controlled drugs were not recorded accurately.

My Comments, I note that sedatives and anti-psychotics are overstocked and pain killers are not in stock at all. This is what I would expect as it is my direct experience of witnessing drugs used as a weapon to abuse, that it is the drugs that make staff lives easier, such as sedatives that are always overstocked, but drugs that benefit the resident such as pain relief come last on the agenda. These are not oversights or errors but the signs of deliberate abuse.

THE REPORT,  The home has a full time activities co-ordinator, the home has an activities programme. We have received comments there are not enough staff or funds for activities. The home needs to formulate an activities programme.

My Comments, The inspectors saying the home has an activities programme and then saying the home needs to formulate one is translated as the bit of paper stuck on the wall promising all sorts is a pack of lies and the home should consider sticking up a bit of paper listing what is really on offer, in the case of this home, bugger all.

THE REPORT. The home has contact with Age Concern and various advocacy services pinned up.

My Comments, No mention if any residents took up this service. Its mere existence on the wall is considered enough to bump the grade on activities up to adequate in spite of there being no activities. 

THE REPORT. The Home has a robust complaints procedure. Since the last inspection the home has received 42 complaints, there was evidence these were investigated. The company has an open approach to investigating complaints.

My Comments, The company has an open approach to investigating complaints but not acting on them, as comments received on the CQC surveys warranted safeguarding referrals having to be made. This explains why the information that there have been 42 complaints made is stated, whilst how many complaints were upheld and acted on is not stated. The manager having made several safeguarding referrals is considered to be good, but the fact that only incidents that require no outside investigation are referred is not considered. I see evidence of a home and a company that only reports what is convenient.

THE REPORT. The home was not clean, there was thick dust on surfaces, equipment was not always available, furniture was worn. There was debris on the floors, the utensils were dirty and stained, there was a backlog of laundry, there was a bag of clinical waste left on a bathroom floor, there were malodours throughout the home, bedclothes were worn.

My Comments, Pretty disgusting for a multi billion pound company. 

THE REPORT. We received comments about not enough staff. Staff comments confirmed a significant backlog in training, but fifty per cent of staff have the required NVQ level two. The Manager is suitably qualified and very experienced. The company has a robust quality assurance system but it is not always identifying shortfalls.

My Comments, What the manager and company are very experienced at is feeding rubbish to a regulator gullible enough to expect it be true.

27 Standards are judged, 10 Fully Met, 7 Nearly Met, 11 Major Shortfalls. Zero Star Poor Rating.


( 5 Months Later )

THE REPORT. This inspection was to check compliance with the statutory enforcement notices served after the previous inspection. We checked a sample of medication and this was in order with one exception. We checked the home was auditing medication, this was in order however it was disappointing that the error was not identified. It is important the home continues to audit drugs particularly when residents with more complex needs are again admitted to the home.

My Comments, I would have expected a full audit of drugs by the inspectors to be carried out before concluding that the requirements have been met. Only a unspecified sample of medication was checked and even then an error was found. However the fact the homes audit had not identified this is described as disappointing and not considered to have any impact on the homes credibility.

THE REPORT. We looked at the care plan of a resident prescribed strong pain relief, there were pain charts in place and evidence of review and referral to the palliative care team who visited and provided support.

My Comments, They looked at the care plan of one resident to judge if all residents who needed pain relief were receiving it, they chose a resident whose care was being supervised by an external agency.

The evidence checked in total consists of one and a quarter pages and concludes the home has met all the requirements from the last inspection which took four pages to list.

The homes rating remains Zero Star Poor.


( 24 Days Later )

THE REPORT. We looked at the homes AQAA. We received comment cards which were positive overall. We saw staff interact well with residents. We were told that new equipment had been purchased. We were told an extra activity organiser would be employed once the home admits residents with complex needs again.

My Comments, The reference to the home being able to admit residents with complex needs in the future is a strong indication that the local authority has suspended placements to the home as it has a Zero rating. I have found this situation follows a pattern whereby the rating of a home will suddenly be increased by the inspectors, who will consider the financial implications for the company to be a priority.

 THE REPORT. Healthcare is good, we looked at five care plans. We sampled MAR sheets on each unit and these were filled in correctly. The homes audits of medication audits were looked at. Staff knocked on bedroom doors and bedrooms were personalised and homely. Training on diversity and understanding the cultural history of residents was being arranged.

My Comments, Only one and a half pages of evidence on healthcare is listed, half of it relating to issues that have nothing to do with this section. Not much is looked at therefore not much is found wrong.

THE REPORT. The home has an activities organiser and the staff are more involved in activities. The manager has inquired about dial a ride and outings have been arranged. The menus are nutritious.

My Comments, The menus are bits of paper and have no nutritional content what so ever. The exact same evidence that on the last inspection resulted in a grade of adequate now results in a grade of good.

THE REPORT. The home has a robust complaints procedure and there have been two complaints investigated. This area is good.

My Comments, Last time this area was judged adequate on exactly the same evidence that is now used to judge it as good. The only change being there were 42 complaints recorded in the same period last time and now there have only been 2. Which is a drastic reduction and at least should have been queried as it may indicate everyone is happy with the care or that people have given up complaining because nothing happens when they do or it may also indicate the complaints have not been recorded by the home.

THE REPORT. Staffing is good, we have not received any comments from staff that there is shortages and viewing the rotas there are sufficient staff on each shift.

My Comments, Last time this area was judged poor. There is a bank kitchen staff employed and the home has increased bank nursing and care staff but not permanent staff as that would guarantee staff actually working on the floor and not on standby.

THE REPORT. Management is good, the manager has the skills and experience to run the home.

My Comments, The last inspection considered the same evidence as Poor.

In just 24 DAYS This home goes from a ZERO STAR Rating to a TWO STAR Rating.


( 11 Months Later )

THE REPORT. Healthcare. There were shortfalls in medication recording which had not been identified by the company auditing tool. Shortfalls could place residents at risk. Pain assessments for residents with wounds were available with one being carried out during the inspection. We saw an example of professional input being obtained. There were gaps in medication received and administered and in one case two doses of a medication were signed as given, we asked the nurse who told us it was only one dose. We discussed with the manager the importance of auditing medication effectively.

My Comments, I expect if you had put a similar question to Dr Shipman he would give the same assurances but assurances do not cancel out an overdose. There never was any improvement to warrant a jump from zero to two star, the inspectors chose not to look too hard last time they inspected. Now they realise that the medication puts residents at risk they have two choices they can either grade this area as Poor which is what it is, or they can completely ignore the risk and find something totally irrelevant as evidence such as the home having Dignity Guardians and grade it as Good. They chose the latter and graded it Good.

THE REPORT. Complaints are well handled and there have been three complaints dealt with. We looked in the home comments book which had several positive comments.

My Comments, No mention of what the other comments were.

THE REPORT. The home advertises its collaboration with the charity Action on Elder Abuse gives a helpline number to ring. The contact details for CQC were being made available at the time of the inspection.

My Comments, If this was the case then the concerns raised about lack of staffing would have been raised with the manager and not on CQC surveys. However this information is relegated to the back of the report under a different heading so as not to shatter the illusion that the home would deal with concerns and staff would ring a help-line set up by a charity funded by a care company.

THE REPORT. We received comments on the surveys about staff shortages on the second floor Dementia Unit, plus some comments about staff shortages on first floor, the manager was aware of these issues and had already increased staffing on the second floor. The need for an extra activity organiser was discussed.

My Comments, Why was the lack of Activity organisers not judged under the section Activities as it may then have had an impact on that section being graded good. As for the manager saying she took action on staffing levels on one of the Units, was this checked? No. When that many concerns are raised about staff shortages to the regulator directly, both written and verbal there is evidence of a home and company that does not encourage such concerns to be raised internally and staff shortages equal neglect and abuse. All the posters about free help-lines are a smokescreen at the end of the day. If this evidence had been dealt with under the section on complaints it may have resulted in a less than good grade, however it was not mentioned or considered relevant. 

The Home Remains TWO Star GOOD.

The actual care remains SUB ZERO.

I have looked at the care industries proposed new regulation and for obvious reasons the worst is yet to come.

Eileen Chubb