A nursing home in Sheffield, Kersal Mount, yesterday admitted it was negligent in the treatment of a Doreen Betts, 78, who was left to suffer with with pressure sores for three months and who eventually died of an infection caused by those same pressure sores. Mrs Betts died in May 2009. Her GP had recommended that the home refer her to a specialist to manage those pressure sores three months previously. They didn’t.
It’s a horrific abuse. The inquest found that she would not have died had she not had the pressure sores. Pressure sores are preventable and treatable.
I decided to have a look at the CQC report from this period which would have been between March and May 2009 and sure enough, it is here.
The Home has changed its name though and is now called ‘The Laurels and the Limes Care Home’.
The inspection that the 2009 report refers to took place in August 2009 so it would have been a few months after Doreen Betts’ death for which the home have accepted responsibility. It received a ‘two star good service’ which in some ways goes to show the flaws in the inspection systems and which, incidently, the home still proudly mention on their website – failing to note that all the star systems are now out of date and are not being updating so it will, forever be a two star ‘good’ home.
Among the report there is a note that four safeguarding issues were raised of which two resulted in there being a shortfall in the standard of care that should be expected and one member of staff was dismissed as a result of this. This is a good home, remember and these homes regulate themselves and report themselves to the CQC.
One area that the home only reached an ‘adequate’ standard was in staffing where there were periods when the home was understaffed. Unsurprising as staffing is one of the higher costs. Still, the report says it’s a ‘good’ home.
I find it hard to understand how a report can fail to make explicit reference to the death of a resident under the circumstances noted above after three months of distress in the next inspection just a few months later but for me, that explains very clearly the problem with the inspection regimes. They are very much box ticking exercises and the reports use language which can seem over positive without being clearer about the problems that exist in a care setting.
How can families be expected to make a fully informed decision about the best placement for their family member when the reports are so sanitised.
Words are fudged and hidden away in terms such as ‘safeguarding issues’ when one of those issues is actually the death of a resident.
It’s interesting that Kersal Mount was registered as a new service in March 2009 and by 2010 it had changed its name to The Laurels and The Limes Care Home. To be fair, the 2010 report is better than the 2009 one and it seems that any issues addressed have been handled but it goes to show that the inspection reports rarely tell the full story. Ideally, I’d want to look at reports for the service before 2009 but they could be anywhere due to the changes in registration.
It does show the importance that frequent, regular, spot checks can make in identifying poor practice and although I feel like a broken record at times, as long as mistreatment of older adults in care homes sneaks onto the third page of the local free newspaper and isn’t addressed with the attention and horror that it deserves, we will continue to have to hunt around for details of these cases and the sadness is that they no longer surprise us.