Negligence and Care – Kersal Mount Care Home


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which, incidently, the home still proudly mention on their website – failing to note that all the star systems are now out of date and are not being updating so it will, forever be a two star ‘good’ home.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.

3 thoughts on “Negligence and Care – Kersal Mount Care Home

  1. Pingback: Negligence and Care – Kersal Mount Care Home - Fighting Monsters - Member blogs - Social Work Blog - Carespace from Community Care

  2. Can you hear my sighs as I read yet another story of horrific abuse in so-called care? This is a ‘care home with nursing’ for up to 88 older people, and the CQC should be required to answer serious questions as to why it can describe it as ‘a new service’ and the Aug 2009 inspection is supposedly its ‘first inspection’. And yet, there have been 4 Safeguarding referrals, with ‘recommendations’ resulting from 2 of those referrals. That’s not what I’d call good.

    As long as there are no strictly enforceable rules regarding staffing levels, rather than this sloppy CQC “Care staffing tool policy & guidance” doc, the majority of care homes (with or without nursing) will continue to operate with shamefully low staffing levels.

    The cynic in me returns to remember that the average length of stay in a residential care home is about 3 years; the average in a care home with nursing is less than 2 years because the residents there are already more disabled and sick and in need of nursing care. That could be one of the reasons behind all the long-drawn out investigations, reports taking more than 4 months to get to the CQC website. And the plan to allow care homes to self-regulate and self-monitor will result in more people dying before the CQC even knows they were residents in care.

    That’s where the record gets stuck – because of the broken needle of the CQC.

  3. And so it continues.

    As you know, I work in a care home and am proud to do so. I leave (it) with a clear conscience after every shift. It provides excellent care and the residents are well cared for and indeed loved – but we are never smug enough to be complacent – always striving to be better.

    I have total respect for the carers who are my colleagues and they and I afford this total respect to the residents. It is a happy home. This is not say that we have never had ‘bad apples’ (and this includes nurses) but they are weeded out through supervisions and appraisals and eventually leave. It is a sad fact that with present legislation, it is very difficult to dismiss a member of staff – outside blatent abuse – as their rights (in law) come into force the minute they first step through the door.

    Homes need proactive management and it is also a sad fact that management need no longer have any nursing background – which I think is essential. A home can only ever be as good as its staff – and if staff are allowed to offer only basic care, it is a reflection of poor distant management.

    We personally feel attacked when care homes receive bad press as it appears that (they) are all clubbed together as ‘hell holes’ but that said, we realise that hell holes do indeed exist. Sadly, excellent care homes never receive media attention – but why would they? It is our sincere hope that many exist out there – but do they?

    With reference to Kersal Mount – it is interesting to note that the inspection was unannounced. Any manager with half a brain will realise that when asked to complete an AQAA – an inspection of some kind is imminent. Thus an inspection is never truly unannounced – giving homes the opportunity to tidy up loose ends.

    An inspection is only as good as the inspector and it is true that ticking boxes does not equate to good care. Local Authorities appear to be more robust in their approach – but perhaps only being more robust in the amount of boxes requiring a tick. The amount of required LA paperwork (outside inspections) is of monumental proportions and actually disallows management time on the shop floor.

    I feel the GP mentioned was scapegoating in his/her statement that the home refer Mrs Betts to specialist care – for only a GP can inniate this. This of course, is not to an attempt to absolve blame from the home. I wish to God that visiting health professionals would speak out, shout from the roof tops, anything that would bring bad practice to the fore before it is to late.

    I don’t have an answer cb – but share your fear that as long as homes are able to self-inspect – the problem will grow. Your point raised that The Laurel and Limes Care Home will always appear to be two starred is not something I had considered – but you are indeed correct.

    Please continue to be a broken record – residents in care homes need you to be!

    Anna :o]

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