Regulation in care homes: what does it take to act?

IT’S SUPPOSED to be at the heart of patient safety in our health and social care system, but an investigation by The Detail into policing of care homes by the Regulation Quality & Improvement Authority (RQIA) raises serious questions about the effectiveness of the agency.

We have studied dozens of reports of inspections carried out by the agency and discovered that in spite of some disturbing findings and police investigations into alleged abuses in care homes, RQIA has not closed any homes and has limited admissions to only two since it was set up in 2005.

The ability of the RQIA to even fully record abuse and poor care is also called into question: we’ve spoken to a woman whose mother suffered six fractures in a home – but the incident is not included in any of the inspection reports for that home; in another home an incident reported as a Serious Adverse Incident by the health trust is also not mentioned in any inspection reports.

The inspection reports available on RQIA’s website show some disturbing examples of poor standards in care homes, including:

• One care home was subjected to 22 unannounced inspections over a nine-month period after serious concerns were raised about issues from staffing levels and morale to infection control and capability of staff.

• In another care home in Antrim an important medical examination/sample was not provided for analysis five weeks after it was requested by a GP as the patient’s health continued to deteriorate.

• In a nursing home in Belfast serious criticisms were made about the treatment of patients suffering from incontinence with nursing staff failing to recognise this as the reason for the patients’ restlessness and discomfort.

However in spite of serious issues raised time and again in many reports, RQIA has never used its powers to cancel a home’s registration or prosecute for specified offences; it has also only used its power of limiting admissions to a home on two occasions.

But does RQIA’s approach reflect that the issues it encounters in homes are not serious?

Figures obtained by The Detail from the PSNI reveal there were 21 cases of alleged abuse of vulnerable adults in care homes in NI deemed serious enough to involve the PSNI’s Public Protection Unit (PPU) from December 2010 to May 2011. The PPU generally only become involved if it is a serious or criminal issue.

These figures, obtained through the Freedom of Information Act, are most likely an underrepresentation of the true scale of alleged abuse as they only include five of the eight policing districts in order to comply with the financial restrictions on FOI requests.

A DAUGHTER’S STORY

Jennifer, who wishes not to use her full name as her mother is currently a resident at another care setting, had cared for her mother for thirteen years but contacted the Brook Nursing Home in Coleraine as she was finding it increasingly difficult to cope with her care needs.

Her mother is in the later stages of Alzheimer’s and, because The Brook care home is purpose-built for people with dementia, she decided to register her mother in the facility. But within a few months she became concerned for her mother’s welfare.

“In June of last year, my mother had been feeling unwell, she had a chest infection which she had tablets for. A couple of days after she’d finished the tablets I received a phone call to say she had fallen twice during the night, but there where no injuries. So I went into see my mother that afternoon and she couldn’t walk.

“I wanted the doctor, but I was soon informed by that staff there that my mother was ‘putting this on’ because I was there and there was nothing wrong with her.”

Because of her condition, Jennifer’s mother was finding it difficult to communicate how she was in pain. Jennifer claims she became increasingly frustrated after the manager of the home took the same approach of the nursing staff and advised that nothing immediate was wrong with her mother.

“I stood my ground and insisted that they call the doctor. They eventually did, but I would find out later in a conversation with this doctor that the staff had played down the situation to him and said I was overreacting. As a result of this, he said he would call out at some stage the next day.”

At 4am that morning, Jennifer’s mother fell once again, but it wasn’t until 1pm the next day, when the doctor arrived, that Jennifer received a call from the home about the incident.

“The call came from the staff saying ‘your mother fell again, the doctor is here now – we think she may have broken her arm’. I was furious that they were only deciding to contact me now and they had actually waited for the doctor to call out instead of contacting him immediately.”

By the time Jennifer arrived, her mother’s feet were so swollen her slippers wouldn’t fit. Jennifer and the doctor made the decision to take her straight to the hospital.

Jennifer’s mother spent the next five weeks in hospital with a broken leg, a broken arm, and four bones in her right foot fractured, as well as a severe chest infection and a severe urine infection.

Afterwards Jennifer wrote to the Northern Trust which manages the home.

She said: “All they could offer me was a meeting, but as I said at the time: ‘I do not want to face these people again’, because when my mother fell and I was basically being ignored I was trying get the point across that I knew my mother better than them. I was saying basically ‘I’ve known her for 60 years, you’ve known her for two or three months.’"

Jennifer’s mother hasn’t walked since; she is unable to stand up on her own and needs assistance to be turned in bed.

We contacted the Northern Trust who confirmed that they had received two letters from Jennifer and that they were dealt with through the formal complaints procedure.

A spokesperson for the Northern Trust said:

“We cannot comment on individual patient or their treatment through the media.

“We take very seriously our duty of care to service users and we actively encourage comments and complaints from patients and their carers. All complaints are formally investigated and responded to through the official complaints procedure.

“The Trust works in partnership with patients and their carers and will discuss and consult on the best available options for individual patients, however if an individual is unhappy with a response we would be happy to discuss this with them further.”

THE REPORTS

In this edition of The Detail, we have looked at some of the findings about other homes detailed within RQIA’s own inspection reports – and a clear pattern has emerged of no action being taken against any of them. We also look in greater detail at the very legislation that established RQIA and ask what powers they have and how they use them.

The majority of RQIA’s inspection reports are published online once open – which is normally around eight weeks after an inspection. RQIA began the process of placing inspection reports online in November last year. At present over 3,200 inspection reports are online. RQIA claim they are adding well over 100 new inspection reports per month but we have had to specifically request for a number of reports that were not available on the RQIA website.

In the inspection reports on The Brook care home there is no mention of the incident concerning Jennifer’s mother.

Initially there were four inspection reports available on RQIA’s website for The Brook care home. They dated from December 2009 to August 2010. However, we had to contact RQIA directly to get the two most up-to-date reports from this year.

In the first inspection report from the 15th December 2009, the inspector notes:

“Concern has been highlighted during this inspection, with the number of residents who have assessed nursing care needs, and the ability of the home to meet these assessed needs.”

The December report also indicated a “recent incident”, which should have been notified to the Authority, of facial bruising to a resident, with an unknown cause. A further requirement was made for the registered manager to investigate this and also to ensure that the residents next of kin and aligned care manger should be notified, which they were not in this case.

The August 2010 inspection still pointed out that “a significant number of accidents and incidents from January 2010 to March 2010, had not been signed off by the registered manager and were not reported as trust protocol to line management. “

It also noted that any accidents affecting the well-being of resident had not been notified to the Authority and this recommendation was restated again. A recommendation by the inspector was made in the Quality Improvement Plan that effectively immediately emphasis would be made to all senior staff and appropriate documentation sent to the authority.

In the August report the inspector claims to have met one relative visiting the home at the time of the inspection who “spoke positively about the home.”

Jennifer, meanwhile, says she was never consulted.

She said: “To be honest I wasn’t even aware the RQIA existed until the other day when I saw one of the inspection reports up on the notice board of the new home my mother is currently a resident in.

“I must admit now, I am extremely careful about everything that goes on in the current home and watch everything that goes on, because if that was able to happen before and there is a body out there that was aware of these failings and it was still able to happen, it leads me to seriously question its ability.”

The incident concerning Jennifer’s mother took place in June 2010, a month before the RQIA report in August 2010. It makes reference to “accidents and incidents” from January 2010 to March 2010, but no mention of Jennifer’s mothers case.

Jennifer says she still feels a certain amount of guilt over what happened to her mother but also believes the system is flawed.

“You do think ‘God if I hadn’t put her in the home this wouldn’t have happened’, but you go into these situations assuming that she’s going to get the best care possible and that they have to be run a certain way, with certain standards.

“All I can conclude is that there isn’t enough being done to check these places out, I can’t speak for every care home, but from my own personal experience I definitely think they should be regulated far better than they are.”

The August report was the latest report we could access online, when we contacted RQIA directly they were able to provide us with two further inspection reports from January 2011 and July 2011.

The report from January noted that all serious incidents were now being notified to the authority and a review of accident/incidents reports, found that they were now being attended to appropriately. However the latest report noted that from April to July 2011, accident reports were were not signed off as reviewed by the head of department, as per Trust procedure. A requirement was made for all reports to be signed off by the registered manager / acting registered manager on a regular and up-to-date basis as reviewed / inspected, and processed as per Trust procedure.

This was the last report published online and there is no specific mention of Jennifer’s mother’s case.

“NO REQUIREMENT”

We contacted RQIA about this case and they claimed that as the tenant was living in a supported living scheme they would not be subject to the same regulation as similar services provided within residential care homes. Jennifer’s mother had an independent tenancy within the Brook Care home and was in receipt of domiciliary care.

RQIA say that under the Domiciliary Care Agencies Regulations there would be no requirement to report such an incident to them – it is only specified incidents reported to the police by the agency that would be reported to RQIA.

While there are six residential care beds within The Brook, the remainder, some 51 service users, also have an independent tenancy agreement and therefore any incidents of this nature that occurred during their stay would not be subject to RQIA regulations either under current legislation.

POND PARK

We have also discovered that care of a woman in a home in Lisburn, Pond Park, was classified as a serious adverse incident – a red flag within the health service – yet again is nowhere to be seen in RQIA reports.

The patient, whose name has been blanked out of the SAI report obtained by The Detail, had been staying in a residential home when they were transferred to Pond Park Nursing Home. Her condition deteriorated during her five-and-a-half week stay there and she was transferred to hospital where she died.

The incident report outlines that a review was carried out by a Northern Health and Social Care Trust staff member and a number of issues were identified with the care being provided in the home.

These issues included:

• reduction in fluid and food intake with a noted weight loss of 8kgs in the five-and-a-half weeks following the patient’s admission to the nursing home;

• that the deceased had been refusing food for two days – later linked to mouth ulcers she was suffering;

• concerns about the administration of sedation to the patient which increased significantly since her transfer to Pond Park nursing home.

• concerns about the number of falls in general in the home which trust staff felt may have been linked to the sedation regime at the home.

• that medication recordings regarding the sedation were not clear in the nursing home records.

The report outlines that the deceased was admitted to the hospital; her daughter advised NHSCT staff that she did not want her mother to return to the nursing home as she was unhappy with the care that was provided there. A diagnosis on admission to hospital was severe dehydration and urinary tract infection; the patient then developed a chest infection while in hospital; her condition deteriorated further and she passed away.

The serious adverse incident reports date to the 21st December 2009 and it notes that RQIA was contacted and advised of the concerns regarding the care of the deceased on the 25th of November 2009. We can reveal the reports that RQIA conducted themselves over the next year that show that the Pond Nursing Home was constantly failing in the very areas that it was alerted to but that little or no action was taken.

Announced Inspection Report from 6th & 7th January 2010

(three months after first being made aware of the problems)

There were seven requirements and two recommendations made as a result of this inspection, included in this the inspectors observed a patient being nursed in a bed and in receipt of subcutaneous fluids for rehydration, the inspector noted that a number of records were not in place to evidence care, including:

-Ensure accurate fluid intake and output charts are maintained

-Monitor the cannulation site and record the findings

-Ensure staff date, time and sign fluid balance charts and reposition records when care is delivered.

The inspector noted the patient’s care records did not contain comprehensive information regarding the care and treatment of subcutaneous fluids which had been prescribed and were being administered. A requirement was made to ensure accurate fluid intake and output charts are maintained and monitor the cannulation site and record the findings. This was noted to by the inspector to be “immediately and ongoing”.

Unannounced Inspection Report from 26th April 2010

(five months after first being made aware of the problems)

A recommendation to promote and make proper provision for the nursing, health and welfare of patients and supervision of patients was stated for a second time. In the “Additional Area’s Examined” a number of patients were observed by the inspector to be requiring a high level of interventions by staff in respect of supporting food and fluids. Concerned was raised regarding the absence of fluid balance records and food intake records by the bedside. Staff are unlikely to return to patients files on each occasion when water etc. is given to each patient, accurate food and fluid intake therefore cannot be achieved. The inspector notes that this was discussed at length with the service quality advisor who gave assurances that this would be addressed immediately.

The inspector whilst touring the original side of the home observed care delivery to one patient named as patient “A”. This patient was restricted to the bedroom due to a wound infection and required full support with all aspects of daily living. Patient A was noted to have poor communication, displaying a lack of response when being spoken to. The inspector observed that in a number of rooms were more frail patients were being cared for there was a lack of documentation available on issues such as fluid balance records, food intake records and mouth care records.

Patient A is recorded as having weight fluctuating, but no record in evaluation of what the weight is or how much is lost. When discussing this with the deputy manager the inspector was advised that both hoist attached scales were broken. This patient is unable to be accurately weighed on the sit on scales. The inspector recommended scales be repaired or replaced with urgency.

Later in the report, the inspector once again refers to fluid balance records not being evidenced to be in included in the daily evaluation of care records of another patient- Patient “B”.

Announced Inspection Report from 7th & 8th September 2010

(11 months after first being made aware of the problems)

While the inspector can verify that there have been significant improvements made to the management of the health and welfare of patients within the home, there is still evidence that patient “A’s” records failed to evidence a reconciliation of the volume of fluid taken in each twenty four hour period. Some records indicate issues around poor urinary output, complaints of low backache and unsettled nights with some elements of increased confusion. The inspector lists concerns that there was no evidence that the nurses had linked the difficulties presented to a possible infection.

The inspector also makes reference to the fact that with patient “B” many references were found in records to “good oral intake” but there was little evidence of fluid reconciliation to the daily records.

They also sight poor management of risk in respect of weight lost in relation to a patient “C”. The inspector notes that recent ill health may have contributed to weight loss but this was not identified in the risk assessment care plan.

Unannounced Inspection Report from 18th October 2010

(12 months after first being made aware of the problems)

The inspector notes that fluid and food intake records should be maintained to reflect a comprehensive detailed overview of dietary intake but notes a new tool to record fluid management is not yet implemented in the home. The inspector was unable to evidence that fluid intake should be reconciled to daily records.

Apart from three medication reports which take place in February 2011, April 2011 and June 2011, this is the last care home inspection report available online.

In the four reports that take place at Pond Park after the death of the patient referred to in the original Serious Adverse Incident findings from November 2009, RQIA repeatedly makes reference to similar incidents as those surrounding the patient in the Serious Adverse Incident but does not take any concrete action or make reference to the original case. We contacted the Northern Trust for a statement but they would only confirm that the Serious Adverse Incident (SAI) was submitted and subsequent review had been carried out by them.

“MONITOR THE SITUATION”

We contacted RQIA about this case and they acknowledged that they had been made aware of the circumstances. After the incident there were a number of strategy meetings led by the Northern HSC Trust in relation to the incident to try and identify any regulatory issues arising from this case.

We asked RQIA why they had continually issued minimal recommendations despite the worrying failures by the nursing home. In a statement they said:

“Following each inspection, RQIA made a series of legislative requirements and recommendations, and the provider has responded to the quality improvement plans outlining how they will meet these requirements and recommendations. RQIA has checked the progress against these during each subsequent inspection and in each case has noted quality improvements. Areas requiring further improvement have also been identified. RQIA will continue to monitor the situation at Pond Park to ensure the safety and wellbeing of all those resident in the home.”

THE SYSTEM

RQIA currently employs 145 members of staff at a cost of £6m per year, including a team of inspectors who are tasked with assessing the standard of care facilities throughout Northern Ireland. They are made up of nurses, social workers, pharmacists, estates and finance officers to carry out a range of inspections across all regulated services.

As of the 31st March this year a total of 1,074 establishments and agencies were registered with RQIA, an increase of 143 from 31 March 2010, and 424 since April 2005, when RQIA was first established.

During the past year (April 2010 – March 2011) RQIA carried out some 1,840 inspections to 493 nursing and residential care homes across Northern Ireland. They only issued four notices of failure to comply with regulations on four occasions despite many inspection reports raising serious concerns about the care provided to some of the most vulnerable people in society.

To date RQIA have never closed down a care facility, they have never cancelled registration or prosecuted for specified offences, despite these powers being enshrined in the legislation that established them as regulator.

Jennifer remains frustrated:

Jennifer says: “If my mother had fell like she did and if I ignored it in my own home, I would have been prosecuted for abuse. If I didn’t get her medical attention the first time she fell I would have been up in court and rightly so. So why are the same rules not applied for care homes?

“I know I can do nothing for my mother anymore, but there needs to be stricter protocols in place so other people don’t have to endure the same ordeal my mother has.”