COLLECTIVE responsibility must be acknowledged over the shocking events that took place at St Michael’s View and to ensure they never happen again.
That was the belief of Dr Sue Ross when asked why visits to the care home by council and health workers failed to recognise the poor standards of care being given to residents.
The Independent Chairwoman of the South Tyneside Safeguarding Adults Board spoke out as the findings of the serious case review it commissioned were being published today.
It was sparked by the death of pensioner Joyce Wordingham – referred to in the report as Resident A in the report – an 80-year-old dementia sufferer who was found dead in her bed at the home in February, 2010.
The review, commissioned in May 2012, highlighted “systemic failings” at the home, run at the time by Southern Cross, and also made a number of recommendations for how agencies looking after residents in homes communicated and monitored their ongoing care.
When asked why council officers or health workers, who had carried out visits to the home, failed to pick up on the inadequate care being provided to residents in the run-up to Mrs Wordingham’s death, Dr Ross said “We need to do a lot more monitoring.
“Basically, it wasn’t good enough.
“The information that was coming out of those visits was not properly managed or co-ordinated – it wasn’t adequate.”
“Now, what we are saying is those arrangements are different, they are much more co-ordinated, and while we can never be complacent, we have addressed those systemic failures.”
“We accept as a safeguarding board that we know the quality of care of residents in that home was wholly unacceptable.
“Clearly we have not done what we should have. We accept it was a systemic failure for which Southern Cross and individuals were responsible.
“And we accept important lessons must be learned.”
Dr Ross also highlighted that new and more stringent procedures are now in place when commissioning contracts, to ensure care home providers are capable of delivering the requisite quality of care to residents.
“Monitoring of homes, which will include unannounced visits and spot checks, will also continue.
Dr Ross said: “We haven’t delayed in making the changes to improve the quality of care for residents.
“The council and its partners took immediate action to improve the quality at the home.”
She added closing the home at the time would have been a very serious decision to make and it had to be balanced out as to whether it would be more beneficial to keep residents in the home and ensuring good care was being provided or risk moving out people who were in the last stages of their lives.
The home, known as Bamburgh Court Nursing Home before Southern Cross taking over, had once before come under scrutiny when in 2004 a pensioner died due to neglect.
When asked whether this should have been taken into consideration and checks should have been more stringent, Dr Ross said that in relation to Bamburgh Court, the serious case review had “only concentrated on the events following the death of resident A”.
She added: “This was quite a wide scope as it also looked at the events of not only her death but also a number of other residents, within the serious case review.
“The scope was specifically in relation to the death of that individual and those others around that time so we could establish what lessons should be learned.”
After the takeover by Southern Cross, an inspection carried out by the Care Quality Commission, in 2008, found that standards were being met.
However, the home was later stripped of its two-star rating after an unannounced visit by inspectors a month after Mrs Wordingham’s death.
In nine and a half hours, inspectors catalogued a series of failings including care plans and assessment for residents not being carried out or left incomplete.
The hygiene of the home was also slammed.
Dr Ross said: “The role of the serious case review is to look at whether there are wider implications not just the events at St Michael’s View.
“The key thing is the relationships between the agencies that commission care in nursing homes have been significantly strengthened.
“There are much stronger monitoring and of coming together of those organisations to share information.”
“This was a very wide ranging serious case review.
“And I believe it was a thorough investigation and it was independently done.
“I am really keen to express our heartfelt sympathies to those families who have been affected by these awful events.
“We want to do everything we can to assure those families and the communities that lessons have been learned.”
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