CQC response

Response to the CQC Inspection Report dated November 2014 and Based on an Inspection Carried Out in August 2014.

Background

In August this year two inspectors from CQC visited Perton Manor.  This was an unannounced visit, which in itself wouldn’t normally have been cause for concern. What did concern us was their manner and behaviour. From the start they were aggressive, demanding and rude, even to a professional visitor. They barraged staff with questions but appeared to listen less to the answers than form their own opinions.
 
On receipt of their findings I responded to each allegation, refuted most and submitted a formal complaint. Based on my response certain areas were re-worded and deleted but still not enough to reflect the reality of the care provided by us at Perton Manor.
 
CQC have now published the report and it paints a picture of poor care, which is far from reality. I therefore have no choice but to publish my own report and outline our response to the issues highlighted in the report. For the sake of client confidentiality I can respond to examples highlighted in the report but not go into further detail. My aim is to reassure you that Perton Manor is nothing like how it is painted in the CQC report and I will do my best to do that.
 
What has been very gratifying and humbling is that we have received messages of support from some relatives who have said that they can see with their own eyes how much the staff care and how well looked after our residents are. Thank you for your words and support. You have brought light to what we feel is a dark and upsetting episode that we’re going through.
 
Before responding to each allegation I would just like to tell you a little about me and about how this report has made me and my staff feel.
 
I have been looking after vulnerable adults with extreme needs for 14 years and have a good reputation with authorities and relatives who place trust in me to care for their clients and loved ones. I never take this for granted, never rest on my laurels and my staff and I are always looking for ways in which we can do what we do even better.
 
Perton Manor and its sister home Woodford House care for vulnerable adults who have extreme dementia and mental health problems. This can make for a very challenging environment to both live in and work in. I am proud of our track record in caring for all of our clients in both homes.
 
Our aim is always to deliver the best care possible and not just make sure our clients are clinically and physically looked after but mentally stimulated and as emotionally contented as possible. To achieve that we recruit only those who want to be there for the right reason – that is those who care and want to make a difference to the lives of our clients and their relatives. We provide extensive training so that best practices are adopted and maintained and also make sure that our strong culture based around the well being of our clients is at the core of all we do.
 
The inspection and the resulting report has upset me and all of my staff, whether my carers who look after and genuinely care for our residents, my nurses who make sure their physical well being is as good as it can be, the well being team who create stimulating activities for our clients and take them out on trips, the kitchen staff who work hard to provide nutritional meals and my housekeeping and maintenance staff who provide a safe environment to live in. All care and the way our home has been inspected and the things that have been said about it has upset all of us.
 
In all these years I have never received an inspection report like this and know that I shouldn’t have this time. But more importantly, I want you to know that. I want you to know that your loved ones are well cared for because my staff and I see them as part of our family and we would never do anything that would cause stress or harm.
 
Before moving on to the inspection I think it’s worth highlighting that not long after the inspection at Perton Manor, Woodford House was inspected and met every single standard. I was there for the inspection and the inspector had a clinical background, was clearly very experienced, asked probing but fair questions and listened and judged objectively. Here is the link to that report – http://www.cqc.org.uk/location/1-121467842.
 
We train all staff for both homes using the same facilities, trainers and agendas. We have the same organisational structure, the same culture and values, the same pay grades, the same everything. The extreme difference of the two reports can only be down to how the homes were inspected.

The Inspection

We found out that, as stated in the report, the inspectors were visiting because of concerns raised. These concerns were based on safeguarding reports, which were individually investigated and for which we were deemed to have done nothing wrong. At no point was there any hint that any client was receiving less than the best care possible.
 
Unfortunately, safeguarding incidents can be reported by anyone including those like a disgruntled member of staff who say, didn’t get the holiday they wanted or by a visitor who may genuinely feel something is wrong but who has next to no experience of a client’s needs or possible extreme behaviour.
 
I wasn’t at Perton Manor at the time of the inspection but have no doubt that my managers can handle any fair inspection carried out by inspectors who are experienced enough in the type of clients we look after and who understand the challenges we face. Knowing this from past, positive inspections and from the independent feedback from a number of my staff I strongly feel that the inspection was unfair, biased, and factually incorrect and that it was carried out in an aggressive manner and by inspectors we felt were not qualified to inspect these types of clients.
 
Because of the extreme mental state of our clients Perton Manor’s two wings are secured and will only open using a key fobs. On arriving the inspectors were asked to wait in reception whilst the Nurse Manager was found and could escort them. Instead the inspectors took it upon themselves to barge past a carer who had opened one of the wing doors.
 
From then on they demanded to know who people were, dismissed their qualifications and experience, barraged people with questions and either didn’t understand the answers or simply chose not to listen and to form their own opinions.
 
A number of claims were made with regards to information they received and they made judgements based on not having the right information. In some cases it came down to our manager’s word against the inspector’s. Either way, in each case I will state the reality of the situation.
 
According to the CQC inspectors, we didn’t meet standards and actions were needed in three areas. I’ll cover each in turn.
 

Care and welfare of people who use services

“Care and treatment was not planned and delivered in a way that was intended to ensure people’s safety and welfare.”
 
They started this section commenting about the ‘loud pop music’. It was ‘Smooth’ radio and if it was too loud on that occasion I don’t think is necessarily detrimental to safety and welfare. The music is the clients’ choice as most are younger in their 50s and 60s and not ‘elderly’ as they are young at heart.
 
“We spoke with or observed the care of the majority of people who used the service. Not all were able to tell us how they found life at the home due to their frailty and health conditions. Some people told us they were ‘alright’, some said they would like to go home. Some people looked comfortable and composed, other people appeared agitated and troubled. Staff had been assigned the responsibility of supporting people when they required one to one support.”
 
We care for clients with extreme dementia and mental health problems. The above sweeping statement paints a negative picture. This describes our client group and the condition of any people who suffer from these diseases. When I pointed this out CQC said. “These are the inspector’s observations on the day and not a direct criticism of the service.” It’s a shame that they made this statement under this section about care and welfare and under ‘Reasons for our judgement’. Why couldn’t they have said this at the start of the report and add that this was simply an observation and not a criticism?
 

Care Plans

There were criticisms of our care plans with regards to accuracy and being kept up to date. Care plans are archived with the most relevant information with the nurses. Complete client folders are far too unwieldy but available if needed.
 
No archived notes were requested. In addition to their behaviour, a large part of my complaint to CQC was the seeming complete lack of communication. CQC have since concurred that this seems to be the case – this being an example in point.
 
After receiving CQC’s findings (over a month after the inspection) I decided to carry out a thorough review of all care plans. Although a few ‘i’s needed to be dotted and ’t’s crossed (no-one is perfect), the care plans did and do reflect the needs of our clients.
 

Wounds and Dressings

The report gives the impression that we don’t treat or care for people with wound issues; that we don’t have a plan in place, don’t use the right dressings and don’t seek guidance.
 
Wounds care plans are supported by additional documents such as body maps and documents called ‘SKIN bundles’, which we could have shown too if they’d been asked for.
 
We can only use specific dressings after a prescription is issued from a client’s G.P. This can take time (including in some cases over a week) and so as an interim we use ‘stock’ dressings whilst waiting for the prescription. These dressings are purchased by the home to use in emergency/crisis situations or whilst waiting the return of a prescription.
 
We have fully qualified nurses who manage wounds and pressure areas and do not need to refer to bodies such as Tissue Viability (TV) specialists for guidance until a wound reaches a certain scale when we follow TV guidelines.
 
Clients, like one referred to in this report can come to us already with wounds and ee follow the correct guidelines for specialist referrals such as this one. Dressings can be ripped off and closed wounds picked open. We respond immediately to these challenges and cannot (and do not need to) wait for ‘guidance’ from doctors or specialists. If we did the physical well being of the client would deteriorate further, hence the need for dressings to be available on site. In this particular case, the client was actually dislodged from hospital without any dressings.
 

Moving and Handling

On feedback at the end of the day my manager was upset to hear that the wrong methods of handling had been spotted in the morning and that the inspectors had waited until the end of the day before bringing this to his attention. We strongly feel that the inspectors’ also have a duty of care to stop such practice or immediately report it. They didn’t and neither could they say who had carried out the practice, which meant we couldn’t investigate it.
 
We provide correct and appropriate instruction to new staff and then mentor them in its practical application and refresh staff yearly in its delivery. We have skilled and senior staff present in a clinical role on every shift, this is inclusive of managerial staff, who monitor the correct application of care delivery. None of the practices described by inspectors match observations over many days, weeks and months by our own staff.
 
All staff know how and when the appropriate equipment should be used and know that no one is lifted under the arms. All staff on shift were questioned post inspection about this comment and behaviour and they are adamant that this did not occur.
 
“In the care records of the six people we looked at we did not see any reference to the use of handling belts in the moving and handling risk assessment.” That’s because these particular clients didn’t need them. Again, the inspectors word it in a way that sounds as if we were doing something wrong or negligent.
 

Safeguarding people who use services from abuse

“People who used the service were not protected from the risk of abuse, because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.”
 

Wings and Doors

This judgement seems to focus around our clients’ restricted access. Again, their comments suggest a lack of understanding of how to care for our types of clients and their challenges.
 
Yes, each wing can only be accessed via a secure door, but each wing works independently of each other, each has its own lounge and dining room areas and access externally to the gardens. Each unit has its own drinks making facilities and is serviced by a hot trolley from the main kitchen. Bathrooms and toilets are available on each unit.
 
The inspectors focused on the locking mechanisms of the clients’ rooms.  The doors are such that they need to be unlocked using a key to get in and hence are deemed locked, but can be opened from the inside to get out without needing a key. Residents are let in by a member of staff and can let themselves out anytime they like. If the doors were kept unlocked then people will wander into each other’s rooms causing distress to those whose rooms they are. These doors are like their house front door.
 
There is only one client who is at potential risk of not being able to leave his room and a risk assessment is in place. This client was also not a straightforward case as he would sometimes lock the door himself out of preference.
 
When I first opened Perton Manor all door-locking mechanisms were checked by safeguarding and the fire officer who all felt that it was an appropriate locking system for the client group. This home was registered by CQC in April 2013 and the locks were signed off as appropriate for use at this time. No changes had been made to the locks during this period until this inspection. Alternative locking systems have since been sourced to satisfy the quirks of these CQC inspectors.
 

Deprivation of Liberty Safeguards

All of our clients have had DOLS requests, made in line with the new guidance following the precedent set in court recently. We know when to make DOLS requests and the need to inform CQC of the outcome. CQC had received notifications of those we held. In fact, the new CQC guidelines mean everyone living in a care home requires DOLS.
 
I have letters from local authorities stating that they do not have the capacity to deal with DOLS quickly at the moment and that they are aware of the shortage in their own resources and government have been informed.
 

Restraint

We absolutely follow and are compliant with the Department of Health guidelines and everything is recorded, as it should be. The inspectors said we were not compliant with NICE guidelines that came out this year. We weren’t aware of these new guidelines and couldn’t find them anywhere on the NICE website. Our staff are trained by NHS Trust trainers and these trainers were also not aware of such guidelines.  Our nurse manager asked the inspectors for a link to these guidelines but wasn’t provided with one. Since then the inspectors and their report dropped any mention of these guidelines and referred only to the known Department of Health ones. This clearly shows a lack of knowledge on the part of the inspectors.
 
Any records of restraint are fully documented and there is no reason why my staff would say otherwise.
 
And here is another example of miscommunication and making judgements without making sure the full facts were known. “We had concerns regarding the safety and welfare of a person who used the service. We spoke with the clinical nurse lead who informed us that a safeguarding referral had not been made in regard to these concerns.”
 
There was no need for a safeguarding referral in this case. For the sake of client confidentiality I cannot go into detail but the person didn’t meet the criteria for making a safeguarding referral. My manager tried to explain this but they didn’t care to listen to this explanation and threatened to report it to Safeguarding if my manager didn’t. Feeling pressured he agreed to do so and having agreed we were then found to be guilty by CQC of not responding appropriately when concerns regarding a person’s safety and welfare were identified. Effectively we were damned if we didn’t and damned if we did. The Safeguarding we raised was actually against a hospital.
 

Assessing and monitoring the quality of service provision

“The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.”
 

Safeguarding

The concerns that CQC refer to are the safeguarding referrals that led to the inspection. Safeguarding referrals can be made by anyone including visitors who, with respect aren’t experts and disgruntled member of staff or even ex-member. It is a case of guilty until proven innocent and we have found to be innocent in all cases where investigations have been completed. We run a good, caring home.
 
Because we’re not made aware of who made the safeguarding referral we did wonder if because of the extreme behaviour of some of our clients and sometimes violent incidents that can occur not just against staff but against other residents, visitors could naturally be upset by what they saw and thought they needed to report. This has led us to thinking that we should try and help visitors understand better the environment they are visiting and why people behave in this way. This does not imply a breakdown in communication but an effort to improve further the strong communication we feel we have with all who visit us.
 

Reporting

CQC talk accurately about the fact we were transitioning all our accident, incident. Complaints, etc reports over to an IT format. This was ongoing at the time of the inspection. “At the time of the inspection the audits and checks that we asked to see were incomplete and inadequate, the quality and safety of the service could not be guaranteed.”
 
This strongly implied that we had no system in place. We still had the current paper system and the inspectors refused to see the paper evidence available for this process. They say they asked to see the paper records which my manager refutes as he would have shown them if asked. Our IT version is showing a full year’s history up to present day. Our memory isn’t that good and so of course we have the paper records and could have shown them on request.
 
We do have deprivation of liberty safeguard authorisations that are up to date and complete. Why would we not do something that is a legal requirement and easy to show? Our records, including safeguarding referrals, are available. We record all safeguardings we are informed about or we raise ourselves, we also double check this with the local authority (LA) on a quarterly basis to ensure we capture correct information.
 
The Specialist Adult Protection Investigation team are good at letting us know the outcomes so tracking documents can be completed and outcomes recorded, this is not so for LA referrals that did not meet the threshold, this has been reported back to LA via the Quality-monitoring officer.
 
The folder is available and we also were in transition of recording this electronically to assist in monitoring.
 
Finally, we invest a huge amount on training our staff and are proud with how much time, money and effort we put into this. I am more than happy to show anyone our full and comprehensive training matrix. We also pay our staff to attend all training, which is not the case for many homes.
 

Actions We Have told the Provider to Take

We have been put in the impossible position of being required to tell CQC of the actions we are going to take to meet the standards they say we are not meeting, but which in fact we are.
 
I have gone back to CQC and refuted 95% of what they said. “We will check to make sure that action has been taken to meet the standards and will report on our judgements.” My staff and I look forward to this check and to the report they will make.
 
Just to comment on a couple of things the inspectors said in their summary. The inspectors referred to our re-organisation. We review and if necessary re-organise on an on-going basis to ensure that our homes run as efficiently and effectively as possible and with the emphasis on the well being of our clients. The inspection report refers to a clinical nurse lead and a deputy care manager, neither of which we have. These roles are not in our organisation. Again, it appears the inspectors didn’t listen to the answers to their questions or didn’t understand.
 
They also quoted apparent concerns by visitors they spoke to. Please, know that if you do have any questions or concerns you can speak to my managers or me.
 
As I said at the start of this document, what’s vital is that you know your loved ones are safe and well cared for in our home. Anything else is, has always been and will always be, unacceptable.
 

Thank you
Julie

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