Learning from Experience Database - Serious Case Reviews

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Msaada (Northamptonshire)

The SCR focused on Msaada Care Services after a safeguarding investigation highlighted widespread and systemic failings in care on the part of the provider.  Two specific cases were examined as part of the SCR as follows:

  • AH was a man of 87 who received domiciliary support from Msaada after he and his family arranged and paid for his own care. On 7th October 2010 AH fell from a stair lift in his own home when being taken upstairs by a carer from Msaada. The cause of death given was ischemic heart disease, a cause with which the family disagrees. What is clear, however, is that AH was not strapped into his stair lift and the arm rest was not in the correct position resulting in the fall.
  • JS was a man aged 37 who lived in rented accommodation and whose care plan involved two half hour visits daily from Msaada to provide support and assistance with medication. On the 16th October 2010 JS was found dead in his home. His family had been unable to contact him for some days and called the police. Subsequent enquiries revealed that JS had not been seen by any carer from Msaada since 11th October, five days prior to him being found.

Professional learning:

  • Where there is divergence between the findings of the local authority and CQC about a provider, there is a need for good information sharing so as to provide a reliable view of the risks posed. Collaborative working between regulators/commissioners in cases where the provider is unable to address service deficits and/or sustain improvements is also necessary to gain a common agreement about the priorities of improvement objectives so that the requirements of both agencies are met. These processes need to have an outcome rather than target focus.
  • Contract monitoring needs to be proactive and not just a reactive response to issues.  These processes need to have an outcome rather than target focus.
  • Services who do not appoint a registered manager for a significant period should be actively followed up by both CQC and commissioners so as to ensure appropriate accountability.
  • CQC and commissioners should have a clear process for checking and monitoring the financial fitness of providers. Commissioners should research with a critical eye and understand the financial probity of organisations with which they contract and fully understand the market in which they operate. Commissioners should have a Provider Failure Protocol and all providers should be required to have a contingency plan in place should the service fail.
  • Safeguarding processes and information sharing about concerns should be applied equitably to self-funders of care services.
  • Commissioners should ensure that preferred lists of providers indicate any current safeguarding concerns to support informed decision making abut placements.
  • Contracts and commissioning activity should support the safeguarding process for example, by implementing timely contract compliance and defaults measures and sanctions. There is a need for a clear audit trail of decision-making and escalation as necessary.

2013 April Serious Case Review regarding Msaada Care Services (Northamptonshire)