Learning from Experience Database - Serious Case Reviews

View Serious Case Reviews by Theme, Local Authority Area or Year

Summer Vale (Leicestershire)

The abuse described in the BBC documentary, ‘Can Gerry Robinson Fix Dementia Care Homes?’ was one of the reasons for having a Serious Case Review. Summer Vale Care Centre was a home for 26 people with dementia and/ or mental disorder, until it closed in October 2009. Nine agencies, including the home’s owner, Minster Care Management Ltd., prepared information about events that led up to the disclosure of sexual assaults in the home. The Serious case Review has found that Summer Vale Care Centre did not ensure the safety of its residents; although the exact number of abusive incidents in the home is unknown, a dismal picture of the lives of residents emerged; a woman who was a National Health Service Continuing Healthcare funded patient was repeatedly physically and sexually assaulted; there were lots of incidents and concerns and even though there were around 60 professionals involved in making sense of this information, all of whom agreed that something should be done, no one asked searching questions and no one assumed a lead role; Summer Vale Care Centre did not train or supervise its staff; those who asked the home to provide placements and those who inspected it believed the home’s managers when they said that they were “monitoring” residents who were either violent and harmed people sexually or were the victims of assaults.

Professional learning:

  • Safeguarding alerts should use unequivocal – as opposed to coded – language, most particularly when these concern sexual assaults;.
  • Resident-on-resident abuse should be reported and acted upon as a matter of urgency.
  • Safeguarding investigators should receive training in order that the functions of “monitoring,” and “risk assessment” and “risk management,” across sectors, are fully understood.
  • Safeguarding should be a central focus of commissioning and contract activity.
  • NHS commissioners, managers and clinicians, most particularly in primary and Continuing Healthcare, be required to receive training in order to be aware of their responsibility to support and protect vulnerable adults in any service, especially those that are failing and to ensure they know how to report concerns.
  • Assessment and admission practices in their homes to be subject to on-going scrutiny.
  • Universities and colleges responsible for the professional training of students (medical, nursing, social work, psychology and therapies) should be familiar with safeguarding procedures and report on all concerns raised by students in their placements.

2010 Serious Case Review regarding Summervale Care Home (Leicestershire)