Learning from Experience Database - Serious Case Reviews

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Torbay NHS Trust

This Serious Case Review was commissioned to consider historical safeguarding adults concerns dating back to 2007 regarding the possible abuse of residents in a nursing home.  The Review looked at the evidence for alleged poor or abusive practice. Records were found to be incomplete, with inconsistencies between records held by different agencies of safeguarding activity, which made it difficult to gain a full picture of the concerns, action taken and outcomes. The concerns led to 21 safeguarding strategy meetings and the majority of these were followed by one or more case conferences. On four occasions the concerns raised were substantiated but further action was taken in only two cases. It was not possible to be certain about whether any abuse was suffered by residents of the nursing home during the review period, or about the standard of care or management of the home at that time. Investigation of these matters at the time was inconclusive and subsequent enquiries have been similarly inconclusive. However, during the review period there were persistent and significant concerns that residents may have been subject to abuse, evidenced by the number of complaints and safeguarding alerts made by residents, relatives, staff and visiting professionals and the associated safeguarding activity. A Whole Home Investigation was held due to the large number of safeguarding concerns to consider the risks to all the residents in the home. This Whole Home Investigation lasted for more than two years and failed to reach a conclusion.

Professional learning:

Decisions to undertake a Whole Home Investigation should be taken at a senior level with due consideration and that the Investigation has clear leadership, management oversight and is adequately resourced so that the work can be carried out within a reasonable timescale.

Safeguarding adults policies and procedures should be reviewed to ensure that the relationships between the commissioning, contract monitoring and safeguarding are clearly specified and that safeguarding matters must have primacy in decisions about commissioning and contracting.

Contracts, commissioning and regulatory staff should have a means of monitoring the take-up and delivery and impact of training modules for staff at all levels in the NHS and the independent sector.

The need to review the arrangements for the provision of health care to residential and nursing homes to make the most effective use of a limited resource and ensure as far as possible continuity of healthcare to residents.

Fully integrated healthcare should be provided to all residential and nursing homes with close clinical oversight and support to home managers. Opportunities should be explored for linking GP practices to Care Homes. Care, nursing and treatment plans must be fully aligned.

GPs should put their medical notes into the Care Home notes as well as their own surgery notes.

The review highlighted CQC’s failings in the follow up of concerns received as a result of operational difficulties within CQC and the adoption of new inspection and review methodologies.

2013 September SCR regarding Torbay NHS Trust