Learning from Experience Database - Serious Case Reviews

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Wyton Abbey (East Riding)

This serious case review was undertaken to examine care offered between May 2011 and November 2012 to three people, two of whom died. The third person continued to live at Wyton Abbey. The circumstances were thought to be significant enough for a serious case review because of the medical condition of the residents and the range and depth of concerns about the safety of the home identified by both CQC and East Riding’s contracting unit and safeguarding team. The Coroner’s report on one of the residents concluded that he might not have died if he had received more timely medical help. From July to November 2012 placements were suspended at Wyton Abbey Care Home, owned by Prime Life.

There were concerns that despite several interventions over a seven-month period, there was no evidence of improvement in the care provided. The Coroner’s narrative verdict concerning one of the people who died said that earlier intervention might have postponed the time of his death.  During this period, a number of statutory partners were involved with Wyton Abbey over the period in question.

Professional learning:

  • The 23 recommendations contained in the SCR report fall into two categories:
  • The systems and processes needed to ensure the effective management of care in residential/nursing homes (including effective clinical management, care planning effective systems to monitor the delivery of care on a day to day basis, clear documentation and recording) and
  • Contracts and commissioning activity should support the safeguarding process for example, by implementing timely contract compliance and defaults measures and sanctions. This case also raised the question of whether there is sufficient focus within contracts and commissioning teams on supporting care providers re quality improvement (and continuous improvement) as a means of preventing the escalation of poor quality care into the safeguarding arena.  Quality monitoring must have an outcomes rather than target focus.

2013 Serious case Review regarding Wyton Abbey Care Home East Riding