Pytchley Court Nursing Home, in Brixworth, failed to meet standards despite five CQC inspections over the past two years demanding improvement. In the latest CQC report the home slipped into an 'inadequate' rating in terms of safety and leadership (other criteria were judged to ‘require improvement’) after inspectors found repeated failures to make sure residents were safe.
Unacceptable delays in seeking medical assistance
Records showed one incident where, after a person suffered a nasty fall, their blood pressure indicated they could have been bleeding or in shock, but staff took two hours to call a doctor. Staff also failed to consult clinical records and grasp the full scope of what was happening to people obviously at risk who may have required medical treatment.
Inaccurate or outdated care plans
Nearly all of the home's nurses were agency staff who relied on care plans and risk assessments to do their jobs, but CQC inspectors found these plans were often incomplete or inaccurate. Sarah Cunliffe, a solicitor specialising in care home abuse and neglect claims, maintains that these failings are not uncommon in her experience, often with devastating consequences. Shoosmiths has dealt with a number of similar and tragically illustrative cases.
Elsie Clarke's story
Elsie Clarke was supposed to have been admitted for a two-week respite stay at a care home after a hospital stay to aid her recovery. Her son, Peter having visited previously, was concerned that his mother’s condition had deteriorated and was assured that a doctor would be called. When Mr Clarke visited again and asked staff what the doctor had said, he was told a doctor had not been called as promised. Elsie died just nine days after being admitted into the home.
Jane Parker's story
68-year-old Jane Olive Parker had a number of food-related choking episodes and her notes stated that she should be on a Stage 3 diet (food that is semi-solid, soft or pureed and easily digested). When Mrs Parker was transferred to a care home in Tameside, Greater Manchester staff did not assess her directly. No new care plan was put in place and crucially the existing care plan made no mention of her choking risk and erroneously stated that Mrs Parker should be on a Stage 4 diet. On 24 August 2016 Jane Parker choked to death after being given an inappropriate meal.
‘Unlike a residential nursing home, no-one reasonably expects that every single member of staff in a residential care home is medically qualified or a trained nurse. But surely it is not beyond those who operate these establishments to ensure that the staff available are trained or at least aware of and alert to the likely medical emergencies that might arise with vulnerable residents?’
‘Ensuring vigilant staff take prompt action in seeking urgent medical assistance when it seems necessary and taking the time to confirm that medical notes and assessments are up to date and accurate seems to be the very least relatives and the residents themselves should be entitled to expect from those, charged with and paid for their care.’
During their visit to Pytchley Court, CQC inspectors raised six safeguarding alerts from risks and dangers they spotted, including the fact that there was no reliable system in place to make sure people were drinking enough water. Inspectors also found three people living with diabetes with no risk assessments in place.
The report concluded ‘People who were living at Pytchley Court Nursing Home were not receiving safe care.’ The home now has six months to improve before they are reinspected and if nothing has improved, potentially closed down.
This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2023