POLICE INQUIRY LAUNCHED INTO DEATH AT A CARE HOME
HEALTH INSPECTORS’ CHECKS ON CHOKING RISK LEADS TO PROBE
POLICE are investigating the death of a woman at a care home.
The Care Quality Commission (CQC) visited Clarendon Mews, in Grasmere Street, Leicester, in September following “notification of a specific incident following which a person using the service died”.
In its report, the CQC said information received about the incident “indicated concerns about the management of people’s eating support needs and specifically the risk of choking”.
The home was rated inadequate and placed in special measures.
A police spokesman said: “An investigation is taking place following the death of a woman at a Leicester care home in September. Two women, aged 50 and 49, and a 39-year-old man have been interviewed on a voluntary basis.”
The CQC said the home’s owner has “taken prompt action” to remedy issues identified in its report.
THE death of a woman living at a care home sparked a visit from health inspectors and a police investigation.
The Care Quality Commission (CQC) visited Clarendon Mews care home, in Grasmere Street, Leicester, in September following the incident.
The home was rated inadequate and placed in special measures.
Concerns raised by inspectors included a PPE trolley stored in a toilet area, routine physical restraining of residents and cartoons deemed “inappropriate” on the TV at a mealtime.
A note in the report said: “The inspection was prompted in part by notification of a specific incident following which a person using the service died. This incident is subject to a criminal investigation.
“As a result, this inspection did not examine the circumstances of the incident. The information CQC received about the incident indicated concerns about the management of people’s eating support needs and specifically the risk of choking.”
A police spokesman said: “An investigation is taking place following the death of a woman at a Leicester care home in September.
“Two women, aged 50 and 49, and a 39-year-old man have been interviewed on a voluntary basis.
“Officers are working alongside statutory partner agencies to carry out further inquiries.”
The CQC team initially visited to carry out a targeted inspection to examine choking risks but ended up widening its remit when it emerged that there were “widespread concerns”.
The report does acknowledge that since the inspection, the provider has “worked at pace and taken prompt action to start mitigating the risks”.
A spokesman for the home said: “While we do not agree with the entire CQC report, we acknowledge improvements are necessary in order to achieve a consistent high standard of care. We are working closely with Leicester City Council and the CQC.
“We have a comprehensive action plan in place to improve the quality of care at the home.
“The CQC report has acknowledged how quickly we have acted and all issues highlighted are being addressed with utmost urgency.”
Inspectors raised concerns about physical intervention and said “people were not protected from abuse and harm”.
People were “routinely restrained”. The report said: “This included being held by their arms and legs during personal care tasks. This put people at high risk of physical and emotional harm.
“The service did not have a physical intervention or restraint policy and the registered manager, provider and staff lacked understanding of what restraint was.”
CQC inspectors observed that staff completed incident and accident forms to report incidents, and body maps to report any marks or injuries.
“This included, for example, unexplained bruising, allegations made by people using the service, injuries and falls,” inspectors said.
“These were not investigated or followed up appropriately by the registered manager or provider.
“This meant systems were not in place to protect people from the risk of abuse or recurring harm.
“People were at risk of repeated incidents occurring such as falls and altercations as there were no processes to analyse what happened and how risk could be reduced.”
The report notes the home is making “urgent improvements” and that staff had received training.
People who were at risk of choking did not have proper assessments outlining the risks. Plans that were in place were described as ineffective.
Nutrition plans were also criticised and medicines were not stored or managed correctly.
Records showed there were not enough staff to “engage meaningfully with people”.
There was plenty of PPE available to staff who were wearing masks. However, a trolley of PPE was stored in a toilet area, something inspectors said was a cross-infection risk.
Inspectors said that people were not always treated with dignity and respect.
However, the CQC team praised staff and said: “Throughout the inspection we saw positive interactions between staff and the people living in the service. Staff generally spoke warmly about the people they cared for.
“There were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of highquality care.”
The CQC report acknowledged the actions of the home’s managers since the report.
It said: “They have engaged a consultancy firm to support them make immediate improvements and have provided the CQC with a comprehensive action plan.
“They are working transparently and co-operatively with all agencies, including the police, local authority and clinical commissioning group.”