28 July 2015
Article by Amy Clifton, National Assembly for Wales Research Service
On Tuesday 14 July 2015 the Welsh Government published the independent review it commissioned into the neglect of older care home residents investigated as Operation Jasmine; Margaret Flynn’s report, In search of accountability.
As Assembly Members noted in Plenary, the report makes for distressing reading. It contains detailed accounts from family members of the suffering their loved ones experienced, and shocking photographic evidence of infected pressure ulcers.
Flynn states that the outcomes experienced by the older residents were ‘grotesque’ and in the light of the neglect experienced by their loved ones, relatives and friends are haunted by questions like, ‘Didn’t they even count as human?’.
‘When she was at the Home she was sedated all day and every day. It was explained that since there were not enough staff it made handling and managing her easier. We didn’t want this. It appeared that they were treating her as though she was without significance, without a history…’
‘In hospital a nurse asked us “Why have you let him go like that?” [He was emaciated.] We explained that the staff in the Home had said that there was nothing they could do – to which the nurse said that there was lots that could have been done…’
Flynn reports that it is astonishing that not even people’s deep pressure ulcers had an effect on the conduct of some business owners.
Hilda Scase was a ‘self-funder’ and yet within 10 weeks of being a resident at Brithdir she had no back – such was the extent of her pressure ulcers. There was no redress for her in terms of consumer legislation and nor, apparently, was this even considered.
Flynn concludes that it is lamentably clear that reporting pressure ulcers to Protection of Vulnerable Adults (POVA) – for which local authorities have the lead responsibility – is inadequate as a response to the urgent clinical care needs of frail older people. She believes there is scope for the Welsh Government and Public Health Wales to assume a lead role alongside the Welsh Wound Innovation Centre in challenging the tolerance of preventable pressure ulcers.
The review recommends that the Welsh Government, in association with Public Health Wales, ensures that the significance of deep pressure ulcers is elevated to that of a notifiable condition. Also, where Public Health Wales has been informed of the existence of deep pressure ulcers, that information is communicated to the Care and Social Services Inspectorate Wales or the Healthcare Inspectorate Wales and appropriate commissioning authorities as well as to people’s families.
The First Minister said in Plenary that he has asked Dr Flynn to lead a series of workshops around Wales this autumn with those involved in the care of older people, to talk through her findings and the lessons. He said he will ‘return to the Assembly after the summer to set out in detail’ what the Government has done and plans to do in response to the review. He also stated:
I don’t want those considering entering residential care to believe this is what to expect. The events described by Dr Flynn were truly terrible, but I want to reaffirm that the vast majority of care for older people in Wales is ‘good’ or ‘excellent’. The most recent annual review by the inspectorate showed that 86 per cent of adult care met requirements, and, of those that didn’t, improvements were made in most cases.
Implications for the Regulation and Inspection of Social Care (Wales) Bill
The Regulation and Inspection of Social Care (Wales) Bill is now in Stage 2 of the scrutiny process and Assembly Members can propose amendments to the text of the Bill for consideration by the Health and Social Committee. Read more about the Committee’s Stage 1 report in our earlier blog post.
The review provided input to the Regulation and Inspection Bill, and the Minister for Health and Social Services stated in Plenary that the Welsh Government will set out a detailed response to all the Committee’s recommendations and also how it sees the Bill responding to Flynn’s review recommendations.
Flynn states that the outcomes of Operation Jasmine predominantly reflected a failure of the market as a mechanism for the provision of residential care.
Some older people were transferred from one failing care home to another. What was in place to prevent providers, who were impervious to rebuke, from providing care for frail older people at as low a cost as possible?
Training and registration for care staff
Flynn highlights the issue that residential care workers in adult care homes are not required to register:
The apparent fitness of owners and managers became a charade when undermined by the recruitment and appointment of unsupervised and inadequately trained staff – for whom there is no registration requirement.
This issue came up during Stage 1 Scrutiny of the Bill, and led the Health and Social Care Committee to recommend that the Bill is amended to require domiciliary care workers and adults’ residential care workers to register with the regulator (recommendation 38). The Committee stated that these workers should be registered because they provide intimate personal care to some of the most vulnerable older people in Wales.
Baroness Finlay informed the review that she has been asking community specialist palliative care nurses who are going into nursing homes: ‘How can we improve care?’ The response she consistently received was ‘mandatory training’. Flynn comments:
It is remarkable that nursing homes supporting frail older people are not required to demonstrate sufficient numbers of trained and competent staff who are able to meet the overarching aims of the service.
Flynn recommends explicit policies are developed to regulate and allow intervention in the social care market to improve the quality of care by directly addressing issues such as pay and working conditions, staffing levels and the knowledge and expertise of commissioners of publicly funded services.
The review concluded that private care homes are businesses and weaknesses exist in the current legal position concerning private, non-listed companies.
Businesses need be made accountable for their trading practices. Directors should be subject to the same rules and accountability framework as other sectors.
Flynn is clear that companies which have demonstrably failed older people should be allowed to fail and their directors should be disqualified.
The Minister noted in Plenary that the Bill will hold people to account with the requirement to have in place a responsible individual and through the duties that will now be placed on responsible individuals in law. He also stated:
Providers will no longer be able to move resources from one home to another, to shore up a failing service in order to escape the regulatory gaze. The Bill provides the flexibility for the regulator to take enforcement action against either individual services or across an organisation as a whole.
The review concludes that the rhetoric of concern has to be matched with credible action, and that care must be provided alongside timely processes to identify ways of preventing further harm – which must include prosecution.