Freckleton care home where grandma, 91, was beaten to death is placed in special measures again after 'inadequate' CQC report

Jessie McKinlay, 91, was dragged out of bed, thrown to the floor, punched and kicked by Alan Whiteside, 75, at the Old Vicarage care home in the early hours of February 14 2019. She suffered a broken hip, a broken arm, and a brain bleed, and died of her injuries nine weeks later.

The care home, on Naze Lane, was placed in special measures by the CQC 10 months after the incident in December 2019, and still ‘required improvement’ following a report in September 2020.

Now the home has been put into special measures once again after a CQC report, published on August 4, rated it ‘inadequate’ following a surprise inspection which found ‘unexplained bruising’ and ‘accusations of physical abuse’.

Jessie’s daughter Mary Eaves said: “I think it shows clear negligence. Where are the lessons learned? It’s the same thing again. Everybody says something has to be done, and nothing is done.

"These old people are vulnerable and are not being safeguarded. My mum’s death could have been avoided. It’s important to me and to my mum that this doesn’t happen to anybody else.

“Old people are being let down yet again. It will never end until real changes are made.

“What I’m bothered about is: what are they waiting to happen before this place is closed down? The worst has already happened, someone has died. So what are they waiting for?”

The inspection, which was prompted partly due to concerns raised about safety and care, found the care home was both unsafe and lacking in good leadership.

There were not enough staff to meet the needs of people living in the home, with no staff supervision found in the lounge when inspectors arrived. There was frequently not a staff member on shift trained to administer medicines, including painkillers, to people who may need them.

Fire safety equipment was not properly checked and there was no comprehensive evacuation plan in place.

The report read: “We spoke with one person who had not been able to get staff attention all night. They had been left without a call bell and staff had not responded to his calls for help. They told us, ‘I've fallen out of bed a few times and have to shout for help’.”

Some members of staff had not been safely recruited, as no legal documents had been filled in for four employees, which breached a regulation of the Health and Social Care Act.

The report read: “Staff did not follow processes to keep people safe. Staff were not trained to keep people safe. When speaking with staff and reviewing records it became apparent that knowledge of when to report concerns was limited. When we looked at training records, we saw only 50 per cent of staff had received safeguarding training in the last 12 months.

"Records showed incidents and accidents that should have been reported and investigated under safeguarding procedures had not been. These included unexplained bruising, people accessing the community independently without the required support and one direct accusation of physical abuse. One person told us, ‘the male staff member could not get me out of bed, so they just pulled me up’. This had resulted in a bruise to person's arm and should have been reported to the safeguarding team.”

Four residents were found locked in their rooms without their consent or an appropriate risk assessment being carried out.

The report also found that risks to residents’ health and welfare were increasing, including risks of malnutrition due to reduced eating and injury due to increased falls, and that nothing had been done to address this.

The home was also not managed effectively.

The CQC had not been informed of numerous changes to management by the home’s provider, Pearlcare. This included the loss of both its manager and deputy manager, which had resulted in audits not being completed, areas of concern not being identified and people being put at risk.

Monitoring of key risk areas such as accidents and incidents, pressure areas and weight loss had not been completed, and the CQC had not been notified of incidents that had been reported ‘for some time’ – another potential breach of the Health and Social Care Act.

The report read: “We spoke with four staff on the day of the site visit who were responsible for supporting people living in the home. Each told us they did not feel supported and did not have the tools they needed to complete the job effectively. This included a lack of suitably trained staff, a lack of suitable equipment including PPE and a lack of leadership and direction.”

Rating the care home ‘inadequate’ and placing it in special measures, the CQC said: “This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

“If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service.”

A spokesman for Pearlcare, which oversees The Old Vicarage, said: “Since this inspection a new manager has started and is working with the CQC and local authority to improve the quality of care at the home.”