Cornwall care homes review highlights failings
Findings found some elderly people in care homes across the Duchy were 'abused and neglected'.
Last updated 2nd Nov 2020
Elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated a new review has found.
The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016.
And now a new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case.
All the homes which were operated by Morleigh have since transferred to new operators or have closed down.
The review looked back over the period from 2013 to 2016 and catalogues a number of failings and missed opportunities to address the situation.
Among its findings are:
- More than 100 residents had concerns raised more than once
- More than 200 safeguarding alerts were made for individuals but only 16 went through to an individual adult safeguarding conference
- More than 80 whistleblower or similar reports were made concerning issues that put residents at risk
- 44 inspections were undertaken at Morleigh Group homes in the three-year period, the vast majority identifying breaches
- There was a period of at least 12 months when four of the homes had no registered manager in place
- During the three-year period reviewed the police received 130 reports relating to the care homes
The review found that there had been failings by the various organisations to share information or to act when reports and concerns were raised.
The 66-page document provides extensive details of all the incidents and reports which relate to the seven homes – Collamere in Lostwithiel; Clinton House, St Austell; St Theresa’s, Callington; Brake Manor, St Austell; Tregertha Court, Looe; Elmsleigh Nursing Home, Par; and Alexandra House.
These include reports of abuse against residents; residents being left to lie in wet urine-soaked bedsheets; concerns from relatives about their loved ones being neglected; reports of there being insufficient food for residents, no hot water and no heating; claims that dozens of residents were sharing one bathroom.
It also details how, in 2014, one member of staff at Collamere was arrested, charged and found guilty of assault after slapping a resident.
Whistleblowing reports were made by care home staff, relatives and GPs however the review found that many of these went to the CQC which then “noted them for the next inspection” which could sometimes not take place until months after.
The review states that these concerns should have been shared with other agencies so that they could be acted on immediately.
It also found that while there were investigations happening about the homes and the overall group during the three-year period these were being done by separate organisations which were not working together.
The review reports that the CQC was undertaking inspections of the various homes and that Cornwall Council had suspended placing people at some of the homes at various times.
However there had been a lack of explanation for this, with no paperwork available and with no explanation for why the suspension had been lifted.
And the review also questions why it was not until the BBC Panorama programme aired that action was finally taken.
It states:
“What was it that brought about such significant change following the Panorama programme that all those professionals working within the multi-agency had failed to achieve over the previous three years, despite the wealth of evidence that is clearly evident within this report and the chronologies and IMR’s prepared before it?
"There is no evidence to suggest that things were any worse at the end of 2016 than they were at the end of 2013.”
The review was completed in April 2019 but has only just been made public – Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
Since then the recommendations made in the report have been acted on and changes put in place to improve the system.
In total there are 15 recommendations made by the review which have been accepted by Cornwall Council and the Safeguarding Adults Board.
These include changes to contract management for the provision of care services so that they link with safeguarding and inspections.
On whistleblowing the review says there needs to be a clear whistleblowing process for all staff, residents, families and professionals to follow and to ensure that information is shared across all agencies.
Other recommendations include better enforcement to ensure action is taken when breaches are identified.
And it calls for a “front door” for all alerts made about care providers so that there is no confusion about who should take responsibility to deal with concerns.
It also says there has to be a clear process for how individual concerns will be reviewed and completed and that they feed into any organisational processes which are ongoing.
“We apologise to the people who lived at the former Morleigh Group care homes and also to the residents’ families.
“This report looks in very close detail at what happened at the homes between 2013 and 2017 and highlights how organisations which worked with the provider should improve to prevent issues like this from happening again.
“Even before this review began three years ago our adult social care services have been making significant improvements to the way we work, ensuring the needs of vulnerable adults in Cornwall are at the centre of the support we provide and have a greater say in choice of services and control over the way in which they are provided.
“Following a Cabinet decision, Cornwall Council is now able to step in much sooner if a provider is struggling, which was demonstrated last year when we took the unprecedented decision to purchase Trefula House nursing home in St Day.
“We have also reviewed our contract with care providers to ensure that safeguarding
is placed at the heart of each organisation we work with.”
Cllr Rob Rotchell, Cabinet member for adult social care, Cornwall Council
“My heartfelt apologies go out to all of the people and their families who were involved in this case.
“Safeguarding Adult Reviews are an essential part of the safeguarding process and we have carefully reviewed the findings in this case, and the recommendations made, so that the council is able to be more responsive to issues that a care home, or a group of care homes, is having.
“We now work with care sector providers to deal with potential risks before they become issues, rather than reacting to events when they happen. We are also continuing to work more closely with our partners to make sure that we are all aware of what is happening across the system.
“The council’s Quality Assurance team, whose role it is to make sure that there is a high standard of care across Cornwall’s care sector, now gives a much wider consideration to the total number of safeguarding concerns that have been raised and the frequency of concerns over time.
"Providers rated as ‘high risk’ are meeting with our officers at least once a month, and if necessary, every two weeks dependent on the situation.
“If a provider enters into the failure process, a project team is established to manage the safe transition of people from one provider to another, minimising any disruption. The project team involves professionals from all relevant organisations who work very closely with those affected and their family.”
Helen Charlesworth May, Strategic Director for adult care and support, Cornwall Council
“I would like to apologise to residents and their families for their experience of care covered during the review period. I would also like to thank those families, residents and members of staff who participated in the review. It was very important to us to hear their personal experiences so we can change and improve local services.
“When situations like this occur, it is really important that we have a detailed, independent investigation into what happened so that we can learn from this and take action to improve services.
“The 15 recommendations outlined what needed to change. Our position statement from the Safeguarding Adults Board partners demonstrates what changed during 2017 and onwards and our current action plan is virtually complete. This comprehensive plan has been closely monitored by the SAB since 2017.”
Fiona Field, Chair of the Safeguarding Adults Board
The Care Quality Commission also issued a statement following the publication of the review.
“Cornwall and Isles of Scilly Safeguarding Adults Board (CIoS SAB) have undertaken a safeguarding review of the services that were provided by the Morleigh Group. CQC worked with the local authority and have contributed to the review.
“During 2016, CQC cancelled the registration of all six of the Morleigh Group services and the provider’s registration. Five of the Morleigh Group care homes transferred to established local provider Cornwallis Care Services Ltd. The sixth service, Clinton House was closed by the Morleigh Group before the notice period we imposed was completed.
“During the inspections we found instances of poor care which no one should ever have to endure and, at the time, took enforcement action to stop this continuing.
“We still continue to monitor these services closely, working in partnership with local stakeholders to ensure that services provide safe, effective care. Where we identify areas for improvement, we have returned to reinspect. If we find they have not improved sufficiently, we will not hesitate to take appropriate action on behalf of the people who use the services.
“Since the events of the Panorama investigation our inspection methodology has tightened further. We respond rapidly to concerns, work with families and utilise our own and other stakeholders data to ensure we have a constant picture of how a service is working.
“During the current climate this continues to be vital in our inspection process and we would encourage anyone with concerns about care services to contact us.”
Deborah Ivanova, Deputy Chief inspector of Adult Social Care (South)
The CQC also provided an update on the current status of the homes.
The services transferred under the ownership of Cornwallis Care Services Ltd are:
Collamere Nursing Home, now registered as Meadowbrook House and inspected on 21/07/17, 26/09/18 and 17/09/19 currently rated as Good.
St Theresas Nursing Home, now registered as Addison Park, and rated on 15/07/2017, 27/07/18 and 13/07/19 currently rated as Good.
Elmsleigh Care Home, now registered as Hendra Court, rated on 20/07/2017 and 21/07/18 currently rated as Good.
The Brake Manor, now registered as Beech Lodge and rated on 30/06/2017 and 12/06/2018 and rated as Good. Beech Lodge was last inspected 04/05/19 and rated as Requires Improvement.
Tregertha Court Care Home, now registered as Rivermead View and rated on 30/08/17, 12/09/18, and 25/08/20. Currently rated as Good.