Opportunities to tackle the neglect of residents at Elm View home in Halifax were missed by agencies because of a “lack of understanding and recognition” of the problem, according to a serious case review.
In December the former owner Philip Bentley and manager Faheza Simpson were each jailed for a year over their lack of care for elderly residents who developed pressure sores.
And the review said it was unlikely the response of officials would improve in future “without significant changes to safeguarding procedures and processes”.
An investigation into what prosecutors described as a “very distressing case” was launched in October 2011 after police and NHS nurses went into the home and found one elderly woman lying in a urine-soaked bed.
But the review said there were a number of incidents in the previous 18 months that should have prompted a collective response.
One was an allegation that a resident was dragged by the hair, which was not looked into by the home, while in March 2010 a resident was admitted to hospital with a fractured shoulder without a “satisfactory explanation”.
The review said: “Safeguarding alerts should have been raised in response to these incidents.”
It added: “There is some evidence from this case that there is not a shared understanding between all internal and external agencies of what constitutes abuse, of when safeguarding procedures should be used in individual or collective care cases and what the response should be to safeguarding concerns.
“There was also a lack of understanding and recognition of ‘collective abuse’. This resulted in agencies missing the opportunity to provide a whole service safeguarding response earlier... It is unlikely, without significant changes to safeguarding procedures and processes, that future responses to safeguarding incidents will be more effective.”
The report said that concerns had been mounting about the home by September 27, 2011, when placements were suspended with immediate effect and a Care Quality Commission review ordered. Police and NHS staff arrived at 7am on October 7 to find evidence of residents with pressure sores, inadequate equipment and concerns about cleanliness.
The review was carried out by the Calderdale Safeguarding Adults Board, which helps statutory agencies work together to protect adults at risk of harm. Calderdale Council’s Adults, Health and Social Care Scrutiny Panel will discuss it today.
The board said in a statement that the review will ensure “all organisations committed to safeguarding adults learn the lessons from these tragic circumstances”.
A report by Bev Maybury, the council’s director of adults, health and social care, set out the changes made to improve the way concerns about poor care for vulnerable adults are addressed.