In May 2011 the Somerset Safeguarding Adults Board published the report of the serious case review into the events at the Parkfields Care Home. You will recall that this was the home near Glastonbury where a whistle-blowing report ultimately resulted in a lengthy court case and the conviction of the registered manager for manslaughter and other offences. This was covered extensively by the local and regional press. The full report as well as an executive summary and a detailed action plan can be viewed on the County Council’s website, at:- What is a serious case review? A serious case review is held whenever there is evidence that a vulnerable adult or adults have been seriously harmed or put at risk by the actions or inactions of others. The purpose of a review is to try and understand how effectively the relevant organisations involved worked together and to identify areas for learning and improvement. It is not an investigation because this will have already taken place. In the case of Parkfields the investigation was a criminal one managed by Avon and Somerset Constabulary in conjunction with the Crown Prosecution Service. Parkfields learning The report identifies learning for a wide range of organisations and professions. There are a number of key points which are of particular relevance for care providers: 1. Professional staff at every level in the caring services have a responsibility to be alert to and question poor or abusive practice. Staff registered with a professional body such as General Social Care Council or the Nursing and Midwifery Council should be fully aware that their codes of practice require them to take appropriate action whenever abuse or neglect is suspected. While trusting working relationships are essential to the provision of good quality care it is important to be wary of a level of informality which may make challenging more difficult. There is a recognition that raising such concerns in your own workplace requires much courage and managers and senior staff should ensure that staff members are fully supported. The statutory agencies such as the County Council are looking at how they can provide additional support to whistle-blowers from care services. 2. In order to reduce the possibility of conflicts of interest arising, the registered manager of a care home should not be registered with the same General Practitioner as the home’s residents. There may also be a conflict of interest for care home staff being registered at a General Practice where their residents are registered. In rural areas, where some practices only have a single GP, this may be difficult to achieve, but the General Medical Council has advised GPs to be alert to the possible difficulties and to seek advice. 3. Where a care home not providing nursing is managed by a qualified nurse it is essential that the manager does not use their professional status inappropriately. Although the knowledge they hold can be used to good effect in providing good quality care they must ensure that all medical decision-making is performed by primary health care professionals from outside the home. 4. The manager at Parkfields was able to significantly influence the prescribing of controlled drugs, some of which were used to feed her own addiction. There are now monitoring procedures in place to identify unusual or notably high levels of controlled drug prescribing and concerns are investigated thoroughly by the PCT. 5. Everyone who has contact with the potentially vulnerable people in a care home needs to be aware of how to raise concerns about poor standards of care including suspicions of neglect or abuse. This includes not only managers and their staff teams and visiting professionals, but also friends and relatives, volunteers etc. Concerns can be addressed to the home manager or owner, to the Care Quality Commission or to Somerset County Council, who have the lead role for investigation. Developments in safeguarding in Somerset 1. Safeguarding training provided by Somerset County Council, Somerset Partnership, and the PCT has been revised in the light of learning from the Parkfields serious case review. This includes training for their own staff as well as for care providers. You may have attended or be aware of the free one day course for managers of care provider services, Managing an Incident, which covers the responsibilities of managers and of statutory agencies in prevention and protection, as well as touching on the relevance of the Mental Capacity Act and the Deprivation of Liberty Safeguards. Bookings for this course are made by contacting Joe Horton at County Hall, on 01823 355216 Dates with spaces currently available are 9th November 2011 and 26th January 2012. The course is being revised and more dates will be planned for April 2012 onwards. 2. As part of their lead responsibility for the co-ordination of effective arrangements to safeguard vulnerable adults, Somerset County Council has recently established a small team to provide advice and guidance to social work teams and to care provider organisations. Contact can be made with Chris Hamilton, Safeguarding and MCA Co-ordinator, or Maxine Walton, Safeguarding Officer, by telephone: 01278 437294 or by e-mail: CAHamilton@somerset.gov.uk or MAWalton@somerset.gov.uk Somerset Partnership and Community Health as well as Musgrove Park and Yeovil District Hospitals have also appointed to posts specifically responsible for adult safeguarding. Free E-learning safeguarding tool www.kwango.com/somsafeadlogin - Safeguarding Adults e-learning Individual details are required for each home – contact Joe Horton on 01823 355216 or JHorton@somerset.gov.uk |
