The Oaks and Little Oaks 'Care' Home, London Road, Newark, Nottinghamshire

Continuing intelligence - 18th February 2016

Following our initial report there now appearsto be a culture of covering up major issues and papering over the cracks, staff shortages remain the norm and the following incidents and information have been highlighted at a recent meeting by relatives, staff and other interested parties.

The initial report led to Nottingham County Council doing an unannounced visit and suspending (in September 2015)The Oaks contract with them. This was then followed by the Newark & Sherwood Clinical Commissioning Group and subsequently other contractors followed suit.

  1. Although after the initial report we published, the relatives, ex relatives and staff waited to see if the suspension of contracts would have a meaningful impact on the level of care and management of The Oaks.Still,after some three months, taking us up to Christmas 2015, they realised that the problems still existed although they were being masked at every opportunity.
  1. On the 30th December 2015 JB was seen by the phlebotomist and refused three times to have her blood taken. After CP saw her alone the phlebotomist reluctantly took the blood, he felt she had been bullied into agreeing and was not comfortable with what had just happened. We do not know if he took this matter any further or noted the incident.
  1. In January JB was showered against her will when she was feeling very poorly the day after she came out of hospital. She was taken into hospital two days after the showerincident and subsequently, regretfully died.The families want to know if this bullying and intimidation of residents really the last thing we want them to remember before they die?
  1. 'Dorothy' was another resident to have a bath against her will despite her not feeling well and refusing. Would a bed bath not have been more appropriate? The staff have been instructed by CP that if they do something against a residents wishes they are to enter it into the records 'for their own good' but encouraging them to eat or drink does not seem to be in their best interests which we will come to later.
  1. Since Christmas the night staff, who were largely made up of agency staff, have been photographed asleep and it has been reported one regular agency staff member has the routine of sleeping for one hour and working one hour throughout the shift.
  1. There is reported a regular lack of the required staff on duty and no monitoring is taking place.At a recent Nottinghamshire County Council visit in the early evening, the home was found to be short staffed with only three carers in attendance we believe.
  1. A resident died and the family heirloom picture hanging in her room went missing before the family arrived at the home hours after their mother’s death. The grandson has made a complaint we believe with no resolution.
  1. Mrs L(who made a statement in the original report) mother’s electric chair which was removed when CP refurbished the residents lounge has not been returned even though Janet's mother is now at a different home (there seems to be many chairs and personal items disappearing and are not returned to relatives after either a move or death of the resident).
  1. On 22nd January 2016 there was no staff on catering duty to make the meals,the manager sent out for fish and chips taking the money again (this is not the first time this has happened) from the 'comfort' fund intended to provide funds for outings and entertainment for the residents. When the manager was questioned about residents on soft diets she was dismissive. We believe those residents did not get a meal this day. It also contradicts the fact that CP changed the main meal time (despite residents complaining) to the evening citing 'it has been proved they sleep better' but has no problem altering this stance when it suits her.
  1. There were visiting relatives at the home this day and they asked for the same meal to be brought in for them and they paid separately for their meal. CP took these two meals and halved them and divided this between herself and another member of staff, leaving the relatives with half the meal they paid for.
  1. At a 'flash' staff meeting on the 8th February 2016 the manager instructed the staff to fill in resident’s records if they (the records) showed gaps in the care plan or observation records regardless of accuracy.
  1. Around this time a resident on nursing had not been seen between six o'clock and midday and had not been changed or given medication or breakfast/fluids.Staff felt this was abuse and falsifying records and notified the CQC. We are aware the records reflecting this have been removedorreplaced from the residents’ folder.
  1. Onthe 11th February, the Four Seasons Chair (Ian Smith) was due to visit the home, care staff were taken off their duties the evening before to finish wallpapering the halls so it would be finished in time for his visit leaving only one member of staff to 'care' for all the residents. Incidentally the Chairman never showed up the following day.
  1. In the week beginning 8th February 2016 the manager instructed members of staff to fill in incomplete care plans for the residents regardless of them having any contact with some of the residents or their families to be able to record and reflect both the resident and the families wishes particularly surrounding end of life plans (note: the manager has added DNR to most, if not all,of the residents records regardless of their wishes and ignores the ruling from the appeal court in 2015 that DNR is only for cardiac arrest and the duty to treat applies in all other circumstances)
  1. At the beginning of the week 15th February 2016 staff shortage was such that CP demanded staff worked double shifts (one member worked a triple shift) and if they refused they were told she would suspend them and bring disciplinary action against them.
  1. A relative (who has agreed to speak to anyone) has spoken of 'ghost' staff, apparently there are people onthe pay role that do not exist in order to fabricate the numbers on duty at any one time in other words an artificial paper trail to fool inspections.
  1. This relative has also spoken and complained about the dramatic weight loss of his relative and that the scales are not accurately recording the weight of the residents. His mother suffered dramatic weight loss when constant changes of staff meant his mothers food was not being mixed properly and assisted feeding was not taking place but he did not feel this was reflected in her care notes.
  1. After complaining he recently found his mother with dried food all over her face and clothes and he had to clean her up, this shows a total lack of concern for her dignity and care. (Note: as being placed on standing scales causes many residents distress why do the Oaks not have similar scales to hospital when they are weighed in a hoist seat?).
  1. Phone calls now madefrom the home especially to the CQC are now being logged and monitored by CP/FSC and staff threatened about whistle blowing despite there supposedly being an open policy on confidential whistle blowing.
  1. A member of staff was told to leave a resident in the bath by CPas she was needed to do paperwork 'and paperwork takes priority'.
  1. One day recently the puddings were not served,staff was again told'paperwork was more important'.
  1. CP has been observed on more than one occasion talking to herself and saying 'they are out to get me' and 'they are watching me' and showing schizophrenic behaviours along with her well reported controlling behaviours.
  1. She has recently started blaming J(the previous area manager) for all of her problems and more recently M who was brought in as the support manager who incidentally told CP she could not change work rotas without the staffs consent, a practice she stopped, but CP has now reverted to doing this.
  1. On Thursday 18th February 2016 there was three staff in the nursing unit, two who have not finished their induction and one who has only just finished induction and takes over an hour to change residents. All three are supposed to be being shadowed while training.
  1. The newly appointed unit manager for nursing has left (she walked out) after just over two weeks giving no notice and stating 'she could not work with that woman' meaning CP and refusing to be party to practising in a understaffed unsafe home where they were being bullied into falsifying records to reflect checks had been made when they clearly had not.

Information from relatives and ex relatives meeting held on the 18th February 2016

  1. This meeting was informed a formal complaint was made to the police's Public Protection unit which is led by DCI Mel Bowden based in Mansfield at Holmes House on the 8th February 2016. A member of staff theresaid that the initial report was 'an excellent foundation for their investigation'.This was the unit that initially investigated Autumn Grange in Nottingham and there were convictions for homicide and falsifying records in Nottingham Crown Court.
  1. Those present voiced concerns that although the cleaning, decorating and presentation of the home has improved the underlying staffing problems, level and duty of care have still not been brought up to an acceptable standard
  1. They spoke of CP lying to staff, bulling them into compliance and pretending that it is everyone else's fault but hers. They spoke of her now insisting they falsify records when omissions in care are identified (normally due to lack of staff not lack of care by the staff) and observations where listed in care plans missed and where relatives checks are seldom made which was of great concern to everyone.

Information from a relatives meeting on the evening of the 22nd February with Nottinghamshire County Council and Newark & Sherwood Clinical Commissioning Group representatives present.

  1. They were told staff leaving was due to 'staff could not cope, had personal issues or not happy with paper work and chose to leave'. It was very much not the managements fault. They were also told they 'were on a very aggressive staff employment policy' which seems to be resulting in several 18 year old teenagers being employed with no training or experience but five being promised a place on a training/advancement programme where there is only one place available.
  1. The relatives highlighted issues such as they were being kept waiting outside for 10 to 20 minutes because no-one is answering the door and policies were not being followed
  1. It was also stated that 'we know there are ongoing issues but we are looking to try and fix them' and 'the home is looking at more extensive changes to allow the home to start taking a 'trickle' of new residents'. Those present were not reassured by this and in particular felt their relatives were baring the brunt of the reorganisation which was very unsettling for them and this did not seem to be being taken into consideration, the focus they felt was getting the contract suspensions lifted at any cost.
  1. A relative told that the previous weekend CPwas overheard shouting at staff and saying 'it' was all ‘their’ fault’.
  1. The families felt on reflection of this meeting that CP had been on a charm offensive popping into rooms to speak with relatives while the same problems highlighted in the original report had still not been addressed and their family residents were still distressed.

Now we move to the most recent and tragic story brought to our attention and one which everyone involved in reporting issues at The Oak's feels a profound sadness that even though we tried we could not protect this resident nor ensure his passing was peaceful and pain free.

  1. Mr MM was initially highlighted in our original report as MM. We told of how he was verbally abused in the residents lounge by CP and how following her instructions he was forcibly taken to the shower and was heard screaming in pain. This was of such concern to the staff hearing this they actually reported the incident to the CQC but no follow up action was taken. Since that incident MM had refused to come out of his room such was his distress, fear and embarrassment. Martin sadly died on the 2nd February 2016.
  1. Three weeks before he died he had a fall and was taken to hospital where his family visited; they were only notified he was in hospital that day, although the fall was the day before. The home’s nurse (K) suspected he had had a stroke and could not swallow. The family told the hospital that he was having difficulties with his throat, the hospital tried to get hold of The Oaks but there was no answer all day. The concerns appear to have been ignored and he was discharged back to The Oaks the same day with no particular care instructions or follow up for his throat.
  1. It appears that the normal care for diabetics was not being carried out or monitored e.g. his feet were not given proper attention in that for many months he had had sores on his feet (apparently the bandages just got bigger), no diabetic eye test seem to have been carried out, no glucose monitoring was taking place and given his diabetes seemed out of control no effort made to tailor his diet to fit his glucose levels and his inability to process sugar and starch as his diet seemed to consist of baked potatoes and tea with three sugars as his staple along with sweets as his snacks.
  1. The home told his daughter that the reason he did not come out of his room was because he had diarrhoea. No mention was made of the incident highlighted in our original report and his reaction after that. He apparently had always enjoyed his time in the residents lounge until that incident.
  1. On the day he died it was the day his priest used to visit and although the family had been told he had gone down hill very quickly over 'the past two days' no one either called the priest or informed him of the death so he showed up as usual to be given the devastating news.
  1. On the day before her father died his daughter was called and told 'the end was near' which came as a complete shock as she thought he was alright after his fall. She visited that day and was shocked to find her father looked like he had lost over half his body weight. He had one eye stuck open and he was desperately dehydrated. His daughter gave him some fluids and spoke to the 'nurse' on duty who did not seem concerned and gave him a couple of hours to live. He was at this time having breathing problems and was desperately dry.
  1. Fifteen minutes after his death the 'nurse' wanted to know which funeral home they would be using. Later she was given a carrier bag with her fathers belongings but items such as family photos in frames and a brass plaque were missing. Onlylater when she spoke with the funeral home and they asked what she wanted him buried in, did she realise his clothes had not been returned.
  1. A cause for concern back in June 2015 was when a nurse told MM’s daughter in a discussion after a fall that she called the doctor to 'cover her back'. She also stated that the cause of the fall was that he fighting against being put to bed; however he normally slept in his chair.
  1. When Ms M’s attended the registrar to register her father’s death she asked if she had any concerns.She said she had and the coroner was informed.
  1. The coroner initially said that the death was not 'criminal' but a 'care issue' and the funeral was planned for the 17th February 2016. The coroner then changed his mind, informed the undertaker to stop the funeral and ordered a post mortem.The post mortem found the cause of death to be Respiratory, Heart and Diabetes but it was also highlighted MM had not eaten for three weeks and was 'dry' as opposed to being dehydrated. For the family this raises many unanswered questions. Why were they not aware of any of these illnesses? Why was nothing done to seek treatment as MMwho was not on an end of life plan and with medical intervention could possibly still be with them. Certainly they feel he was left to die a slow painful death without the benefit of his family around him until his last day when they arrived at after 19.00 but according to his records no member of staff had seen him since 16.30. The nurse when she eventually attended she refused to administer any pain relief because he could not swallow but the family felt other alternatives could have been administered.
  1. MM was laid to rest on the 24th February 2016 but family, people with relatives still in The Oaks and families who have already lost their loved ones ask the question how many more people are going to die as a result of the neglect and failure of duty to care by the management of this 'care' home?
  1. MM's daughter LM has agreed for her contact detail to be listed and welcomes someone contacting her. (Not published on the public page but is available from)

The author of this report, Chris Ward, can be contacted on 01623 825621 or 0750 555 7569 email: