REGULATORY FAILURES:AN "INADEQUATE and unacceptable" system of nursing home supervision in the Northern Area Health Board (NAHB) contributed "in no small measure" to the fate of Leas Cross residents, the commission of inquiry into the Leas Cross nursing home has found.
It examines the way the NAHB and the Health Service Executive (HSE) dealt with the 11 complaints it received about Leas Cross before the RTÉ Prime Time programme in 2005.
It also looks at complaints to the management of Leas Cross nursing home and criticises management for not having a system in place for recording verbal complaints.
If these complaints had been recorded, it would have been easier for the health authorities to identify “emerging patterns of inadequate care”, the report said.
Leas Cross is also criticised for providing no written responses, having no formal complaints system, for a lack of staff to whom to complain and for the English language levels of staff.
Due to a lack of records, the commission could not say how many complaints were made to the home and the report is mainly based on submissions by 70 families of former residents.
The health board failed to take into account the “cumulative” nature of complaints it received and its approach to nursing homes “does not appear to have been coherent”, the commission said.
It said there was “ample evidence” to alert the HSE to problems before the RTÉ report. The information on complaints was divided between a number of health board locations but the HSE “cannot rely on administrative arrangements to excuse this failing”.
When an individual complaint was resolved by the health board, there was “rarely” adequate follow-up to ensure that similar problems did not recur, the commission found.
No senior health board management took responsibility to consider all information before reregistering nursing homes, it said.
It found that one nursing home inspector had taken an initiative regarding Leas Cross but that “a system which left it to chance” for someone to spot a “pattern of deficiencies” was “inadequate and unacceptable”.
However it did find that most of the individual complaints to the health board were dealt with adequately.
Most of the complaints made directly to the nursing home, which families have told the commission about, relate to early 2003 when the home increased its intake of patients.
Issues covered in complaints directly to Leas Cross include rough handling of residents by care staff, unnecessary use of sedation, inadequate supervision of fluid and food intake, lack of regard for residents’ hygiene and personal care, failure to check on residents or respond to calls for assistance and loss of residents’ clothes.
They imply “a lack of adequately skilled staff at the nursing home at that time”, the commission found.
The family of resident “JB” complained about his continuing diarrhoea and dramatic weight loss and raised questions about the use of physical restraints.
However, the family received no response to verbal complaints or to a written complaint to Leas Cross in October 2004.
Another family told the commission about its concerns over sedation. “Prior to [my sister’s] transfer to Leas Cross, she was capable of speaking coherently and making intelligent conversation. During her time in Leas Cross, her speech was often slurred and she was unable to participate in conversation.”
Another family questioned care by staff.
“I had found Dad walking with difficulty and when I decided to change his shoes I found a very infected big toe, as the nail had been badly cut. On questioning the staff, nobody knew anything about this, yet I was told he had a daily supervised shower.”
Concern about adequate supervision was raised by another family: “We would sit with our father for hours and nobody would come to check in on him whilst we were there.”
A complaint to both Leas Cross and the health board by the family of Alzheimer’s patient Kathleen Reilly was examined by the commission.
In September 2000, she was found by her family wandering around Swords. She had been sent to Beaumont Hospital for an X-ray in a taxi on her own and on leaving Beaumont she told the porter she would take the bus instead of the taxi.
The matron of Leas Cross apologised to the family and the health board found that she should not have been allowed to go unaccompanied.
However, the commission criticised the health board for accepting that such an incident would not recur at the nursing home and for not putting in place monitoring or spot checks.
