CQC accepts it was too 'easily reassured' failing care home could improve

The CQC has accepted it could have done more to respond to early warning signs to prevent the mistreatment of residents at Hillcroft Throstle Grove care home in Lancashire in 2012.

A Learning Review into how four care staff were able to neglect and mistreat residents of the home between December 2010 and May 2012 found the CQC, as well as other agencies, could have done more to protect them.

The mistreatment was revealed in an investigation by Lancashire Constabulary which saw one carer plead guilty to charges relating to mistreatment and neglect at the home and three carers found guilty at trial, after initially pleading not guilty.

Debbie Westhead, the deputy chief inspector of Adult Social Care in the North, said: “I was appalled by what happened at Hillcroft Throstle Grove and my thoughts remain with the people who suffered such awful care and with their families. The Learning Review highlighted serious failings in the way the home was managed by Hillcroft Carnforth Limited between December 2010 and May 2012, but it also made recommendations for all agencies, including CQC.

“Our own review has identified a number of areas where we can learn lessons: at times we missed opportunities to take action with this service.”

The CQC’s review of its response to the events at Hillcroft Throstle View care home highlighted a number of areas where it could have done more to investigate the care home.

Although the CQC knew the care home did not have a registered manager at the time of its first inspection in July 2011, there were no systematic triggers to highlight this as an issue.

Despite the CQC receiving information from four whistle blowers between December 2011 and March 2012, no action was taken by the regulatory board and the record of information was left incomplete. At the time the CQC felt Lancashire County Council was carrying out a review of the service, however it has now said it needs to be vigilant about the potential loss of information and making clear managerial oversight is crucial to make sure regulatory risks are acted upon immediately.

Following the first two whistleblower referrals there was no record of conversations between the CQC and the LCC and a Management Review Meeting did not take place to discuss escalating concerns and breaches the home had made, which included creating a fake registration certificate.

The review into the CQC’s actions recommended more time should be given to inspectors to consider all elements of risk including conditions of registration when planning an inspection. The importance of collaboration was highlighted in the review and the CQC accepted it was too easily persuaded by the failing provider that they would be able to improve the home’s standards of care.

Ms Westhead said: “The way we worked at the time meant we did not respond to early warning signs, we did not fully recognise the increasing risk to people using the service, and we were too easily reassured by the responses of the provider that it was able to improve.

“Since then, we have done a great deal to drive forward significant and sustained improvements on many issues we identified as areas of concern. For example CQC is now more responsive to whistleblowing concerns and more effective in monitoring notifications of risk; our inspection techniques have improved with a greater focus on public involvement, and recruitment of additional staff is ongoing.

“However, there is more we can and will do. We will keep working hard to make further improvements in partnership with people running care services, local authorities and other agencies.”