Two residents die after start of ‘inadequate’ Hove care home inspection triggered by whistleblowers

Posted On 31 May 2017 at 9:51 pm

Two residents died between the start and end of an unannounced care home inspection in Hove, which was triggered by whistleblowers.

The registered manager walked out on the second day of the three-day inspection by the Care Quality Commission (CQC), the official government watchdog.

Now a report by the CQC says that the Bon Accord nursing home, in Church Road, Hove, has been rated inadequate and placed in “special measures”.

The report said: “The inspection took place on (Monday) 6, (Tuesday) 7 and (Wednesday) 15 February 2017.

“The inspection was brought forward due to information of concern that we had received from relatives, the local authority (Brighton and Hove City Council) and the (Brighton and Hove) Clinical Commissioning group (CCG) due to information of concern.

“The first and third days of inspection were unannounced which meant that the provider, registered manager and staff were not expecting us.

“Bon Accord is a nursing home providing accommodation for people who are living with dementia and who require support with their nursing and personal care needs.

“On the first day of our inspection there were 31 people living in the home. On the second day of our inspection there were 30 and on the third day of our inspection there were 29 people living in the home. This was due to deaths that had occurred.

“The home is owned by Four Seasons (No 9) Limited, which is part of a large, privately owned, national corporate provider called Four Seasons.

“The management team consisted of a registered manager and senior care assistants. On the second day of inspection the registered manager resigned with immediate effect.

“The overall rating for Bon Accord is ‘inadequate’ and the service is therefore in ‘special measures’.

Bon Accord – Google streetview

“Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

“The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

“If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service.

“There were systematic failings, poor leadership and management and ineffective governance that meant that people did not always receive good quality, safe care.

“Quality assurance processes, while sometimes recognising that there had been inadequate care, were not robust and had failed to adequately improve the care that people received.

“There had been ongoing, longstanding issues with regard to people’s access to medicines that had not been suitably managed or improved.

“The registered manager, who was new in post, was not suitably supported to ensure that they were able to assess, monitor and improve the care people received.

“The provider had failed to ensure that people received a good-quality service that they had a right to expect.


“There was low staff morale, staff were unhappy and felt unsupported and this was embedded in most staff’s practice and in the culture of the home.

“People were at risk of social isolation and were not adequately monitored to ensure their safety, nor did they have access to call bells to enable them to summon assistance when needed.

“People did not receive safe care and … people had consistently not had their prescribed medicines for several days and this had a direct, negative impact on their health and wellbeing.

“People did not always receive support to access healthcare that was responsive to their needs.

“A relative told us, ‘We weren’t happy. X had a high temperature for a few days and they were coughing when they were drinking. Eventually my relative had to insist that they call the doctor which they did and X had got a chest infection and was given penicillin. They hadn’t picked up on it and in the end X had to go to hospital and was diagnosed with pneumonia.’

“Some people had lost significant amounts of weight. While this had been monitored, it was not apparent what action had been taken in response.

“Food and fluid charts lacked detail to identify if people had been continually refusing food and not all people had access to supplements or fortified food to increase their calorie intake.

“Not all people received appropriate support to eat and drink. A relative told us, ‘I’m not confident that they would give X the attention they need to make sure they eat properly so I come in every day to feed them and make sure they have fluids too’.


“People were not always assisted to move and position in a safe manner. People were not always protected from harm and abuse.

“Some people, who were living with dementia, sometimes displayed behaviour that challenged others.

“Observations of staff practice when assisting people during times of distress, as well as records, raised concerns with regard to the use of restraint.

“Staff had not received training in how to deal with such situations and as a result asked a CQC inspector of the correct way to do this.

“There was a lack of understanding with regard to circumstances that could be constituted as abuse.

“The registered manager had failed to identify these and medication errors as safeguarding incidents and had not always reported the incidents to the local authority for consideration under safeguarding guidance.

“There were no meaningful activities for people to participate in and people spent their time in their beds or armchairs, sleeping or walking around the home looking for something to occupy their time.


“Some people were socially isolated in their rooms. One person, whose room was on the upper floor of the home, and who had no access to a call bell, was continually crying and calling for help and was showing signs of apparent anxiety.

“People were not always treated with dignity and their privacy was not always maintained. Most staff treated people with respect. However, observations of some staff’s practices demonstrated that they did not maintain people’s privacy when discussing sensitive information.

“Observations showed staff discussing people’s confidential healthcare needs as well as organisational information in front of other people and relatives.

“Staffing levels were not effective during peak periods and when people required assistance from staff they were not always available.

“A significant amount of staff had left and there had been an influx of new care and nursing staff.

“Existing staff told us that new staff often lacked the skills and experience required to enable them to carry out their roles and that their inductions into their roles were not effective.

“Some staff held roles which enabled them to carry out certain nursing tasks. However, there were concerns, due to the high levels of agency registered nurses used, that these staff were often unsupervised and not adequately supported.

“Due to the level of concerns with regard to people’s safety, subsequent to the inspection safeguarding alerts were raised with the local authority.”

  1. Maureen Plank Reply

    I lost my mum in October of last year from pneumonia which was not picked up in the nursing home they said my mum had a chest infection and when I asked if the Dr was coming out to see mum the nurse informed me that the Dr listened to my mums breathing and cough over the phone whilst the nurse held the phone to my mum and prescribed antibiotics and said mum had a chest infection which I was angry about.
    Later that evening I was phoned by the nursing home to say they had called for an ambulance by the time I reached my mum there was 2 ambulances and a paramedic car in total there was 5 paramedics working on my mum.
    Mum was taken to hospital and passed away the next morning.
    There has been a number of incidents with my mum prior to this which I highlighted and one incident mums social worker was involved and soon after this the manager of the home resigned. Another incident was in 2013 were my mum had a stroke and was left for 4hrs before my sister visited mum and found her the nurse on duty saying mum was fine whilst the carer was trying to feed mum whilst she still had her breakfast from that morning still in her mouth was not able to speak or move mum ended up in hospital and it was touch a go if we would loose her.
    After this incident I wrote a letter to the manager as I was concerned with the safety of my mum and other residents the nurse that was involved in this was removed from the nursing home. I was later to find out last year that the Social workers were not informed by the manager and my letter was nowhere to be found, I do have a copy of the letter.
    I feel so frustrated angry and upset at the care my mum received from the manager and nursing staff at Middleton Grove nursing home and I am concerned for the remaining residents in the home.
    The last visit they had from the CQC was 2011 year before my mum went into the home.
    To this day I feel my mum would still be with us if it wasn’t for the lack of care from the nursing staff within the home.
    To read what has happened in the Bon Accord home has really upset me to know that this kind of care is happening across other homes and getting away with it.
    I would never ever recommend the home that my mum was in and I feel ready to write a letter and feed back the care my mum had but who do I send it to that will sit up and listen so that other poor men and women don’t go through what my mum and family did.

  2. Anacleto Reply

    Unfortunately the country is full of bad care homes where old people are treated very badly indeed. No doubt there are also excellent ones but if you end up in the wrong establishment than It could be a nightmare

  3. Meg Reply

    It is outrageous but while people in need of care are seen by some as a financial opportunity to be taken advantage of, such underfunding, under-training and under-resourcing will remain prevalent. It’s wrong but it’s the truth

  4. keir Reply

    my granddad went through all of this and died from pneumonia at the beginning of march , he was always isolated in his room , the room and toilet were always filthy it was an ongoing thing complaining about that , thin bedding in mid winter , he lost so much weight due to the poor food , other residents would wander into his room and when looking for a member of staff they were less than helpful when asking them to remove someone from my granddads room unless you shouted at them , before he got pneumonia he had not had any of his medication for 2 or 3 weeks which obviously made him quite ill and not with it , asking the staff for any help you would get the response “sorry I don’t I have just started working here ” that’s when you could find a member of staff there was often no one in sight , clothes would go missing … the people that ran the place would ignore anything we brought to light…. I had to shave and cut my granddads hair as they didn’t do it for him …. I hope the place gets shut down so no one else has to go through what my granddad went through

  5. keir Reply

    was not march he died we buried him in march it was the 7th of feb so he would be one of the residents that died during their visit… my family and myself will taking this further

  6. lorraine bolt Reply

    We placed our Dad/Grandad in this hell hole after reading the CQC reports that had rated Bon Accord as “excellent”. When we visited to look around we were bare-faced lied to about a lot of the practices/conditions of the home, for example that residents could choose to opt out of the meal provided and ask for something else instead.He often didn’t eat the meal(broccoli cheese and baked beans for example! ) and he lost a lot of weight.The room was often dirty and it wasn’t unusual to find medication on the floor.His wheelchair was ” borrowed” on several occasions without permission.Everything about this home was penny-pinching to maximise profits. We were constantly on the phone to the manager and visited him in his office frequently to voice our concerns but it was like talking to a wall.We couldn’t move Dad as his house was being sold to pay for his care and until then we were part-funded ( a loan)by Lewisham Social Services as we’d moved him down from London .I telephoned the day before Dad was hospitalised to say we would be in to visit the following day but were not informed that he was ill.Dad was desperately unhappy here and gave up on life. It was 7th February that Dad died.We buried him in March.

  7. Anne Reply

    I work in a care home and not get away it want happen to all their training we had to do all of ours and our nvq so were was there it’s out of order one of our lady’s went there I hope she still there and alive

  8. Anne Hill Reply

    I work in a care home and ours classed as I standing so were was all their training we had to do all ours it’s a shame these people should be ashamed of themselfs to let the home get Like it these poor people want were they going though I would lose my job if treated them like the staff and mangers there thank god I don’t work there

  9. Julia Baily Reply

    As above Dad/grandad pass away 7th February. We booked an appointment to visit the home, to make sure this was the perfect place for our dad/grandad to spend the rest of his life. We were so impressed with what they were offering and the CQC report being excellent . HOW CAN THIS HAPPEN ? Who do you believe? You do your research and still you have no garentee.
    Where does anyone go from here.

  10. Lucy Reply

    Profiting from healthcare is wrong in all its forms. There is clearly a major floor with running elderly care services for profit. Staff need to be trained and retained. This means in part to be paid fairly, offered adequate supervison, adequate staffing and regular training and developement.
    I wonder what this company’s profits were. So sad to know that this is now the norm. Having increasing needs is daunting. I fear for my future self.

  11. Emma N Reply

    My Nan was in Bon Accord for a year and she was shouted at by staff, her bedguards were left off more than once, she got her leg trapped between the bedguard and bed and was left like that for goodness knows how long until my Mum visited. My Nan was also NOT always fed (she’s blind, has dementia and was mostly bedbound at the time) her notes were left blank or on at least 1 occasion they were filled in after a complaint reflecting a completely different version of events! She was also left alone for hours on several occasions, items were stolen from her room as well. My Mum complained to both of the managers who were there during her time there and also to the CQC several times but she was ignored! I’m glad that this place is finally being held accountable but how sad that people died in the course of the investigation 🙁

  12. Anne Reply

    I sgeee hope get closed down it don’t get it self sorted out and the mangers are not nice to their staff had a friend work ghere and she left because he was bulled so he left work in some were better now

  13. Jane Reply

    My father went into Bon Accord in January. He is self funding and within 2-3 weeks the manager attempted to put his fees up from £4,000 per month to nearly £12,000!!!!!! Needless to say I moved him to another home where he is far better cared for and for the same price as the original Bon Accord fee!

  14. Keith Stewart Reply

    I had similar experiences. If you have a record of events that will help. Involve your m.p. and local councillor. Write to the cqc and check if you can involve the ombudsman. Get your m.p. to write alongside you. Request independent investigations. Also involve the council if funded through them. And the local health authority. Get and keep copies of any correspondence. And how much it costs. Be clear about the outcomes you want. Be clear it will not be an overnight thing.
    I got and won an independent investigation into my complaint. 21 of my 24 points were upheld. The local government ombudsman also investigated and upheld much case. Also put in freedom of information requests for copies of files that thing he home, council or local authority holds on you or your relative. They will take their time in the hope that you get frustrated and give up. They lose when you dont.

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