'Missed opportunities' to take action before some residents died at Covid-hit Kettering care home

There were missed opportunities to take action and support a Covid-hit Kettering care home before many of its residents died, a report has found.

Temple Court was shut down and the firm which ran it, Amicura Limited, was fined £120,000 over its 2020 failures at the height of the early stages of the pandemic.

The home’s population doubling and a lack of staff and basic care meant residents were found in appalling conditions, with some discovered to be ‘unkempt’ or ‘skeletal’. A total of 19 died between January and May. None of the deaths were proven to have resulted from any failure to comply with health regulations.

Covid outbreaks were not notified to the county’s public health team and some deaths were not notified to the Care Quality Commission (CQC), a report found. But a safeguarding adults review (SAR) published today found that the deteriorating situation may have been spotted sooner had county health and care teams taken a more proactive approach in contacting them.

The report said: “There were missed opportunities between April 3 and 9, 2020, to identify that the home may have been experiencing some difficulties and for the Covid-19 emergency response system to take supportive action sooner.

“After April 9 there was no further contact from statutory partners with the care home until April 20 and no suspected cases or deaths reported. The definition of a Covid-19 outbreak required two confirmed cases within a 14-day period and whilst the care home did not say they had this level of cases, the status of three residents transferred to hospital was unknown. An enquiry with the care home could have triggered a response or at least clarified the situation.”

Toby Sanders, chief executive of Northamptonshire’s Integrated Care Board, said: “We acknowledge that despite the pressures during this period, there was more we could have done to proactively contact care homes across the county to ensure they had the support they needed, and for that we are sorry.

“Since the review partners across our system work much more closely together and there are more opportunities to share information and concerns about quality of care, and we have clear pathways in place to escalate and swiftly act on any concerns if needed.”

What happened at Temple Court?

The Albert Street care home was rated as ‘requires improvement’ in 2019 and concerns and complaints had already been raised prior to the Covid pandemic. Then, as hospitals desperately tried to free up beds ahead of an expected influx of patients, 23 people were transferred there, mainly from KGH and NGH. The home did not properly assess the impact this would have on those already living there.

Routine testing of patients prior to discharge from hospital was not announced by the Government until April 13. Temple Court stopped accepting new residents on April 9.

The report said: “The number and speed of discharges into the care home was inappropriate and there does not appear to have been any consideration given to the previous CQC inspection grading of ‘requires improvement’ when determining the volume and specific needs or patients being discharged to the care home.”

In early April the home’s registered manager became ill and began isolating. A previous court case heard there was no manager, deputy manager or clinical lead for weeks, with nobody appearing to be running it. The registered manager did not engage with the safeguarding review, the report said.

Between April 3 and 6 authorities were notified of one confirmed case of Covid at the home, three residents in hospital and one death.

Whistleblowers made reports to the CQC about the lack of care and staff and by April 20 the deteriorating situation was identified. A visit to the care home on April 30 found that by then 13 residents had died but the health regulator had not been informed of all of the deaths.

Amicura Limited say it is on that date that they sought assistance as it was ‘clear they could not cope’. A ‘health tactical team’ was deployed on May 3 but they could not recover the situation. Ten clinically unwell residents were initially moved before all remaining residents were taken to other accommodation just over a week later.

The home was then rated as ‘inadequate’ by the CQC after an inspection in May, with a report saying people were subjected to degrading treatment.

A police probe into the home ended with no further action before the CQC launched their own prosecution.

The shocking lack of care

The report laid bare the shocking levels of care provided at Temple Court, which had to rely on agency staff when employees were isolating.

One man was found with untreated bedsores when he was admitted to hospital. Another resident who was discharged in April was described by one of his daughters as ‘grey, filthy and skeletal’ and wearing someone else’s clothes. They said he looked half the man he was after he left hospital.

Cards and presents which were sent in by families were unopened in a pile with wilted flowers.

The family of a woman who was at end-of-life say she had clearly not been fed properly or had her basic personal needs met. They intervened and insisted she be taken to a hospice so she could be treated with dignity.

A report said: “Some residents were left with little stimulation, poor nutrition and hydration to the extent that some residents experienced very significant weight loss. Staff seemed to pay little attention to the personal appearance of residents with reports of matted hair, residents generally looking unkempt and poor standards of room cleanliness.”

Agency staff said they felt that they were not listened to and whilst they did make some reports about lack of equipment and medication, they felt nothing was done and no action taken.

Accounts from staff who went in as a health tactical team were ‘distressing and harrowing’ with some residents found in wet beds with minimal clothing. A CQC report said one relative had told them their family member was covered in dried faeces.

Jackie Barrett, whose uncle Leroy Cunningham died at the home after being transferred from NGH, said: “It’s just disgraceful and appalling what happened at that care home.”

One nurse said that the compassion and care had ‘gone out of the building’ and that on VE Day there were no celebrations, with residents fed with chicken nuggets.

The report said: “Its significant deterioration during April/May 2020 was truly shocking and despite intervention and support from health colleagues it failed to respond and recover.

"Again, the oversight, governance and control by the service provider were absent. Residents within the care home were neglected and suffered significant harm as a result.”

The impact on families

The report said families experienced significant downplaying of the true nature of their relative’s health conditions and denial that the care home was struggling with the impact of the virus. With visits banned to try and restrict the spread of Covid, they could only call but the phone often went unanswered. Relatives reported that there seemed to be a stock answer from staff who always reported their relative was fit and well. They said there was no consideration of the use of other technologies in trying to keep the families in touch with loved ones. One relative said they only found out that another resident at the home had already died after reading about it in the local media.

One woman said her husband was a proud man who shaved every day. He took an electric razor – a birthday present – into the home with him. When he died his wife was extremely upset because he had a full beard.

Many families also reported difficulties obtaining their relative’s belongings from the care home following their relative’s death and in one case the staff appeared to show a total lack of empathy when they merely placed resident’s belongings into black bags and put them outside of the front door as the relatives arrived. One relative said that the staff were laughing and joking as he saw them approach the door.

Cathy Cantrill’s father-in-law Stanley Cantrill died at Temple Court but she says she was not told of his death for 14-and-a-half hours. She added that she spent a year trying to get his personal belongings back.

She said: “I’m just disgusted. This brings back a lot of hurt.”

Another relative of a resident told the report author: “I don’t know what the scene [in the care home] was like when almost half had died. What had he [their dad] seen and experienced? It must have been bedlam.”

Actions taken and the response from those involved

Amicura Limited, hospitals and council chiefs have set out a series of actions they have taken since the first wave of the pandemic, including to strengthen information sharing, testing, staffing and risk assessment processing.

Cllr Helen Harrison, North Northamptonshire Council’s executive member for adults, health and well-being, said: “We would like to extend our condolences to all the families involved who lost loved ones during this extremely difficult period of time and we unreservedly accept the findings of this report. While events took place during an unprecedented period at the start of the Covid-19 pandemic, the report recognises that the events outlined should never have happened. The care provided by Amicura Limited at Temple Court Care Home fell well below the standards expected and they have since been prosecuted for failing to protect residents from avoidable harm.

“However, the report has highlighted learning that can be adopted to make processes more robust and make adults in care safer now and in the future. While the period of time was before local government reorganisation took place in the county and the formation of North Northamptonshire Council, we recognise it is now our duty to work with partners to continue to act on recommendations outlined.

“Already numerous measures have been put in place, with partners, to ensure that we have done as much as we can do to reduce the risk of this scenario ever being repeated. Furthermore, we will continue to work within the health system of Northamptonshire to further develop the recommendations as we strive to make sure that everyone receives the quality and dignified care that they deserve. While many of the issues identified have led to change already there is a significant national issue in relation to attracting and retaining quality nurses and care workers. This is a significant challenge but we are resolute in our commitment and have introduced a number of programmes to bolster our workforce.”

David Watts, the Northamptonshire Safeguarding Adults Board chairman, said: “This was an awful situation for all concerned, particularly families who were separated from their loved ones, and we offer our heartfelt condolences to them.

“SARs are about learning, not apportioning blame. Their purpose is to identify where processes might not have been as effective as they could be and offer potential solutions to help avoid similar issues arising again in the future.

“We’re publishing the report into the care provided at Temple Court Care Home today and acknowledge that its contents are challenging regarding the activities of a number of organisations.”

SAR report author Heather Roach added: “It is important to remember that in the early days of the Covid pandemic definitive information was scant, routine testing was not available and the situation was ever evolving.

“That said, and while the responsibility for care of the residents lay with Amicura Limited, which has been prosecuted by the Care Quality Commission, there were shortcomings in the part played by others.”

Amicura Limited did not agree the report, citing concerns about the approach and ‘lack of impartiality of the review’.

A Temple Court spokesman apologised unreservedly to everyone affected by their failures and said they immediately set about learning lessons from these events.

The spokesman said: “With the benefit of hindsight, we recognise now that whilst we felt at the time we were acting in the national interest and supporting the NHS by accepting patients discharged from hospitals into care homes under Government policy at the start of the Covid-19 pandemic, this actually placed incredible strain on our team – leaving many of them overwhelmed, exhausted and themselves ill with the virus.

“The combination of these factors left the home disproportionately reliant on the use of available agency staff, with very little opportunity to adequately train them on our policies and procedures, and had a significant and detrimental effect on the running of the home and the care provided to our residents.

“We recognise these factors were unprecedented, but that does not excuse what happened and we know we must do better in the future. We are fully committed to our journey of continuous improvement and remain determined to deliver the best possible care for every resident.”

‘This isn’t justice’

Relatives who spoke to the Northants Telegraph after this year’s CQC prosecution said the outcome was not justice and was a kick in the teeth. One of them was Belinda Kelland, whose mother Kathleen Blunsom was admitted to Temple Court for respite care. She had a wound that was not dressed properly by care home staff. Relatives raised concerns that she was not eating, witnessed dirty dressings and reported that she was dehydrated. She was eventually relocated to another home after nurses also raised concerns.

Belinda said the report was well put-together and that she is sure that lessons will be learned.

But she said: “Unfortunately nothing is going to alleviate the loss or quell the uneasy feeling of how our loved ones were treated by the people who were supposed to care for them.

“If I could put out a message to anyone it would be for those that work in the care sector to not be scared to come forward and whistleblow on any colleague, manager or business owner who does not safeguard and uphold the dignity and rights of their service users. These people, a lot of them vulnerable, are at the mercy of these providers.”