Murray Hyslop

(1) Prevention of pressure damage – there was a lack of appreciation of the need to consider Mr Hyslop’s extreme vulnerability to pressure damage when he was very unwell, dehydrated, malnourished and largely immobile. Policies and practices supported only monthly review of his needs and that is insufficiently responsive in order to appropriately prevent damage from occurring;

(2) Identifying a resident in need of medical attention – some of the difficulties in Mr Hyslop’s care were exacerbated by the outbreak of Covid-19, but there was no evidence of any expectation upon any members of staff to consider a broader view of Mr Hyslop’s presentation than how he was on a particular day. The witnesses did not seek to suggest that they usually did this but were unable to during the outbreak and so I consider that it is likely that this was an issue was existed both before and after the outbreak. I was more reassured in this area by “Restore 2” materials and training which provide very clear and helpful guidance to carers. It is not clear to me how this training, which has been completed by the registered manager, has been effectively cascaded to frontline care staff and their evidence to me suggested that this has not happened to date; and

(3) Learning from adverse events – the culture within senior staff of obfuscation and denial when issues regarding care are raised was of significant concern to me as it is hard to have confidence that, as they said to me, “lessons will be learned”. It was appropriate for the senior management to be supportive of their frontline staff who, as set out above, worked hard when the care home was understaffed. They were not, however, open minded to consider areas where significant changes in practice and culture needed to take place.