"I think that, clearly there were people In the Haven who were not protected."
Jonathan Phillips, Calderdale Social Services when interviewed by Panorama.
In December 2004 the Commission of Social Care Inspection (CSCI) noted concerns at the Haven Nursing Home in Brighouse, West Yorkshire. An announced inspection had highlighted 14 statutory requirements which indicated non compliance with the Care Standards Act 2000 and National Minimum Standards. These ranged from requiring the home to install a fax machine to ensuring that all clients were properly assessed prior to admission to the home and a concern that that new staff were starting work without the correct criminal checks being carried out.
The home was warned that improvements had to be made to avoid CSCI taking further action.
When Arthur Worrell was admitted to The Haven with dementia his family weren't aware the CSCI inspection reports could be available on the internet. He had been cared for by The Haven's sister home and all had been well with his time there so they were confident that he would be cared for well at The Haven. But within days of his admission to The Haven his stepson John Burton was beginning to have concerns. Arthur had developed unexplained bruising.
What the family didn't know was that authorities were also having increasing concerns about the standard of care being provided at The Haven.
In April 2005, inspectors returned to the home to check that improvements had been made but the situation had in fact worsened. There were now 26 statutory requirements indicated.
Out of a total of 28 staff only eight had Criminal Record Bureau checks that had been taken up by The Haven. There are a number of nurses both general and mental health qualified working at the home. There was no evidence on some files that their registration had been checked and verified.
April 2005 to May 2006
Inspectors visited the home 21 times. Some of the issues the inspectors discovered included:
"I was very concerned to see that one resident was sitting in the dining room. The back of her chair was against the wall and the dining room table had been pushed right up to her, making it impossible for her to get up. Staff must be made aware that this is a method of restraint. This practice is unacceptable."
There is no policy or procedure in place regarding restraint of residents.
Wounds and sores
There are residents who have wounds/sores. There are no acute care plans in place for the treatment of these.
Mediation records are not being properly maintained. There are stocks of medications that do not tally with the amounts recorded on the medication administration records.
Food and fluid
Food and fluid charts are not being accurately maintained. For example one residents record for the November 2 2005 indicates that they had nothing to eat or drink until 1800 that day.
There was an incident recorded where one resident had hit another. This has not been reported using the adult protection procedures or reported to the Commission for Social Care Inspection.
The adult protection officer from Calderdale attended the home to offer training recently. This was cancelled as only two staff turned up.
But no-one told the public. Visitors to the CSCI website would not have known. The only report available to new or even existing residents was April 2005 report.
The first that relatives and the public could have known about these concerns was when the report for the new inspection which had taken place on May 9 2006 was published.
"This is a poor home that has received 21 inspection visits since April 2005. The purpose of these inspection visits has been to try and get improvements in the standards of the home." (CSCI report 09 May 2006)
The regulators had spent the previous 12 months relying on The Haven's owners to get the improvements made. Making repeated visits and sending reports to the owners. But significant improvements had not been made
Mike Rourke from CSCI: "It took time to realise that the provider simply was incapable of making the changes necessary."
It is within the powers of CSCI to go to a magistrate, put their case and ask for the immediate closure of a home. But that option was not taken with The Haven.
Mike Rourke said: "One of the things that we certainly considered was whether we shouldn't take urgent action to close the home down immediately. But it's a difficult decision and needs to be looked at very carefully simply because, as I'm sure you'll appreciate, being told that you've got to move within 24 hours, not knowing where you're going to move to can be enormously distressing and we do know that very frail and elderly people do not necessarily cope all that well. It can have serious consequences."
After May 2006, nearly two years after concerns about the care and safety of residents at the Haven were first raised, CSCI put the home on notice to close but that would take time. And the owners had leave to appeal.
The home still was operating.
The inspectors continued to visit. Again relatives and the public weren't told was what the inspectors were finding on those visits. Reports were written after every visit and sent to the owner. The CSCI website continued to only show the May 2006 inspection report.
But BBC Panorama gained access to those reports, reports that the public knew nothing about and discovered:
Records showed that a resident who is diabetic had not had their blood sugar level has not been tested for a week, because there were no 'strips' available to carry out the tests. Staff had failed to monitor this residents blood sugar, which is leaving the resident at risk.
Records show that eight out of the 15 residents have only had one bath in over a month. Only one resident is bathed on a regular basis.
The home had run out of medication for two service users. One service user was without his anti convulsive medication for two days.
Daily records for one service user stated that he had been "touching" other residents. There were no further details or reports on these incidents. "Staff are not making sure service users are safe."
Bruising noted on service user on his back and hand. Staff had not investigated the possible cause of the bruising.
Relatives were told by The Haven's management it would fight the closure and take steps to improve the home. And it wasn't just the regulator who had concerns about the Haven.
Social Services also carry a responsibility for the protection of the elderly in care homes.
Calderdale Council was aware of the CSCI findings and during the summer of 2006 the council suspended its admissions to the home. But nothing was made public at the time.
And for any prospective clients approaching the Haven? The authorities were relying on the owners own responsibility and professionalism not to take new clients in that time. The CSCI website did not indicate admissions had been halted.
In September 2006, Calderdale Social Services sent a letter to resident's families with a copy of the inspectors August visit report. Relatives were asked to consider the possibility of moving residents. But there was no doubt the final decision was to be the relatives' decision.
John and Dorothy were facing a difficult dilemma. Social services wouldn't or couldn't tell them categorically to move Arthur and they had been told by staff at the home that moving an elderly relative could be fatal.
John Burton told Panorama: "I'm very uneasy about moving Arthur from The Haven, from the point of view of his health. But, you know, I feel as though I'm between a rock and a hard place really. You know, that I'm damned if I do and damned if I don't."
And relatives were left to make the difficult choice unaware that residents continued to be at risk.
In September 2006 a new allegation was made: this time of a physical assault. Social services knew and the regulator was told but relatives were not.
The owners of the home, the Malik family, told Panorama that a member of staff was dismissed. West Yorkshire Police confirmed that they had been informed of the allegation and that "the incident is currently being investigated to ascertain whether a crime has been committed and enquiries are ongoing."
The Protection of Vulnerable Adults (POVA) scheme was set up to increase the protection of elderly people. From 26 July 2004, anyone who has abused, neglected or otherwise harmed vulnerable adults in their care or placed vulnerable adults in their care at risk of harm would be referred to the list. If the person sought work elsewhere, employers would check the list.
In certain circumstances referral could be done by CSCI or the Care Standards Inspectorate for Wales but in the main it is responsibility the registered care home owner/provider to refer the carer.
Without a referral to POVA and without a prosecution by the police the care worker is free to work at another care home.
It is currently unknown if the carer dismissed from The Haven has been referred to the POVA list.
The Burton's decided they had no choice but move Arthur to another nursing home. In January 2007 he left The Haven. He's settled in well and the family are very happy with the new place.
The Commission for Social Care Inspection will hold a directional hearing regarding its intention to close The Haven on 21 February 2007.