Page last updated at 16:38 GMT, Friday, 9 April 2010 17:38 UK

Baker home inspector 'missed drug warnings'

By Matthew Hill
Health correspondent, BBC News

Rachel Baker
Rachel Baker started abusing drugs in December 2005

The carer who blew the whistle on Rachel Baker has accused government inspectors of failing in their duty and is calling for a public inquiry.

Sarah Barnett said the Commission for Social Care Inspection did not discover that controlled drugs were unaccounted for which meant lives were lost.

The Commission gave Parkfields home in Butleigh, Somerset, a good report months before the scandal emerged.

Its successor, the Care Quality Commission (CQC), defended its record.

But the inspector who gave the home a good report did not ask staff at the care home if they kept controlled drugs.

Invented illnesses

Mrs Baker started abusing drugs in December 2005.

She exaggerated and invented illnesses for her residents and, by claiming they needed end of life care, she was able to persuade GP Richard Hughes that she needed the medication.

Dr Hughes accepted excuses that she had damaged some ampoules of pain killers or lost prescriptions.

In April 2006, when Dr Hughes was on holiday, his GP colleagues became suspicious and stopped prescribing the painkiller pethadine.

But the manager of the care home continued to take what she could get hold of.

In June 2006 the Commission for Social Care Inspection (CSCI) made an unannounced visit to the care home.

In distress

Inspector Alison Philpott told the court Mrs Baker was distressed and in tears throughout her seven hour visit.

She asked to be given the care plans for two named residents, but was only offered plans for other clients.

The inspector said she was shown the medicine cabinet for over-the-counter drugs like aspirin.

But she never asked if the home kept controlled drugs and staff never told her they had them.

Her report was positive, describing a "comfortable and homely atmosphere".

It said: "Medicines are stored securely. The management of medication procedures protects residents."

Controlled drugs were kept in a summer house in the garden and paper records of their administration were in a mess or missing.

I would give anything to turn the clock back and report things earlier
Sarah Barnett

Controlled drugs, such as diamorphine, have to be stored in a double-locked cabinet.

Whenever they are removed and administered to a patient it is best practice for this to be witnessed and signed off in a record book by a second member of staff.

But this was not happening in the care home.

Sarah Barnett said she regrets that she did not raise her concerns sooner.

She said she felt she had to resign in November 2006 after receiving conflicting advice from CSCI when she approached them about whistle-blowing. The Care Quality Commission could not find any record of any contact.

"I would give anything to turn the clock back and report things earlier," Ms Barnett said.

"Looking back now I have some anger. I don't feel only Rachel Baker is responsible...there are individuals and agencies who have to take some responsibility for what happened."

Sarah Barnett
Sarah Barnett worked as a care assistant at Parkfields care home

The CSCI has now been replaced by the Care Quality Commission (CQC).

A spokesman for CQC said: "This is a very sad case and our thoughts are with the families affected.

"Testimony made clear that Rachel Baker went to great lengths to hide her illegal use of drugs from her staff, friends and family.

"CSCI's inspection of Parkfields in 2006 involved extensive checking of medication records and stocks of prescribed medicines, which were in order.

"These records should also - by law - have made clear that controlled drugs were prescribed on the premises, but they did not.

"As a result, the inspector had no reason to believe controlled drugs were being used at Parkfields or any reason to take further action to look for them.

"Staff later brought concerns about Mrs Baker to CSCI's attention and the regulator acted quickly to inform police."

'Tougher system'

So under this new set up is it more or less likely for future Rachel Bakers to be spotted?

Nowadays, care homes that have good reports are not inspected every year.

But those homes with bad reports are visited every six months.

The spokesman said: "CQC is introducing a new, tougher system of regulation for health and social care and now has in-house expertise on controlled drugs.

"Since changes to the law in 2008, every social care service that looks after controlled drugs must make an annual declaration to CQC, and our inspectors check arrangements for controlled drug handling during site visits."

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