Dunmurry Manor: what next?

Naturally it has concentrated on the appalling failings of the home and the harrowing experiences of residents and their relatives together with sharp criticisms of the “slow and inadequate response” from the authorities. It is inexorably moving on to what the legal consequences might be, who is to blame and who should be sacked as a result.

This is important. There has to be accountability. But if we are to avoid a repetition it is every bit as critical to examine what went wrong and why and what needs to be done in order to prevent such appalling treatment to happen again. Some of  these should be relatively straightforward to fix. Others not.

The Home Truth report investigates the operation of Dunmurry Manor from when it opened in 2014 until January 2017. It makes for a disturbing read.

There are accounts of physical and psychological abuse and neglect. It has collected evidence of  residents suffering significant loss of weight, raising serious concerns about nutrition; of relatives finding their loved ones soaked in urine; of a lack of equipment; of dirty bedrooms and outbreaks of infectious diseases and of vulnerable residents leaving the home unaccompanied and unobserved. 

Dunmurry was funded by Health Trusts to care for vulnerable patients and was under the scrutiny of the regulator, the RQIA during this period – and the Commissioner’s report characterises the authorities response as “inadequate” despite multiple concerns being raised about the home.

So what went wrong?

How could professional staff preside over a regime which led to such misery for residents and their relatives?

The report states: “The evidence given to the investigation describes a chaotic environment. The nursing staff, many of whom were temporary agency staff, working single shifts and never returning and where staff were under immense pressure to meet the complex needs of a large number of residents living with dementia.”

This finding has drawn few headlines but to those in the sector it is one of the most disturbing of all because it is unlikely to be confined to the home in question. There is a general shortage of nurses in Northern Ireland. This is most acute in social care, not least because past workforce planning for nursing needs was not extended to the independent sector. This despite the fact that the health service depends upon it. And the commissioning of care, characterised by the recent Power to People report on adult social care as a “race to the bottom” has helped to ensure that pay for care workers is low. This impacts on recruitment and retention.

There is a fix for this but it will take time, years in the case of ensuring adequate numbers of nurses and a working government to review and fix and properly fund the correct remuneration for staff looking after vulnerable people.

This is not to say that bad practice is prevalent, but to point out that the driver associated with it at Dunmurry – staff shortages and high turnover – is a general problem. It can impede the continuity of care, unsettle residents and lead to important induction and training procedures not being followed through. All these things happened at Dunmurry Manor.

This was exacerbated by the home managing the extraordinary feat of having 10 managers over a three and a half year period. This clearly impacted both on staff morale and was another significant driver for the home’s dysfunctionality. The report recommends that high manager turnover should be a red flag to the regulators. It should be. That kind of situation is a clear symptom of a failing organisation in any sector or industry.

Dunmurry’s parent company Runwood Homes Ltd is a private sector company based in England which runs 10 homes in Northern Ireland. 

The report states that its turnover for the year ending September 2017 was £130,103,993  and that the profit for the same period (before impairment) was £13,746,075.  That equates to about 10% just above the industry norm which was put at 8% by Laing & Buisson in 2014.

After the publication of the report there have been calls for residential care to be provided by the state rather than private companies on the grounds that the latter are more interested in profit than care. This is an ideological debate. However it ignores the fact that in Northern Ireland the market is currently controlled by the Trusts who commission services. Runwood may be turning a healthy profit but other suppliers claim that they are stretched. The only solution to this is to do what Power to People recommended and conduct an independent review of the true cost of quality care and, within that to allow for a reasonable return for providers. This would drive up standards whilst at the same time protecting society from profiteers.

The report is particularly scathing about the response of the authorities to the gathering crisis at Dunmurry. It says of the Trusts: “The evidence supports the conclusion that the HSC Trusts did not use the mechanisms available to them in the Regional Contract to ensure providers maintain levels of service delivery to the required standards.”

And of the RQIA: “the result of the current architecture, roles and responsibilities is a complex system where the rights and needs of the individual older person are not given sufficient priority.”

And: “ The officials of RQIA interviewed during the investigation were clear in terms of the limits of their role not extending to monitoring the performance of Dunmurry Manor and the management of complaints by families. However, their strict adherence to their current approach to inspection proved unhelpful in recognising, reporting and addressing the evident failures of care and treatment in the home.”

After its publication the RQIA has come under intense scrutiny and criticism and has hit back claiming there was no institutional abuse.

The Commissioner’s report also noted a lack of coordination between the authorities, as per this recommendation: “The sharing and analysis of communication regarding concerns about low standards of care must be improved within and between the HSC Trusts, the RQIA, including its Board and the Department of Health to enable a more efficient and effective information flow, action and follow-up in all matters pertaining to failures of care.”

This is an area that the authorities could fix. The entire Programme for Government is based around the principle of Outcomes Based Accountability. Government is now expected not to work in silos but to work across its organisations to work for ensure progress against agreed indicators.

Those most relevant are: Increase healthy life expectancy; Improve the quality of the healthcare experience.

It should not be beyond the competence of those involved to re-engineer the way that care homes are scrutinised in order to ensure that swift and appropriate action is taken when problems emerge.

Finally there is this comment in the introduction to the report written by Commissioner Eddie Lynch:

“I was disappointed by the defensive and sometimes unhelpful nature of some of the relevant authorities. I believe that this investigation could have been concluded more quickly had some relevant authorities adopted a more co-operative approach from the outset.”

The report goes on to claim: “Throughout this investigation, the Commissioner has been frustrated by the lack of certainty that full disclosure of evidence has been made by the RAs (relevant authorities) as well as the delay in production of information and documentation by a number of them. This was further exacerbated by the slow response and lack of availability of some witnesses for interviews. Some HSC Trust staff and Dunmurry Manor staff and former staff appeared reticent to openly challenge the status quo. Many families and relatives spoke of their frustration at not being able to speak openly to staff and management and that they became seen as part of the problem when they raised concerns or complaints. It is concerning that, despite the legislative protections for whistleblowers, witnesses expressed a chill factor in making adverse comment or reporting concerns.”

There is a solution to this, as followers of the Inquiry into Hyponatraemia will attest. And this is captured by the report as follows: “An individual Duty of Candour should be introduced in Northern Ireland for all personnel and organisations working across and in the system which governs and delivers care to older people to encourage openness and transparency.”

There will of course be all sorts of repercussions as a result of this inquiry. What should be front of mind for the authorities is to ensure that they learn the lessons, accept that there were failings and fix them. We cannot allow this horrific episode to be repeated.