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Department of Adult Social Services

SAFEGUARDING ADULTSESCR 26

AlerU Refe rral Reco rd i n g/Mo nito ri n g Re port Form

CONFIDENTIAL

Location - Where abuse is alleged to have occurred -

Date Incident occurred:

WWHffiffi&fu

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on 1 - ' lndident . ' . . ,. . . : : . :

. ' : . , . . : . ' : . , ' . ; ' : , : : l ' , ,

Start date: - A4rc112011Referral date: - 1311212010

Name of person completing this form: -Susan chambers, Social worker.Responsib le Care management Team: -Birkenhead Access TeamSWIFT number 157069 ( i f t .ownlName of Vulnerable Person: Mrs. Doreen Beddows

- Date of Birth: 10/03/1945 * Gender: Female * Ethnicity: White British

Address: Elderhome Nursing Home, Ciatterbridge Road,Bebington, Wirral

.

Post Gode: CH63 4YJTelephone No: 0151 334 0200

* GP Details: Dr. Meyer, NestonRoad,Willaston."GP not known: l-l

Client Category: (regardless of age)E.rprlty or lllness

,lfdme of AlefterHeather Ward l

Telephone No.1513340200

Contact Source TypeResidential Care Staff

Desc ription of 4!!9gtrtion(s) (ptease inseft appropritii))Ete?fi6rati6-g-6_ealth has triggered increased anxietyldistress for this lady's husband"Mrs, Beddows is in avirtual ': vegetative state" and unable to communicate.Mr Beddows has expressed" Suicidal thoughts" to a Care worker that he would harm himsetf and thoughts ofending his wife's l i fe.He Beddows visits his wife daily, spending long periods with her.

Staff had been advised as to how they could manage these contacts to reduce "Risk" as far as possible fore.g. Leaving the door of the room open (Mr Beddows had been in the habit of closing it).Relationships between Mr Beddows and care staff are strained due to his demanding nature. They felt thiswould be further exacerbated were he to know of the referral.CHC Team were to be contacted as they know the family well and may be able to discuss health concernswith him.It is not known who Mr. Beddows GP is.

Main category of alleged abuse Physical Potential for, if Mr Beddows becomes increashglydistressed about his wife's condition.

Alk/SAO/SAdociOctO91t6

Relationship of alleged perpetrator - Husband/WifeAther (only use OTHER if Relationship not listed)

Name of alleged perpetrator (if known)Mr Len Beddows

Perpetrators Date of Birth:

Address of perpetrator (if known)

ls vulnerable person plaeed in Wirral from outside the area?lf Yes s/ate Ihe funding authority.

How is the vulnerable adult funded? Service funded by Health(lf service user is placed by anather lacat authoity, we do not need to know haw s/he is funded)ls vulnerable person in receipt of any type of Individual Budget or Direct Payments?

Once this Section is completed email as a weblink to

IiDi"e$,s;tdX,..i.".,,.'f.,..,;ii,:l,.,..'i''.'.,,i,:,iill',;l.t,;l.ili,.'.,:':1i'll.','....,;lLevel of Risk Low Total Risk Seore 1.

ls the alleged victim agreeable for any action to be undertaken?

Does the alleged victim have the capacity to decide whether they wish the actionlinvestigationto continue?

No

lf the alleged victim lacks capacity, has a Formal Capacity Test been completed aboutthis issue?

No

2t6AJk/SAC/SAdoc/OctO9

Responses from L.Beddows on behalf of Iloreen Beddows to theReferral Safeguarding Adults form ESCR 26 dated 13 December 2010Made by Heather WardrMatronrElderholmeSTATEMENT BY HEATHER WARD MATRON/MANAGER ELDERHOLME:Mr Beddows rs descrrtled as tie perpetrator of abuse "Physlcal Potentlal tor, d Mr ljeddows becomesincreasingly distressed about his wife's condition". Deteriorating health has triggered increasedanxietyldistress for this lady's husband who has expressed suicidal thoughts to a care worker that hewould harm himself and thoughts of ending his wife's life. Staff have been advised to leave door open(Mr Beddows has the habit of closing it). Relationships between Mr Beddows and staff are shained due tohis demandinq nature. Thev felt that this would be firther exacerbated were he to know of this referral.FACTS:On Friday l0'r'December 2010 the Deparhnent of Adult Social Services were conducting an inspectionof Elderholme. On the same day Mr Beddows met with Elderholme Chairman Brian Rourke and DirectorBrian Woods.He gave them,again,full details of all of his concerns and they promised to discuss them thatafternoon with Heather Ward. On Monday 13th December 2010 Heather Ward made this referral to^ ^ f ^ - . , ^ - l : - ^ r f - D ^ l J ^ - - ^ ^ + + ^ 1 ) ^ f + L ^ - ^ C ^ * ^ 1 ^ - ^ C ^ - ^ J ^ . . - , ^ ^ - - - - ^ 1 1 : - - l ^ ^ ^ : ^ a ^ * ^ ^ - - - i a l . l , : ^JOTV6U@Uur5i aY[ UVUUVVVJ V'OJ r lVL LVrU Vl UrV rVrViaG Vr VrlVrVU 4rJ WUrJVIXrErOJJrrLurev ]r l l l r [J

perceived mental condition.DASS issued a good report for the Home and even though the ComplaintsManager confirms that he gave the Contracts Manager firll details of Mr Beddows's complaint,none ofthose concerns wsre investigated.

Mrs Beddows had been in her normal state of health for at least two weeks prior to Heather Ward makingths statement. Hlderhotme had iarled to detect an eye rntectron wfuch had caused Mrs tseddows to keepher eyes closed as if asleep.Two nurses from CHC visited Mrs Beddows a this time and said that HeatherWmd had told them that Mrs Beddows had slipped into a deeper coma. Shortly afterwards the Doctorconfrmed that it was not a deeper coma but an eye infection miss diagnosed by Elderholme,which waskeeping her eyes closed.He prescribed an antibiotic and Mrs. Beddows was soon and back to her normalpattern TWO WEEKS BEFORE THIS REFERRAL WAS MADE. When this referral was made MrsBeddows was in good health, she had not deteriorated and Mr Beddows was under no more strain than forthe previous eleven years. Relationship with staff was as good as ever and Mr Beddows had made nodemands which were not part of the care plan.

On Friday lle June 2010 Pam Marr gave Mr Beddows a letter from Brian Woods, director ofr l 1 J ^ - L ^ l . * ^ - - . L : ^ L - ^ f ^ * ^ l a ^ ^ ^ . . - , ^ - ^ ^ i ^ - ^ , - , j r l . + L ^ . - ^ s ^ . . ^ - . l ^ ^ : J r L ^ + + L ^ - - A I A . . - + - ^ ^ ^ j - . ^l luulrvi l t iw, wluul rvrvrrvu ru vur lvvl-4arui ls vr lLr l ulv r l rduul l , dlu Duu utoa artwJ utu r tvL rwwwrtw

payment for addifional care (hourly checks). Mr Beddows asked Pam Marr to tell Mr Woods that all hewanted was what was in the care plan and that " if he had the means he would have killed his wife andhimself with atl the worry the Home were causing" and he asked her to sort it out. Parn Mar said shewould speak to Heather Ward and there is little doubt that Pam Marr told Heather Ward of the suicidecomment. No one from Elderholme offered any counselling/assistance to Mr Beddows over his comment.It was not mentloned agarn untrl Heatier Ward made thrs sat'eguardrng retbrral SIX MUN'I'HS LA'I'L,R.

As for the door being closed, on 3'd June 2011 Nurse Alix told Mr Beddows that Heather Ward hadinstructed her to tell him that the door of the room must be kept closed because Mrs.A, the lady in theopposite roonr"thought Mrs Beddows was her daughter and had taken to going into Mrs Beddows's roomand leaning over her bed asking her quite determinedly for the money she was owed.

Heather Ward left it six months before bringing this "threat" to the attenfion of safeguarding? Probably inorder to divert DASS attention away from checking documents which the NHS Review now show to havebeen below standard and that should have been apparent to the inspectors. They did not report on any ofMrs Beddows's care, and so missed the opportunity to resolve all matters.The only reason for notinforming Mr Beddows of the referral was that he would have been able to give all of the foregoingexplanations and demonstrate that the statement made six months previous was made in an effort to showthe depth of his concern, on his wife's behatf, over the failure by the Home to follow the care plan.Thisfailure is acknowledged in the NHS Independent Review of clinical care.Otherwise why did DASSsafeguarding not seek to resolve the issues which they were aware of and which had lead to the inspectionor action this referral?

Department of Adult Social Services #FWIRRALSAFEGUARDING ADULTS

ESCR 26AlerUReferra I Record ing/Monito ring Report Form

CONFIDENTIAL

Start date: - 9411112011Referral date: - 4.11-17

1: i . i : : : i i i ' .1 , - : l j r i i ; : .1 : : j l j ' ; : . : ' .1 . . : . : . . , r

Name of person completing this form: -Bernadette HeqartvResponsible Care management Team: -Bebinoton West Wirral Access TeamSWIFT number 157069 NHS numb'er (if known)Name of Vulnerable Person: Doreen Beddows

n Date of Birth: 10103t1945 * Gender: Female Ethnicity: White British

Address; 7 Burrell Road,Prenton,Birkenhead,MerseysidePost Code: CH42 8NHTelephone No:

* GP Details: Azurdia; Carlas Dr (303613) 0151645 6936 Civic Medical Centre,CivicWay,Bebington,Wirral,Merseyside,CH63 TSFlCivic lUledical Gentre (Surgery)(l1330) 0151645 6936 Civic Medical Centre,CivicWay,Bebington,Wirral,Merseyside,CH63 7SFiGP not known: | |

ContacG-ource fype.Social Services - Wirral

Client Category: (regardless of age)Physical Disq!ility

Name of A,lederWalker, Julie (30{501} I

TeleRhone No.

Description of Allegation(s) (please fasert qpprqp riate text)have just had a discussion witfr my colleagues Steve lthan and $heila Fairclough from Wirral CT re the

above resident of Elderhome nursing home

Basically, the relationship between this lady's husband, Len BeddoWs, and the home have irretrievablybroken down to the extent that the homb are to issue a 28 day notice period on 11 November

However, follovving a meeting earlier today with the home s chief exec, it has been established that there areserious safeguarding concerns re Mr Beddows behaviour and Lynn Burton, locum social worker, has beenasked to launch it as a safeguarding referral via CADT

This case needs to go to a straiegy meeting so when you receive the referral, can you please ensure that thisrequirement is made clear to the team receiving the referral

Many thanks, Julie7111t'1109.51hrs Full details of the information and action,to be taken as discussed in meeting withEfderholme and Continuing Care Team on Friday 4l1U11are not clearly identidfied by information above.lssues around safeguarding are concerning the action being taken by Elderholme by evicting Mrc Beddowswho cannot act for herself as she is in a Persistant vegative state. Please see profile notes for account ofmeeting. JHughes

Alk/SAClSAdoc/Oct091t7

Main Category of alleged abuse Emotional

Location - Where abuse is alleged to have occurred - Care Home - Permanent

Date lncident occurred: 04111 l2O1 1

Relationship of alleged perpetrator - HusbandlWifeQthet (only use OTHER if Relationship not listed) This case is focussed on removing Mrs Beddows frcm herpermanent placement of l1 years with Elderhome who will be serving notice for this lady to lose herplacement - placement has broken down as a result of alledged behaviour of Mrs Beddows husband towardsResidential Care Manager of Eldercare - relationship between Elderhome and Mr Beddows is irretrievablybroken down

Name of alleged perpetrator (if known) | Address of perpetrator (if known)Mr Len Beddows

Dat6 of Birth:

Does the vulnerable person want to make a forrnal complaint to the Police? No

What defines this person as a vulnerable adult i.e. Disability etc: Vulnerable in persistent vegetative state -no communication

Are there any previous incidents of note for this vulnerable adult? YesNote: lf 'YESI pleaae provide details. Adult Protection concern recorded 13b Decemb er 201O - She has been aperrnanent resident in Elderholme NH for a rnember of years and admifted in 2000" She is in a virtualvegetative state and unable to communicate. Husband visits every day and stays all day. He is hoping shewill make a full recovery.

There has been lots of tension between staff and Mr Beddows as he constantly wants attention for his wifeand unfortunately in the last couple of weeks her condition has deteriorated and GP has informed him thatshe is deteriorating.

Originaly GP did not want to tell him but he phoned GP himself - Dr Meyer, Neston. Dr Meyer has told himthat she is deteriorating and he is quite distresssd.

Unfortunately Mr Beddows does not know that the home knows that he has spoken to the GP. He will notspeak with members at the home and ths home is very concerned about him.

A number of weeks ago he attended the wheelchair assessement centre with home's physio and he said tothe physio that if he had a gun he would shoot himself and his wife. At this time her condilion had notdeteriorated

He is under the misguided thoughts that referrer is against him but this not so. He was expressing this to thephysio. She reassured him that this was not ths case. Over the weekend they had staff Christmas party anddiscussed concerns for husband Len and on Sunday physio phoned refurrer at home to say he hadexpressed a couple of wEeks ago suicldal thoughts and thoughts about ending his wife's lifo.

Asking urgent intervention as eoncerned for them both. He is not aware of this referral-

AlltlSAC/SAdodOct092t7

ls vulnorable person placed in Wirralfrom outside the area?lf Yes sfafe the funding authority. -

No

How is the vulnerable adult funded? Commissuioned by another authority(lf seruice user r.s placed by another local authority, we do not need to know how s/he is funded)ls vulnerabl psrson in receipt of any type of lndividual Budget or Direct Payments? YES/NO

Name of establishmenUcare provider: - Where appropiateElderholme Nursing Home

DO NOT record any additional information gathered as a Contact this MU$T be recorded in ProfileNotes

Once this Section is completed email as a weblink to

Level of Risk High Total Risk Score 2

Il

; lI

Has the alleged victim been seen by the Care Manager as an agreed part of information gathering orinvestigation of this incident? Yes

lf not, state the reason

Atk/SAC/$Adoc/Ocrt093ft

Lesley Weston,

Jayne Marshall, Principal Adult Social Seruices (Chair 1 1 . 1 1 . 1 1Acting Team Manager, AdultSocial Services

1 1 . 1 1 . 1 1

Bernadette Hegarty, SocialWorker

Adult Social Seruices 1 1 . 1 1 . 1 1

Mal Price, Principal Manager,Contracts

1 1 . 1 1 . 1 1

Steve Khan, CHCHeather Wad, Matron,Lawson Stebbings, DirectorJohn Cadden,

CHCElderholme Residential HomeElderholme Residential HomeMerseyside Police VictimSupport Unit

11t11t2011

$trategy Discussion findings (please se/ecfSu mmary of strategy disc ussio n fi nd i ngslactions/safeg uard in g plan :

Meeting with Mr Beddows to take place week commencin g 14l11t2}11to let Mr Beddows knowthat his behaviour is unreasonable and clearly explai,n the situation to Mr Beddows.

To clarify at meeting if Mr B holds Enduring or Lasting POAMental Capacity Assessment to be completed with Mrs BeddowsContact Official Solicitor re POAReview of Mrs Beddows to check if she is robust enough to be moved - research and adviseTo go to Police if harassment situation becomes untenable for supportDASS/CHC to feedback to Elderholme following meetingOnce meeting has taken place and Elderholme advised, Elderholme to serve noticeSeek legal advice from Legal Department

ls fuilher investigation needed No

The following information is Mandatory and if not completed this form will he returnedlf Yes who is the Lead Agency (you MUST setect from tist)lf Yes please proceed to Section 3

lf No select appropriate Outcomes you MUST select one option from each Outcome box below

Vulnerable Adult Protection Plan Outcome Moved to lncrease / Different CareOutcome for ^ Alleged Perpetrator/Organisation/Service No Further ActionReferral Summary O utc ome Partly S ubstantiated

AlkiSACiSAdocJoct094t7

Date Strategy discussion completed:

Mr Beddows removed hie wife from Elderhotme to Vala Court Residential Home in Cheshire on 6s December2011

DO NOT record any additional information gathered as a Contact this MUST be recorded in ProfileNotes

IF CASE IS CLOSING YOU MUST NOW COMPLETE SECTION 5Once this Section is completed email as a weblink to

safe-q u a rd i n q adu ltu n i t@wi f Ifl I, ggv-. u k

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ldentify Lead Agency Actual Start Date I Actual End Datel

lf Provider please enterdetai ls

Name of establishmentName ofAgency

lf Other please specifyInvestigation findings$ummary of investigation findings/actions/safeguarding plan (please insert appropriate text)

ls Safeguarding Conference needed -lf Yes please proceed to section 4

lf No seleet appropriate Outcomes you MUST select one option from each Outcome box below

Vulnerable Adult Protection Ptan OutcomeOutcome for Alleged PerpetratorlOrganisationlServiceReferral Summary Outcome

DO NOT record any additional information gathered as a Contact this MUST be recorded in Profile

IF CASE IS CLO$ING YOU MUST NOW COMPLETE SECTION 5' Once this Section is cornpleted emailas a weblink to

Alkl$AC/SAdocJOct09

The Safeguarding Adufts conference process brings together the victim, the family where appropriate and thoseprofessionals most involved with the adult and farnily following an Adult protection investigation when it is deemed a

Criteria for Protection plans ESCR 26aThetes tas towhether theadu l t i s inneedofaadu| tp ro tec t ionp |an is .ls the adult at continuing risk of significant harm

|facaseconferenceishe|d.theminutesandthe'Protect ionP|anmustbestoredonEScR

Findings of Conference at case conclusion

Has the Protection Plan ESCR26a been eompleted?

Has the Protection Plan been agreed by the Vulnerable Adult

Select approprihte Outcomes you MUST select one option from each Outcome box below

Vulnerable Adult Protection Plan OutcomeOutcome for Alleged Perpetrator/Organisation/$erviceReferral Summary Outcome

IF CASE IS CLOSING YOU MUST NOW COMPLETE SECTTON 5Once this Section is completed email as a weblink to

Indicate which of the following have been informed of decisions/outcome, noting the following:. Allfeedback must be confirmed in writing.t The alefier only has the right to be informed that there has been an investigation not the details of the case.. Family of a vulnerable adult may only be contacted if the individual wish them to be notified or if they lack

capacity.. lnformation should be shared only on a'need to know' basis, wiih those people who have a right to

information.. Consider whether service user consent is needbd and seek line manager and legal advice if necessary,

Alleged victim t] Alleged perpetrator I Family member /carer f

Advocate n Alerter X t-tcQcRatified Yes

Team Manaqer t Rachael Grockett Date 11?J11112

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Once this Section is completed email as a weblink tord inqad u ltu n it(Owirra l.qov.u k

Quality Assurance completedBv Safequardinq UnitDate Name

AIkiSAC/SAdoc/Oct097t7

Responses from L.Beddows on behalf of noreen Beddows to theRefei'rai safegiiarding Adiilts form ESCR 26 dated 4.i!.2tiiMade in response to the eviction by Elderholme Nursing Home.STATEMENT BY ELDERHOLME:{The tbrm shows rncorrect address and Gp detarls tbr Mrs Beddows)a) There are serious safeguarding concerns re Mr Beddows behaviour.Placement has broken down as aresult of alleged behaviour of Mrs Beddows husband towards Residential Care Manager. Alleged abuse -Emotional. Previous incident 13.l2.10.Husband is hoping wife will make a full recovery.

h) There has heen lofs of fension hefween sfaff as he cnnqfanflv wants affention for hiq wife anrlunforfunately in the last couple of weeks her condition has deteriorut"d and GP has informed him she isdeteriorating. Originally GP did not want to tell him but he has phoned him himself. - Dr Meyer,Neston-Dr \4e;'er has told hrn that she is deterioratrng e:rd he is quite distressed. I-Infort.mate!;, \4rBeddows does not know that the home knows that he has spoken to the GP. He will not speak to membersat the home and the home is very concerned about him.

c) A number of weeks ago he attended the wheelchair assessment centre with home's physio and he saidto the physio that if he had a gun he would shoot himself and his wife. At this time his wife had nordeteriorate

'#Wffiffiffi&fu

Strateqv Meetin relati nglo Doreen Beddowshetrd on Fridav 11 NoVembqf 201{ at Girtrell Court

Present: Jayne Marshall , principal Manager, Adult Social services (chair)Lesley weston, Acting Team Manager, Adult social servicesBernadette Hegarty, sociarworker, Adurt sociar ServicebMal Price, Principal Manager, ContractsSteve Khan, CHCHeather Ward, Matron, EtderholmeLawson Stebbings, Director, ElderholmeJohn Cadden, Merseyside police, Vict im Support Unit

The meeting today has been called following a meeting held last week on 4thNovember 2011 atwhich concerns were raised. Elderholme, where Mrs Beddowshas resided for the past 11 years in a vegetated state, have said if-l"t tn"u *iff Uuissuing notice on Mrs Beddows due to her husband's cornplaints and unreasonabledemands over the years. Concerns were highlighted as to whgt the impact wouldbe if this notice is served, both on Mrs Beddows being evicted from hei home of thepast 11 years, and whether Mrs Bbddows is fit enough for such a move, and alsothe reaction of Mr Beddows on receiving the notice letter.

The Nursing Home has reported ihat it has not taken the decision to serve noticelightly and it follows 11 years of what Elderholme consider to be vexatious andirrational complaints from Mr Beddows to the home and in particular, Heather Ward,Mat ron ,whoMrBeddowshasaccusedof ly ing .MrStebb ingswentontosay tha tthe19 complaints, which have got worse over ihe past 4/5 years are not rational andare libellous against the Matron; Mr Beddows has made further complaints to hisMP, CQC, the LA and also the Nursing and Midwifery Council and also accused theMatron of lying to Health Professionals. The home feels this is harassment and MrSiebbings stated that Elderholme have taken a view that.

they must protect her and as such hEEEade anirreVocable decision that Mrs Beddows will have to leave the care of Elderholme.Mr Stebbings said that his concerns are for the other residents at the home andalso the staff there. He is also concerned about how Mr Beddows will react to thenotice letter.

Departrnent of Adult Social $ervicesHoward CooperDirector

Beb-ington Locality Team,Beliington Town Hall AnnexeCivic WayBebingion Wirral CH63 7PT

Steve Khan flom CHC reported that after numerous complaints made by MrBeddows, staff from CHC visited Mrs Beddows to complete a Review. Thevreported no concerns in the way Mrs Beddows was being cared for and say nerneeds are being met through her current care plan which has been agreed betweenCHC and Elderholme. CHC received a letter from Mr Beddows in August raisingconcerns about the way his wife was being cared for. Steve Khan wrote back to MrBeddows saying their report stated no concems. During meetings with Elderholmeand CHC there has been no evidence to suggest that Mrs Beddows requires hou.rly

wtrwv.rvirral.gov.uk

turns, as Mr Beddows insists on. When Heather Ward took over as Matron sherluesiioned ihe hourly checks as she felt they were not neeciecl and not in theoriginal car.e plan, which has been reviewed regularly.

Lawson arid Heather told of one incident which had occurred. Mr Beddows hadbeen to Elderhotme to visit his wife. After leaving he called the home to say he hadleft his mobile phone there and could staff call as soon as it was found. The phonewas found wedged behind Mrs Beddows' back, in her bed. As Mrs Beddows isimmobile, staff feli this was a test from Mr Beddows to find out when they were nextturning his wife. Staf[ reported that the phone had left an indent in Mrs Beddows'back. This incident took place prior to Lawson and Heather being empioyed byElderholme

Last Deiernber Mr Beddows made a comment about a shotgun saying that hewould kitl himself and his wife. This comment seems to have been ah isolateoincident and has not been mentioned since.

At a meeting in 2009 with Mr Beddows, Elderholme advised him that i f he was nothappy with the level of care they were providing to his wife, then he coutd take herout of the home. There has been no recent conversation with Mr Beddowsregarding his unreasonable behaviour

Elderholme do not feel that Mrs Beddows is too frail to be moved to a new homeand say that her hus[and takes her on daily visits home once a week by bus.John Cadden from Merseyside Police was asked if he thought any crime had beencommitted by Mr Beddows. He stated that no crime had been committed butadvised that i f they are being presented with a challenging individual, then the lawis there to.offer support i f they feel they are being.harassed, but i t would need to befrom them as an individual and not from their professional role as a ernployee ofElderholme. John said that the Harassment Act would cover this i f Heather wishedto pursue, but that the Police could not get involved in Care Management issues.

Mal Price from Contracts Department stated that it is extremely unusualfor a hometo serve notice on a client but under the contract they are within their rights to servea 28 day notice.

Jayne Marshall has asked Elderholme to not send the notice letter unti l thefollowing actiops have taken place, which Lawson and Heather have agreed to do.

Actions

Meeting with Mr Beddows to take place week commencing I SKI\ / N/lp14111nA11 to lei Mr Beddows know that his behaviour isunreasonable and clearlV explain the situation to Mr Beddows

To clarify at meeting if Mr B holds Enduring or Lasting pOA

". Protection Plan to be put in place at meeting to support untilthe end of the placement

Lawson Sfebbings and Heather Ward to be advised of date ofmeeting

www.wirral.gov-uk

,dental Capacity Assessment io be completed with Mrs L3eciCows

Contact Oficial Sofic

BH, LW

LW

Review of Mrs Beddows io check if she is robust enouoh to be moved- research and advise

SK

To go to Police if harassment situation becomes untenable for support HW,LS

Contact Jay Glover at Alison ltlcGovern's office LW

DASSICHC to feedback to Elderholme following meeting Ail

Once meeting has taken place and Elderholme advised, Elderholmeto serve notice

LS,HW

Seek leqal advice from Leqal Department DASS.CHC

Next meeting to be held in 3 weeks time to Review situatian (Gina to organise andadvise all attending of date and time).

Minutes taken bymTeam Support OfficerBebington Locality

www.wirral.gov.uk

Responses from L.Beddows on behalf of Doreen Beddows to theDASS Strategy Meeting Minutes 11 November 2011 resulting in Ilorren's eviction from Elderholme

ALDERIIOLME'S STATEMENT:Elderholme claimed that the eviction is due to Mrs Beddows's husband's comolaints and unreasonabledemands.There has been eleven years of vexatious and irrational complaints, which have got worse over the last 415years, are not rational and have included that Heather Ward,Matron, tieO.tr,tt Beddows riade further complaints tohis MP,CQC,the LA and also the Nursing and Midwifery Council and also accused the matron of lying toprofessionals.

FACTS:Mr Beddows has made 1l complaints between 2000 and 2008. AIl are in writing and detailed and all concern nonperformance of the agreed care plan. The NHS Investigation notes that Elderholme were unable to provide themwith any files in a recognised format to support that they had investigated any of Mr Beddows's complaints. Theeviction ietter states that the reason tbr the notice was the compiaint macie to the T,iMC.Heather Warci iaici that MrBeddows had victimised her. She "categorically refuted" everything. The directors of Elderholme supported her andevicted Mrs Beddows.

NIIS.CHC DIRECTOR STE\rE KHAN'S STATEMENTHe reported that Mr Beddows made numerous complaints so a review was arranged. There were no reportedconcerns and Mrs Beddows's needs were treing met through the care plan.steve Khan wrote to Mr Beclelows InSeptember 2011 saying there were no concerns. He said there has been no evidence to suggest that Mrs Beddowsrequires hourly turns as Mr Beddows insists on.When Heather Ward took over as Matron sf,J questioned the hourlychecks as she felt thev were not needed and not in the orieinal care olan.which had been reviewed resularlv

FACTS:The NHS Investigation shows that this statement was incorrect because Mr Khan's department has confirmed thatthey made no investigations into complaints by Mr Beddows and he had made no complaints to them.Turns wereneeded every four hours and Mr Beddows has never asked for hourly turns as stated by Simon Khan.

The Review also confirms that hourly checking was essential to meet Mrs Beddows complex needs. CHC nursePauline Hurst was following this up as part of her review of care. Elderholme had stopped hourly checking, shewanted it reinstated, hence the suggestion of a review by a consultant. CHC held a meeting with Elderhorie theminutes ot which show that the Home agreed to reinstate houriy checks but they

altered taking out the requirement for hourly checking. It was not mentioned again until Heather Ward made asafeguarding referral on l3b December SIX months later

3) John Cadden from Merseyside Police Victim Support Unit was asked if Mr Beddows had committed any crimebut Heather Ward could eain suonort from the law if she felt harassed.FACTS:This was supposed to be a safeguarding meeting to help Mrs. Beddows and instead only dealt with protectingHeather Ward.With all the professionals in attendance why did no one realise that there was no one present to speakon behalf of Mrs Beddows as required under the Mental Capacity Act. Mr Beddows could act on her behalf but hehad not been informed of the matter under discussion therefore the meeting should have stopped until an IMCA orMr Beddows had been invited. Although it was a meeting for professionals Lawson Stebbings was present and hedid not know either Mr or Mrs Beddows and was certainly not a professional.

a) Mal Price,Principal Manager Contracts, confirmed that it was within their contractual rights for Elderholme togive 28 days notice.FACTS:DASS conducted an Independent Investigation which concluded that Mal Price's opinion was incorrect. Elderholmecould not evict Mrs Beddows under the contract of care because of her husband' s behaviour.

ACTION POINTS:Although the meeting delegated a review of the Action Points to be undertaken by Simon Khan, Director of CHC,with Mr Beddows, he failed to do so. Although a second meeting was scheduled it never took place so Mr Beddowswas never given the opportunity to speak on his wife's behalf and DASS refused to consider his evidence to supportthe complaint made by Mr Beddows in order to ensure that decisions made on her behalf were in her best interests.

flFWIRRAL Department of Adult Social ServicesGraham HodkinsonDirector

PO Box 351BirkenheadWirralCH25 gEF

date 18 April 2013to Mr Leonard Beddows7 Weald DriveLittle SuttonSouth WirralCH66 4YW

my ref WBC/08720/QAUservice Care Governance

tel 0151 666 3650fax 0151 666 Please ask for

email jacquievans@winal.gov.uk

Dear Mr Beddows

I write to respond to the complaints you presented about the service received fromthis Department in relation to the care of your wife

I understand that the Investigating Officer has interviewed you as part of theinvestigation. I enclose a copy of the Investigation Report and Independent Person'sReport for you to consider.

Your complaint involved a number of issues and the Investigating Officer has lookedat each in turn. The Officer has interviewed all staff thought relevant to yourcomplaint, read all the available documentation and liaised with other organisationsas appropriate. As I hope you will agree, the Investigating Officer has undertaken anin-depth study of this matter.

I have carefully considered the Investigation Report, and accept the conclusionsarrived at and I shall ensure that the recommendations are implemented in a timelyfashion. I am sorry that the Department did not act in a more robust manner inaddressing the eviction of your wife and for any distress and inconvenience that mayhave been caused.

I note the comments of the Independent Person regarding your unresolvedcomplaints about Elderholme and I have reflected upon these comments. lt may bethat with hindsight the Department could have done more to facilitate a detailedconsideration of the complaints you had about the care provided at Elderholme.However I am aware that the Primary Care Trust, as the lead agency, did take stepsto assure themselves that the care provided was of the appropriate standard. Withthe passage of time, I do not think there is further action this Department can take inrelation to these concerns, although you may if you wish refer these concerns to theOmbudsman

Please note that the Investigation Report uses particular language. lf there isevidence to prove that what is alleged in a complaint is correct, it is determined to be'upheld'. lf there is evidence to disprove the allegation in any complaint, it isdetermined to be 'not upheld'. Finally if there is no evidence, or if it is conflicting, theoutcome is described as "no findinq".

This is lof/o rycled paps

I hope you feel your concerns have been listened to and considered carefully, and Iwould thank you for raising this issue with the Department. lf you remain dissatisfiedplease contact the Complaints Manager to discuss how your concerns can beprogressed.

Yours sincerely,

Jacqui EvansHead of Transformation

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Deparhnent Of Adult Social Services

COMPLAINTS PROCEDURE

INDEPENDENT PERSONS REPORT

WBC/08720'QAU

1. Name of Independent Percon Chris Carroll

2. Name of Investigation Officer Jen Harris

3. Name of Operational UniUAdministrative Section about which Complaint was made

DASS Safeguarding

4. Name and address of Gomplainant

Mr Leonard Beddows7 Weald DriveLittle SuttonSouth WirralCH66 4YW

5. Percons interviewed Date Comments

Mr. Beddows _

Complainant 1410112013 Very upset and anguishedAmanda Kelly

_

Service Manager, 110212013 Honest and openSafeguarding

Bernie Heggarty _

SocialWorker 410212013 DittoJayne Marshall_ Principal Manager 7lA2l2Afi Guarded

--esley Weston _

Acting Team Manager 1410212013 Honest and openMal Price

_

Principal Manager 1910212013 GuardedContracts

6. Records/Documenb Inspected7. Correspondence from the complainant8. SWIFT Contact and Refenals History (2 July 1999 to 15 August 2012) -9. SWIFT Profile Notes (17 Dec 2000 to 6 December 2011\ -10. Letter from Elderholme - 17 November 201111. Strategy Meeting Minutes- 11 November2011*12. Safeguarding Adults Procedures and Guidance - 4 July 2011 (reviewed July 2012)13. Safeguarding Adults ESCR26 (AlerUReferral Recording/Monitoring Report Form) - 4 January 2010 -14. Safeguarding Adults ESCR26 (AlerUReferral Recording/Monitoring Report Form) - 4 November 2011 -15. Safeguarding Adults Protection Plan ESCR 26a - 16 November 2011 -16. Checklist for Assessment of Best Interest ESCR 7 -21 November 2011 -17. Assessment of Mental Capacity ESCR I *21 November 201'118. lndependent Mental Capacity Advocate Report (WIRED) - 13 December 2011 -19. Mental Capacity Act 200520. Primary Care Trust Letter to Mr Beddows - 18 November 201121. \Nirral DASS Complaints Procedure

flFWIRRAL

22.Have you received a copy of the lnvestigating Officers Report? *YES/

23.Was the investigation carried out in an independent and impartial manner?

The investigation was very impartial and independent. The investigating officer was very fair andunderstanding of all interviewees. She was well prepared and very thorough in her questioningwithout being confrontational or accusatory. She put all interviewees at ease and quietly extractedmaximum information without being forceful or accusatory.

24.Do you consider that the investigation addressed all the complainants concerns andconsidered all relevant evidence?

- \estigation addressed all the complaints and concerns as defined in the precise remit andacfu.. rd all evidence relating to the remit, but I feel the real cause of the eviction of MrsBeddc :nd subsequent complaint was not included as part of the investigation.

I believ.- t,re reason for the eviction of Mrs Beddows and hence the safeguarding issues being-raised and investigated was due to the breakdown in relationships between Mr. Beddows and the

Matron of Elderhome.

The reasons for that breakdown were caused by direct disagreements on certain specific issuesbetween the two parties which have not, as far as Mr. Beddows is concerned, been investigatedsatisfactorily. Elderhome have themselves investigated his accusations and rejected them entirelywhereas Mr. Beddows states he has evidence for his complaints which no one has reviewed andfeels a third party should carry out an independent review of his alleged evidence.

It may well be that neither DASS or CHC have an obligation or even an authority to carry outfurther investigation into Mr Beddows precise complaints but it would help him if he could beinformed as to the correct body to address those issues, which may well be a solicitor.

25.Were the findings and recommendations of the Investigation Officer logical andproportionate?

-Yes I fully agree with the conclusions stated in the Investigating Officer's report

26. Any additional comments

Please use additional sheets if necessary

27. Time spent considering Complaint

Signature of Independent Person: Chris Carroll

Date: 2 April2CI13

28.

lnterviews PhoneCalls

Travel Case Recording Meetings (e.9.Inv.Officer, staff)

ReportPrep'n

TOTAL

8hr 45 min 1 0 4Hrs ! hour 2 hours25hrs 45min

29.

flFWIRRALDepartment of Adult Social Services

Jen Harris

Chris Carroll

Elderholme

Jayne Marshall

10 December 24fi

Mr Leonard Beddows

wBc/08720/Q.AU

INVESTIGATION OFFICER'S REPORT

Complaint Procedure

Name of Investigating Officer

Name of Independent Person

Service Provider

Principal Manager

Date Gomplaint received

Complainant

7. Complaint Ref No.

1 .

2.

3.

4.

5.

6.

8. Summary of Outcomes

Registered Complaints

1) That neither Mr Beddows, nor Mrs Beddows GP where invited tosafeguarding meetings - PARTIALLY UPHELD

2) That contrary to the Mental Capacity Act an lndependent Mental CapacityAdvocate (IMCA) was not appointed when a move to another home wasdiscussed, nor was an IMCA appointed for the safeguarding meetings -NOT UPHELD

3) The IMCA did not interview Mr or Mrs Beddows until after she had moved -NOT UPHELD

4) At the safeguarding meeting it appears no attempt was made to resolvethe differences, even though Social Services were aware of the complaintwhich had caused the rift - NOT UPHELD

5) DASS allowed the eviction without insisting on a proper investigation -UPHELDRecommendations

o The Department to devise and circulate guidance notes to contractedHomes regarding managing unreasonable behaviour from visitors

o DASS to formally apologise to Mr Beddows for allowing the eviction to goahead under the Contract and without a review of the action points fromthe Strategy Meeting

o Formal process to be devised and implemented to ensure action pointsarising from Strategy Meetings are formally reviewed

o Formal process to be devised and implemented to ensure SafeguardingReferrals which remain open after 28 days are reviewed

o Safeguarding Referralto be closed9. Complainant's Desired Outcome

Mr Beddows' only requested outcome was that the accusations he believeswere made against him by Elderholme in a letter dated 17 November 2011 areinvestigated and proved to be true or false. lt was explained to Mr Beddowsduring the initial meeting on 14 January 2013 and in writing to him on 22January 2013 via email that it was not considered the role of the Department toinvestigate allegations of accusations between himself and the Home.

10. Person's Interviewed

Leonard Beddows ComplainantBernadette Heggarty SocialWorker Duty TeamLesley Weston Interim Team Manager - Access TeamJayne Marshall Principal Manager Bebington and West WirralAmanda Kelly Service Manager - SafeguardingMal Price Principal Manager - Contracts

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11. Documents Examined

o Correspondence from the complainanto SWIFT Contact and Referrals History (2 July 1999 to 15 August 2012)o SWIFT Profile Notes (17 Dec 2000 to 6 December 2011)o Letter from Elderholme - 17 November 2011o Strategy Meeting Minutes - 11 November 2011o Safeguarding Adults Procedures and Guidance - 4 July 2011 (reviewed

July 2412)o Safeguarding Adults ESCR26 (AlerVReferral Recording/Monitoring Report

Form)-4January2010o Safeguarding Adults ESCR26 (Alert/Referral Recording/Monitoring Report

Form)-4November2011o Safeguarding Adults Protection Plan ESCR 26a - 16 November 2011o Checklist for Assessment of Best Interest ESCR 7 - 21 November 201 1o Assessment of Mental Capacity ESCR 8 -21 November 2011o fndependent MentalCapacityAdvocate Report WIRED) - 13 December2011o Mental Capacity Act 2005o Primary Care Trust Letter to Mr Beddows - 18 November 2011o Wirral DASS Complaints Procedure

12. Person's Consulted

Damien Boden Management AccountantDavid Golding WIRED - lndependent Mental Capacity

Advocate (IMCA)David Jones Complaints ManagerJulie Walker Service Manager Quality AssuranceGina Lunt Team Support Officer Bebington LocalityDavid Grisenthwaite Safeguarding Officer

13. Methodology

13.1 The investigation began with an interview with Mr Beddows on 14 January2013. A timescale for completion of the investigation and formal responseof 4 February 2013 was agreed with Mr Beddows.

13.2 The investigation was delayed as Mr Beddows requested that theregistered complaints (shown in section 8) be expanded to include otherareas of concern as noted in Section 9 of this report. After considerationthe Complaints Manager instructed the lnvestigating Officer to continue onwith the investigation within the original parameters set. The revisedtimescale was set as 25 February 2013.

13.3 The Investigating Officer did not deem it necessary for representativesfrom Elderholme to be interviewed as part of this investigation based onthe nature of the registered complaints.

13.4 All interviews undertaken as part of this investigation have been carriedout in the presence of the Independent Person and interviewees haveattended without any representation.

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13.5 Throughout this process it has been necessary to consult with individualswho have been selected to clarify processes and procedures in relation tothe issues raised as part of this complaint (shown in Section 12).

13.6 A number of points in relation to this complaint depend upon the verbalevidence provided by recollections of people involved. Verbal evidencecan, by its nature, be subjective and must be considered with care,especially if not corroborated by other sources of evidence.

14. Brief Case History

14.1 Mrs Beddows was placed at Elderholme Nursing Home in October 2000following an operation which left her in a continuing vegetative state. Theplacement was arranged by the Continuing Health Care (CHC) Team partof Cheshire and Wirral Partnership Trust who are also responsible forfunding the placement.

14.2 An allocated Social Worker was not assigned to Mrs Beddows as her casehad been closed to the Department of Adult Social Services (DASS) as theCHC Team are the lead agency for her care.

14.3 ln November 2011 Elderholme approached DASS and the CHC Team toraise concerns about the volume and nature of complaints that MrBeddows was making against the Home. As a direct result of thecomplaints made the Home confirmed its intention to issue an evictionnotice to Mrs Beddows.

14.4 A Safeguarding referral was logged by DASS due to concerns about theproposed eviction of Mrs Beddows and a multi-disciplinary approach wastaken to review and manage the concerns raised primarily that evictingMrs Beddows was not in her best interest. The Home issued the evictionnotice to Mr Beddows on 17 November 2011 and Mrs Beddows wastransferred to a new Home on 6 December 2011.

Glossary

DASSCHCIMCACQCQuality Assurance Team (OAT)DASS Contract Nursing HomeCareSWIFTCWPTMCA

Department of Adult Social ServicesContinuing Health Carelndependent Mental Capacity AdvocateCare Quality CommissionDASS team overseeing Contractsfor HomesContract detailing obligations for Homes

DASS Client DatabaseCheshire and Wirral Partnership TrustMental Capacity Assessment

1 5 .

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1 6 . Chronology

13 October 200013 December 20104 November 20114 November 201111 November 201117 November 201117 November 2011

21 November 2011

21 November 20112 December 2011

5 December 20116 December 2011

Placement started at ElderholmeSWIFT Adult Protection Concern loggedInitial meeting to discuss EvictionSWIFT Adult Protection Concern loggedStrategy MeetingMeeting to inform Mr Beddows of EvictionLetter from Elderholme advising Mrs Beddowswould be evictedESCRT Mental Capacity Act 2005 AssessmentcompletedReferral made to WIRED for IMCAWIRED received the above referral andaccepted caseAdvocate contacted Social WorkerMrs Beddows moved to Vale Court NursingHome

17. Summary of Investigation

Safequarding referral 4 November 2011

17.1 A meeting took place on 4 November 2011 between Elderholme, SocialServices and the CHC Team. The Team Manager Support Planningattended the meeting as there was no designated Social Worker assignedto Mrs Beddows as her case had been closed to DASS as she was a CHCpatient. During the meeting the Home informed the attendees they hadendured 11 years of vexatious and unsubstantiated complaints from MrBeddows and planned to serye Mrs Beddows with a notice of eviction.Some of the complaints raised by Mr Beddows have been sent to theHome, the local MP, the Care Quality Commission (CQC), Social Servicesand the Nursing and Midwifery Council. A record of complaints producedby Mr Beddows shows that in the first three years of Mrs Beddowsplacement no formal complaints were raised.

17.2 Following this meeting the Team Manager discussed the case with theService Manager - Quality Assurance who raised a Safeguarding Referral.The initial referral was accompanied with the Team Manager's notes fromthe earlier meeting. The notes record the following concerns:

o Uncertainty that it was in Mrs Beddows best interest to be moved andthat it is 'potentially punitive' for her to be evicted from her home of 11years

Concerns about how Mr Beddows may respond to the eviction letter

Thoughts that evicting Mrs Beddows will simply shift the problem ratherthan deal with the cause

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17.3 The Safeguarding Adults Procedure and Guidance document dated 4 July2011 outlines the procedure as follows:

o Alerto Referralo Decisiono Safeguarding Strategy Meeting/Discussiono Safeguarding Conferenceo Safeguarding Plano Reviewo Recording and monitoring

Due to the nature of the issues raised the case was deemed appropriate toprogress through the Safeguarding procedure and was allocated out to theBebington and West Wirral Locality Team to arrange a Strategy Meeting.

Strateqv Review Meetins 11 November 2011

17.4 A Safeguarding Strategy Meeting was arranged by the Principal Manager -Bebington and West Wirral for 11 November 2011. The purpose of themeeting was to formulate a multi-agency plan for assessing/investigatingthe risk and addressing any immediate protection needs.

17.5 Mr Beddows has raised concerns that he did not receive an invitation toSafeguarding Meetings and nor did Mrs Beddows GP. The SafeguardingManager was interviewed as part of this complaint and explained that thestrategy Meeting is for professionals onfy. section s.2.2 of theSafeguarding Adults Procedure and Guidance document provides a list ofindividual's who should be consulted in a Strategy Meeting if they aredeemed to be relevant to the case. lt was confirmed by the Manager thatthe Chair of the meeting is responsible for identifying the relevantindividual's to invite and that the Chair should routinely ask the clients GP.

17.6 The Principal Manager - Bebington and West Wirralwas noted in the minutesas the appointed Chair and reasoned that Mrs Beddows GP was not invitedto the Strategy Meeting as the Safeguarding referral concerned two issues.1) Mr Beddows behaviour2) Mrs Beddows proposed evictionThe Principal Manager was of the opinion that Mrs Beddows health needshad not changed and the Safeguarding referral did not concern her care.One of the action points arising from the Strategy Meeting (17.12) was forMrs Beddows to be reviewed to establish whether she was considered'robust'enough to move. lt is noted that had Mrs Beddows'GP been presenton the day this point could have been discussed and possibly addressed.

17.7 The Strategy Meeting minutes record that 'The Nursing Home hasreported that it has not taken the decision to serve notice lightly'. TheDirector of Elderholme also stated that the Home have made an'irrevocable decision that Mrs Beddows will have to leave the care ofElderholme'.

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17.8 lt has been noted during interview by three attendees of the meeting thatboth the Principal Manager Bebington and West Wirral and the CHC Teammade attempts to intervene by asking the Director of the Home toreconsider. The lnterim Team Manager recalled the Home being 'upsetand distressed about the eviction as they had looked after Mrs Beddowsfor many years'. lt was also made clear by the Home that there were noissues caring for Mrs Beddows the purpose of the eviction was due to MrBeddows' behaviour.

17.9 lt was reported that Elderholme brought two large 44 box files to themeeting containing evidence of the volume of the complaints received andshared some examples with the attendees of the nature of complaintsreceived. lt is noted that a full review of the complaints received by theHome was not undertaken at this meeting.

17.10 The CHC Team reported during the meeting that their team had visitedMrs Beddows in response to previous complaints received from MrBeddows. The Team raised no concerns in the way Mrs Beddows wasbeing cared for and confirmed that her needs were being met through theCare Plan.

17.11 The Principal Manager - Contracts attended the Strategy meeting andconfirmed that it was extremely unusual for a Home to serve notice on aclient but 'under the contract they are within their rights to serve a 28 daynotice'. The lnvestigating Officer has reviewed the Contract for the Provisionof Nursing Care and has found that a Home may terminate an individualcontract on the expiry of at least four weeks prior written notice only:

(i) lF in the Service Provider's reasonable opinion, and that of aqualified medical practitioner, the Service User's condition hasdeteriorated irreversibly to a point where long term care is neededof a standard which the Service Provider is unable to provide;

(ii) lF in the Service Provider's reasonable opinion and that of aqualified medical practitioner, the Service User's behaviour ispersistently unsociable to such an extent that it has a seriousadverse effect upon the well being of other residents or staff.

(iii) lF the Service Provider has been advised by the Commission forSocial Care Inspection that the continued accommodation of theService User constitutes an actual or potential breach ofregistration conditions as referred to in Clause 8.1 and 8.2 above.In such circumstance, the Service Provider must, concurrent withissuing notice of termination, request a review of the ServiceUser's care needs in accordance with 51.10 below.

It is evident from the extract that the Contract applies solely to the ServiceUser and not third parties (i.e. family members or friends). There is also norecord in the minutes that the terms of the contract could not be applied tothis particular situation/scenario or be used to reinforce the Home'sposition that an eviction notice be served on Mrs Beddows.

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17.12 Several action points were recorded at the Strategy Meeting including:

No's Actions ResponsibleOfficer

1 Meeting with Mr Beddows to take place weekcommencing 1411112011to let Mr Beddows know thathis behaviour is unreasonable and clearly explain thesituation to Mr Beddows.

o To clarify at meeting if Mr Beddows holdsEnduring or Lasting POA

o Protection Plan to be put in place at meeting tosupport until the end of the placement

Lawson Stebbings and Heather Ward to be advised ofdate of meeting

Steve Khan,Lesley Westonand Mal Price

2 Mental Capacity Assessment to be completed withMrs Beddows

Bernie Heggarty& Leslev Weston

3 Contact Official Solicitor re POA Lesley Weston4 Review of Mrs Beddows to check if she is robust

enouqh to be moved - research and adviseSteve Khan

E To go to Police if harassment situation untenable forsupport

Heather Wardand LawsonStebbinss

6 Contact Jav Glover at Alison McGovern's office Leslev Weston7 DASS/CHC to feedback to Elderholme following

meetinqAtl

8 Once meeting has taken place and Elderholmeadvised, Elderholme to serve notice

Heather Wardand LawsonStebbinqs

I Seek leqal advice from Leqal Department DASS, CHC

17.13 The Principal Manager - Bebington and West Wirral clarified that due toMrs Beddows being on a Health placement it was agreed that the CHCTeam as the Lead Agency should arrange the planned meeting with MrBeddows for week commencing 14 November 11. The SafeguardingReferral form records that no further investigation was required and thatthe referral would not progress onto the Safeguarding Conference stage.

17.14 Due to the level of actions to be completed resulting from the StrategyMeeting it is evident that this referral had not been fully resolved andfurther work was required. After reviewing the Safeguardingdocumentation the Service Manager - Safeguarding confirmed that in herprofessional opinion this referral should have progressed to theSafeguarding Conference stage.

17.15 The minutes stated that the 'next meeting to be held in 3 weeks time toreview situation'. Through consultation with the Safeguarding Officer it wasconfirmed that some Safeguarding referrals may involve more than oneStrategy Meeting depending on the complexity of the case. The reviewmeeting referenced did not take place and during interview the ServiceManager - Safeguarding noted 'in the past there had been problems withTeams following the process'.

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17.16 lt is evident that a formal review of the action points (17.12) agreed as partof the Strategy Meeting did not take place. lt has also been found that theSafeguarding Referral remains open on SWIFT. The process wouldusually involve the referral being closed within a 28 day period. ThePrincipal Manager - Bebington and West Wirral has clarified that the Teamhave completed a rec,ent review and that this case has been identified andis awaiting closure in the near future.

Meetinq with Mr Beddows 17 November 2011

17.17 This meeting was organised and Chaired by the Head of Continuing Carefrom the CHC Team. Mr Beddows and the Interim Team Manager where inattendance as was another representative from the CHC Team. The Head ofContinuing Care has now left employment with this organisation and it hasnot been possible to interview him as part of this process. The CHC Teamhave confirmed that no minutes were taken from the meeting although a copyof a letter sent to Mr Beddows confirming details of the discussions whichtook place on the day have been reviewed as part of this investigation.

17.18 The decision taken by Elderholme to evict Mrs Beddows was shared with MrBeddows during this meeting and it was explained that the 28 day noticeperiod had been actioned by the Home. lt was noted by the Interim TeamManager that Mr Beddows was 'shocked and upset' at the outcome and it wasmade clearthat he would prefer his wife to remain in the care of Elderholme.

17.19 The previous Safeguarding Referral logged on 13 December 2010 wasdiscussed with Mr Beddows and attempts were made by the lnterim TeamManager to ensure that Mr Beddows was not going to place either himselfof his wife in danger. Counselling support through Mr Beddows GP wasencouraged by the Interim Team Manager and advice was givenconcerning the option for a Carers Assessment to be completed.

17.20 During this meeting Mr Beddows was informed that Social Services hadrequested that an Independent Mental Capacity Advocate be involved inMrs Beddows case.

17,21 The letter states 'we all agreed that the main issue for everyoneconcerned now was the safe and seamless transfer of Mrs Beddows toanother Nursing Home.' A list of alternative Homes was provided to MrBeddows on the day and the Interim Team Manager offered reassurancethat the Local Authority would support Mr Beddows in identifying anappropriate Home.

Independent Mental Capacity Advocate (IMCA)17.22 The Service Manager - Safeguarding confirmed that in order for an IMCA

to be assigned to a client the Local Authority are required to provideevidence that the client lacks capacity. One of the action points from theStrategy Meeting on 11 November 2011 was for a Mental CapacityAssessment (MCA) to be completed with Mrs Beddows, although recordsshows this Assessment did not take place until 21 November 2011.

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17.23 The Principal Manager - Bebington and West Wirral confirmed that theIMCA was discussed at the Strategy Meeting on 11 November 2011. ThePrincipal Manager took the decision to request that an IMCA referral bemade as a 'precautionary measure'. Under the Mental Capacity Act MrBeddows was in a position to act as Mrs Beddows nominated familymember and could decide what was in his wife's best interest and thereforean IMCA should not have been required. The Team however were aware ofthe previous Safeguarding referral and there were concerns as to how MrBeddows would react to the news that Mrs Beddows would be evicted. ltwas unknown how the news may have affected Mr Beddows ability to act inhis wife's best interest which is why the Principal Manager requested that areferral be made. The Manager also noted during interview that she wantedMr Beddows to remain involved in the process to ensure he was able to puthis own views and wishes forward on what was best for his wife.

17.24 Following the completion of the MCA on 21 November 2011 whichrecorded that Mrs Beddows had 'no capacity' the Social Worker emailed acopy of the assessment paperwork and an IMCA referral form to WIRED.The referral was not received by WIRED as an incorrect email addresswas used. The Social Worker did not receive an error notification toconfirm that the email had not been delivered and contacted WIRED on 2December 2011 to query the delay.

17.25 On 5 December 2011 the IMCA contacted the Social Worker to discussthe case and arranged a meeting later that day. During the meeting theSocial Worker provided the IMCA with 'full details of the case'.

17.26 The IMCA did visit Elderholme on the afternoon of 5 December 2011 andmet with the Home Manager and the Director. Mrs Beddows was notvisited by the IMCA during this visit.

Eviction/Transfer to new Home

17.27 After receiving confirmation that Elderholme had served notice on MrsBeddows asking that she be relocated to a new Home on or before 15December 2011, Mr Beddows began the task of locating a suitablealternative Home. Mr Beddows contacted the lnterim Team Manager on29 November 2011 to confirm that he had located a new Nursing Homeand requested some advice as to how Mrs Beddows would be transportedto the new Home. lt was agreed that the CHC Team would pay for theassociated transportation costs and that the Social Worker would makethe necessary arrangements. Mr Beddows was planning for his wife to bemoved to the new Home on 6 December 2011.

17.28 The move went ahead as planned and Mrs Beddows was transferred toVale Court Nursing Home on 6 December 2011.

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18. Findings

It is important to note that during this investigation the lnvestigating Officerhas made no judgement as to whether Mr Beddows behaviour referred toin this report was unreasonable.

That neither Mr Beddows, nor Mrs Beddows GP where invited tosafeguarding meetinos

18.1 There have been three significant meetings which have taken place linkedto the Safeguarding Referral:

o 4 November 2011 - lnitial meeting with Elderholme to discuss the concernso 11 November 2011 - Strategy Meetingo 17 November2011 - Meeting with Mr Beddows to inform him of the

planned eviction

18.2 The meeting on 4 November 2011 was not part of the Safeguardingprocess as the purpose was to discuss the impact of the complaintsElderholme had received from Mr Beddows. The concerns raised duringthis meeting triggered the Safeguarding Referral (17.2).

18.3 The Strategy Meeting on 11 November 2011 does form part of theSafeguarding process although at this stage as noted in 17.5 this meeting isfor professionals only. The Investigating Officer is of the opinion that MrBeddows should not have been included in this meeting. With reference tothe inclusion of Mrs Beddows GP a review of the Safeguarding AdultsProcedure and Guidance document confirms that only those people whoare relevant to the case should be invited to the Strategy Meeting it goes onto reference that GP's should be considered. The Service Manager -Safeguarding clarified during interview that 'the Chair should routinely askthe clients GP to attend for their medical opinion'. Referring back to thereasons for the Safeguarding referral being raised (as noted in 17.2) it wasbased on the uncertainty that it was in Mrs Beddows best interest to bemoved and that it was 'potentially punitive' for her to be evicted from herhome of 11 years. The Investigating Officer is of the opinion that the GPshould have been involved to report on the impact the move may have hadon Mrs Beddows wellbeing not solely focusing on her physical robustness tobe transferred to another Home.

18.4 Mr Beddows was asked to attend a meeting on 17 November 2011. Thismeeting was organised and lead by the CHC Team with the purpose ofadvising Mr Beddows of the forthcoming eviction and to ensure he wasreceiving the correct level of support. Due to the set parameters of thismeeting the Investigating Officer would suggest that it would not have beenappropriate for Mrs Beddows' GP to have been invited to such a meeting.

18.5 The Service Manager - Safeguarding believes that this referral shouldhave progressed onto the Safeguarding Conference stage of the process.Had the Chair opted to take this referralforward both Mr Beddows and MrsBeddows GP would have been invited to a Case Conference.

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That contrary to the Mental Capacity Act an lndependent Mental CapaciVAdvocate (IMCA) was not appointed when a move to another home wasdiscussed, nor was an IMCA appointed for the safequarding meetinos

18.6 The Mental CapacityAct 2005 (Part 1) advises when an IMCA should beappointed. The Act references that either the NHS or the Local Authoritywould need to appoint an IMCA for a change in the clients accommodationto another care home if they are satisfied that there is no person, otherthan one engaged in providing care or treatment for the client in aprofessional capacity or for remuneration, whom it would be appropriatefor it to consult in determining what would be in thd blients best interests.

18.7 As noted in 17.23 The Principal Manager - Bebington and West Wirralconfirmed that under the Mental Capacity Act Mr Beddows was in aposition to act as Mrs Beddows nominated family member and coulddecide what was in his wife's best interest and therefore the decisionIMCA was only requested as a 'precautionary measure'.

The IMCA did not interview Mr or Mrs Beddows until after she had moved

18.8 lt is evident that delays in completing the Mental Capacity Assessment forMrs Beddows by the Social Worker and Interim Team Manager (10 days)and the subsequent email error preventing the referral being receiveddrastically reduced the timeframe available for the IMCA to review andinvestigate the case. lt is however more significant to note that accordingto the Mental Capacity Act 2005 concerning the need for an IMCA to beappointed that Mrs Beddows had her husband to make the decisions withher best interest in mind and this referral was made as a 'precautionarymeasure'only.

18.9 The referral was received and accepted by WIRED on 2 December 2011.The Advocate reviewed the paperwork on 5 December 2011 and on thesame day the Advocate met with the Social Worker and further into theafternoon visited the Home and met with the Director of Elderholme andthe Matron. Due to the limited timeframe available to the Advocate hadpre-planned meetings with other clients which resulted in the Advocate notbeing able to meet Mrs Beddows prior to the move.

At the safequarding meetinq it aopears no attempt was made to resolvethe differences, even though Social Services were aware of the complaintwhich had caused the rifi

18.10 Attendees of the Strategy Meeting have confirmed during interview thatElderholme where asked by both the Chair of the meeting and the CHCTeam to reconsider their position in relation to serving an eviction notice toMrs Beddows. The minutes record the Home's decision as being'irrevocable'.

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18.11 lt is evidentthat both the CHC Team and DASS had awareness of someof the complaints made against Elderholme for the following reasons:

o Contracts had completed a four day Inspection Visit of Elderholme onthe request of the Director of Social Services following complaints fromMr Beddows and also political enquiries from a MP

o CHC reported as part of the Strategy Meeting that after numerouscomplaints a review was completed at Elderholme and the Teamreported that there were no concerns in the way that Mrs Beddows wasbeing cared for and that the Home were meeting her needs

o Elderholme shared some examples of complaints received by MrBeddows as part of the Strategy Meeting

It is noted that a full review of all complaints received by Elderholme whichwere brought to the Strategy Meeting did not take place on the day,although this was not the purpose or requirement of the meeting.

DASS allowed the eviction without insistinq on a proper investiqation

18.12 As discussed in the above section both DASS and the CHC Team hadsome awareness of the history and nature of the complaints raised by MrBeddows. DASS were also aware that the CHC Team had investigatedconcerns raised by Mr Beddows and found that the care provided to MrsBeddows by Elderholme was not of a concern.

18.13 At the Strategy Meeting on 11 November 2011 it was reported by thePrincipal Manager - Contracts that 'under the contract they are within theirrights to serve a28 day notice'. lt is evident that the Contract for the Provisionof Nursing Care does not provide guidance to assist with the particulars ofthis situation. During interview with the Principal Manager - Contracts it wasaccepted that the Contract did not provide specific guidance for either theHome or the Department and the decision was taken 'in the spirit' of thecontract. Point (ii) as referenced in 17.11 was used flexibly to include theclient's family. A review of the contractual guidance shows there is noreference to relatives behaviour when considering serving eviction noticesand therefore the decision to expand point (ii) 'in the spirit' of the contract isnot considered to be the correct course of action.

18.14 A review of the documentation has evidenced that a formal review of theaction points agreed at the Strategy Meeting on 11 November 2011 did nottake place. The Principal Manager - Bebington and West Wirral confirmedduring interview that the Head of Continuing Care 'chaired a follow-upmeeting on 17 November 2011 and that these action point would have beenreviewed at this meeting'. The minutes of the Strategy Meeting do not makereference to support that a review of the action points would take place aspart of this meeting and it has not been possible to clarify this matter with theHead of Continuing Care. lt is clear that the letter sent to Mr Beddows fromthe Head of Continuing Care following the meeting on 17 November 2011 didnot contain a formal review of the action points. The Investigating Officer is ofthe opinion that the Chair of the Strategy Meeting should be responsible for

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reviewing actions points to ensure all necessary tasks have been completed.The Safeguarding referral has also been left open for an extended period oftime which also supports that the process has not been completedappropriately.

18.15 The Investigating Officer is of the opinion that the Home were notcontractually within their rights to serve notice of eviction to Mrs Beddowsunder the Contract for the Provision of Nursing Care. From a proceduralperspective as the action points were not formally reviewed following theStrategy Meeting the Investigating Officer believes the eviction wasallowed to proceed without a proper investigation.

As regards the specific complaints my findings are that:

1) That neither Mr Beddows, nor Mrs Beddows GP where invited tosafeguarding meetings

I find this complaint to be PARTIALLY UPHELD.

Procedurally out of the three significant meetings which took place linkedto Elderholme's planned eviction (noted in '18.1) this report has evidencedthat Mr Beddows should only have been invited to the meeting dated 17November 2011 which was in fact the case. The Strategy Meeting whichtook place on 11 November 2011 forming part of the Safeguardingprocess was for professionals only.

The Investigating Officer has identified that Mrs Beddows GP wasinvited to the Strategy Meeting on 11 November 2011 which isconsidered to be good practice. This decision was not in-line withSafeguarding Adults Procedure and Guidelines.

2) That contrary to the Mental Gapacity Act an Independent MentalGapacity Advocate (IMCA) was not appointed when a move toanother home was discussed, nor was an IMCA appointed for thesafeguarding meetings

I find this complaint to be NOT UPHELD.

The Mental Capacity Act has been reviewed and it is clear that an IMCAwill only be required if the client does not have anyone who can beconsulted with to determine what would be in the clients best interest. MrBeddows was able to act in this role and therefore an IMCA was notrequired. In this case the IMCA Referral was made as a precautionarymeasure to ensure that had concerns raised and adffis56d thrquEh aprevious Safeguarding referral returned then the IMCA could take a directrcile. Following such matters being discussed with Mr Beddows on 17November 2011 it was clarified by Mr Beddows that this was not the caseand therefore the IMCA referral is deemed unnecessary.

notnotthe

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3) The IMCA did not interview Mr or Mrs Beddows until after she hadmoved.

I find this complaint to be NOT UPHELD.

Based on the above finding the lnvestigating Officer believes thisregistered complaint to be not valid as Mr Beddows was acting on hiswife's behalf and therefore there was no requirement for an IMCA to beinvolved. This was evident by Mr Beddows finding alternativeaccommodation for Mrs Beddows which was suitable to meet her careneeds.

4) At the safeguarding meeting it appears no attempt was made toresolve the differences, even though Social Services were awareof the complaint which had caused the rift.

I find this complaint to be NOT UPHELD.

It has become apparent throughout this investigation that Home's servingeviction notices is quite rare. The Principal Manager - Contracts can onlyrecall one other example of this nature and in that case the client was notevicted. The Home was asked at the Strategy Meeting on 11 November2011 by the Chair and the CHC Team to reconsider their decision to evictbut refused to do so.

It is important to note that Mr Beddows did not attempt any remedial actionhimself with the Home directly or via DASS following the news that MrsBeddows would be served notice.

5) DASS allowed the eviction without insisting on a properinvestigation.

I find this complaint to be UPHELD.

Contractually Elderholme should not have served the eviction notice onMrs Beddows as it was her husband's behaviour the Home could nolonger manage, not the clients. In the absence of contractual guidelines,the professionals involved in this case continued to work with Mr Beddowsto try and support him through the transitional period although from acontractual stance DASS could have prevented the eviction.

In addition to the contractual failings it must also be noted that the actionpoints from the Strategy Meeting on 11 November 2011 were not formallyreviewed by the Chair. ln the absence of such a review the Chair hasallowed the eviction to proceed without thoroughly re-considering thedecision to evict based on the outcomes. The Investigation Officer is of theopinion that without such a review the eviction should not have beenserved at this time.

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19. Recommendations

19.1 The Department to devise and circulate guidance notes to contracted

Homes regarding managtng' *t"""onable behaviour from visitors

T h e C o n t r a c t f o r t h e P r o v i s i o n o f N u r s i n g C a r e i s c l e a r a s t o w h a tbreaches could result in an lviction notic-e being served'

ln order to

prevent similar experienc"g ,u"n iuio"n"" notes should run alongside the

contract ensuring Homes n"u" u iood practice document to reference'

1g.2 DASS to formally apolog^ise to Mr Beddows for allowing the eviction

to go "f,""J-unier'the

bonfi"t and without a review of the action

Poi'nt" from the StrategY Meeting

The investigation has found that from both a contractual and safeguarding

stance the -eviction

notice tilld not have been served on Mrs Beddows

at this time.

1 9 . 3 F o r m a | p r o c e s s t o b e d e v i s e d a n d i m p l e m e n t e d t o e n s u r e a c t i o npointsarisingfromstrategyMeetingsareforma||yreviewedAStrategyMeetingisthekeyproce.ss. in.determininghowbesttorespondto the concerns of abusJiJ piotect the. indiviOuat'

Without a formal

process in place to review ".t,otipolnts

arising from such meetings clients

maY be left at risk'

1 g . 4 F o r m a | p r o c e s s t o b e d e v i s e d a n d i m p | e m e n t e d t o e n s u r eSafeguardingReferra|swhichremainopenafter28daysarereviewedIn order to prevent such cases remaining open for

prolonged periods of

time (in d;!"* for over ti montns) a foimal process for periodic reviewswill act as a preventative measure'

19.5 Safeguarding Referral to be closed

B e b i n g t o n a n d W e s t W i r r a l L o c a l i t y o f f i c e t o r e v i e w a n d c l o s e t h eSategu#ing tet"tt"l raised on 4 November 2011'

Jen Harris

28 March 2013

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DASS INDEPENDENTS PERSONS REPORT : COMMEMS BY MR BEDDOWSThe Report refers to the PCT having taken steps to assure themselves that the care provided was of the appropriate standard. The NHSIndependent Revierv, which was not allowed to be included in your investigation, concludes that "it is the opinion of the reviewer that due tolack of consistent record keeping clinical care of Mrs Beddows at Elderholme was compromised and fell below expected standards. Fwthermore.the Continuing Care Team, failed to follow expected standards in respect of its responsibilities and duties under its Continuing Healthcareicuri ' ' ' , issiuuu'g)'cs1.lulsiLii i t i{,sirr 'giadur,rui"irs.Ecdduws'-vrv'i 'guiuirBgdduwsasigr' i iurdrciiH3R.v1ultsconsidered the role of the Departrnent to investigate allegations of accusations between Mr Beddows and the Home". You have however, includedthose made by the Home about Mr Beddows. That would not seem to be equitable.

The allegations made by the Home were repeated in some depth but the NHS report that Elderholme could not substantiate their claims that MrBeddows made any complaints at all. If there is any doubt about the lack of integri[, at Elderholme see DASS Report page 13 para 18.11 inwhich it states that DASS Contracts comoleted a four dav insnection of Elderholme and found nothine untoward. Please refer to the four davDASS inspection report page 3 item 1.2 where they state: " ln the previous manager's reign Elderholme received in excess of 100 complaints.Historic complaints rvere evidenced by offrcers, only one of these appeared to have been dealt with properly.The Directors of Elderholme felt thatthese complaints had not been dealt with effectively nor did thev follow their complaints policy. Para 1.2.2. The present manaser (Heather Ward)had received 5 complaints in two and a half years." All 5 had been recorded. The dates are shown - none of these dates applies to my complaint.How can it be explained that Heather Ward managed to bring io the meeting "fwo A.4 boxes fuIl of my complaints" so she either misled thecontracts insnector or she misled the safeslrard meeting The COC insnection re.nort states that the Manaser told them that they had received "nowritten complaints". Either way none of these statements were accurate.

A safeguard meeting was held and the report confirms that a multi disciplinar_v approach was taken to review and manage concerns raisedprimarilv that evicting Mrs Beddows was not in her best interests. However the Action Points recorded at the strategv meetins show that l. LetMr. Beddows knorv that his behaviour is unreasonable 5.Elderholme to go to Police "if harassment situation untenable for support and 8.Oncemeeting has taken place Elderholme to serve notice.It was in Mrs Beddows's best interests for the safeguarding team to ascertain r'r'hether thecomplaints referred to raised safeguarding concems for Mrs Beddorvs NOT the matron of Elderholme . ln other words the strategy meeting hadr r u tgu r r s i dc r cda ta i iw i r v r i t c rd rg tgwasusa i cgua 'd i r r g i ssug iu r r i r cpa t i c r r r .T i r cyaoccp t c r . iw i r i r ou l . 1 I gu l r t I l l r i r a r i rw t s i i ca t i r lneeded safeguarding and the eviction would take place irrespective of best interests.

At the l7h November meeting Mr Beddows was told by both CHC and DASS that the "complaints" were of no concem to them and neither partl'could qfon Flderhnlme evictinp if thev so wished No menfinn was made of anv of the acfion noints from the strate.q"' meeting Mr Beddows wasgiven no opportunity to speak on his wife's behalf. DASS said "we are were we are".

The renort is correct when it states that an IMCA is onlv needed when there is no one who can be consulted on what would be in the best interestsof the resident. However the Offrce of the Public Guardian say that such a person has to be declared and consuhed BEFORE the decision is made.As a Deputy, under the Mental Capacity Act Mr Beddows should have been consulted because he was,in law, his wife's decision maker. He wasnot told andhing about an eviction until l7s November when he was told that the decision had already been made and the move was not ug fordiscussion. He stressed to the meeting that both CHC and DASS knew of the dispute which had caused the eviction and done nothing about it.Both said it was not their concern. This rvas incorrect. Therefore DASS cannot now say that they did not appoint an IMCA prior to the decisionhecar rse MrReddowswash iswi fe 'sdec is ionmaker i f thevd idnot in tendtoadv iseh imof thes ih ra f ion I )ASSchnsetoanno in f anTMCAla te inthe day so having done so they were obliged to facilitate a meeting with Mr and Mrs Beddows wife to the move and prior to the decision beingmade. As already known the appointed IMCA did not visit until later. DASS had decided on an IMCA instead of consulting Mr Beddows (whichco{travenes the ACT anl.rray) so cannot now say that it was onlv a precarrtion.

Mr Beddows states : "On Page 15 of the report item 3 you state that my complaint that the IMCA did not visit until after the move is not upheldhecarse I rraq nctins on mw rvife's behalf evidenced hv mv findino nerv accnmmodation DASS had annointed an TMCA anr{ therefore he shnrrldhave done his job. Horv was I expected to act on my wife's behalf when DASS had not told me about the situation prior to having to the decisionhaving been made. DASS did not help at all, they did not even arrange transport or issue a purchase order to the taxi company when asked .I waslefl fo do eve.n'thing so the fact that T did jrst that cannot he lsed aq a reason for the IMCA not havins to do his ioh"

Also on page 15 item 4 states that "it is important to note that Mr. Beddows did not attempt any remedial action himself with the Home directll'orvia DA SS" He hed heen aqlrinc f)A SS fnr ^arer t\rr^ \ 'ears f^ heln Pleaqes see the NHS ren^rf naoe I O nara ? h/r Rerldnrvs nnnoinfed n snlicitnrto approach the Court of Protection.He asked Elderholme to stay the eviction pending the process of obtaining Protection but Elderholme refused.

Had Mr Beddows been consulted or if Dr. Meyer had been invited to the strategy meeting the failures in the care plan would have been brought tol isht and anv reasonahle nartu wotrld have sfonned the eviction and inqtnrcted the Home to nrot'ide nrrrsins services as ner the care nlanAl&ough the matron says that the referral to the NMC victimised her, all good practice guides stress that a resident will not suffer t}roughcomplaints being made by them or on their behalf.The Independent Investieation Conditions state that the back uD storv should be included and anv evidence provided.whether it appears to berelevant or not, should still be considered. It was not. Under 4.2 it states that individual remedy will seek to address the individual situation towhich the complaint relates, where fault has been found it will seek to place the individual in the position they would otheru-ise have been in.Obviously another change of residence would not be beneficial at this late stage. The CHC Manager, Simon Khan, was appointed to follow up theAgiiurrFoirrtsbuibceauscoiirciaiiurcoiirisric;l:uirrrcIl i ' i(Julrglsientire process was comrpted.

Finallv the Renort mentions that there has onlv been one other similar eviction case brousht before safecuardins. Annarentlv an elderlv ladv wasto be evicted because of her son's behaviour.He was not invited to the strategy meeting but the nursing home matron was there with her directors.The matron was tearful and regretful on that occasion as wll. An independent investigation was authorised but the evidence of the misinformationwas not verified or considered relevant. Both the report and the following ombudsman's report recommended that at future strategy meetingswhere a compiaint about behaviour was invoiveci the Saieguarciing nciuirs Proceciure an