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A Mencap area operations manager, Director of Services and Chair walk into a bar…

01 May 2018 - No Comments

The barman describes poorly staffed, unsafe, unkind, chaotic care in the two years before a resident in one of their services died.

The Mencap operations manager said we had plans. The Director of Services said he was proud. The Chair paid tribute to the staff and said they were amongst the best in the country.

I know, I know, it reads like a really bad joke. Sadly Mencap’s behaviour since Danny Tozer’s inquest concluded has reflected just that, so I thought I’d go with it. I wrote a blog post at the weekend touching on four elements of Danny’s inquest:

  1. Lack of investigation and scutiny
  2. Families under the spotlight and parent blaming
  3. Trust, and
  4. Dignity and risk or dying to have a wank.

I’ll not revisit those here. Instead today I thought I’d have a quick look at overall how the care was described in the inquest and how Mencap responded to that in the media. You can watch the interview below:

Tim, Danny’s father, when describing Danny moving into a Mencap home for BBC Breakfast, described what they thought would happen:

I thought that’s great, we’ll get involved, we’ll have meetings, we’ll see how it all works, we’ll be part of the Mencap family. That never appeared at all, it was a house which just ran under its own rules, run by the staff, some of whom perhaps one would rather wish they weren’t running it.

Later in the same piece when asked how he thought the verdict reflected on Mencap, Tim said:

Well, they didn’t find neglect but I think if you listened to the evidence during the two weeks there were a lot of concerns about Mencap and I don’t think these are going away.

You can read the @TozerInquest tweets if you’re interested in the detail of how poor the care was. In a nutshell we heard about poor staffing, Gary Brittan [GB] the Head of Commissioning at City of York Council revealed:

There was much discussion about whether the missing hours compromised safely. Oddly CYC staff seemed to just accept without any scrutiny the Mencap line, that it didn’t impinge on safety, although no-one could provide any clarification of how they knew that. Sue Newton, Service Manager for Learning Disability at the council gave the most soul destroying answer:

People stay in the house to make sure basic care needs are met.

Stay in the house. Basic care. Units for processing not lives for living. This is Mencap care in 2015, before the care crisis or recession hit home [edit: as badly as it has now, see here for valuable comment from John Lish about this point]. The only CYC staff member who seemed able to acknowledge their failings was Ralph Edwards, Principal Social Worker who admitted their monitoring was sub-standard:

Let’s see what CQC found months after Danny’s death [pages 8 and 9]:

At the time of our inspection, the registered manager told us there were 15 full time equivalent vacancies across the service (equivalent to approximately 560 hours per week). The registered manager told us that there had been on-going problems recruiting new care workers, but they used agency care workers where necessary, had relief care workers to provide cover and service managers provided care and support to fill gaps in the rota due to sickness and absences. However, rota’s we saw showed that not all shifts were covered. Service manager’s we spoke with told us “Whilst there are vacant positions there will be shifts not covered” and “We have regular agency if needed, but they are not always available.” Another service manager said shifts were not covered because they had a limited agency budget. The registered provider told us that there was not a limited agency budget; however, we were concerned that a service manager, responsible for organising rotas, was working under this impression.

The registered manager said that the number of care hours provided each week was flexible and there was an “Ebb and flow” from week to week. Care workers we spoke with told us “Some days there are not enough staff, we could do with more. Sometimes there are only two staff on for four tenants, we do our best, but we are stretched”, “There have been some shifts when it’s felt like there is not enough staff” and “Staffing levels are terrible; there is a lot of lone working.” We asked care workers what the impact was for people using the service when shifts did not get covered; comments included “It’s some of the activities and hours for going out that get missed.” One care worker told us that shifts not getting covered meant “At the weekend everyone stays in the house, we can’t take people out.”

The description of what CQC found continues and concludes:

We concluded that the system used to monitor staffing levels was not sufficiently robust. We concluded that there was a lack of clarity and accountability around staffing levels and the system used to ensure that gaps in rotas were covered was not robust enough.

This was a breach of Regulation 18 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A regulatory breach. Shoulders shrugged by CYC and Mencap. This was the environment Danny was living in. He was not able to go to activities he’d been promised. His parents spent two years raising concerns and being dismissed by the service:

So much so that they eventually had to take him home due to the poor staffing and concerns that he would be warehoused in his room all weekend:

We heard that there was poor, and in some instances no, understanding of person centred care:

The picture that emerged was of a chaotic service with no keyworkers or routine, even when it was clear people would benefit from it:

How did Mencap respond when Danny was alive?

When Danny was alive and his parents raised concerns these were continually dismissed or not resolved by Mencap. In this post I’m not going to concentrate on the evidence given by the individual support workers, or indeed the house manager. Let’s stick with those with managerial responsibility at Mencap, those paid to manage.

The most senior Mencap witness who gave evidence at the inquest was Tracy Edwards, area operations manager and registered manager with the CQC. She confirmed to the coroner she’d worked for Mencap for 27 years. She is deeply embedded in Mencap, its attitude, culture and values.

When asked by Ben McCormack [BM] counsel for Danny’s family how seriously she took the concerns they raised her response was underwhelming to say the least.

As Liz observes there is so much apathy. She didn’t have any specific issues. This in response to concerns raised by Danny’s parents. Concerns being discussed at his inquest.

How did Mencap respond immediately after Danny died?

Earlier Tracy had talked about what happens when someone dies in Mencap care:

Lots of people who could provide support to Danny’s family, who could immediately ensure a thorough investigation of the circumstances of his death, including the CEO of the organisation Jan Tregelles [known for her tendency for blocking campaigners, myself included, so please feel free to share this blog post with her].

Did the immediate review into Danny’s death happen at Mencap? Did they seek to find out what happened asap to ensure other people were safe? Did they conduct an open, honest and transparent investigation, fully embracing the Duty of Candour throughout? Did they embody everything they have campaigned about for donkeys years? A complete commitment to scrutiny and learning when a learning disabled person dies?

Of course not. What follows is a cross examination of Gill Poole [GP] author of the independent review into Danny’s death commissioned by CYC by Joseph O’Brien [JO], counsel for Mencap:

How did Mencap respond when Danny’s parents asked for a full jury inquest?

Well there’s a blog post here that details their actions at the final pre-inquest review hearing. Where the ‘leading voice of learning disability’ didn’t support Danny’s family’s calls for a jury, and as wide a scope as possible.

Instead they tried to limit the scope and timescale of the inquest, to a period where they’d lost all the daily logs. Reference to this loss by Tracy Edwards, area operations manager, was perceived by some as indicative of the general blasé indifferent attitude to care.

How did Mencap respond during Danny’s inquest?

I don’t want to get into a discussion here about the merits of the approach of Mencap’s brief, Mr Joseph O’Brien. What I would say is that several members of Mencap staff sat in court throughout every pre-inquest review hearing and Danny’s inquest, his actions were fully supported by Mencap.

Including this utterly bizarre attack of Gill Poole, the author of the CYC commissioned report into Danny’s death. Mr O’Brien decided to focus on GP’s independence, whether she involved Mencap enough, and whether she was too overly critical. Mr O’Brien seemed to think that the independent report should be ‘balanced’ as opposed to a report of the facts as she found it.

Remember this is the self-styled ‘leading voice of learning disability’, an organisation that claims it has no conflict of interest in providing poor services and supposedly campaigning and holding the government to account. Danny’s parents had to find and pay for an expert from another support provider to come in and work with Mencap staff.

What also became apparent during the inquest was the complete absence of professional curiosity. This was a conversation between Ben McCormack [counsel for the family ] and Tracy Edwards [Mencap area operations manager] where Ben asked if she had read Gill Poole’s report:

There is so much we could focus on about the Mencap staff at the inquest, instead lets move on to what happened at the end.

How did Mencap respond after Danny’s inquest?

John Cowman, Director of Services at Mencap read this statement to the media. He ends with:

We’re so very sorry that Danny died… Mr and Mrs Tozer felt that at times Mencap fell short of the high standards which we set ourselves. This is of huge concern to us and we very much hope they will work with us, should they wish to

When asked by Jayne McCubbin, BBC Breakfast journalist ‘I just wanted in this moment to ask, if the description of this service has been one that you are proud of?’ Cowman responds with a confident ‘Yes’ together with nodding head.

We have heard about poor staffing levels, a lack of activities for Danny, his needs not being met. CQC, two months after Danny died, rated the Mencap services in York as requiring improvement. They found:

  • The service was not always safe.
  • It was not always effective.
  • It was not always caring.
  • It was not always responsive.
  • It was not always well led.

Yet John Cowman is proud.

Later in the same report Derek Lewis, Chair of Mencap, was asked how he felt watching the BBC Breakfast film and hearing criticisms against Mencap. This is how he responded:

First of all desperately sad. Danny was a lively, energetic, engaging young man and his early death is a matter of sadness, real sadness for all of us and our sympathy goes to the parents who had to endure his early death, but also had to go through a very traumatic two weeks of an inquest into the reasons for that death. He was a much loved boy, the people who looked after him were very dedicated to him, loved him, they were distraught at his death and it has been very traumatic for them too going through this inquest. That’s now done. The Coroner has given his verdict which was that the death was due to natural causes linked to epilepsy and that there was no neglect involved, so we remain very sad and very sympathetic to all who have suffered as a result.

OK, a few reflections:

  1. Derek didn’t know Danny. He never met Danny. His parents had just described him, Derek had no need to try and do the same.
  2. Real sadness for all of us – what does that even mean? I agree with Derek the world is a less bright place without Danny in it, but why is Derek referencing sadness for all of us? Is that what he meant or is it simply a line laid down to prepare the way for staff trauma?
  3. I don’t think Danny’s parents want Mencap’s sympathy. They have spent years ignoring and diminishing them when they could have engaged with them. What use is sympathy?
  4. Why is Derek talking about the trauma of the inquest? Why has he distanced this from Mencap’s own actions? If they wanted to lessen the trauma why didn’t they support the family’s request for a jury? If they didn’t want to cause trauma to Danny’s parents why did their brief force them to relive in minute detail their son’s masturbation habits? Where did the trauma of Danny’s inquest come from and how much was heightened by Mencap, their counsel and their staff?
  5. Danny was not a much loved boy. Just stop Derek. He was a 36 year old man.
  6. Why are you talking about staff loving Danny? Being dedicated to him? Being distraught at his death? Does Derek honestly think this is appropriate? Some staff were no doubt fond of Danny and his parents were at pains to point that out, more balanced people you’d struggle to meet. Those staff weren’t supported by Mencap. Indeed one was sacked, after whisteblowing about the care provided.
  7. The Coroner ruled that neglect, on the balance of probabilities, did not cause Danny’s death. That’s not quite the same as saying there was ‘no neglect involved’.
  8. Sad and sympathetic to all who have suffered. WTAF? Tea and sympathy?

Luckily the BBC presenters were on the ball. They pointed out:

There have been criticisms though because CQC found people in the house weren’t safe, an independent council report also found failings and the family clearly weren’t happy. They talked about the lack of communication with Mencap. So how do those things go hand in hand?

How did Derek respond? Well with a side swipe of parent blaming of course, followed by the usual trite rendition of ‘of course we learn from this’:

Clearly the Coroner identified some failures in communication between Mencap, Mr and Mrs Tozer, and the City of York and we accept those and actions have been taken to address those. As always we learn from situations like this and a number of other actions have been taken.

The BBC presenter asked what actions had been taken. This is a key point, Derek responded:

Such as the way we transfer people with learning disabilities from one carer to another to ensure that is seamless, but the quality of care, the caringness of it was of a very high standard and the staff there were among the best in the country and I pay tribute to them.

Where to even go with this. It’s simply lies. There was no evidence that ‘the caringness’ of the care Danny received was of a high standard. Absolutely none.

We heard evidence from Danny’s parents that staff didn’t understand Danny, and didn’t want to learn from them.

At the end of her evidence Rosie, Danny’s mum, addressed the Coroner to say she’s brought Danny’s scrapbook with her to the inquest, so people could get to know him:

The evidence we heard at the inquest described the backdrop to Danny’s life being one of poor staffing, a lack of meaningful activities, no person centred care and Danny’s needs not being met. The concerns of Danny’s parents were echoed in the CQC report and Gill Poole’s Independent Report commissioned by CYC.

Derek Lewis’ suggestion that the quality of care Danny received was of a high standard, especially the caringness, is in direct contradiction of the evidence we heard in court, given by people under oath, rather than advised by PR and communications colleagues.

We heard about a lack of rapport between staff and residents and how Emmett Smyth, the Behaviour Analysts from Dimensions, was brought in to address that, and within that PBS plan Mencap staff had to be reminded to show kindness to Danny:

Emmett described system-less chaos:

When asked whether he was confident the PBS plan was followed when it was left to Rachel Drammeh, the Mencap home manager, this was how he responded:

I think Mencap need to take a long hard look at themselves. Tracy Edwards, their area operations manager who had oversight of the ‘care’ Danny received. John Cowman who sat in court listening to evidence and is proud of what he heard. Derek Lewis who clearly has no real idea of what went on and no ability to understand what good quality person-centred care looks like in 2018, or should look like.

Let’s not forget the Mencap CEO Jan Tregelles either. After Danny died she had the gall to suggest to Danny’s parents that they should have come straight to her, that her door was always open. She also told them that the staff were ‘crap’ and that the atmosphere in the house was ‘clearly toxic’.

I’m still left wondering how Mencap are going to square that circle.

Final word to Tim, Danny’s Dad, let’s not forget how adept at brushing things under the carpet Mencap management clearly are. It’s in all our interests to ensure that’s not allowed to happen on this occasion:

I think if we hadn’t really pushed things we might to this day possibly never have heard anything again from anyone.

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