A Wokingham care home was at the centre of a criminal investigation after an 89-year-old grandfather with dementia was found with a maggot-infested pressure sore, it has been revealed.
Thames Valley Police were called after Royal Berkshire Hospital staff treated the retired butcher, known only as Ben, for the shocking sore and bruises in July 2015.
A Safeguarding Adults Review, published this week, revealed the care home, which has not been named, was investigated for possible ill-treatment or wilful neglect.
Police officers seized paperwork and potential evidence, while staff were interviewed by a detective sergeant.
No criminal charges were brought against the care home provider, but they were ordered to implement an action plan and make a range of improvements.
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After being diagnosed with vascular dementia in January 2013, Ben’s condition deteriorated and after several hospital admissions he was transferred to a care home in 2014.
In April 2015, Wokingham Borough Council accepted that Ben “lacked capacity to consent”, following a Deprivation of Liberty Safeguards (DOLS) assessment.
During that assessment, Ben’s daughter raised concerns about the quality of his care, but they were not shared with the council for five months.
She said her father was left to sit in his own urine at the care home, went days without a wash and once went a day without food.
The review states: “Concerns were not fully shared with the local authority until August 6, approximately five months after the submission of the DOLS assessment.
“The opportunity to appropriately respond and assess the quality of care and impact for Ben was missed.”
When Ben was admitted to hospital in July 2015, staff found bruises all over his body and 12 pressure sores, including one in his heel which had maggots in it.
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They said most of the bruises appeared to be the result of being bed bound but one on his neck “was consistent with a hand mark”.
Police launched an investigation and the council teamed up with several agencies to carry out an inspection of the care home, to check on other residents.
The care home was also placed on an embargo list during the investigation, so no more people could be admitted to the home.
Following the investigation, no criminal charges were brought against the care home provider but they were ordered to implement an action plan.
According to the review, the action plan was “applied in a timely and effective manner”.
The investigation also found that a member of staff had “correctly” raised safeguarding concerns when Ben was a resident there, but the council failed to conduct a thorough investigation.
The review states: “The referral was considered by the local authority but ultimately closed as the findings concluded that the care and support within the home were enough to meet the identified needs.
“It is not clear how this decision was reached by local authority and may reflect the need scrutiny of such decisions in safeguarding.”
The review concluded that “all agencies were responsive” after concerns were raised about Ben’s injuries.
But it also states that “it was clear that preventative measures such as regular a programme of contract monitoring and proactive quality assurance visits” should have been carried out.
After the incident, Ben was transferred to another care home where he died following a brief battle with pneumonia. He had several pressure ulcers, but they were not found to have contributed to his death.
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