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ILL-TREATMENT: Beloved great-grandmother who was psychologically abused at a care home

ILL-TREATMENT: Beloved great-grandmother who was psychologically abused at a care home

The late Hilda England, Image: M.E.N

Hilda England was a formidable woman. Heywood born-and-bred, she raised seven children while working at the town’s Mutual Mills and later Hanson’s Bakery.

She remained highly active after she retired – becoming chairwoman of the townswoman’s guild, and getting involved with drama and church groups.

But in her final years she suffered appalling indignity and ill-treatment at one Rochdale care home before being badly failed by another.

First she was subjected to psychological and emotional abuse at Beechwood Lodge where the manager ‘tapped’ her nose and interrogated her while she sat naked on the toilet.

The great-grandmother then moved to Springfield Park Nursing Home, where staff would fail to urgently call her an ambulance despite the fact she had suffered a fit and was being sick.

Less than two weeks later she died in hospital  from aspiration pneumonia, having ‘likely’ inhaled her own vomit while at Springfield Park, according to an ombudsman’s report.

She was 94 years old and had been suffering from cerebral atrophy – a brain condition that causes fits which manifest as a vacant appearance, paralysis and an inability to respond.

Her devoted family has had complaints about both homes upheld by the Local Government and Social Care Ombudsman (LGSCO) – which ordered Rochdale council to pay compensation.

They have now raised serious concerns to the Local Democracy Reporting Service over the way elderly people are looked after in the borough.

A ‘ticking time bomb’


Ann Cooney and Susan Coates with a photograph of their mother, Image: Nick Statham

Ann Cooney, Mrs England’s youngest daughter, claims that some care homes are ‘not safe’ and that the local authority is facing a ‘ticking time bomb’.

“I have worked in social care all my life, managing services – specifically safeguarding cases as well, so we are quite used to professional standards and processes. We are happy to follow that,” said Ann.

“We do believe that  it’s a ticking time bomb –  adults in care homes in Rochdale aren’t safe, processes aren’t safe.”

Although the two homes Mrs England stayed at are privately run, they were commissioned by Rochdale council – which is ultimately responsible for adult care in the borough.

Ann took her complaints about her mother’s care to the ombudsman as she was unhappy with the way the council had handled matters.

She raised safeguarding concerns about Beechwood Lodge with the council, but the authority later had to apologise that its investigation did ‘not meet best practice standard’.

Mistakes ‘swept under the carpet’

According to the LGSCO report it should not have held a mediation meeting with the family and home while safeguarding enquiries were ongoing.

The council also failed to give the family accurate information about timescales and did not share information in a timely manner  – resulting in delays.

In Ann’s experience “Rochdale MBC swept stuff under the carpet, they don’t do thorough investigations,” she said.

“We get sick and tired of listening to ‘lessons learned’, she said.

She believes the local authority needs to take some responsibility for their ‘incompetence’- both in terms of commissioning care homes and investigating complaints.

“They need to be transparent. Somebody needs to start taking a look at the councils and how they actually operate, because we feel they are not accountable to anybody,” Ann said.

Mrs England was still living a relatively independent life in sheltered accommodation at Cherwell Court before entering residential care.

But after a stroke brought on seizures she began to need the sort of round-the-clock care her family was sadly no longer able to provide.

Beechwood Lodge

Mrs England became a resident at Beechwood Lodge, in Meadow View, Norden,  in May 2015.

And it was here in August and September 2016 that she suffered emotional and psychological abuse, according to investigations by both the council and LGSCO.

The investigations came after her daughter Ann raised safeguarding concerns over two incidents of alleged neglect. One on August 8 where a carer ‘forgot’ to help Mrs England to bed after she reported feeling unwell. And another on September 2, where no one was available to take her to the toilet, resulting in her soiling herself.

Even more disturbing was an incident on September 2, where the manager was reported to have come into bathroom while Mrs England was naked on the toilet ‘and kept poking her on the nose saying ‘what have you been saying about staff?’.

The council’s ‘lead assessor’ visited Mrs England on September 12 when, according to the LGSCO report,  she ‘anxiously explained that she was scared that [the manager] might reprimand her if she said too much’.

However, at a later ‘unannounced’ visit, at which no family was present, Mrs England told the assessor she had not been abused but only ‘tapped gently on the nose to attract her attention’.

She reportedly said she did not want the manager sacked but wanted her to know that confronting her naked in the shower without her consent was unacceptable.

Psychological and emotional abuse

The exact date of this interview was not recorded, but was after the ‘mediation session’ between the family, council and home on September 28.

Because of her comments in this second interview, the allegation of physical abuse was ultimately found to be ‘inconclusive’ by the council, although the complaint psychological and emotional abuse was ‘substantiated’.

Mrs England’s family totally reject the finding that their mother was not physically abused.

“There’s no record of that interview, we’ve never seen it,” said Ann.

“He says Mum said it wasn’t abuse. So he decided because Mum felt it wasn’t abuse – because [I believe] she was scared of speaking out, she had spoken out once   they didn’t uphold it because of that. But we never ever saw the report.”

However, the council’s assessment that the allegation of neglect on August 8 was ‘inconclusive’ was found to be ‘flawed’ by the ombudsman, which also said there was ‘no good reason’ for the authority’s enquiries to have taken eight months.

By the time a case conference – including the Care Quality Commission, council officers, Ann and two of her sisters and the home – was held on March 17, 2017, further concerns had been raised by the family.

These included failure to manager Mrs England’s seizures properly, improper moving and handling and lack of staff to take care of toileting needs.

Restricted visiting

The family had also been put on ‘restricted visiting’ and Beechwood Lodge threatened to evict Mrs England.

The ombudsman’s report notes there had been a breakdown of trust between Mrs England’s family and the manager and this led to the threat of eviction which had been averted by a mediation session.

Ann went on to say that she believes ‘there was a culture at Beechwood Lodge that if you rocked the boat your parents would be evicted or you would be put on restricted visiting or your life would be made horrible’.

“It’s basic care – fed, dressed, bathed, medication, drink – that was all we were asking for and all we wanted, and a bit of dignity and compassion,” she said.

The LGSCO ordered the council to apologise to Mrs England in writing and pay her £500 for the distress she had been caused.

“It also had to pay Ann £250 for her trouble pursuing the complaint and explain what action it was taking to ‘to ensure its safeguarding enquiries are completed in a reasonable timescale and to the required standard’.

Springfield Park

In spring 2018 Mrs England’s family began looking for a new home for her and she moved into Springfield Park Nursing Home in May that year.

“When we moved her, we did not think the care home could meet her needs, to be honest, but the difference was the manager was lovely,” said Ann.

“We thought we could go four times a day, it’s in Springfield Park, we can take her out for an ice cream, or a cup of tea, take her to the pub across the road to spend some nice quality time with her.”

She continued: “There were lots of things wrong. We decided we would put up with that because we had been so brow-beaten and the council had not bothered that much we just felt ‘we can’t do it anymore, we just can’t do it.”

While the shortcomings at Springfield Park were obvious, the family enjoyed better relations with the staff and tried to compensate by helping as much as they could.

But in May 2019 health watchdog the CQC came in and ‘wiped the floor’ with the home – rating it as ‘inadequate’ and placing it in special measures.

“Mum was in the small unit upstairs. It wasn’t ideal, but we were managing,” said Ann.

‘Absolute chaos’

“But when they moved her downstairs to this chaotic,  horrible unit that was in absolute chaos… The staff didn’t know what they were doing.

“They moved all 11 people upstairs to downstairs. Fortunately they gave us a change of room and we made it as nice as possible. The rooms were awful.”

Ann’s sister, Susan Coates, said it also became ‘really apparent’ throughout her mother’s stay, that the home had ‘no idea’ how to manage her mother’s condition – particularly her seizures.

“We just thought, wrongly, that the social worker who was dealing with it and the home would ensure that this seizure management regime was in place with the care that my mother was getting,” said Mrs Susan.

The family raised concerns with the council after it became apparent that no seizure management plan was in place.

However, with the allocated social worker about to head off on holiday, it fell to Susan to draw up a workable plan, which was agreed by Mrs England’s GP.

The family says that, prior to this, there had been several episodes of serious failings in her mother’s care.


Describing one such incident, Ann said: “When I went in, the bed was laid flat, which it shouldn’t have been, she should always have been propped up.  And she was choking on her own vomit and she was going blue.

“She was in this new room downstairs. I didn’t know where the emergency bell was, because nobody had shown me where the emergency bell was.

“I was rooting around, trying to get assistance off the staff. I went in the corridor screaming for someone to help me.

“I was trying to sit the bed up, but the controls on the bed were that badly worn I didn’t know which button was to raise the head or raise the feet.

“The staff came and assisted us to get her on her side and clear her airways. She got admitted to hospital.”

Mrs England’s care plan said that if she suffered a seizure 10 minute checks must be put in place until it has stopped. If the seizure continued for longer than 45 minutes, carers were to call the emergency services and tell her family.


On August 22, 2019, however, the ombudsman found that staff at Springfield Park Nursing Home failed to follow those instructions in the seizure report plan that was not in place.

According to a ‘likely scenario’ set out in the LGSCO report, at 7.24pm Mrs England was in bed having a seizure.

When the night shift took over at 7.30pm, checks should have continued every 10 minutes.

But she was not checked again until 8.05pm according to a ‘retrospective’ entry in her seizure monitoring chart made by a senior care worker.

This did not note her condition but the ombudsman found it ‘unlikely’ she was having a fit or vomiting at this time.

But when two care workers looked in on her at 8.50pm, she had suffered a seizure and was vomiting. They called a ‘Nurse J’ who asked ‘Nurse K’ to check her observations.

However, according to ambulance service records, they were not not called until 9.43pm – nearly an hour later.

At 2am Ann went back to the care home to get her mother’s medication chart.

Here Ann claimed she was told by two ‘really upset’ young carers -referred to as ‘Care Worker B and Care Worker C in the ombudsman’s report – that they had been told not to monitor her mother when they came on duty at 7.30pm

“The care plan clearly said if she’d had a seizure we should monitor her every 10 minutes. That didn’t happen. The nurse told them to go and look after someone else,” said Ann.


“When they went back in to mum she was choking on her own vomit, she was aspirating, she was choking on vomit and she wasn’t well.

“They were insistent that he call an ambulance. When you read that ombudsman’s report it’s quite clear that didn’t happen. There was a delay.”

This account accepted in the ombudsman’s report, which states that ‘Care Workers ‘B’ and ‘C’ told nurse K that Mrs England needed an ambulance – but he said he needed to check her first, they need to clean her and he would ‘sort it out’.

It also records how Care Worker ‘C’ had checked Mrs England’s seizure management plan folder, which said to call an ambulance if she had secretions after a fit. She showed this to Nurse K who ‘ignored’ her.

It adds: “Nurse K said to leave but Care Worker C said she would stay as she felt uncomfortable leaving Mrs Y while she was covered in vomit and ‘how she was with her breathing’. Care Worker B told Nurse K he needed to call the out of hours GP service. Nurse K said he would do this after taking Mrs Y’s observations. Care Worker C said they needed to contact Mrs Y’s family and she needed an ambulance.”

Ann explained : “In terms of me going to the ombudsman, Rochdale council dismissed all that, and yet it’s in black and white.  What those young girls told me happened on that night happened, because it’s in the report.”

She added: “Rochdale council had that information, so why was it not upheld by Rochdale council? Why? I don’t trust them one bit to safeguard anybody.”

‘The council is accountable’

The Ombusdman report adds that, given Mrs England ‘was vomiting and for all anyone knew at the time could have been having a seizure for more than 45 minutes, there was an urgent need to call an ambulance. The failure to do so was a fault, for which the council is accountable’.

Mrs England was taken to Fairfield Hospital and on September 3 died in Rochdale Hospice  of aspiration pneumonia, having inhaled – or ‘aspirated’ her own vomit.

The ombudsman found that it seemed like she had aspirated while at Springfield Park.

However, it was not possible to say the outcome would have been any different if not for the failings identified.  Moreover, any aspiration was ‘ likely to have occurred between 8.05pm and 8.50pm  when there was no need for 10‑minute observations’.

The report adds that 10-minute checks would ‘not necessarily have prevented’ Mrs England from aspirating.

Nevertheless, the council was ordered to apologise to Ann and pay her £400 in recompense for her distress and time pursuing the complaint.

Ann said a social worker made contact with the family and said she was going to visit Mrs England at Fairfield Hospital. This was in order to tell her she would not be able to go to Springfield Park and would need a nursing placement.

But it was made clear she would not be welcome.

“I said no way are you coming up to sit at my mother’s bedside at  94 years old,” said Ann.

“They’ve just told her she’s dying and you think you are going to come up and sit by her bedside and tell her she’s not going back to the care home because they can’t manage her care needs?

“They’ve never been able to manage her care needs. I said you failed her. The system has failed her.

An ‘horrendous episode’

Reflecting on what she describes as a ‘horrendous episode’ she added: “I know she is old and isn’t going to live forever and we all accept that.

“But you shouldn’t have to die like this. You shouldn’t have to be in a bed where you’re covered in vomit, they’re not calling an ambulance, it shouldn’t be like that.”

Ann and Susan say they have donated all the compensation money paid by the council to charity, with the last payment going to Rochdale Hospice.

What the council says

Claire Richardson, the council’s director of strategic commissioning (DASS), said the authority had accepted and implemented the ombudsman’s recommendations and reiterated ‘our apology to the family for any shortcomings in services provided at the care home’.

“Following publication of the ombudsman’s findings we commissioned an independent report into our original safeguarding investigation, and ensured each of its recommendations was promptly actioned and shared with the family,” she said.

“This included a copy of our comprehensive safeguarding procedures plan, a meeting between the family and our director of adult social care, and details of our robust new allegation management procedure. Our safeguarding policies and procedures are regularly reviewed and updated and the safety, wellbeing and protection of residents is a priority.”

What Beechwood Lodge says

A Spokesperson for Beechwood Lodge said: “Beechwood Lodge  is part of a group with an excellent reputation that has been operating care homes for over 30 years. We are immensely proud of our brilliant caring staff who work tirelessly to make sure that residents are kept safe, healthy and well cared for.

“We have since introduced a new home manager who has done a fantastic job in implementing many improvements over the last 18 months, including processes and systems to ensure that care is of the highest quality.

“We have always fully supported residents and their loved ones in raising any concerns or complaints, and continue to do so.”

Select Healthcare Group, which runs Springfield Park Nursing Home, did not respond to a request for comment.

The home is currently rated ‘Good’ by the CQC.


Words: Nick Statham, Local Demcoracy Reporter

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