Jessie McKinlay, 91, was thrown to the floor, punched and kicked by Alan Whiteside, 75, at the Old Vicarage care home where they both lived on February 14 2019. She suffered a broken hip, a broken arm, and a brain bleed, and died nine weeks later.
READ: Grandmother, 91, died after being thrown on floor, punched and kicked by man at Freckleton nursing homeTen months following the attack, in December 2019, the home was placed in special measures after a CQC inspection found a number of serious regulation breaches there.
A CQC spokesman said: "There is a history of non-compliance and people were at risk of avoidable harm. Medicines were not always managed safely which placed people at risk of harm. Care records did not always reflect discussions about people’s needs or the equipment they required to maintain their safety."
The home was rated as 'requires improvement' on five consecutive inspections between October 2015 and April 2019. It was rated inadequate in November 2019, and currently holds a 'requires improvement' status.
At the inquest for Jessie McKinlay, which took place at Blackpool town hall this week, the court heard that Mr Whiteside, who suffered from dementia, was known to be aggressive and had attacked both residents and staff before. Despite this, he was allowed to wander around the home, and would frequently go into other people's rooms.
Former Old Vicarage carer Samantha Davis said staff were ordered by their manager to stop making complaints about Mr Whiteside's violent behaviour, and that any reports about him would be deleted.
She said: "He hit me many times. I reported it, but nothing was ever done."
The court also heard that multiple alleged violent incidents involving Mr Whiteside had not been reported to social services.
Caroline O'Brien, a social worker for Lancashire County Council, said: "When we do undertake visits, we only see a snapshot. We have to rely on the reports of the manager and any concerns that the manager has."
She told the court that the only report of violence social services had received was from Mr Whiteside's daughter in December 2018, in which it was alleged that he had kicked a female resident. The home itself failed to report the incident.
It is understood that the manager at the time, Sharon Clayton, who was responsible for communicating the information, no longer works at the care home.
The Old Vicarage was taken out of special measures in August last year when its 'inadequate' rating improved. Residents were found to be 'happy' in the home, and 'cared for in a clean and homely environment by staff who were caring, competent and keen to improve'.
However, inspectors said it still required improvement, as the home was found to be unsafe and lacking in good leadership.
They said: "The overall rating for this service is requires improvement. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress."
A spokesman for Pearlcare, the care provider which oversees the Old Vicarage, said: “The Old Vicarage Care Home was devastated by the incident involving Mrs McKinlay. The incident was duly reported by the home to the relevant authorities and an extensive, multi-agency meeting took place, as is routine following an incident of this type. Details of the learning and outcomes that arose as part of the subsequent investigation form part of the coroner’s inquiry and it would not be appropriate to comment on this whilst the inquest remains ongoing. The Old Vicarage Care Home takes the safety of its residents very seriously and will continue to assist the coroners’ investigation insofar as it is able.”