1

Elderholmes response to the Final Report

( recommendations of the Independent Review of Clinical Care
of Mrs Beddows at Elderholme between 2008 and 2011)

(Elderholmes comments are in red with my explanations in black italics)

NHS Report: Mr Beddows first raised concerns in 2008 regarding the care provided to Mrs D Beddows at
Elderholme Care Home which were resolved at the time. Mr Beddows raised further concerns with the home in
2009 and via a formal complaint with Wirral PCT in 2011 that remain unresolved.

Elderholme: This first paragraph is factually in error.Elderholme received 11 written complaints from Mr
Beddows and many more verbal complaints before the current Matron took up her duties in August 2008.
Please see timeline below.
LB :CQC standards call for the recording of verbal complaints. If there is no record then there were no verbal complaints.
The NHS investigations only cover the period 2008 to 2011 when Doreen Beddows care was the responsibility of the
present matron / manager. If many more verbal complaints were made before she arrived how does she know that? As
an independent provider to the NHS Elderholme are required to follow the Local Authority Social Services and National
Health Services Complaints (England) Regulations, Elderholme admit that they have not treated my complaints
according to their own policies but have now put together a timeline as they call it. This cannot be considered as a true
record as there are few acknowledgments or resolution letters from Elderholme. I have detailed responses to their timeline
and added further details as follows:

27th September 2011

Timeline Mr Beddows
1)
13 October 2000 Mrs Beddows admitted in persistent vegetative state.
LB: This cannot be counted as a complaint

2)
30 August 2001 Written complaint about security
LB: This was not a complaint but a request for the front door security number which had just been changed. I received a
reply giving me the number.

3)
12 October 2006 Written complaint about standard of care and shortage and deployment of staff
LB: This was in response to a questionnaire sent out by the Home. I pointed out that three staff were no longer being
provided to transfer Doreen as called for in the care plan because they were short of staff due to opening of an extension
without taking on extra staff.

4)
3 December 2006 Written complaint about staff shortages. How Elderholme organises its finances. Advice on
fundraising. Shift patterns.
LB: This letter was in reply to one from Elderholme following a relatives meeting and discussed matters arising from the
meeting. I acted a secretary and took the minutes at such meetings and we put forward ideas to raise funds and
suggestions for improvements.

5)
12th December 2006 Written complaint female carers only as wife who is in persistent vegetative state will be
embarrassed by attendance by male staff. Accusation his wife is being left without care on purpose.
LB:Response to a meeting called by the matron to review care. My wifes care plan called for female only carers for
intimate care.Elderholme held a meeting for relatives and there were many complaints about lack of staff. One male carer
shouted out to the meeting that the reason my wife was left in bed was because I insisted on no men. My complaint was
that he should not have been discussing my wifes care needs at a public meeting.I received no reply.

6)
21st December 2006 Written complaint about 15 months of complaints. Lack of care shortage of staff .
LB:This was a reply to a letter from Elderholme director Mr Woods who asked if he could have details of any reservations
about care as they hoped to improve.The matron replied on 12th January thanking me for my support.

7)
28th September 2007 Written complaint about care and form filled in
LB: A letter from the hospital arranging for Doreen to have a procedure to her PEG feed tube under anaesthetic was not
passed on to me. It was an error and no such operation was needed. This only came to light when I accompanied Doreen
to the pre op clinic.Elderholme apologised and promised to ensure correspondence is passed on to relatives.

LB: Omitted from timeline; 27th December 2007 letter from Elderholme to LBwill allow the opportunity to improve communication of
the nursing department and encourage a more knowledgeable base of Doreens care needs. Chris Whiteside matron.
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8)
18th February 2008 Written complaint form filled in shortage of staff and instructing us what consumables to use
LB:Shortage of staff meant that there were not enough on duty to transfer Doreen or turn her on eleven occasions in the
previous month. There was also a shortage of inco sheets and no pads during a period when Doreens bowel movements
were loose. Elderholme replied on 4 th March saying they were short staffed due to sickness and they would obtain a review
of continence needs. Complaint upheld.

9)
6th March 2008 Written complaint form filled in shortage of staff and instructing us what consumables to use
LB: Reply to letter fromElderholme. This was to correct a misunderstanding over the type of pad that Doreen had been
prescribed referred to in Elderholmes letter of 4 th March and to correct the Homes statement in that letter that I had
agreed to a reduction of staff for transfers .I had not done so. Complaint upheld.

10)
11th March 2008 Written complaint about closing the Home to visitors on advice from CSCI and local
authority. Mention that he enquires about moving his wife to another home.
LB: The letter of March 11th 2008 refers to Elderholme having closed the Home to visitors because of a cdif outbreak. It
was our Ruby Wedding anniversary and I telephoned the Home and asked them if they could bring Doreen (who was not
affected by the outbreak) out side on that day so I could see her.They refused and said it would be another week before
the closure was lifted. I contacted the Long Term Care Team and spoke to them about moving my wife to another home
that was not infected as I knew she would be fretting. They told me to speak to CSCI and Infection Control.I spoke to
CSCI and they said that they had not been advised of an outbreak. They gave me a number to ring. I spoke to Julie
Sarong, Infection Officer, and she told me that it was a cornerstone of Health policy that nursing homes are NOT closed
during an infection as the trauma caused to patients in not seeing their relatives was often worse that the risk from
infection. The Officer telephoned the Home and told them to reopen it to visitors. CSCI and the local authority had NOT
told the home to close to visitors the Home said in their response to me that no one had told them not to close!

LB: Omitted from timeline; 10th April 2008 Letter from Elderholme to LB:I am writing to invite you to discuss your wifes care at
Elderholme Chris Whiteside matron.

11)
16th May 2008 Written complaint about care and accusations Elderholme is discriminating against his wife
LB: This letter was in response to a letter from the Matron dated 10 th April asking me to comment on Doreens care at
Elderholme.There were compliments as well as observations.One of the concerns was that Doreen was not been turned
during the night as per the care plan between 2am and ten am,meaning she could be wet for such a long time or her peg
feed could have been disconnected or blocked. During a recent CSCI inspection the report showed concern that residents
could not use the nurse call system in many parts of the Home. Elderholme installed an expensive call system connected
to a computer and with portable call buttons.Some residents had been put on 30 minute watches because they could not
use the alarms.I asked why this had not been done for Doreen was it discrimination? The matron replied admitting
Unintentional Discrimination through lack of knowledge and deciding to provide hourly checks and recording of same.
This letter is the starting point for the enquiry conducted by Lorraine Norfolk into the clinical care of Doreen at
Elderholme between 2008 and 2011.

LB: Omitted from timeline; 22nd May 2008 Letter from Elderholme to LB:..it may appear that through attitudes, complacency, lack of
knowledge and failure through all of the abovewe may have be seen to have unintentionally discriminated against Doreen - matron

Of these first eleven, between 2000 and 2008 nos. 1 and 2 are NOT complaints, nos 3 to 6 and 8,9 and
11 were seven responses to questionnaires or letters from Elderholme asking for comment. Five of
these refer mainly to a shortage of staff. Nos.7 and 10 were each upheld and received an apology.
HEATHER WARD TAKES OVER AS MATRON
LB: Note the change in character of Elderholmes letters and statements from this point.

12)
7th October 2008 Written (not official) complaint giving advice on how to care for his wife and the mistakes in care
Elderholme has made.
LB: This letter which states in the first paragraph this is not a complaint and I do not expect a reply in writing and
followed a relatives meeting which the Matron had conducted. I gave examples how a lack of staff meant that staff were
not available to transfer Doreen as per the care plan and care staff were receiving no assistance. I received no reply.

LB: Omitted from timeline 4th March 2009 Verbal Your wife gets more care than anyone else in this home. If they were all like her we
would not be able to keep going. Heather Ward

LB: Omitted from timeline 15th March 2009 :Letter from Elderholme to LB: Elderholme wrote to ask for a top up fee and I replied that the
NHS are responsible for my wifes fees.
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LB: Omitted from timeline 20th March 2009 Verbal Your wife gets more attention than anyone else you dont need three people. (It is in
the care plan) - Heather Ward

13)
12th May 2009 * Meeting at Elderholme. Mr Beddows critical about care
LB: This was a meeting called by the Matron, attended by the assistant matron and my wifes GP.I was not critical about care
at this meeting the Matron was critical of me . The matron told me five days earlier that the GP wanted to see me about my
wifes diet to allay my fears. This was not true.The matron had asked the GP to attend because she said that she had received
complaints about me interfering in my wifes care from the dieticians and that the continence service had complained that I
stopped their nurse from removing my wifes catheter and treating a nearby wound. She said that I had instructed staff that
they could not call the GP in without my permission.Prior to the meeting several nurses had given the GP details of
complaints which were then repeated to me by the GP and the Matron.The matron also complained to the GP that I was
insisting on three staff to transfer my wife and that I was also insisting on hourly checks and recording of same. The NHS
have established that no such complaints were made by their departments and I had never given such an instruction about
the GP. Three staff and hourly checks were part of the care plan. I was in tears at the end of this meeting,upset at the
accusations and not knowing at the time whether they were true or not.The GP called an end to the meeting. The matron was
aggressive towards me at this meeting which is evidenced by the GP and complained that my wife received more care than
any other resident in the Home and she had 59 others to look after.She said she would not receive such attention in intensive
care .Nurses statement: I can further confirm that whilst I was Mrs Beddows named nurse Heather Ward tried to pressure
me into making false complaints to Dr Meyer about Len Beddows

LB: Omitted from timeline 12th May 2009 Verbal (In presence of Dr. Meyer)He insists on three and his wife checked every hour and
marked on charts. She would not receive such attention in intensive care.She received more care than any other resident in the Home and
there are 58 others to look after Heather Ward

LB: Omitted from timeline 30th June 2009Letter from Elderholme it is pointless responding to the numerous details in your letter
matron Heather Ward.

14)
11 September 2009 * Written complaint about care and Matron Manager attitude and complains he is being
victimised.
LB: This letter was a complaint about the lies told by the matron at the meeting on 12 th May with the GP. Both Dieticians
and Continence have confirmed that they made no complaints about me. The Director of Elderholme replied 28 days
later repeating the same accusations.

LB: Omitted from timeline 24th May 2010 Verbal How do you know she wasnt checked? Checks are not needed .Im not arguing Im
telling you.Your wifes careplan is the thickest in the Home. Heather Ward

LB: Omitted from timeline 10th June 2010 Letter from Elderholme:. You are under the misapprehension that Elderholme receives an
enhanced payment for your wife. If you want additional care at Elderholme then make out a case to the PTC B.Woods director.

15)
20th November 2010 Email to Alison McGovern MP questioning integrity of Elderholme Management
LB: I was asking her to ascertain from CQC who was responsible for complaint handling and as such is not a complaint.

16)
27th December 2010 * Letter to Dawn Vasco Continuing Health care team NHS.Accuses Elderholme of not caring for
his wife correctly and Matron Manager being stubborn.That his wife gets less care than other continuing health care
patients.
LB: Elderholme wrote to say that they considered that checking Doreen four times per 24 hours was sufficient and if I did
not agree then I should write to the NHS.This letter asks CHC to verify if this was satisfactory. I did not say my wife gets
less care - I said her needs are less.

17)
28th December 2010* Letter to Alison McGovern MP. Accuses Matron Manager of telling lies to GP.Contains: As I
have stated all along I am happy with my wifes care and the NHS said they could not believe how well she was after
ten years.
LB: I was explaining the resolution meeting with Elderholme re complaint of September so is not a complaint but part of
the complaint process to the 11th September complaint.

18)
21st March 2011 Letter Wirral Council to MP. Including report about unannounced visits.Report very
complimentary about Elderholme and Matron Manager
LB:This is a letter from Wirral Council to my wifes MP enclosing a copy of an inspection report following a visit to
Elderholme. It was intended to investigate complaints received from myself and others.The inspection took place 9 th and
10th December 2010 and 8th and 10th February 2010. On Friday 10 th December 2011 the Department of Adult Social
Services were conducting an inspection of Elderholme. On the same day I met with Elderholme Chairman Brian Rourke
and Director Brian Woods.I gave them,again,full details of all concerns and they promised to discuss them that afternoon
with Heather Ward. On Monday 13th December2010 Heather Ward made a referral to safeguarding. Mr Beddows is
described as the perpetrator of abuse Physical Potential for, if Mr Beddows becomes increasingly distressed about his
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wifes condition. Deteriorating health has triggered increased anxiety/distress for this ladys husband who has expressed
suicidal thoughts to a care worker that he would harm himself and thoughts of ending his wifes life. Staff have been
advised to leave door open (Mr Beddows has the habit of closing it). Relationships between Mr Beddows and staff are
strained due to his demanding nature. They felt that this would be further exacerbated were he to know of this referral
My wife had been in her normal state of health for at least two weeks prior to Heather Ward making this statement.
Elderholme had failed to detect an eye infection which had caused Mrs Beddows to keep her eyes closed as if asleep.
After a course of antibiotics Mrs. Beddows was soon back to her normal sleep pattern TWO WEEKS BEFORE THIS
REFERRAL WAS MADE. When this referral was made Mrs Beddows was in good health, she had not deteriorated and
Mr Beddows was under no more strain than for the previous eleven years. Relationship with staff was as good as ever and
Mr Beddows had made no demands which were not part of the care plan.

On Friday 11th June 2010 Pam Marr gave Mr Beddows a letter from Brian Woods, director of Elderholme, which
referred to conversations with the matron, and said that they did not receive payment for additional care (hourly
checks). Mr Beddows asked Pam Marr to tell Mr Woods that all he wanted was what was in the care plan and that if he
had the means he would have killed his wife and himself with all the worry the Home were causing and he asked her to
sort it out.

Pam Marr said she would speak to Heather Ward and there is little doubt that Pam Marr told Heather Ward of the
suicide comment. If they were really concerned why did no one from Elderholme offer any counselling/assistance to Mr
Beddows over his comment. It was not mentioned again until Heather Ward made this referral six months later.

As for the door being closed, on 3 rd June 2011 Nurse Alix told Mr Beddows that Heather Ward had instructed her to tell
him that the door of the room must be kept closed because Mrs.A, the lady in the opposite room,thought Mrs Beddows was
her daughter and had taken to going into Mrs Beddowss room and 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 attention of safeguarding. There is no doubt it was in
order to divert DASS attention away from checking documents which the NHS Review now show to have been below
standard and that should have been apparent to the inspectors. They did not report on any of Mrs Beddowss care, and so
missed the opportunity to resolve all matters.The only reason for not informing Mr Beddows of the referral was that he
would have been able to give all of the foregoing explanations and demonstrate that the statement made six months
previous was made in an effort to show the depth of his concern, on his wifes behalf, over the failure by the Home to
follow the care plan.This failure is acknowledged in the NHS Independent Review of clinical care.Otherwise why did
DASS safeguarding not seek to resolve the issues which they were aware of and which had lead to the inspection or action
this referral? DASS issued a good report for the Home and even though the Complaints Manager confirms that he gave
the Contracts Manager full details of Mr Beddowss complaint,noneof those concern were investigated.

LB: Omitted from timeline 3rd March 2011 Following receipt of a good report from DASS Elderholme chairman Brian Rourke
wrote to DASS and circulated copies to all local MPs claiming myself and another relative had been vexatious complainants
over a long period. He blamed DASS for encouraging us.There are many false statements in his circular.

19)
20th April 2011 * Letter to Wirral MP accusing Elderholme of blatant disregard of standards in some instances.
Accuses Elderholme of disregarding accepted care standards . Accuses Elderholme of telling lies to wifes GP and
local PCT. Accuses Matron manager of bloody mindeness
LB: These were my Comments on DASS Inspection Report of Elderholme so is not a complaint. My comments were
similar to the findings of CQC when they inspected in 2015.

20)
21st June 2011 email to MP. Complaint about Matron Manager lying and verbal and emotional abuse. Complaint
about management/directors handling of complaints.
LB: I was suggesting agenda for meeting MP had arranged with Elderholme re my complaint.

21)
23 June 2011 email to MP they will realise that Doreen knows nothing about anything going on.Yet
on 12th December 2006 he stated that she was embarrassed by being attended to by male carers
LB: This was my email to MP acknowledging that meeting had been cancelled. This comment by Elderholme shows on
many levels managerial ignorance of best practice in looking after a PSV patient (probably any other as well). Always tell
them what you are doing and what is happeningtalk to them as if they understand everything because maybe they do. In
this email I refer to my not discussing anything about what Elderholme management were up to with Doreen so that she
knew nothing about what was going on but was depending on Elderholme to ensure her safety,comfort and well being
(why did Elderholme miss this off their comment above?) Furthermore, under the Mental Capacity Act nurses and carers
should take note of the wishes of patients as described to them by people who knew them best before they were ill. Doreen
would not have liked to lie naked on a bed being washed by a man because she was due to appear in court to testify about
inappropriate comments about her figure from a GP.Her illness prevented her appearing. No men carers (not trained
staff) was an accepted preference. However it is a private dignity issue and at a public relatives meeting a member of
Elderholme staff told all present that my wife was often left in bed because she did not want men carers attending to her.
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Such matters should not be divulged to all and sundry by nursing home staff. Elderholme never replied to this complaint
until this comment above.

22)
5th July 2011 * email to MP in which he accuses Hetaher of lying to the mayor who was visiting when she said
there were no smells in the corridors.Mr Beddows states that nursing homes and smells go hand in hand. The report
by Wirral social services who were in attendance for 4 days states there were no malodorous smells present during
inspection days.
LB: I enclosed a copy of response from CHC to my request for a reply to my letter of December 2010.They replied that
the Review Nurse had left causing delays in replies. As an aside I referred to the mayors visit when the matron had said
to him that she had never noticed any smells in the Home in all of the three years that she had worked there. I remarked
that she lies when there is absolutely no need to make such obviously false comments.

23)
15th July 2011 Letter to MP criticising Matron Manager and telling MP how to solve problem .
LB: I was requesting advice as to how to proceed following cancelation of meeting.

24)
26th July 2011 Letter to Mr Glover (agent to MP) complains about Matron Manager behaviour towards him and that
she has told lies. Accuses Matron manager of victimising his wife and that she gave false information to his wifes
GP.
LB: The MP had received written confirmation from the NHS that showed that the matron had given incorrect
information to the GP and asking for advice re hourly checks.

25)
1st August 2011 email to MP stating he believes his wife is being victimised
LB: I was commenting on the MPs advice re hourly checks

26)
13th August 2011 email to MP states he has registered his dissatisfaction with the management of Elderholme on survey sheet
and accuses management of being dishonest.
LB: I was giving comments on DASS inspection report and enclosed copies of my statement criticising managements
treatment of my complaints which had not been included in the satisfaction survey results. Wasnt that being dishonest?

Number 12 states This is not a complaint but reminds Elderholme of lack of staff
Number 13 is not a complaint in itself, but details of the meeting called by the matron
Numbers 13,14, 16,17,19 and 22 ( marked * ) are referred to in Lorraine Norfolks Clinical
Care Review.
Number 14 is my only formal complaint to Elderholme and numbers 15 to 26 are copies of
correspondence between myself and my wifes MP who was advocating on her behalf and
were subsequently provided to Elderholme by the NMC for their comment. They all refer to
evidence to the original complaint to the NMC concerning the lack of integrity by the
matron manager and / or nurses under her control and management. As such they cannot
be cannot be considered as separate complaints. Collectively they give evidence that
Elderholme:

NHS Report: Two investigations have been undertaken into Mr Beddows complaint an Independent Review* in
February 2013 and a further investigation** in November 2013.The purpose of the Independent Review was to
determine if there was any evidence to indicate that Mrs Beddowss clinical care fell below expected standards
during her residency and review the actions taken by the Continuing Health Care Service in respect of its
commissioning responsibilities.

*Independent Review of Health Aspects of complaint received by NHS Wirral form Mr Leonard Beddows in regard to
Mrs.Doreen Beddows. Lorraine Norfolk Clinical Lead NHS Merseyside.3rd February 2013.

**Confidential Report on Complaint Received from Mr Leonard Beddows with regard to Mrs Doreen Beddowss Healthcare
During her residency at Elderholme Care Home.Mary Barlow, Clinical Quality,Safeguarding & Performance Lead,Continuing
Health Care/Complex Care Services,Cheshire and Merseyside Commissioning Support Unit.

Several recommendations were identified as a result of this Report which included:

1. An acknowledgement from the PCT that the care plan for Mrs. Beddows should not be altered without a formal
review of her care needs, by the appropriate professionals, and only where a formal review be indicated because
there is a change in need identified.
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Elderholme Response:This recommendation raises several issues
How can the PCT acknowledge that the care plan should not have been altered? The PCT does not exist
any more. The recommendation does not say why. Does this recommendation stand for all patients in a
persistent vegetative state? Is it for all CHC funded patients? Did Mrs Beddows have a special condition
that needed appropriate professionals to be involved? Who were the appropriate professionals? In the
experience of our 18 qualified nurses with the combined qualified years of work numbering 364 the
appropriate professionals to change care plans are nurses with advice if offered from other health
professionals. Not one of them have ever had to have input from a consultant.

CHC : from Report by Mary Barlow MSc,DMS,RGN, Clinical Quality, Safeguarding & Performance Lead, Continuing
Health Care/Complex Care Services Cheshire and Merseyside CSU following visits to Elderholme Nursing Home November
2013: The closure of the PCT has lead to the evolution of the Clinical Commissioning Groups supported by
Commissioning Support Units. Wirral CCG has commissioned Cheshire and Merseyside CSU to provide Continuing Health
Care process in line with national and local guidance. Continuing Health Care clinical reviews process confirms clinical
reviews are undertaken by the appropriate clinician and only when a change in clinical need has been identified is a change
in the care plan formerly acknowledged and agreed. Elderholme accept that this is current practice and the patients care
plan is agreed with the individualised Commissioning Nurse and altered with clinical discussion between those clinical
professionals involved in the patients care and as part of a clinical review. The National Framework for NHS Continuing
Health Care should be applied where CHC patients are concerned and not by an individual RGN in a nursing home on her
own initiative.

2. A review of the care home records at Elderholme to ensure the daily records are being completed in line with
the identified care plans of patients.
Elderholme Response: These are reviewed as a matter of routine by Wirral DASS and CQC and are possibly the most
detailed electronic daily care records of any home in Wirral.
LB: Electronic records are only as good as the information input. Following entries on Doreen Beddows electronic record:
Doreen asked for her door to be shut (Doreen cannot talk) Doreen refused to have a wash (Doreen cannot communicate or
move voluntarily) ) Use standaid (Doreen has not stood up since 1999) Doreen refused to go on day trip to Liverpool.
Doreen refused her medication (peg only). Could these entries be for the wrong Doreen?

3. A review of the record keeping of the CHC Team and entries on the database.

4. Training and Development in relation to commissioning responsibilities of the PCT and / or CHC Team and the
PCTs responsibilities concerning the National Framework for NHS Continuing Healthcare

5. An investigation into the response of Elderholme Nursing Home to Mr. Beddowss complaint. This should
include a review of the Homes Complaints Policy.
Elderholme Response: As the above timeline shows Elderholme has responded at
length to every complaint received from Mr Beddows
LB: The timeline gives no explanation of any responses made, indeed most of them received no response. Elderholmes
resolution to the final eleven stated issues was to evict Mrs Beddows.

6. A review of the payments made by Mrs. Beddows in relation to her care. It is clear that Mrs. Beddows care
needs have not changed since discharge from Wirral Neuro-Rehabilitation Unit. It is not clear that all care costs
have been met by the NHS.

Elderholme Response: This comment raises interesting issues around the care plan for Mrs
Beddows.Elderholme has the discharge papers for Mrs Beddows. If Mrs Beddows condition had not
changed since admission it follows that the care plan recommended on discharge was the correct one.
The care plan our current matron was changing for Mrs Beddows was one that matched the care plan
guidance given in the discharge notes.

I attach a copy of the 24 hour nursing needs issued on Dr Colin Pinders letterhead (appendix 3). There
no mention of hourly checks to be recorded and many other demands Mr Beddows has made about his
wifes care.

The care plan required by Mr Beddows was not approved by a consultant or external professional. It was
devised by Mr Beddows and the previous Matron to our current one and therefore if the CCG report is
correct was improperly modified. Elderholme under our current Matron was seeking to do was the
course in re-introducing the original care plan.

LB: Mrs Beddows care needs had not changed but the methods of meeting those needs have improved since 2000 and the
care plan has been improved and updated, as it should be. For example, it is no longer acceptable to use check frequently,it
is not detailed enough a time gap has to be specified.
Elderholmes reasons for changing the care plan rely on the original nursing needs from Dr Pinder not mentioning hourly
checking. The document was not written by Dr Pinder but by the ward manager Vera Simpson. As I was leaving the Neuro
Rehab with my wife I asked her should I not have some paper or other identifying document to show the Home when we
arrived there in case the file had not arrived from the NHS. She wrote that one out whilst I waited. It was not intended to be
inclusive. The full assessments of which I have some copies, are extensive and covered a period of nine months whilst
negotiations between the NHS and Social Services continued. They refer to her breathing difficulties and her complete
 7
inability in every tick box of assessment. In those days it was taken for granted that a nursing home would take great care
(we now know different).Elderholme Director Mr Woods was at the Home at the time so he was aware of the need for close
observation (the main reason for going into a nursing home and the reason extra fees were agreed).He confirms this in his
letter dated 10 June 2010 when he writes When Doreen arrived we did receive a marginally higher payment and in his
letter dated 23 December 2010 when he writes It appears to me that when Doreen arrived at Elderholme her condition
required hourly checks with full documentation. Furthermore the Elderholme letter from the previous matron informing me
that hourly checks were to be entered on the care plan is conclusive evidence. Elderholme comment that I changed the plan
- as if I had that authority.This statement from the NHS Review Nurse confirms that the care plan had been reviewed and
accepted by CHC including hourly checks:

-------- Original message --------

From: pauline hurst <paulinehurst24xxxxxxxxxx.com>
Date:21/06/2015 21:54 (GMT+00:00)
To: leonardbeddows@xxxxxx.com
Subject: Care Plan FIY

Whilst I worked at NHS Wirral as the Physical & Sensory Disability Reviewing Officer, part of my role was to review patients
in receipt of Continuing Healthcare Funding who were resident in care homes with Nursing. In April 2010 I visited Elderholme
to review Mrs Beddows as routine for an annual review, after reviewing the care plan I discussed Mrs Beddows care with one
of the staff nurses, she told me that they needed more funds to carry out the care that Mrs Beddows required and that if 3 staff
were needed to carry out the care, they should receive an increase in what the NHS were paying, I explained that evidence
should be provided in the care plan that the needs had increased to recommend a new application to panel, for further funds.
The care plan did not show any increase in needs and the staff felt that if they were to carry out regular Checks on Mrs
Beddows they would need extra funding for more staff. This concerned me somewhat as regularly checking patients in your
care should be part of basic nursing. There appeared to be a disagreement in whether or not Mrs Beddows required checking
hourly between the Matron and Mr Beddows, I therefore recommended that the Nursing staff refer Mrs Beddows back to the
Rehab Consultant to clarify the needs. Mrs Beddows condition meant she had no head control, if left unsupervised there would
be a high risk that her head position could change, this could restrict her airway. In order to gain clarity from the Consultant
and agree the care plan going forward, an MDT was arranged for July. At that meeting the referral had not been made for a
clinical review, the Matron had agreed to reinstate hourly checks and to document when those checks had been made, any
issues noted and any actions required, as far as I am aware these checks were not put in place, unfortunately I moved on from
the PCT shortly after.

Kind regards,

Pauline Hurst

In fact Elderholme never kept care plans anyway until 2006, as can be seen in CSCI inspection reports for February and
September 2006.It mentions we asked one nurse how she knows what a patient requires and she replied I ask them. There
are extensive criticisms of the Home and they were instructed to prepare proper care plans for all patients immediately. The
matron was dismissed and a new matron employed who was an expert in documentation and procedures. Nurse Evans prepared
a very detailed plan for my wife dated November 2006 and this was used as an example to CSCI on their follow up visit of how
the Home had improved their systems.

The comments from Elderholme say that they are not aware of any regulations that a care home cannot alter a care plan; they
ask why could not her care plan be altered just like they alter the care plans for their other residents; this reinforces that our
current matron was correct in changing the care plan to more closely adhere to what Dr Pinder wrote in 2000 and finally this
(the care plan) was changed by the previous matron and changed back under our current matron. Until now they have denied
changing the care plan.

Elderholme explain above that they tried to return to the original care needs before improvements were made not an ideal
situation. The improved care plan was assessed and verified by CHC Nurse Assessor Alison Aldcroft on 10 th November 2008.It
was confirmed as correct again by CHC on 20th August 2009.On 21st April 2010 CHC Physical and Sensory Review Nurse
Pauline Hurst copied the file and agreed it with hourly checking in. (Elderholme gave her Photostat copies).See statement
above.

Furthermore Elderholme have not recorded in their timeline the following complaints:
I reported nurse R for shouting loudly at CHC patient D.OH. Nothing was done about it.
I reported nurse T for shouting at me over a long period. She apologised and Matron said We all have a bad day now and
again
2003 13th April: Catheter change and bladder washout procedure not followed according to the consultants instructions
NO response from Elderholme
2004 8th August: Catheter bag fastened above level of body resulting in constant bypassing and faeces left on side rail
bumpers in sight of wife.
NO response from Elderholme
2006 31st October: No staff available to provide three on transfers as called for in care plan.
NO response received from Elderholme
2006 20th November: Staff shortages preventing three staff being available for transfers.
 8
RESPONSE received from Elderholme promising more staff shortly
2011 17th November:letter from Elderholme stating matron claimed that I had victimised her by reporting her behaviour to
the NMC. Elderholme upheld her complaint and gave notice to remove my wife from the Home.

A further investigation and report was completed in November 2013 following discussion with Mr
Beddows which aimed to:-

1) establish that all the recommendations made from the first report had been acknowledged and identify
what actions had been undertaken as a result of these findings;
2) examine the complaint process for all relevant parties involved in relation to the complaint made by Mr L
Beddows with regard to Mrs D Beddows

Terms of Reference for Final Report:

To investigate and Explicitly Respond to the Following Matters Outstanding from Both Reports.

1) that Elderholme should have delivered Mrs Beddowss care as stated in the care plan
and as agreed with Mrs Beddows Consultant.
Elderholme Response: Please note above this is exactly what Elderholme was seeking to do. (further
on page 7) This we probably did.if the CCG rules invented for this report is correct then the change to
the care plan made by Elderholme previous Matron and Mr Beddows was changed improperly and our
current Matron by changing it in the way she did was adhering more closely to that recommended by
Mrs Beddows consultant

LB:Mr Beddows does NOT change care plans but ideally is consulted. Inclusion of a specified time for checks was made
after a need had been identified ie increased safety and comfort.These changes have been accepted by the CHC assessors.
Elderholmes alteration to reduce care was not accepted by the CHC assessor. Therefore Elderholme did not provide the
hourly checks called for in the plan so therefore did not provide the care as stated in the plan.

2) that the Home changed the care plan,specifically a reduction in the frequency of
observations, without the change being endorsed by the GP/Consultant;
Elderholme Response: Elderholme is not aware of any guidelines,rules or regulations that state that a care
home cannot alter a care plan on its own responsibility and has to refer every care plan to a GP or
consultant before any change can be made. Please confirm where this rule is published. As shown above
the care plan we changed was closer to the one recommended by Dr Pinder. It was only because of Mr
Beddows requirements that the hourly checks were instituted after seven years at Elderholme without
them.During that time Mrs Beddows condition had not altered.
LB: Mr Beddows did not require hourly checks Previous Elderholme Matron suggested this as a way of ensuring safer care.
CSCI criticised the Home during 2007 visits because their nurse call system was inadequate. Elderholme installed a new
computer recorded system costing about 40k. but residents such as my wife could not summon help because of the clinical
condition. This was one reason why the then matron added to the care plan the frequency of the checks called for in plan 7.
The amendment was reviewed annually by the NHS Review Nurse on behalf of the CHC department who were acting for
those clinicians responsible for my wifes care as required under the Continuing Health Care Framework.When I
explained this to the current matron at the meeting of 12th May 2009 she replied that half the people in the Home couldnt use
a nurse call system. Elderholme had stopped using the nurse call computer recordings (one could see the computer read out
in the foyer which constantly read system full) after HW arrived as matron.
The guidelines are provided under the National Framework for Continuing Health Care,Care Home Minimum Standards,
Mental Capacity Act, CQC Standards. Elderholme can get further guidance from NHS Choices How to Manage Care
plans.A nursing home cannot unilaterally alter care plans for NHS funded patients.

3) that Elderholme did not respond appropriately to Mr Beddowss Complaints regarding

a) adherence and changes to Mrs Beddowss care plan b) the Care Manager HW

Elderholme Response: On the contrary as you have seen from the timeline and as made available to the
investigator two lever arch files of papers dealing with Mr Beddows complaints over the years prove that
this statement is wrong.
LB: A timeline is not an accepted way of dealing with complaints. They should be entered in a log, given a reference and
acknowledged and a response given in writing . Elderholme, as an independent supplier to the NHS ,should have applied the
National Health Service Complaints (England)Regulations 2009 and the Minimum Care Standards and should take steps to
make themselves aware of the requirements.

4) To address the outstanding issues around appropriate funding of Mrs Beddowss care
package by the NHS.

Background Brief Timeline of Events

Mrs Doreen Beddows was transferred to the Walton Centre in June 1999 for acute management having
suffered a catastrophic intra-cerebral haemorrhage. She underwent craniotomy and evacuation of the
 9
haematoma the same day as her collapse. Her best post-operative neurological status was flexing to pain.
Her recovery was complicated by several chest infections. She was admitted to Elderholme Nursing Home in
October 2000 following discharge from Wirral Neuro Rehabilitation Unit .

At this time Mrs Beddows was described as being in a vegetative state and although she experienced some
spontaneous eye opening there was no evidence of purposeful response to stimuli. She had a supra-pubic
catheter and Percutaneous Endoscopic Gastrostomy (PEG) feeding tube in place. She was diagnosed with
epilepsy and suffered seizures. Her care needs were clearly identified at this time and management of care
was prescribed by Specialist Registrar and Ward Manager.

Mrs Beddows required splints and passive exercises for her limbs to prevent the development of contractures.
She required the administration of multiple medications and feeds and monitoring of symptoms by a registered
nurse. She had a tendency to bite her lower lip and required oral hygiene. Repositioning was a critical element of
her care as she experienced vomiting if she was repositioned too quickly after a feed and problems with breathing
due to poor neck posture.She required 3 people for all repositioning to ensure effective head control.Her optimum
time in a wheelchair was 4 to 5 hours.She also experienced excessive salivation.She required careful monitoring
of her bladder, bowels and skin integrity and required the use of anti-embolism compression stockings on a daily
basis.

She was identified as requiring hourly monitoring for pain,

Elderholme Response: Where and when was this diagnoses produced. The 24 hour nursing needs from
Dr Pinder made no mention of this. We have no record that Mrs Beddows was identified as requiring
hourly monitoring and to the best of our knowledge this was not introduced until on or around 2007
under the direction of Mr Beddows.
LB: The diagnosis were produced from CHC records by Ms Norfolk in her independent review of clinical care. The
improvement by Elderholmes previous matron was recorded in CHC records. Elderholme would not accept direction from
Mr Beddows even if he tried it. There is a constant theme running through Elderholmes responses that everything is Mr
Beddows fault because he wants things. All Mr Beddows ever wanted was what the care plan called for (and to be treated
with respect.) Edlerholme try to make out that I wrote the care plan because I asked for the care described in it.Also see
statement page 8 explaining why checks were needed.

signs of catheter bypassing and signs of detached PEG tube by a qualified nurse. She required the supervision
of a qualified nurse during all transfers between bed and chair, and during her weekly submersion bath.

Elderholme Response: There is no mention in nursing discharge needs that a qualified

nurse is required to supervise transfers or bathing
LB: CHC Records show this to have been a requirement since the updating of the care plan in 2006.Mrs Beddows was in
Elderholme to receive 24 hour nursing. The presence of nurses was in risk assessments prepared by the previous matron. Mr
Beddows wanted to bath his wife on his own using the equipment he paid for but the previous matron did a risk assessment
and said it was unsafe for him and a nurse had to be present to change dressings whilst bathing and ensure that Mrs
Beddows did not float off the bathing trolley. Elderholme should be able to locate copies of all the risk assessments in their
timeline.

Mr Beddows raised concerns with the Matron of Elderholme Care Home in April 2008 regarding his wifes
care,which was resolved following a meeting with the care home.

Elderholme Response: As has been noted there were many complaints before 2008
LB: See previous notes on the unsuitability of reliance on a timeline

The Continuing Health Care Services reviewed Mrs Beddows in 2008 and the outcome confirmed Mrs Beddows
remained eligible for Continuing Health care funding.

In May 2009 a meeting took place between the Assistant Home Manager, Mr Beddows and the GP Dr.
Meyer.There is no record of the purpose of this meeting and the minutes made by the GP reflect this.

Elderholme Response: The only minutes of this meeting we have a copy of are the notes made by Mr
Beddows after the meeting and given to Dr Meyer after the meeting.They were not composed by Dr
Meyer indeed he wrote to Mr Beddows on 18 May 2009 stating I must say it had not occurred me to
minute the meeting. Are these the minutes you refer to or do some other minutes composed by Dr
Meyer we have not seen.
LB:They are the minutes made by Mr Beddows, amended and agreed by Dr Meyer as he confirms in his letter of 18 th May.
The minutes were sent to the matron and assistant matron along with explanations for all of the complaints that she had
made about Mr Beddows to Dr Meyer, including the complaint by Nurse John Sandes that I had victimised him.She
acknowledged receipt in her June letter along with the statement that she had drawn a line in the sand under these issues.
Despite this Elderholme continue to state that Nurse Sandes complaint was upheld.

On 11th September 2009 Mr Beddows wrote a letter of complaint to the Chairman of Elderholme Nursing Home,Mr
Rourke,about the treatment he had received from the Matron. Mr Rourke responded on 8 th October 2009
 10

confirming reason for the Meeting and that the care staff would attempt to meet the targets of checking Mrs
Beddows every hour but stating that sometimes other demands on the corridor may sometimes cause a delay.

Throughout 2010 there was an on-going dialogue between Mr Beddows,the PCT and Elderholme with reference
to Mr Beddowss concerns regarding Mrs Beddowss care plan and Hourly health care checks. There is no
evidence of any change in Mrs Beddowss health care needs and in November 2010,following a further review of
her health care needs,Mrs Beddows remained eligible for Continuing Health Care. During this meeting Mr
Beddows raised his concern that a recommendation for Mrs Beddows to be referred to Dr Pinder had not been
actioned.

Elderholme Response: It is not the duty of a care home to arrange a consultant to visit.That is the duty
of the patients GP.
LB:The suggestion was made by CHC Review Nurse Pauline Hurst after Elderholme asked her for additional fees because
three staff were called for. If it was not their duty it was certainly in their interests to comply.See CHC nurse statement page 7

In July 2010 Mr Beddows requested a copy of Elderholme Care Homes Complaints Policy and there is further
reference made to Mr Beddows expressing concern that his complaint was not being dealt with appropriately.
Elderholme Response: On Friday 30th July a review meeting was convened by
NHS (copy of minutes attached appendix 4) There is an error on one name. The nurse noted as
Rachel Blackstock is really Tanya Blackstock. These minutes are illuminating. It appeared at
this time Mr Beddows main concern was the fact that hourly checks had been stopped being
recorded. This was discussed at the meeting and towards the end of the meeting Mr Beddows was told
by Tanya Blackstock that she was willing to go through the care plan with Mr Beddows if he wished Mr
Beddows replied No he was happy with the care plan as it is Mr Beddows was
also asked if he had any other issues he wished to bring up. He raised no other issues

LB:See NHS Review Nurse statement page 8. Mr Beddows was happy that the meeting had agreed to reinstate hourly checks
which was the purpose of the meeting. Elderholme chairman Mr Rourke wrote saying that the minutes would become part of
the care plan but he never actioned that promise.Elderholme never rewrote that part of the plan to include hourly checks and
over six months later placed on the new electronic records check frequently without specifying a time.

In 2011 Mr Beddows wrote to the PCT stating that he had made one complaint to Elderholme Care Home which
he believed had never been investigated and he requested an investigation by someone with medical knowledge.

Elderholme Response: May we have a copy of this complaint to check if we received it and if
we responded please?
LB: It is listed in Elderholmes timeline 11 September 2009.Elderholme replied in October repeating the same accusations
that the matron had made to Dr Meyer at the 12 th May meeting. Mr Beddows wrote back to ask if this was their final word on
the matter because he did not accept their response. He received no reply.

On the 10th April 2010 a request was made by the PCT and Social Services to Elderholme Care Home requesting
an investigation and concerns raised by Mr Beddows. There is evidence of a subsequent telephone call and letter
in response to this request.The letter was sent to the NHS Wirral Senior Complaints Officer on 16 th April.

In June 2012 both the PCT and Social Services wrote to Mr Beddows confirming their agreement to commission
an independent review to examine the safeguarding concerns and eviction of Mrs Beddows. There is a joint
apology given to Mr Beddows in acknowledgement of the distress caused to him.

There is no evidence in the records that Elderholme Nursing Home made a response to the letter from the PCT.

Elderholme Response: Which letter is there no record Elderholme responded to?

LB: Letter from NHS dated 10th April 2012

Mr Beddowss Outstanding Issues of Complaint

Complaint Elements 1 & 2: That Elderholme should have delivered Mrs Beddowss care as stated in the care plan
and as agreed with Mrs Beddowss Consultant;
Elderholme Response: This we probably did
LB: Probaby was not acceptable

that the home changed the care plan,

Elderholme Response: if the CCG rules invented for this report is correct then the change in
the care plan made by Elderholme previous Matron and Mr Beddows was changed improperly
and our current Matron by changing it in the way she did was adhering more closely to that
recommended by Mrs Beddows consultant
LB: The CCG did not invent the rules. The National Framework for Continuing Health Care provides the guidelines.

specifically a reduction in the frequency of observations, without it being endorsed by GP/Consultant:

 11

Elderholme Response: This conclusion is not backed up with any evidence to support it.
Mrs Beddows consultant never specified hourly checks recorded as such.
LB: Elderholme admit that they changed the care plan taking out hourly checks (destroying the original in the process and
not entering on the review record and explanation for the change). The care plan had been updated and approved by CHC
themselves several times. See statement page 7

Findings: LNs report states the following:-

The care plan for Mrs. Beddows was prescribed in her discharge plan from neurological services, and has been
reinforced as appropriate by the previous Matron in her response to Mr. Beddows in 2008.

LNs review identified that due to poor record keeping it was not possible to evidence that care was given in
accordance with the care plan. She states:- It is the opinion of the reviewer that due to a lack of consistent
record keeping clinical care was compromised and fell below expected standards.
Elderholme Response: Can we please be told over what period of time were the records not kept
consistently.
LB: Lorraine Norfolk, RGN,BSc.MSc., Clinical Lead, NHS Merseyside reviewed Elderholmes and CHC clinical records
between 2008 and 2011.

In 2008 the Matron of Elderholme wrote to Mr Beddows and agreed to provide hourly observations in accordance
with Mrs Beddowss care plan.The Nursing Home Care records from May 2010 indicate that the care plan
changed from hourly observations required to continue as much as possible; by June 2010 the care plan no
longer states hourly checks required. There is no evidence available that this change was endorsed by Mrs
Beddowss GP or Consultant.
Elderholme Response: See Notes Above

LNs report states that the care plan should not have been altered (ie hourly check stopped) without an
assessment of Mrs Beddowss care needs.
Elderholme Response: Again we ask the question why could Mrs Beddows care plan not be altered as
are the care plans for Elderholme 59 other residents. What condition did Mrs Beddows have that
prevented normal care home activity taking place.
LB: Mrs Beddows is a CHC patient.The National Framework for CHC applies.See also National Minimum Standards. It is
relevant to note that Elderholme alter care plans for 59 other residents as they wish without apparently following
recognised standards.

In addition,the report states that in January 2010 the PCT CHC nurse recorded in the Elderholme notes the
recommendation to the GP that Mrs Beddowss care needs to be reviewed.This recommendation was also
recorded in the PCT records. The report further states that in the PCT response to the MP on July 2011 the
comment that (there was ) no record of a recommendation of referral was therefore incorrect.

Mr Beddows wrote to the PCT regarding the amended care plan in September 2011 but there was no reply.

In response to a further letter to the PCT on 27/9/11 the CHC Manager stated that it was inappropriate for the
PCT to direct care given.It is the view of the author that this was incorrect given the PCTs responsibilities as a
commissioner of Mrs Beddows care package.

LNs report states that in May 2010,Mr Beddows informed the PCT that Matron had advised him that hourly
checks would no longer be implemented and referred to the home not getting extra payments.

The report states: As Mr. Beddows understood a referral was being made to Dr. Pinder he spoke to the GP
because he thought an updated nursing needs assessment could be undertaken.The GP confirmed that he had
not received a referral from the Home to contact Dr.Pinder.

Elderholme Response: Any referral to a consultant is the responsibility of the GP. We do not understand
that even after this conversation between Mr Beddows and Dr Meyer that a referral by Dr Meyer to Dr
Pinder was not made. If they could not institute it how on earth could Elderholme
LB: CHC Physical and Sensory Review Nurse Hurst visited the Home on 21st April 2010 for her annual review. She was met
in reception by nurse D who asked her if Elderholme could have increased fees because of the need for three staff on
transfers.Nurse Hurst wrote in the care plan suggesting that the Home ask the GP for a referral for a review of needs to
support or otherwise the request from Elderholme. It was Elderholmes decision not to follow this suggestion with the result
that CHC confirmed the fees as in order. See statement page 7

Mr. Beddows states that GP Dr. Meyer spoke to Matron the same day and that Matron had reinforced to him that
the hourly checks would not be continued as the care plan had been written by the previous Matron and she did
not have to follow it. Mr. Beddows also states that the Matron informed Dr. Meyer that she had not asked the GP
to refer Mrs. Beddows to Dr. Pinder because after further discussion with other nurses they felt that a referral to
Dr. Pinder was unnecessary as Mrs. Beddowss care needs had not changed. Dr Meyer told Mr. Beddows that
 12

he agreed with the Matron.The reviewer is unable to establish from the records if the GP agreed with Matron that
a referral was not required and/or that Mrs. Beddows care needs had not changed. The records reflect that Mrs.
Beddows care needs had not changed and therefore there is no indication that a change in care plan was
required.

Elderholme Response: This reinforces that our current Matron was correct in changing the care plan to
more closely adhere to what Dr Pinder recommended.
LB: See previous notes on this matter.The care plan had been updated in 2006 enlarging on the methods of meeting original
nursing needs and improving care. It had been approved by CHC under the National Framework for CHC. Having been
approved the matron should not have altered it without the agreement of CHC. Irrespective of any of this the care plan was
altered without following proper procedures ie retaining the original page and entering on the plan the reasons for making
the amendment .As this was not done the plan was changed without an indication of a change of need and without following
proper procedures.

LNs report concluded that until a review established that a change in care plan was required the existing plan
should remain unchanged.The pCT should have insisted on this

In addition,in a letter written to the PCT by Mrs Beddowss GP,on 4 th July 2012,he states the following:-

5) Heather Ward complained to me that Mr. Beddows was insisting on his wife being checked every hour. Mr.
Beddows said that it was in the care plan but was not always done. I was invited to a meeting arranged between
the CHC team, Elderholme and Mr. Beddows called to discuss hourly checking which had been stopped by the
Home. I could not attend but I was sent a copy of the minutes. On page three, paragraph 8 Heather Ward says
will always check hourly and in paragraph 10 Pauline Hurst (NHS) says can evaluations be done showing
what care has been delivered. On page 4 paragraph 5 Heather Ward states will do what has been agreed.

I have seen the letter from Elderholme written sometime after the meeting in which they suggest that checking
Mrs. Beddows when giving her medication four times per 24 hrs. is considered regular enough. In my opinion a
patient in Mrs. Beddowss condition in a bed with detachable side rails is at risk and checking four times per 24
hrs is insufficient. In March 2011 I saw severe bruising to Mrs. Beddowss foot which was unexplained by staff but
was consistent with having been trapped in the side rails of the bed.

Elderholme Response: The issues raised from these passages are two.Matron
was committing Elderholme to do what it always does. All staff as they walk past the
room with a patient in a PVS will look in making a quick visual check. This is by its very
nature not recorded or recordable.The other issue is the comment about bruising to feet
consistent with having been trapped in the rails of a bed. Mr Beddows took Mrs Beddows
for a walk every day the weather was good enough.He took her to church and to their home.
Could any bruising of her feet have happened then? If it couldnt could we please be
told what evidence was presented that ruled this possibility out? Having seen a copy of
Dr Meyers letter to {PCT on 4th July 2011 we offer Mrs Wards responses in appendix 10
LB: At the meeting with CHC on 30 th July 2010 the matron was concerned about providing hourly checks for Mrs Beddows
being documented and this is confirmed in the above comment. She said that these were legal documents and staff are
worried that if they put things on forms,and a chart is not completed hourly then they would feel they would be liable in a
court of law. If something is not recorded it has not been done. The matron agreed at this meeting that hourly checks would
be collated and entered in the care plan. However this never happened. One cannot make a bedrail safety check by staff
casually walking passed the room. When Mr Beddows took his wife outside she wore protective boots. If checks had been
made and recorded properly than Elderholme would be able to prove when and how the injury to the foot occurred.It is
relevant that there is a list of thirty (30) unexplained cuts and bruises (some with photographs) that Doreen incurred between
2008 and 2011.see foot of this report. Also see statement page 8 which refers to this meeting and LNs Clinical Care Review
page 17.

This clearly indicates that the minutes evidence HWs commitment to check Mrs Beddows Hourly,CHC Nurses
request for evidence of care given and HWs subsequent agreement to comply with this request.

Complaint Elements 1 & 2 Conclusions

Elderholme should not have changed the care plan without a review of Mrs Beddowss care needs by the GP or
Consultant; evidence clearly indicates that this happened.

Elderholme Response: See above this conclusion does not stand up to any scrutiny
under any circumstances whatsoever
LB: Elderholme changed the care plan without entering in the plan the reasons for the alteration therefore there is no
evidence that they held a clinical review of Mrs Beddows needs before changing the plan.Even if it was human error not to
change the plan following proper procedures, Elderholme were told by CHC to reinstate hourly checks at the meeting on 30 th
July 2010 and failed to do so. see statement page 8
 13

There is evidence in the GPs letter of minutes of meeting between Mr Beddows,CHC Nurse and HW,Matron of
Elderholme in which HW sayswill always check hourly however, there is no evidence this was acted upon;
Elderholme Response: that was also referred to in the minutes as a specific point.
As a matter of principle Elderholme would not record they had taken place and Matron
explained why in great detail
LB: This statement illustrates above everything else why the independent review nurse concluded that
It is the requirement of the care home and its staff to keep contemporaneous and accurate records for each patient.The daily
charts did not reflect that the care had been consistently managed.It is the opinion of the reviewer that due to lack of
consistent record keeping clinical care fell below expected standards. see statement page 7

Elderholme therefore failed to deliver the care package as proscribed by the PCT and from the GPs perspective
presented a risk to Mrs Beddowss safety.
Elderholme Response: I am confused by this statement.if something is proscribed
it is forbidden;if the statement is supposed to mean that Elderholme did not deliver
the care package as prescribed by the PCT then that is untrue. I repeat the only
care plan given to us was by Dr Pinder which we followed.I have never known a PCT
prescribe a care plan for any resident. Please detail examples where this has happened.
Elderholme devises its own care plans and modifies them based upon the judgement of
our nursing team supported by advice from other health professionals.
LB: The CCG are responsible for Doreens care and they have the responsibility under the National Framework for CHC to
ensure that care plans reflect that the needs of the patient are being met. To do this they review the care plans at least
annually. This had happened every year since 2006 when the present plan was written.Therefore Dr Pinders was not the
only care plan and had been superseded with the agreement of CHC.Obviously if the plan written by the Home is acceptable
to the CCG then there is no problem but in this instance care was reduced and CHC health professionals asked Elderholme
to reinstate hourly checks.They failed to do so. Mr Beddows recollects that after Dr Meyer spoke to the matron about the
referral he called Mr Beddows back and said that the matron was adamant that hourly checks would not be reinstated and
she did not have to follow the suggestions of an NHS nurse .see statement page 7

There is evidence in the nursing home and PCT records that the CHC Nurse recommended referral to the
Consultant;however this was not done by Elderholme.
Elderholme Response: We knew nothing of CHC nurses opinion.Why did they
not action referral?It was not Elderholme place to contact consultant this was
always done through patients GP
LB: As already noted the CHC nurses opinion was written in the care plan on 21 st April 2010 so Elderholme did know about
it. The suggestion was made in order to resolve the confusion that Elderholme had created by complaining about three staff
and hourly checks.see statement page 8

The PCT failed:

a) to acknowledge its responsibility as commissioner of Mrs Beddowss care package by stating that it was
inappropriate for the PCT to direct care given,failing to follow up the request for a consultant referral;
b) by providing incorrect information in its letter to the MP of 11th July 2011 regarding PCT records related to a
request for a consultant referral.

Complaint Element 3: That Elderholme responded inadequately to Mr Beddowss Complaints regarding a)

changes and non-adherence to Mrs Beddowss care plan and b) the Care Home Manager HW.

Findings:

Mr Beddows states in his letter to Wirral PCT on 8th December 2011 that he has made six complaints to the home
in eleven years and all but one concerned failure to adhere the Care Plan. He states that since 2009 he had made
one complaint about the Matron giving his wifes GP false information and being aggressive towards him.
Elderholme Response: This statement by Mr Beddows about the number of
complaints is provably wrong
LB: It is provably correct. See notes under Elderholmes timeline

LNs report identifies the following:-

Mr Beddows initially raised concerns with the Matron,Christine Whiteside,at Elderholme Care Home about the
standard of care of his wife in Aril 2008
Elderholme Response: Wrong.Please see schedule of complaints on first page.
LB: See notes under Elderholmes timeline

He eventually wrote to Matron on 16th May 2008, following her invitation to make an appointment to meet. A
meeting was held on 20th May 2008,and the Matron wrote to Mr. Beddows on 22 nd May 2008 to clarify the
outcome of their meeting. All issues raised were discussed,clarified and a clear plan of action was agreed.
 14

There is a theme running throughout LNs report re concerns being expressed by the Home to the PCT regarding
perceived inadequate funding for Mrs Beddowss care package.During a visit to the home on 24 th October
2008,Nurse Assessor from the Continuing Health care Team, Alison Adcroft,was approached by Mr Beddows.She
recorded that Mr Beddows informed her that he was aware of the funding issues and raised concern that the care
of his wife may be affected. Mr Beddows expresses this concern on a number of occasions in subsequent years.

LNs report describes how on 11th September 2009 Mr Beddows wrote a letter of complaint to the Chairman of
Elderholme Nursing Home,Mr Rourke,about the treatment he had received from the Matron. He stated that he
remained upset by the events earlier in the year and felt his relationship with the Matron was not satisfactory and
he was entitled to receive dignity, respect and kindness from the Matron.He requested an explanation to the
events discussed at the meeting in May with particular reference to the manner in which the meeting was
convened and the attitude of the Matron. Mr Rourke responded to this letter on 8th October 2009. He confirmed
that the meeting had been called because they had received a complaint from a member of staff and also
because Mr Beddows was continuously querying and questioning the care of the professionals at the
home. Mr Rourke confirmed that the care staff would attempt to meet the targets of checking Mrs
Beddows every hour but stated that sometimes other demands on the corridor may cause delay. He went on
to explain that the home receives the same payment for Mrs Beddows as for every other patient on the
corridor and therefore the care must be realistic and proportionate .
Mr Rourke also stated that he doubted the care for Mrs.Beddows would be better in any other home
but you are free to transfer her if you so wish. For the future, I trust you will desist from the constant
interfering with the professional care of your wife, and should you have a point to make or suggestion then it
should be directed to the Matron only, and if thought fit, Mrs. Beddows GP.

On 28th October 2009, Mr Beddows and Matron met in an attempt to resolve the ongoing issues. There is
no evidence in the records to support that the issues were resolved at this time.

There is a copy of a letter dated 10th July 2010 in the records written by Mr Beddows to the care home. He
asks for clarity as to whether the letter he received from the home dated 8 th October 2009 is the home's
full response to his complaint. He requested a copy of the Homes complaints procedure and reiterated his
concerns. There is no record of a response from the care home to this letter in the PCT files

On 30th November 2010 a review by the CHC Team was undertaken.Prior to this various email and letter
correspondence was sent to the PCT in which Mr Beddows indicated that there remained issues with how his
wifes care was being managed. He also outlined concerns in terms of the relationship between care and the care
fees. He also identified the remaining issue of complaint with regard to the recommendation that a referral be
made to Dr. Pinder and the subsequent decision not to do so by the Matron.

Elderholme Response:This was not and is not a decision a care home makes.
This is a decision taken by the patients GP
LB: As already noted the CHC nurses opinion was written in the care plan on 21 st April 2010 after Elderholme had requested
additional funding from the CHC nurse. The suggestion was made in order to resolve the confusion that Elderholme had
created by complaining about three staff and hourly checks .see statement page 8

He felt that this issue remained unexplained.

Mr. Beddows received a letter from the Director of Elderholme Nursing Home,Mr Woods,on 23 rd December 2010
outlining the basis of a discussion held in relation to Mrs Beddows. The reviewer assumes that the discussion
referred to was that between Mr Beddows, Mr Brian Woods,Director of Elderholme, Mr Brian Rourke, Chairman of
Elderholme in December 2010. Mr Woods indicated that his understanding of the minutes of the meeting in July
2010 was that hourly checks could be dispensed with,and that Mr. Beddows agreed to this. He suggested further
discussion with the Matron and the PCT staff should any further clarification be required.

Mr Beddows wrote to his MP, Alison McGovern 28 th December 2010 in which he referred to the December
meeting with the care home director and chairperson.Mr Beddows seemed assured in his letter that the nursing
home would reinstate the care plan in relation to hourly checks of his wifes needs. However,he did express some
concern that his complaint was not being dealt with properly.

In addition,referring to a recent review carried out by CHC nurses,Mr. Beddows stated that the nurses felt that the
difficulties with the Matron were related to differences in personalities. He stated in his letter that he did not agree
with this and gave an example of how inconsistency in monitoring his wife can affect her care. Mr Beddows stated
that he felt he had exhausted the complaints policy of the care home,and had received no support from the Care
Quality Commission or the Local Authority. Towards the end of his letter Mr Beddows refers accurately to the
descriptions of previous statements made to him in letters from the nursing home.
 15

In a letter to his MP dated 9th May 2011 Mr Beddows stated that he had only made one direct complaint to
the care home in September 2011

Elderholme Response: We have no record of this complaint in our files.

Can we have a copy please
LB: September 2009

and that related to the alleged behaviour of the Matron toward him. Mr Beddows describes examples of
responses made to him by the care home accurately.He oulines the areas of his concern and his dissatisfaction
with the Care Quality Commissions and Local Authoritys responses to his complaint.

On 16th May 2011 the PCT is asked to provide a response to MP Alison McGovern in relation to the issues
outlined in Mr. Beddowss letter. A letter of response dated 11 th July 2011 stated that information has been
gathered from Mrs Beddows GP and also the relevant Heads of Service in NHS Wirral and Wirral
Community NHS Trust. The letter outlined the instructions given by the Dietetic Service in relation to a call
from the care home. The RGN at the home had contacted the service as she was concerned that the fluid
intake was too high in relation to urine output. Information was also provided in relation to the continence
service and its response to issues related to the supra-pubic catheter. Both services clarified that they did
not make any complaints about Mr Beddows. Dr Meyer provided a response that stated that he was happy
with the care the home was providing to Mrs. Beddows.

Elderholme Response: Please note this comment

LB: As stated in the NHS letter of complaint of April 2012 the complaint stated that I was happy with the care at Elderholme
my complaint was and is about the integrity of the management. During their investigations the NHS have discovered
many discrepancies in the standard of care and treatment of complaints and their reports reflect this.

He also indicated great respect for Mr. Beddows in overseeing his wifes care and remarked that Mr Beddows
concern to do the very best for his wife was commendable. Confirmation was also provided in relation to
reviews undertaken by the CHC Team and that no complaints had been received in relation to the medical
care given to Mrs Beddows.

Elderholme Response: What does this mean? Does it mean the medical care given
by the home?The GP?
LB: It means that I made no complaints about my wifes care at Elderholme to CHC only about the attitude of management.

However the confirmation that there was no record of a recommendation made to refer Mrs Beddows to Dr.
Pinder was inaccurate. There is evidence that this was recorded in both the nursing home notes and the PCT
records electronically and in the case file.

Elderholme Response: Elderholme position was that this was discussed

but no conclusion was reached and as noted before any reference to a
consultant comes through a GP.
LB: There is no record of it being discussed either in the care plan or the Mental Capacity Record of decisions made.
There is no mention of with whom they discussed it. The CHC Review Nurse refers to this in her statement on page 8

In fact this recommendation delayed the case being prepared for panel as Pauline Hurst wished to have the
information from the outcome of this referral to complete her presentation.

In Dr Meyers letter to Wirral PCT on 4th July 2012 he refers to a meeting in July 2011,called by the Care Home
Manager to discuss Mr Beddowss expectations.In Dr Meyers view,it was apparent that Mr Beddows was not
aware of the reason and it was very intimidating for him. He also states that it was apparent that Mr Beddows did
not expect to be present when the GP visited in spite of the Care Home Managers assertions to the contrary.He
further accepts Mr Beddowss statement that the Care Home Manager was aggressive stating that she sat close
to him, interrupted him on several occasions without letting him complete his sentencesspoke down to him.

Elderholme Response: The recollection of the three registered nurses who

attended this meeting is different to Dr Meyer. Their memory is that Matron was
not aggressive to Mr Beddows.She was assertive and tried to ensure that the homes
point of view was aired.
LB: Dr Meyer ,my wifes GP, and directly employed by the NHS at the time, confirmed the matrons behaviour in his letter to
the NHS in July 2011.The only RGNs present were the matron herself and the assistant matron,who was the one who started
everything by saying that it was not necessary to flush the feeding tube. If three other nurses have made statements why
werent these provided when the NHS set out the complaint to Elderholme in April 2012

Dr Meyer reports that he did intervene when he (Mr Beddows) became quite upset over the accusations that
were made and subsequently called an end to the meeting.
 16

Dr Meyers letter further states that the Care Home Manager (HW) informed him that the Dietetics Department
had made complaints that Mr Beddows was interfering in care of his wife.

Elderholme Response: We stand by this comment.These remarks were

made to our staff by visiting nurses
LB: After the May meeting at which I was told of this, I wrote to the dieticians personally and asked if they could let me know
how I may have unintentionally given them cause for complaint and one of them telephoned me at home and said that they had
no complaints what so ever and offered sympathy to me for having to listen to such claims. The NHS letter of July 2011
confirms from the Head of the Dietetic Service, that NO complaints were made by their staff about me to Elderholme. Note that
Elderholme now refer to visiting nurses making remarks rather than complaints. If they were only remarks then why report
them to the GP as complaints.

From the PCT letter dated 11th July it is confirmed that Elderholme informed the dietetics department that Mrs
Beddows was passing too much urine. However, Dr Meyer states that he was not informed of this and further
expresses the view that if Mrs Beddows was passing too much urine he would have expected to see this
accurately recorded on a fluid balance chart; he notes that the only such chart he has seen at Elderholme
recorded fluid input only. He goes on to confirm that no complaints were made to him from the Dietetics
Department and notes that the PCT letter of 11th July confirms no complaints were made at all.

Dr Meyers letter states that the Care Home Manager complained to the GP that Mr Beddows had been insisting
on three people to transfer his wife; Dr Meyer verifies that this is the requirement in original discharge letter from
Walton Neuro Rehabilitation Centre.
Elderholme Response: We do not recognise this remark as conveying an accurate impression of what
was said. As a matter of interest we have recorded in our communication a note on 6 th May 2011 an
instance where following a bath under Mr Beddows instruction he and one carer transferred her back to
bed and did not wait for a third person to attend.

We also have a long standing member of the nursing staff who has cared for Mrs Beddows since
admission in 2000 who can attest to the fact that many he was content to assist in the transfer and
movement of Mrs Beddows with just one member of staff and not three as stated in the transfer form.
LB: Extract from Quality Survey 2006
Question: Do you feel that you have enough assistance and Are staff always close at hand
My comment: For the past month there has only been one nurse to help me put Doe back to bed.As you know there should be
three and I do not mind being the third but when there are only two of us it takes so much longer and difficult to get her
positioned right in bed. By the time they have finished their break time or are writing paperwork, one nurse has become the
norm. When that one nurse herself is available depends on who is on duty so instead of being five thirty it is upto seven
thirty.Elderholmes comment shows that they were aware that three staff were required and that they did not ensure that
those staff were available. The survey form shows that I did bring this to their attention.

In another instance we were short of care staff and wish to delay the start of Mrs Beddows bath. The
duty nurse instructed staff not to bath Mrs Beddows and to stay on the floor caring for twelve residents
leaving Mrs Beddows until sufficient staff were available to cover both requirements.

Shortly after the same nurse saw the carers taking Mrs Beddows to her bath and asked why. They told
her that they had been told to do it by Mr Beddows consequently leaving eleven other residents with no
carer cover and therefore vulnerable.

Our trained nurses can attest to the fact that when we could not or would not do what Mr Beddows
wanted because we had other residents to attend to he would regularly say I dont care about anybody
else, I only care about Doreen. A very laudable position for him but not one any responsible care home
could be persuaded to agree with.
LB: On 31st October 2006, 20th November 2006,18th February 2008,and 6th March 2008 I wrote letters of complaint to
Elderholme stating that on numerous occasions there were insufficient staff available to provide three staff to make transfers
as per the care plan.On three occasions Elderholme wrote back to apologise for staff shortage due to sickness,leave or
additional patients. Elderholme often ignored the care plan requirement so what was I supposed to do leave my wife in her
chair?The following contemporaneous diary extracts explain the real position with Elderholme regarding three staff.

With regards to the third paragraph this is my diary extract for

Friday 27th March 2009
Doe bypassed last night at 0200.When I arrived Doe was asleep. Just after two Julie and Sue came and said they would run
the bath and started to get things together. When we had placed the trolley and had Doe ready to transfer, Sue went to get
Tanya. She came back and said that Tanya would be coming at two thirty. This was about twenty past two.The girls asked me
what should we do. I asked Sue if the water had been run and she said that it had so I said well lets carry on at least get her
in the water. It is not unusual for Tanya not to come straight away. After bathing Doe we were turning the trolley into the
room about quarter to three ,when Tanya came down the corridor and said to me Thanks for taking two girls off the floor. I
said Dont get on to me to which she replied Im seeing Heather about thisYou can get on with it on your own now
She went and did not come to do the change of dressings or help transfer Doe. The girls asked Simone to help with the
transfer and Sue did the dressings. Every thing was finished before three .Over an hour Later Tanya came in with the meds
 17

and I asked her whether she had calmed down. She shouted that there had been no staff on the floor and she was not loosing
her job because I had told the girls to bath Doe. I told her that I do not tell anyone what to do and there was no need for her
to shout at me .She said that she had been shouting at the girls and I said she had shouted at me. She said that I had said to
her in the corridor that I had said the water would get coldI told her that the only thing I had said to her was Dont get on
at me She said this was a lie, I had said about the water. And she was not arguing about itit was what I said.Then she
went out shouting. It certainly was not what I had said and it was me she was shouting at not the girls. She has acted
completely unprofessional and should not have brought me in to her problem with the staff.She came in later to give Doe her
meds and start the feed.She said Its dark in here and I said Put the lights on. She didnt and neither did she say another
word. Sorry would not have gone amiss.Sue and Julie helped put Doe back to bed and Tanya did not appear so Sue went and
asked Kelly to help for two minutes. Doe went straight to sleep once back in bed.

My diary extract from

Monday 30th March 2009
Doe was still I bed when I arrived and it was gone two before Emma and Sarah helped by Tanya,got Doe up. Tanya
apologised for her behaviour on Friday and tried to make light of it saying she often got in a temper. I said that an apology
would not have gone amiss on Friday when I asked her had she cooled down. She said that she thought that I was being
sarcastic. Anyway she blamed the carers. Later Heather came in and said that she had hoped that Tanya and me could have
talked it over with Heather but she did not know that Tanya had already dealt with it. I had written a two page letter for
Heather but said that I would not give it to her now that the matter had ended but then went on to bring up nearly every point
in the letter! I told Heather that she was being very defensive and it was not worth mentioning the things that bothered me
then she apologised and said she did tend to be defensive. The main point was that on 29 occasions there were not three
people and she went on to say how three were not needed if I was in the room. I was exasperated and said that that comment
illustrated how she really felt that three was not necessary and her feelings filtered down to the staff. She assured me not
convincingly enough that this was not the case. She kept saying if you are bringing up matters from months back in a diary
that was not mentioned at the time and I said it is not months it is ten weeks and it is 29 times that three people have not been
in attendance. Eventually she accepted after I asked her if she was confident that Doe would not hit her head on the hoist
then two would be enough. She returned some time later with a notice which she was going to pin on the wall of the staff
room saying that three people must attend to Doe on transfer whether I was there or not.

Dr. Meyer reports that on 5 th September 2011 when he visited Elderholme the Care Home Manager asked him to
countersign a Do Not Attempt Resuscitation form. Dr. Meyer verifies that he asked the Manager if she had
obtained Mr Beddowss consent which she confirmed so he duly signed the form. Mr Beddows later telephoned
Dr. Meyer and informed him that the DNAR form had not,in fact,been discussed with him. As a result Dr Meyer
telephoned Elderholme and instructed them to destroy the form and confirmed the instruction in writing.

Elderholme Response: This is not the recollection of our Matron of this conversation. In the first
instance there is no countersignature required on a DNAR form. It is purely and solely the responsibility
of the patients GP to sign. What happened was Dr Meyer had been visiting another patient at Elderholme
on a medical matter and whilst completing relevant documents of his visit, Matron, who was sitting
opposite him said do you think it is appropriate to resuscitate Doreen? He replied instantly no.
Matron responded does a DNAR need signing. He said yes. Matron asked another member of staff
who was in the office standing near the blank forms to pass a form which Dr Meyer signed. At no time
did he ask if this had been discussed with Mr Beddows and in most cases and particularly with Mr
Beddows it is the sole responsibility of the GP to discuss this with the patient or their representative.
Under the circumstances of Mr Beddows numerous complaints Matron would not have raised this matter
with Mr Beddows under any circumstances. There was a qualified nurse within earshot of this
conversation who will confirm that at no stage did matron say she had spoken to Mr Beddows and
obtained his consent.
LB: From the above comment Elderholme agree that it was the matron who asked the GP about signing a DNAR and not the
other way round. However when the matron asked the GP she already knew that I did not want a dnar and I had completed
an Advance Care Plan to that effect. These diary notes were contemporaneous whereas Elderholmes recollection of what
was said is written over three years later. Matron says that under no circumstances would she have discussed the dnar with
me, however she asked RGNs on a least three occasions to ask me to agree to a dnar for the purposes of the advance care
plans which she required to be completed to comply with the Gold Standard. Nurse Lisa confirms that she was asked to speak
to me about DNAR and Heather herself spoke to me about it. Elderholme state that issuing a dnar is a GP only decision but
by their own admission they brought the subject up with the GP knowing that I disagreed. Issuing a dnar must be considered
a major decision and as such the Mental Capacity Act requires such a matter to be discussed with the relative. Elderholme
should have entered on the Mental capacity Record of Decisions Made the decision to overrule myself and issue dnar. They
did not do so.

My Diary extracts re DNAR

Sunday 8th May 2011
After tea Lisa set the feed up and asked me if I would sign a form stating if I wanted Doe to be resuscitated.
 18

Lisas statement:
I was Doreen Beddows named nurse for a period at Elderholme. I can confirm that hourly checking and
recording was part of her formal care plan. I can also confirm that I spoke to Mr Beddows regarding dnar. He
said that while his wife's condition remained stable he wanted every effort to be made to resuscitate her. I
informed Heather Ward of this both verbally and in writing. I can further confirm that whilst I was Mrs Beddows
named nurse Heather Ward tried to pressure me into making false complaints to Dr Mayer about Len Beddows.

Lisa Barker RGN

Wednesday 24th August 2011

Heather saw me making tea and said that they had asked the various G.Ps to decide which of their patients were to receive
resuscitation. I told her that I had already told nurses that I did not want a dnar. She said it was a clinicians only decision.

Monday 5th September 2011

Shortly after I arrived at the Home Heather asked to see me and we went into the corridor. She said that she had a form
signed by Dr. Meyer to say that Doe was not to be resuscitated but the final decision would be with the clinical staff at the
Home. She said that resuscitation was a wholly clinical decision and not to be made by a relative. I think that her statement
is incorrect,but she had already entered on the care plan that DNAR form signed by Dr. Meyer 5.9.11

Tuesday 6th September 2011

Following the conversation with Heather yesterday,I wrote to Dr. Meyer protesting about the DNR decision and then I came
in matron had already stuck a red dot on Does name plate indicating DNR and without my permission. This cannot be right.

Wednesday 7th September 2011

I checked out as much as I could on the internet about DNAR (do not attempt resuscitation) and it is apparent from the
Resuscitation Society that I should have been consulted by Heather Ward and the doctor before they signed the DNAR form.

Friday 9th September 2011

I telephoned Dr, Meyer about the DNAR form and he said that Heather had told him that she had discussed the form with me
and I was in agreement, and that is why he signed it.I told him that she had not discussed it with me and I was not in
agreement, particularly over the paragraph that gives Elderholme nurses to make the decision.He said that he would
telephone Heather or if she was out the person in charge and he would tell them to ignore the DNAR. I helped Elisa and Julie
put Doe in the bath but then I went to phone Dr. Meyer so I did not help and I was still on the phone when they brought her
back.

On 26th September Mr Beddows wrote to Mr Khan (Head of CHC PCT) via email asking for a response to his
earlier letter by 2nd October 2011. In his response dated 27th September 2011 Mr Khan wrote that the PCT are
happy that Mrs Beddows is appropriately placed at Elderholme and acknowledges the point of tension about how
the care is delivered.

He stated that it would be inappropriate to direct how the care is given by the home and informed Mr Beddows
that the matter did need to be dealt with by himself and the home.

ln November 2011 the PCT received a letter from Lawson Stebbings, Chief Executive Officer, Elderholme
Nursing Home informing them of formal notice given to Mrs Beddows citing her husband's conduct as the
reason for this. A strategy meeting was held and the PCT met with Mr Beddows along with Local
Authority colleagues on 18th November 2011.On 23rd November the PCT received an email from the MP Alison
McGoverns office to inform them that Mr Beddows does not feel he is getting support from the PCT.

On 25th November 2011 Mr Beddows solicitor wrote to Elderholme to request a withdrawal of the eviction
notice and stating that they will seek Court of Protection and a decision by a High Court Judge. A request
for a written decision is made by 28 th November 2011.A response is made by Elderholme Nursing Home the
same day stating the eviction notice is irrevocable. Mr. Stebbings states that in the light of independent
advocate being appointed for Mrs Beddows and the involvement of Wirral Social Services the demands of the
solicitor are unnecessary and premature as are the suggested recourse to the courts.

Mr Khan,PCT, spoke to GP Dr Meyer on 28th November 2011 in relation to Mrs Beddows and the potential
move to another care home. Dr Meyer felt that Mrs Beddows would become distressed by a move.

Elderholme Response: Dr Pinder has judged Mrs Beddows to be in a persistent vegetative

state and Mr Beddows wrote in an email to the MP on 24 th June 2011 Doreen knows
 19

nothing about anything going on. Also in a complaint dated 11th March 2008 Mr Beddows
stated he had made enquiries about moving Doreen to another home.
LB:This statement illustrates a complete lack of knowledge of my wife. Basic nursing procedure in nursing of PSV patients is
that one always tells them what you are doing and talk to them about everyday matters because no one can be sure of the
depth of understanding. Doreen knows nothing about anything going on refers to my keeping all the trouble that the Home
were causing from her by not discussing it in front of her. The letter of March 11 th 2008 refers to Elderholme having closed
the Home to visitors because of a cdif outbreak. It was our Ruby Wedding anniversary and I telephoned the Home and asked
them if they could bring Doreen (who was not affected by the outbreak) out side on that day so I could see her.They refused
and said it would be another week before the closure was lifted. I contacted the Long Term Care Team and spoke to them
about moving my wife to another home that was not infected as I knew she would be fretting.They told me to speak to CSCI
and Infection Control.I spoke to CSCI and they said that they had not been advised of an outbreak. They gave me a number
to ring. I spoke to Julie Sarong, Infection Officer, and she told me that it was a cornerstone of Health policy that nursing
homes are NOT closed during an infection as the trauma caused to patients in not seeing their relatives was often worse that
the risk from infection. The Officer telephoned the Home and told them to reopen it to visitors.

Dr Meyer explained that whilst Mrs Beddows was diagnosed as being in a Persistive Vegetative State she
did respond to touch, was familiar with her surroundings and did respond to simple questions by
blinking her eyes.

Elderholme Response: see comments above by Mr Beddows who knew her best.
LB: As said above,Doreen may well know everything that is going on.Even a PSV patient may be reacting to what is said and
going around her.Elderholme do not appear to understand basic care for PSV patients.

Although Dr Meyer felt it would not be in her best interests to move, she was medically fit to move. Mrs
Beddows transferred to Vale Court Nursing Home on 6th December 2011.

MBs report examined Elderholmes records of complaints and states that the lastcomplaints were logged
08/01/2013 and 22/03/2011 both were resolved. However Mr Beddows wrote a letter of complaint in September
2011 which appears not to have been recorded by the home.

Elderholme Response : We have no record of this complaint.Can we have a copy please .

LB: NMC Complaint October 2011 which lead to the eviction not logged or listed in timeline.NHS complaint April 2012
also not listed in log or timeline. These were major complaints yet not entered through the complaints system.

Given the apparent constant dialogue and correspondence between Mr Beddows and the Home regarding his
concerns around Mrs Beddowss care plan this is a significant gap in the homes records.

MBs further states that in examining the complaint process involved in relation to the complaint made by
Mr.L.Beddows with regard to Mrs D Beddows in April 2008 the lack of evidence available would suggest this was
not managed in an appropriate manner.However it is the view of the author of this report that MB was referring to
Mr Beddowss complaints made in September 2011 rather than April 2008.

MB concludes that there have been substantial improvements in the complaints process (at Elderholme) since
the original date which is also acknowledged by both CQC and Social Services in subsequent monitoring visits
and reports.

Complaints Element 3 Conclusions

Mr Beddows states in his letter to Wirral PCT on 8th December 2011 that he has made six complaints to the home
in eleven years

Elderholme Response: Wrong see above

LB:See Elderholmes timeline and notes at front of this report

and all but one concerned failure to adhere to the Care Plan.

Elderholme Response: Wrong - see log above

LB:See Elderholmes timeline and notes at front of this report

On reviewing the evidence it appears that :

Elderholme failed to acknowledge that Mr Beddows was correct in requesting that the home adhere to the care
plan as agreed with her Consultant and/or GP;

Elderholme Response: wrong see above.Elderholme under current Matron did

 20

adhere to the care plan devised by Wirral Neuro Consultant. This was changed
by previous matron and Mr Beddows and changed back under our current Matron
to more closely adhere to what the consultant requested.
LB:Elderholme refer to clinical needs from 2000.No one with any nursing knowledge would seek to return a care plan to its
position eleven years prior.The care plan was completely rewritten in 2006 and updated in 2008.Under the National
Framework for CHC the former PCT and now the CCG are responsible for care and as such inspect the care plan annually.
They confirmed the addition of hourly checks in their 2009 and 2010 inspections. The review nurse has made a statement see
page 7

Whilst the home appears to have been proactive in arranging meetings with Mr Beddows to resolve his concerns
it appears to have failed to adhere to commitments made at those meetings.

Elderholme Response: Wrong our commitments were adhered to but they

were not all logged.That is what Elderholme committed itself to and that is what it did.
LB: See Nurse Pauline Hurst statement page 8

There is evidence from Dr Meyer that one meeting in particular was managed poorly by Elderholme in that Mr
Beddows did not know the purpose of the meeting and the Matron,HW,reportedly behaved in an aggressive
manner towards Mr Beddows,interrupting him and speaking down to him. Dr. Meyer reported that he had to call
an end to the meeting.

Elderholme Response: Wrong this opinion does not accord with the recollection
of the matron.There were three registered nurses who will give sworn statements
to that effect if required.
LB: Dr Meyer has made a statement two years earlier than this comment from Elderholme. If the Home had contrary
evidence such as three RGNs statements why on earth did they not give them to the NHS when the original complaint was
made? Probably because there were only two RGNs at the meeting as can be seen from the minutes. These were the matron
herself who was the aggressor and the assistant matron (who started all of this by stating that the feeding tube did not need
to be flushed).

There is evidence that some held the view,including the PCT,that there was a clash of personalities and tensions
between Mr Beddows and the Matron HW although there is evidence Mr Beddows disagreed with this.

Elderholme Response: Evidence does not support this statement.Matron only had two
Residents relatives who may have concluded there was a clash of personalities.
The reason for the described clash is that Matron is employed to manage
Elderholme including supporting and protecting staff from bullying and that is
exactly what she does
LB: It was the PCT and/or CHC who made this comment. The Social Services DASS investigation report remarked that
Wirral DASS had only had one other eviction safeguarding application. That was also made by Elderholmes matron HW
who claimed that relative had made numerous complaints and was very demanding, insisting on the care plan being kept to.
DASS did not allow eviction because of the age of the 98 year old mother,so Elderholme issued the relative with a solicitors
letter in which he was told that he could only visit his mother accompanied by a member of staff and must not leave his
mothers room when visiting. Circumstances were almost identical to the way Elderholme treated me. It may be coincidence
that the other relative was chair of the properly constituted relatives group and I was vice chair. Elderholme state that the
Matrons job includes protecting staff from bullying and she did that by bullying relatives who dared to complain.

There is evidence from the GP that the Matron HW made unsubstantiated accusations that professionals involved
in Mrs Beddowss care had complained about Mr Beddows.

Elderholme Response: as we have stated before Comments were made to Elderholme

staff by to her health professionals involved in her care that they were uncomfortable treating
Mrs Beddows when Mr Beddows was present.Other Elderholme staff have also said they
dreaded working when Mr Beddows was in Elderholme and he was unreasonably
demanding.indeed before our matron made an official complaint another qualified nurse also
officially complained about Mr Beddows.
LB: The NHS letter of July 2011 confirms that neither the Dieticians or Continence nurse made any complaint and the
Continence even confirmed that the nurse would telephone me at home to make arrangements to meet. These specialist
nurses work in the community and as such are used to doing their job with relatives present. That leaves Elderholmes own
staff .If a nurse is experienced and confident about what she is doing she does not mind anyone else being present.
Dreadis only experienced by nurses who are hesitant and careless. There were only three of them at Elderholme out of a
staff of nearly 100. If people dreaded my presence why do over twenty Elderholme staff keep in touch with me and why was I
invited to a former matrons staff reunion?. I have a certificate from an RGN naming me as her Dirty Nurse due to the help
I gave in changing the supra pubic catheter. Elderholme have not investigated the complaint made by nurse John Sandes and
made no comment about my explanation about the circumstances, accepting the nurses version without question. It is now
apparent that they hardly investigated the matrons complaint that I victimised her by reporting her to the NMC for being
aggressive and giving false information to the GP.
 21

There is evidence that the Matron HW complained to Dr Meyer that Mr Beddows was insisting on three people to
transfer Mrs Beddows when this was a requirement in the discharge plan from Walton Neuro Rehabilitation
Centre.

Elderholme Response: There was never any complaint made to Dr Meyer about this
matter
LB: In the notes to the timeline at the front of this report one can see that there were several complaints by me about
Elderholme not providing staff for the care plan requirement of three on transfers.It is in the minutes, agreed by Dr Meyer, a
copy of which was sent to the matron in 2009.She did complain to Dr Mayer about three. The statement from the CHC review
nurse also mentions Elderholmes concerns about this requirement.see her statement on page 7
I discussed Mrs Beddows care with one of the staff nurses, she told me that they needed more funds to carry out the care
that Mrs Beddows required and that if 3 staff were needed to carry out the care, they should receive an increase in what the
NHS were paying,

There is evidence that the Matron HW informed the GP Dr Meyer that Mr Beddows had consented to a Do Not
Attempt Resuscitation order;Mr Beddows subsequently denied having given consent.

Elderholme Response: Wrong see above

LB: There is enough evidence that the matron knew that I did not want a dnar so why did she bring the subject up with the
GP at all? See previous notes

It is the view of the author that it was inappropriate for Elderholme to insist that Mr Beddows raised his concerns
with the Matron,HW,when she was the source of one element of his complaint and there was evidence that the
relationship between them had broken down.

The PCT failed to intervene and resolve Mr Beddowss complaints regarding Elderholme which,as Commissioner
of Mrs Beddowss package of care,it should have done.

Elderholme appears to have incomplete complaints records since Mr Beddowss complaint of September 2011
does not appear in its records.

Elderholme Response: Repeat we have no record of ever receiving this complaint

LB: NMC Complaint October 2011which lead to the eviction not logged or listed in timeline.NHS complaint April 2012
also not listed in log or timeline. These were major complaints yet not entered through the complaints system.Others are
detailed earlier in this report under the Timeline

Complaint Element 4: To address the outstanding issues around appropriate funding of Mrs Beddowss care
package by the NHS.

There are a number of references in the evidence that from June 2008 up to date of discharge from
Elderholme,there were points of contention between the home and Wirral PCT around whether the funding for
Mrs Beddowss care package was adequate to meet her needs as identified in the care plan. There are also a
number of references to Mr Beddowss concerns that this was having a detrimental effect on her care.

Elderholme Response: What were these detrimental effects? Mr Beddows

wrote the following to the MP on 28th December 2010:

As I have stated all along I am happy with my

wifes care and the NHS said they could not
Believe how well she was after ten years
(Elderholmes emphasis)

Elderholme has always satisfied that it could deliver Mrs Beddows care needs at the
fee paid by Wirral CHC. Any reference to funding was to emphasise the fact that the care
regime Mr Beddows wanted,but was not clinically necessary was not economically feasible
for the standard CHC fee.Never in all the meetings our current matron had with dozens of
healthcare professionals including her GP have any of them produced a medical reason as
to why hourly documented checks were required for Mrs Beddows.
 22

LB: First of all I would point out that my complaint is about the integrity of the Elderholme management. It is stated in the
NHS letter of complaint in April 2012 that I was not complaining about the standard of care at Elderholme. The NHS
decided to review clinical care whilst doing their investigations and most of this report is critical of that care. Their
statement above is incorrect. The Independent Review of Clinical Care details much correspondence and telephone calls by
Elderholme about fees. In addition the statement by CHC Review Nurse confirms both fee problems and the clinical need for
hourly checks it. She also told the matron at the meeting in July 2010 so Elderholmes statement that they have never had any
medical reason for checks is not correct. See NHS Review Nurse statement page 7

The evidence indicates that Mr Beddows first raised concerns with a CHC Nurse Assessor that the care of his wife
may be affected by the funding issues in October 2008.She assured him that the review of care needs which took
place on 10th November 2008 would identify all care needs. The outcome of the review clarified that Mrs Beddows
remained eligible for NHS Continuing Healthcare funding.

Elderholme Response: This confirms the above statement made by our Matron
LB: In her evidence to the DASS safeguard meeting prior to the eviction Matron HW said that hourly checks was in the care
plan when she arrived (in August 2008) Therefore this statement and comment also confirms that the care plan with hourly
checks and recording of same was approved by the CHC And was therefore part of the formal care plan and should have
been followed. See statement page 7

At a meeting in May 2009 the Matron made reference to the level of care for Mrs Beddows in relation to the
number of other residents in the home,and in comparison to a patient in intensive care.

LB:The matron complained at the meeting on 12th May 2009 Mrs Beddows receives more care than any other resident in
the Home and there were fifty nine others to look after

Evidence indicates that the care home continued to raise concerns about payments for Mrs Beddowss care
during 2009 including a letter from the Director of Elderholme who stated
Mr Beddows continues to insist that the protocol laid down by Walton Neurologic Unit is executed to the
letter.

Elderholme Response: Our previous notes confirm this

LB:As the protocol remained part of the care plan - of course I insisted that the care plan be followed.Matron HW told
nurses that they did not have to help with the bath but did not alter the risk assessment in the care plan.

Furthermore he insists he is present whenever any procedure is carried out on his wife and is at pains that his
requests are made within the agreement before his wife came to us. For example it takes 1.1/2 hours with him
present to bath his wife where he insists Care Assistants and Registered Nurses are present on each occasion.
Therefore in each case,I believe Elderholme is entitled to a reasonable increase in fees bearing everything in
mind and I trust you will take a personal interest in this request. The PCT wrote to the care home on 20 th August
2009 and confirmed the funding arrangement for the patients, including Mrs Beddows, as correct.

Elderholme Response: The PCT position at that time confirms our position.Care
Needs can be covered by standard fee not Mr Beddows desires.
LB: My desires were that the care plan be followed. Bathing was determined by the previous Elderholme matrons risk
assessment made when the bath arrived.(Paid for by my donation) I wanted to use the equipment on my own as shown in the
manufacturers video but the matron in conjunction with the manufacturers agent, decided that it would not be safe. It never
took longer than one hour start to finish. Elderholme would only provide bathing once per week; every resident needed a
bath therefore bathing was something that should have been included in the standard fee. Furthermore this comment shows
that Elderholme did query the fees which they deny elsewhere.

In a letter to Mr Beddows in October 2009,Mr RourkeChairman of Elderholme,confirmed that the care staff would
attempt to meet targets of checking Mrs Beddows every hour but stated that sometimes other demands on the
corridor may sometimes cause a delay. He went on to explain that the home receives the same payment for Mrs
Beddows as for every other patient on the corridor and therefore their care must be realistic and proportionate.

In May 2010,Mr. Beddows writes to the PCT,via email,following a conversation with Matron HW. Mr. Beddows
stated that Matron wanted to discuss the issues of hourly checks and subsequent recording on charts and
expressed concern that the care needs of his wife are being compared to other residents in the home and the
fees that are paid.

On 1Oth June 2010 the Director of Elderholme, wrote to Mr Beddows in relation to the care fees and stated
that the original funding for care was transferred from Arrowe Park to the Primary Care Trust in 2008. From this
point Mrs. Beddows care was funded through the NHS Continuing Health Care. Mr. Woods informed Mr. Beddows
that if he wants additional care for his wife then he should make out a case and submit his findings to the
Primary Care Trust as the purchasing authority. A copy of the letter was sent to Pauline Hurst at the PCT via
email on 13th June 2010.
 23

Complaint Element 4:- Conclusions

There were clearly unresolved tensions between Elderholme Nursing Home and
Wirral PC regarding whether the level of funding for Mrs Beddowss care package was sufficient to meet her
needs.

Elderholme Response: No unresolved tensions.Elderholme was and is prepared to give

the best possible care to all patients.The tension was purely on behalf of Mr Beddows
because he could not get his own way.
LB:After the meeting on 12th May 2009 when the matron made so many accusations that I was interfering in the care of my
wife, I sent her detailed explanations as to why she was mistaken. She could have just replied either where she disagreed or
where she accepted my explanation and the matter could have ended then. Instead she wrote that she was not going to go
into every detail. My own way was insisting on the care plan being followed.

Wirral PCT did not adequately address the funding issues with Elderholme;the PCT
should have facilitated a timely resolution informed by an up to date care plan which had been signed off by the
consultant;
As a result of the PCTs poor management of the situation,Mr Beddows was left to
engage directly with Elderholme to ensure appropriate levels of care were provided.

Elderholme Response: They were - see Mr Beddows comments to the MP and Dr Meyers comments he
was happy with the care provided.
LB:It is stated in the NHS letter of complaint in April 2012 that I was not complaining about the standard of care at
Elderholme. The NHS decided to review clinical care whilst doing their investigations and most of this report is critical of
that care.

Report Recommendations:

That Wirral CCG write a formal apology to Mr Beddows for the above failings of the
predecessor PCT which undoubtedly contributed to the distress experienced by Mr Beddows;

That Wirral CCG,as commissioner of existing packages of care at Elderholme Care Home,meet with Senior
Representatives at Elderholme Care Home to discuss the findings of this report and agree what action they need
to take to resolve Mr Beddowss complaint and bring closure.

LB: These multiple comments are Elderholmes idea of bringing closure. The least they can now do is to apologise.

Yvonne Lochhead
Head of CHC/Complex Care
Cheshire and Merseyside CSU
February 2014

Elsewhere in Elderholmes New Evidence they make the following comments:

Elderholmes response to the recommendations of the Independent Review of Clinical Care of Mrs
Beddows at Elderholme between 2008 and 2011:
(Elderholmes comments are in red with my explanations in black)

Elderholme: We did point out to the NHS that Mr Beddows was by any definition a vexatious complainant and
therefore Elderholme did not wish to spend any more of the charities management valuable time and resources on
matters that we considered past and closed.

LB: A complainant cannot be labelled vexatious, only a specific complaint can be so described. The NHSCCG s own
complaints policy, Appendix C ,warns that if a complaint is labelled as vexatious from the start then it will never be
anything else. This may get in the way of your ability to understand why the complainant is so persistent and may only prolong
the time it takes to reach a conclusion. This policy will be used as a last resort and after all reasonable measures have been
taken to try and resolve complaints during the NHS Complaints Procedure. By the NHS policy, Appendix C, Elderholme
cannot claim that I was vexatious until the complaint process has been followed and the complaint has been answered
properly. Furthermore I cannot be classified as vexatious if the complaints that I have made have been upheld, which they were
in the various independent reports. Elderholmes new evidence was not based on a properly conducted investigation.
 24

Elderholme: From the outset he was a demanding relative whose requirements were beyond what a reasonable
person would consider fair and normal .During the time Mrs Beddows was resident in Elderholme Mr Beddows was
a serial complainer about the delivery of care to his wife and other matters.

LB: The only care I wanted was that set out in the care plan and agreed with the NHS in their annual reviews. No more and no
less.

Elderholme: The charity solicitor had to write to him to request he remove a harassing libellous statement from
social media written about our matron manager. Mr Beddows continued to complain about Elderholme
management in a manner that crossed the boundaries of acceptable behaviour and moved into employing
unacceptable language, written harassment and libel against Elderholme management and staff.

LB: There is no evidence that I used unacceptable language. The only occasion which could be criticised was when male nurse
J spoke to me in an inappropriate manner and I replied in a similar manner man to man. He often spoke inappropriately to
female staff who could not respond but I saw no reason why he should speak to a relative in that fashion. The libellous
harassing statement that I was asked to remove referred to statements made by the matron to my wifes GP and which she has
repeated in her statement and which I have proved to be inaccurate on her part from written evidence referred to in the
Comparison of Statements posted on this site.

Elderholme: Regrettably the report published by the CCG is unbalanced, unchecked ,full of inaccuracies, errors of
fact, and opinions on procedure contrary to accepted medical practice and unsupported by guidelines.

LB: The Report was the result of Independent Investigations by such experienced clinicians as the Clinical Lead of NHS
Merseyside and the Head of CHC/Complex Care Cheshire & Merseyside CSU. They had used the NHS own records and the
clinical records from Elderholme, and had not relied on my statement. Elderholme acted in defiance of established guidelines
and medical practice as defined in the Mental Capacity Act 2005 and the National Framework of Continuing Health Care
National Framework for Continuing Health Care Commissioning, Care Planning and Case Management.

Elderholme:All these complaints were exhaustively investigated and appropriately addressed. It is clear looking back
on the records that Mr Beddows caused Elderholme to spend an abnormal amount of management time attending
to his demands and complaints.

LB: Elderholme are an independent provider to the NHS in respect of my wife and therefore must apply The Local
Authority Social Services and National Health Service Complaints (England) Regulations 2009. Under section 6
Elderholme have a duty to co-operate with any complaint investigations. They did not do so. These regulations call for
complaints to be acknowledged in writing, files to be opened and letters of resolution sent. After asking Elderholme for their
files, the NHS concluded in their report: There is no documentation available to highlight any actions taken to address the
complaint and therefore no formal record of complaint investigations in any recognised format. This could suggest that no
action had been taken. A timeline is not an accepted way of recording complaints and whatever the complaints were, they
were not addressed appropriately as required under the Regulations.