A FRUSTRATED family have spoken out at their dismay after an enquiry into their grandma's treatment in a care home.

Monica Holt was 98 when she was attacked in the early hours on Wednesday, December 13, 2017, in her room at Heathercroft Care Home by another resident.

She died in March 2018, just weeks after turning 99.

In the space five hours, she had been attacked twice leaving her with severe bruising and swelling on her face and body.

The family of the former Lymm nurse were shocked when they were not contacted immediately by staff at the home who waited eight hours to report the incident.

The safeguarding enquiry, held under section 42 of the care act and seen by the Warrington Guardian, has just been published.

It found the male patient had head-butted a member of staff, punched one and attempted to hit another in the days leading up to the assault on Monica and one-to-one care was provided.

In May 2018 a CQC report rated the home as 'requiring improvement'.

Due to low staffing levels on the night of the incident, it was agreed that in the absence of agreement for one-to-one care, they were to conduct 15 minute checks, utilising the staff available.

This was undertaken but at 11.30pm Monica was heard shouting and informed staff that a man had entered her room and hit her on the face.

He then attempted to regain entry to her room two more times before Monica was heard shouting at 4am and staff found the man in her bedroom with the door closed.

Monica told staff he had punched her in the face.

Warrington Guardian:

Some of the injuries

Gary Brun, Monica's grandson, said: "The initial actions where a shambles.

"It was only when we as a family published our horrifying images on Facebook of our grandmothers’ injuries in January 2018 that the CQC and the council started their investigations and the police were involved.

"The conclusions of the safeguarding report are feeble and outstandingly weak.

"Nothing proactive has happened to ensure that the mistakes made by Heathercroft do not happen again and no one will take responsibility.

"It is clear from the report that the attacker was not assessed correctly and should not have been admitted to the EMI residential unit.

"Every day from November 28 he was attacking other residents or staff. Heathercroft should have put in additional one-to-one support but failed to do so because of lack of funding.

"It has been proved that after the first attack, Heathercroft was to carry out 15 minute checks but this did not happen as Heathercroft was short staffed on the night shift and was using agency carers with the consequence that the residents were not being monitored.

"We requested the records for our grandmother yet we still not have heard a peep from Heathercroft.

"There is something very wrong with the system when a private company can refuse its staff to be involved in such an important enquiry and none has the authority to make the company comply.

"All parties know that Heathercroft has a duty of care to protect the vulnerable residents at the home but they failed miserably and allowed two attacks by the same resident within a few hours.

"It should never have happened and could have been avoided."

Gary also said that the recommendations made after Monica's assault have not been met as incidents continue to happen at the home including the resident who died in the smoking shed as he was allowed to smoke unsupervised, a woman who broke her arm in March and a woman who was assessed as in risk of falling and fell on her second night and broke her hip when an agency carer was in charge.

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Lance Holt, Monica's grandson added: "There is no malice towards the gentleman. It’s not him – he probably didn’t have the mental capacity, but it’s the care home."


A spokesperson for Warrington Borough Council said: "We accept the findings of the report and have used them to inform our own areas for improvement.

"We recognise that the report reflects a very sad situation and raises questions about the levels of care offered within a private residential setting both to Mrs Holt and to the other resident, who had been placed by another local authority.

“The report shows that there are clear conclusions for all parties, including the Council, and the findings of the report have contributed to our learning about how to reduce the risk of incidents like this reoccurring.

“The council and care home have worked closely with the Care Quality Commission to ensure the report’s feedback is factored into wider service improvements.”


Nigel Denny, managing director of Ashberry Healthcare said: “The safety and wellbeing of everyone who makes their home with us is always our absolute priority, and we apologise wholeheartedly to Mrs Holt's loved ones for the circumstances surrounding the 2017 incident.

“We accept the findings of the report and are fully committed to working with all the relevant bodies to make sure we learn from this case and an incident like this never happens again.

“We have already taken a number of steps to address the issues raised in the report.

"This includes appointing a new home manager, undertaking an in depth review of our safeguarding and communication policies, and a weekly review of staffing levels.

"We will continue to work with the relevant bodies to make sure all residents receive the high quality care they deserve and rightly expect."