A Birmingham nursing home where a pensioner died after allegedly being left in a wheelchair overnight was criticised by inspectors just months earlier, an inquest heard today.
Brigid O'Callaghan, 74, was found with the chair's seatbelt wrapped around her neck at the Bupa-run Amberley Court Nursing Home in Edgbaston, during a week's stay, a jury at Birmingham's Coroner's Court was told.
The body of the widow from Sutton Coldfield, was discovered in her bedroom on the morning of October 28, 2005, by the home's cleaner.
Today, Kathleen Strong, an inspector for the Commission for Social Care Inspection (CSCI), told the inquest that prior to the death, inspectors graded the private home as poor.
A report following an inspection in July that year said that care plans for residents were "inadequate" and that there were long-standing concerns regarding a lack of formal staff supervision.
Ms Strong said: "The inspection of July 2005 was a typical example of the continuing lack of appropriate care plans for people."
She added that risk assessments had also been an "ongoing problem", describing them as "generic and not individualised".
Another inspection in November the same year, following the death of Mrs O'Callaghan, saw the CSCI issue the home with an enforcement notice regarding care plans, she said.
The home is now risk-rated as being adequate and has been since October 2006, Ms Strong said.
Mrs O'Callaghan, known as Vera, suffered from brain damage following a road traffic accident two years earlier and was staying in the home for a week's respite care while her daughter and full-time carer, Ann, took a break.
After her accident she was wheelchair-bound and needed a hoist to move her from the chair to her bed, the inquest has been told.
A pathologist has told the inquest that Mrs O'Callaghan's cause of death was given as asphyxia due to an obstruction to her breathing.